Intervening Earlier in Mental Healthcare for Kids with Lauren Wakschlag, PhD

[00:00:00] Erin Spain, MS: This is Breakthroughs, a podcast from Northwestern University Feinberg School of Medicine. I'm Erin Spain, host of the show. According to the US surgeon General, approximately 20% of children as young as three have identified mental health problems, and this could lead to persistent mental health challenges for many as they age. But Northwestern medicine investigators are looking at ways these mental health issues can actually be reversed or even prevented with earlier detection. Developmental and clinical psychologist, Dr. Laurie Wakschlag, is Director of the Institute for Innovations and Developmental Sciences at Northwestern. The Institute's new Mental Health, Earlier Center, which she co-directs, recently received an $11.7 million award from the NIH. The award will fund research targeting early signs of vulnerability to mental health problems and toddlers throughout routine pediatric care. She joins me today to discuss this project as well as her own research, which has pioneered ways of distinguishing mechanisms and markers of clinical mental health risk in the first years of life. She's a professor of medical social sciences, pediatrics, psychiatry and behavioral sciences at Feinberg. She is also a professor of psychology in the Weinberg College of Arts and Sciences at Northwestern. Welcome to the show. 

[00:01:32] Lauren Wakschlag, PhD: Thank you.   

[00:01:33] Erin Spain, MS: Let's start off with that statistic that I've mentioned about 20% of children as young as three have an identified mental health problem. So this can mean a lot of things to different people these days, mental health. So can you unpack this statistic for me? What is the age range? How are these mental health problems being defined? Is this depression, ADHD, autism, and what percentage of this 20% is affecting toddlers. 

[00:01:58] Lauren Wakschlag, PhD: These statistics are about the common mental health problems of children and youth, and so we're talking about. the drivers of the youth mental health crisis: ADHD, depression, anxiety, oppositional and disruptive behavior. This statistic does not include autism. So we're talking about what we sometimes call in the field, internalizing, like mood and anxiety, and externalizing, which are more acting out, ADHD, oppositional disorders. So those are the most common kind of garden variety mental health syndromes that affect children and youth. And they are early on setting, meaning the seeds, the roots, the early vulnerabilities to these problems most often are expressed by the age of five. Even if at that time they're not full-blown clinical syndromes that interfere with children's functioning. So this idea of identifying early, the Surgeon General's report says by the age of three, these are children who may be medicated, may have a diagnosis, they might have 504 plans in school because of these emotional and behavioral issues. We're saying age three is too late. And so our center is trying to focus even earlier, before a full-blown clinical syndrome, before these are functionally getting in the way of children, for early signs of vulnerability of greater likelihood of developing these emotional behavioral problems. 

[00:03:26] Erin Spain, MS: You mentioned the word mental health crisis. This is something that's come up a lot lately on the news and post Covid. Can you describe what we're seeing now with children and mental health and how this is different than maybe 20 or 30 years ago? 

[00:03:39] Lauren Wakschlag, PhD: Yes, there's a significant rise in mental health problems of children and youth, and it's alarmingly increasing. And this was amplified by Covid. And suicide rates, the need for treatment. have really been on the rise and escalating. And so, certainly we don't make the claim in the center that by intervening early we are gonna eradicate youth mental health problems. But what we're saying is there are a proportion of kids that have these early warning signs, and if we can help them build what we call self-regulation muscles, so how do they cope with distress or frustration or anger or feeling sad and build coping skills and help families learn to support these, that it's almost like inoculating them against risk. Not in a way that they absolutely will not develop mental health problems if we catch them early, but they will be less likely. And interestingly we've done some work that shows that during Covid, parents' report on children's emotions and behavior pre and post Covid that irritability or tantrums of difficulty managing frustration are the areas children most showed an increase and that is actually a key target of our center. 

[00:04:51] Erin Spain, MS: So this issue of mental health and the mental health crisis is compounded by the fact that pediatricians don't currently operate under any official guidelines for pediatric mental health when it comes to identifying concerns. Explain this to me. What can be assumed regarding children's mental health needs and whether or not they're being met? 

[00:05:11] Lauren Wakschlag, PhD:Well, the challenge that the field has faced and that our center is targeting is the fact that many of these problems manifest in very young children. But the conundrum of the pediatrician is when is it more than the terrible twos? Because these are also normal misbehaviors of young children. If you ask the parent of a young child, has your child had a tantrum in the supermarket, most of them are gonna say, yes. The pediatricians have a dilemma. It's what we call decisional uncertainty. So they're like, in the absence of tools and science-based guidelines, well, it could be something to worry about or it could be something that they're gonna outgrow. And so maybe it's just better to wait and see what happens, which is a benevolent intention. But it also allows these to escalate, to spiral, to get in the way of friendships and family management. And that is counter to the evidence base that children's brain and behavioral development are most responsive to input and growth promoting strategies during early life when the bulk of the brain is developing very rapidly. And so really the issue is too that the traditional mental health syndromes were adapted from some symptoms for adults. But they're not the kind of problems in that big DSM Bible that are what pediatricians present with. And that really was the impetus for my own program of research, which we call the science of when to worry, to have evidence and make it easy for a pediatrician to, to resolve this very legitimate decisional uncertainty by giving them evidence-based brief tools that can be used in clinical care and referral guidance. And so our work has shown that the quality and the frequency, particularly of tantrum behaviors, expressions of irritability, difficulty managing and redirecting anger and frustration is both a common presenting problem and also predicts, it has strong predictive value for whether or not children will develop later mood and behavioral problems. For example, we've shown that two indications of dysregulated tantrums, as we say, so maybe trouble getting over the tantrum or a tantrums that happen very frequently or where you wouldn't expect it, lead to four times greater odds of having mood and behavioral problems as a teen. And those would be assessed at preschool. So the good thing about them is they can be differentiated in terms of these qualities of behavior. It's not just having a tantrum and also they're predictive for later and they can be feasibly assessed by a clinician. Pediatricians are busy. 

[00:07:49] Erin Spain, MS:  This almost $12 million grant from the NIH. This is the grant that has launched this Center, and I wanna hear a little bit more about the genesis of this. How did this all come together? Well, this is a labor of seven years of love funded by the National Institute of Mental Health after multiple submissions. And it was the brainchild of myself and my co-lead, J.D. Smith, an implementation scientist now at University of Utah. It is part of a network that the NIMH funds called the Alacrity Network. They're implementation science centers. And where we became inspired about this is what implementation scientists call the know-do gap. I'm a developmental scientist. I know how much we do know about early childhood as a critical period, this whole question of when to worry. But I kind of had an epiphany when I came to Northwestern as I was surrounded more by implementation science, prevention science, more community engaged scientists, that all the things that developmental science knows, a lot of them are stuck in the ivory tower. And that was really horrifying. And at the same time, meeting JD and being introduced to implementation science and together we had an aha moment that we needed to close the gap between what science knows and what the real world is doing to promote mental health early on. And then the third leg of that stool is one of the leaders of the center, Dr. Matthew Davis, now a partner in Nemours Children's Health in the Center, helping us understand that this is one of the most common presenting problems to pediatricians. And indeed pediatricians, they know promoting that social emotional health is really important. But their confidence in doing so is low. So together that was the genesis of this idea. We have the tools. We have the knowledge about how to integrate in systems. We have to develop pediatric partnerships, which includes Lurie Children's Hospital here in Alliance Chicago and University of Utah Health. So we have four health systems partners. 

[00:09:50] Erin Spain, MS: So walk me through how this is going to work. This is brand new. This is just getting off of the ground. How are you going to implement this and evaluate it and get it into the hands of pediatricians and see how it's working? 

[00:10:02] Lauren Wakschlag, PhD: Well, the most important principle of implementation science is nothing about us without us in terms of the communities with which we engage. Lurie Children's, Alliance Chicago, Nemours Children's Health are our key co-design partners for our strategies, for our decision making. across the life of the center. And so we are engaging intensively with them already and talking about our approach and getting input. And what's very exciting about the center is that we get three bites of the apple in the method that we will begin to do the randomized trial. We will pause, we will get input data and also input from our community partners, and we can optimize what we do next. We get to really refine in real time with partnership from the community partners. Sometimes scientists have lofty ideas and a pediatrician is like, I got five minutes with a family dude, like I am not gonna be able to do that. So this is why it's so important that we are co-designing in a way that's feasible, realistic, ultimately would be reimbursable. The important thing to know about the Center is that it's kind of an integrative hub of over three dozen scientists, many at Northwestern, and this leadership from University of Utah and then from across the country, and includes in addition to developmental and psychiatric and implementation prevention, scientists, methodologists, ethicists, pediatricians, child psychiatrists. So the full range of what you need to actually think deeply about health equity researchers as well. In addition to this the kind of centerpiece randomized trial, and then referring to prevention that we'll provide, which is digital, so families don't have to leave the house. And they will have a remotely engaged coach. And it's really centered on building those self-regulation muscles and having parents feel confident. And then there are three other related projects that the Center will do, one of which looks at potential unintended consequences of the Center, because we're all gung-ho, but sometimes we forget to look at things like, could there be stigma attached? Even though a strength of this developmental, irritability centric approach is that children are not being diagnosed, we are saying you are vulnerable to these problems later on. One that is working with clinicians with the ECHO program at U Chicago to develop this particular training that helps pediatricians know how to discuss this with families, both because families have different ideas about development and when they wanna be worried and taking action. And also because pediatricians, it's a gray space. It's not, you have it or you don't within an equity orientation. And then the third one is something called a single session intervention that helps promote engagement with families also remotely. So we're trying to reduce burden to pediatricians and reduce burden to families. 

[00:12:50] Erin Spain, MS: So what does the digital intervention look like? You mentioned, parents don't have to go anywhere. They can be at home doing this. Is it more training for the parent digitally and then they in person are working with their toddler, or is their toddler in front of the screen as well?  

[00:13:05] Lauren Wakschlag, PhD: The intervention is called the Family Checkup Online. It's one of the best validated interventions for prevention of mental health problems. It's been validated in diverse families and with many clinical trials for children as young as two. It is mostly guidance to the parents as would be common in this age and then they will be trying it out and implementing it at home. And then the coach, who they also engage with digitally, unless they want to meet in person, will do things like problem solve, role play, how did it go? When was it an issue? And one of the nice things about the family checkup is it's tailored. It's tailored to be as customizable, as brief as possible for what the family needs. It's all broadly within this helping parents with effective strategies and building child self-regulation and helping the relationship be more harmonious and supporting developmentally promotive. But some families might need two sessions. Some families might decide they want six sessions, so they customize it with the coach before they start. JD Smith and his colleagues have done a version of this, not the online version, but a version of this in primary care to promote self-regulation along with obesity reduction. And it has been very well received by pediatricians and by families. I think the point that it's customizable and it's not this really long standard thing that you have to finish and that was developed in general and not for your family. I think that is a major strength that families like.  

[00:14:33] Erin Spain, MS: You talk about self-regulation quite a bit, that's a key component here and a skill that toddlers can learn to help them with their mental health development. So explain to me how self-regulation might work for a toddler. And also, what do you say to parents who are a little leery that their toddler can self-regulate? 

[00:14:49] Lauren Wakschlag, PhD:Self-regulation is probably the key developmental task of young children. It's their work and it's a process that is evolving from the time a child is born when things are more externally regulated by the parent, through like age five. This is the key developmental task of the child and these skills are coming online across that period. That's why sometimes you'll have a child and they'll be engaged and patient and waiting and communicating, and then 10 minutes later, you know, you're out at the grocery store and all of a sudden they totally lose it. And so parents are like, what gives. And that's because these are skills that are developing. They are not fully consolidated during this period. All kinds of learning and interactions with the world, as well as brain changes enable the child to bolster these skills. So the key components of self-regulation are planning, like being goal oriented, learning to wait. Having coping strategies for managing frustration, which it is super frustrating when you're little. Nobody demands anything. And then when you become a toddler and a preschooler, all of a sudden there's rules at school. There's having to wait, there's having to listen, there's having to follow directions. And so it's very natural. That's why we have the terrible tools 'cause the skills aren't fully set yet. And so, planning, learning to wait, learning to use other strategies besides outbursts, such as asking, getting engaged with something else and kind of how you organize yourself and your emotions and behavior. And that really problems in self-regulation are one of the things that underlie all the common emotional and behavioral problems that are common, including depression, anxiety, ADHD, oppositional problems. So that's why it's what we call a trans diagnostic pathway. It's a one stop shopping for risk, and that's why it's also clinically feasible, 'cause we don't have to assess for all those different symptoms and syndromes. It's a one path in. 

[00:16:47] Erin Spain, MS: Tell me about the tools that you're developing and how they will be used. 

[00:16:51] Lauren Wakschlag, PhD: Well, ultimately the tools are very relevant to all kinds of care providers. What's unique in the Center is that we have something called the Decide Tool that assesses irritability within the context of what we would call the family ecology, stressors and compensatory factors, So what we know when a child is highly irritable in a sustained way, we know behaviorally they are vulnerable, but perhaps they have other qualities such as being very sociable or very communicative that might offset that in terms of how it impacts their interactions with others. Similarly, some parents might feel very intuitive about how to help create a structure that helps tone that down or other resources in the child's context. And so by using this decision tool, the Decide Tool, it weights all of those things. Just like when you go to your primary care physician as an adult and they have you fill out questions about BMI and smoking, et cetera, and then they tell you your risk for cardiovascular events. That's what this Decide Tool is doing in developmental context for the risk of mental health problems. And so that Decide tool is specifically made to be incorporated into the workflow during 24 and 30 month well checks. And that's the cool thing about partnering with pediatricians and why we think that this is where we're gonna get the biggest bang for our buck, the biggest reach, because 95% of us children see a pediatrician, and in early childhood, those visits are very frequent. And so when we give a pediatrician this probability of having impairing mental health problems, we wanna make sure that we've kind of accounted for all the things that tune into that individual's child life context, et cetera. We don't wanna over identify children, but we also don't wanna miss children and it's a personalized score, so it's a kind of precision medicine for the terrible twos. 

[00:18:49] Erin Spain, MS:And again, working with this population, with children and families, there are some special considerations. Some people are hesitant to do any sort of interventions with their child. They may be worried about stigma, as you said. Can you just talk a little bit about some of the challenges that you face when working in pediatrics.   

[00:19:06] Lauren Wakschlag, PhD:  I talked about the science of when to worry on the side of the clinicians, but in many ways parents need a similar framework because there's a lot of information on the internet. There's your cousin, there's your aunt. You know, there's a lot of sources of information. There are cultural differences in how families think about mental health and who should be engaged in the decision. The very cool thing about the Center, this co-design process, is not only with clinicians, it's also with parent advisors. For example, the whole goal of the special clinician communication training that the Center will be developing and testing is to increase shared decision making between the parent and the pediatrician. So the pediatrician feels they have the language, because the tool is gonna say the probability that your child will have mental health symptoms at preschool age that get in the way of school readiness and other kinds of functioning, they're gonna give them an actual like 50%, 20%, 10%. And that's gonna be linked to, you know, red light, green light, yellow light, green light. Like when should you refer? But then together, the family and the pediatrician have to decide whether they wanna take action now, watch her wait till the next appointment. And so, parents will be hopefully getting clearly stated meaningful information. And they will be true partners with the pediatrician in deciding what's best for their child. 

[00:20:30] Erin Spain, MS: Again, this Center, as you mentioned, this is the first of its kind and you're doing a lot of new things here. And the goal is to really, you know, target it on early childhood and routine pediatric care to get these children the skills that they need. Tell me why Dev Sci and Northwestern is uniquely positioned to support such an ambitious project. 

[00:20:49] Lauren Wakschlag, PhD: DevSci I is all about connecting the dots. Across typically siloed disciplines. We do it here across our arts and sciences and medical campuses. But more broadly, our mantra is the most impactful work occurs at the boundaries of discipline. So, for example, when we developed this Decide Tool that came out of a collaboration that DevSci catalyzed with cardiovascular epidemiologists. Seeing these risk calculators that cardiovascular doctors do in routine care gave me like risk calculator envy in the developmental sciences. And rather than spend decades reinventing this wheel, through DevSci, making these bridges between physical and mental health, between scientists who are in an arts and sciences field, and clinical scientists and pediatricians, we got to skip some steps. We have a coalesced community. We have infrastructure support, students engaged. And so we've already created those linkages and created these collaborations. One of the things in doing this kind of large scale science requires a lot of trust. It also requires a lot of listening because different fields say the same thing with different words and different things with the same words. DevSci is that hub for translation that helps us understand that we are stronger together. And so DevSci was really poised to convene, to lead, to support, to enable with this large collaborative, which now it also includes national collaborators. 

[00:22:25] Erin Spain, MS: So big picture 10, 15 years from now, what are your hopes for this project? What do you hope it will become and how it might change the way that mental health care is delivered to children? 

[00:22:37] Lauren Wakschlag, PhD: A mantra in implementation science is scalability. My hope would be hopefully with the success of the center, what we learn about it together with our community partners, that a decade from now it will be routine for clinicians to understand that mental health is broad. It doesn't belong just in a specialty clinic or an ER. It belongs in the way we think about the whole child, just like physical health. And that the sooner we can help children have the skills for their own mental health, the sooner we will be able to ameliorate some of these early starting pathways, which are actually the most chronic. The earlier these problems manifest, the more likely they are to be persistent as children and youth develop. One reason about that may also be the children's biology and intergenerational risk. But another reason is that these take on a life of their own. We would call it a negative spiral . If you can't manage your emotions, if you're always throwing yourself to the ground, if you're not able to show self-control, which is a big key component of self-regulation, kids don't wanna play with you. Nobody wants to babysit for you. Your parents feel like they can't leave home. So it's not only that it may progress, it's that it has an impact on how others interact with you. That only makes it worse. And so we're trying to, cut that off at the pass. 

[00:24:02] Erin Spain, MS: Well, Laurie, thank you so much for coming on the show. Your research is fascinating.thank you.  

[00:24:06 ] Lauren Wakschlag, PhD: Thanks for having me. 

[00:24:08] Erin Spain, MS: Thanks for listening, and be sure to subscribe to this show on Apple Podcasts or wherever you listen to podcasts. And rate and review us also for medical professionals. This episode of Breakthroughs is available for CME Credit. Go to our website, feinberg northwestern edu, and search CME. 

Physicians who listen to this podcast may claim continuing medical education credit after listening to an episode of this program.

Target Audience

Academic/Research, Multiple specialties

Learning Objectives

At the conclusion of this activity, participants will be able to:

1. Identify the research interests and initiatives of Feinberg faculty.
2. Discuss new updates in clinical and translational research.

Accreditation Statement

The Northwestern University Feinberg School of Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

Credit Designation Statement

The Northwestern University Feinberg School of Medicine designates this Enduring Material for a maximum of 0.50 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

American Board of Surgery Continuous Certification Program

Successful completion of this CME activity enables the learner to earn credit toward the CME requirement(s) of the American Board of Surgery’s Continuous Certification program. It is the CME activity provider's responsibility to submit learner completion information to ACCME for the purpose of granting ABS credit.

Disclosure Statement

Lauren Wakschlag, PhD, has nothing to disclose. Course director, Robert Rosa, MD, has nothing to disclose. Planning committee member, Erin Spain, has nothing to disclose. FSM’s CME Leadership, Review Committee, and Staff have no relevant financial relationships with ineligible companies to disclose.

All the relevant financial relationships for these individuals have been mitigated.

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