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\n Illustration: Olivier Heiligers\n <\/p>\n<\/p>\n
Last year, on an unusually rainy Tuesday in Los Angeles, dozens of pediatricians<\/a> and pediatric professionals gathered in an imposingly high-ceilinged, crimson-walled auditorium to attend a conference co-hosted by Children\u2019s Hospital Los Angeles and a California chapter of the American Academy of Pediatrics. The event was called \u201cFrom Screening to Treatment: A Case-Based Exploration of Pediatric Anxiety and Depression,\u201d but despite that name, it was created for general pediatricians, not psychiatrists or psychologists. On its face, it looked like a standard half-day symposium \u2014 a chance to earn a few continuing medical-education credits and throw back some finger foods. But given the dire state of childhood mental health<\/a> in America, and the pressure that has been placed on often ill-prepared pediatricians to fix it, the mood was far from light.<\/p>\n Data from nearly 2 million children\u2019s pediatric visits in Massachusetts found that the rate at which minors were brought to primary-care offices for visits related to their mental health significantly increased over the last decade, growing from 9.5 percent of pediatric visits in 2014 to 16.2 percent in 2023, according to a study<\/a> published in JAMA Network Open in May. Among the disorders the study tracked, visits related to anxiety rose most sharply. In light of this uptick, the Los Angeles conference \u2014 and many more like it that have cropped up across the country \u2014 was a tacit acknowledgment that the bread and butter of pediatrics has changed and pediatricians must change with it.<\/p>\n \u201cWhen children are trying to access services outside of primary care, they often face a lot of barriers,\u201d explains Megan Cole Brahim<\/a>, an associate professor of population medicine at Harvard Medical School and a corresponding author of the study. \u201cThere may be very few mental-health specialists in-network. If you do find one, it may be hard to get an appointment in fewer than 12 months.\u201d The solution seems obvious: Treating mental-health disorders must fall to pediatricians, who already have regular contact with their patients and are trusted providers. It\u2019s such an intuitive idea that parents have already started demanding it. But implementing mental-health assessments and treatment in a pediatrician\u2019s office is rarely straightforward.<\/p>\n That day at the conference, speakers took turns imploring those in attendance to diagnose and treat the mental-health disorders they observe or suspect in patients. One session was devoted specifically to encouraging pediatricians to stop avoiding conversations about anxiety with children and parents and to teach methods that help children confront their anxiety triggers rather than dodge them. Another aimed to interrupt the tendency to automatically \u201crefer out\u201d a patient with a mental-health struggle. Both were intended to combat what research<\/a> has identified as a prevalent \u201csense of hesitancy in approaching mental and emotional development in pediatrics.\u201d\u00a0A 2022 survey<\/a> of graduating pediatric residents published last year found that almost half of respondents did not feel confident addressing patients\u2019 mental-health needs overall. Just 64 percent felt they could care for children with low mood or depression, and 57 percent felt they could adequately address childhood anxiety, which is estimated to affect up to 20 percent of kids in the U.S.<\/p>\n Concern around pediatricians\u2019 training to treat these conditions is not new. In a 2008 study<\/a> of Ohio survey data, many pediatricians said they agreed with an assessment that their mental-health skills were lacking. What has changed, says pediatrician Christine Mirzaian, who taught at the CHLA mental-health conference, is that this deficit can no longer be swept to the side or downplayed.\u00a0\u201cWhether they like it or not, this is the reality now. We just don\u2019t have the resources to be able to pass on every case.\u201d<\/p>\n Pediatricians-in-training learn about childhood mental-health conditions in medical school, like all doctors do. But it\u2019s during residency that they get the opportunity to see firsthand how such conditions manifest and learn how to treat them. Over a three-year residency, each physician\u00a0completes clinical \u201cblocks,\u201d or chunks of time, in specific rotations, or areas of study. Most blocks are four weeks long, focusing on, for example, the NICU, the newborn nursery, adolescent medicine, and the\u00a0pediatric emergency department.<\/p>\n But how that brief training impacts a doctor\u2019s real-world acumen is hard to say. Darcey Winterland, division chief of pediatrics at Phoenix Children\u2019s, describes feeling initially unprepared to treat mental-health problems after her training. \u201cIn my residency, mental health wasn\u2019t really a formal part of what you focused on,\u201d she says, \u201cI think I probably had a 30-minute lunch lecture on ADHD when I was a second-year resident. And then it\u2019s like, Okay, go take care of kids.\u201d Since 2020, her hospital has hosted\u00a0detailed training series on pediatric mental health, with lectures on everything from treating ADHD to addressing substance use in minors. The most recent training was in progress when we spoke; Winterland says she attends as many as possible, but sometimes they are scheduled during her patient-care hours.<\/p>\n In July 2025, the Accreditation Council for Graduate Medical Education announced<\/a> that all pediatric residents in the U.S. will need to perform an additional rotation in mental and behavioral health.\u00a0It\u2019s progress. But the rotation, the new rules specify, is required to be only four weeks long and does not need to involve exclusively hands-on experience<\/a>.\u00a0Evelyn Berger-Jenkins<\/a> is a pediatrician in Harlem whose research focuses on improving mental-health care in the pediatric primary-care setting. She doesn\u2019t think four weeks of training is enough to bridge the gap the profession faces. \u201cI think it would be better to have that rotation in all of the three years of residency,\u201d but it\u2019s a start, she says.<\/p>\n And a systemic lack of training is far from the only barrier to competence. AAP survey results published earlier this year found that a majority of pediatricians say that limited time for patient visits is a significant obstacle to effectively treating their mental-health concerns.\u00a0\u201cThe primary-care cadence is quick,\u201d says Amanda Furr, a pediatrician and chief medical officer of Zarminali Pediatrics, headquartered in Chicago. \u201cIt\u2019s often 15 to 30 minutes at most. But mental-health concerns require in-depth discussion. I think the time crunch, more than knowledge, is often what makes pediatricians feel unequipped.\u201d It\u2019s also a challenge to have a conversation about observations regarding a child\u2019s mental health with a parent while the child is present.<\/p>\n Anna, a mom on the West Coast,\u00a0learned how important the parent-pediatrician relationship can be when her 10-year-old daughter, Margot, endured a mental-health challenge \u2014 acute anxiety \u2014 last year. (Anna and Margot are both pseudonyms.) The triggers were clear: a serious health diagnosis in the family and weather-related damage to their home. Amid these destabilizing events, nighttime became fraught for Margot. She begged her parents to stay in her room as she fell asleep because she was terrified that if her parents left her presence, they might die. \u201cAll her anxiety got concentrated at bedtime,\u201d Anna says. \u201cIt became so scary and hard for her.\u201d<\/p>\n Margot had a beloved pediatrician whom Anna called soon after the evening ordeals began. The doctor sent her a standard questionnaire to gauge the severity of Margot\u2019s anxiety: the \u201cpoorly named SCARED<\/a>,\u201d Anna jokes. The form stands for Screen for Child Anxiety Related Emotional Disorders, and it lists 41 sentences both parents and children can rate as \u201cnot or hardly ever true,\u201d \u201csomewhat true,\u201d and \u201cvery true,\u201d including \u201cPeople tell me that my child look nervous\u201d and \u201cMy child has nightmares about something bad happening to his\/her parents.\u201d Though the doctor \u201cknew us very well and likely had a good idea of what was going on with Margot,\u201d Anna says, she presumed that it was still helpful to have empirical data. Once the form was returned, the doctor shared the results: Margot met criteria for an anxiety disorder.<\/p>\n Screening forms help to alleviate two pain points for pediatricians: They paint a more detailed picture for a physician who may have only a few minutes to meet with patients, and they tap into a parent\u2019s high attunement to their child. Using them can also help pediatricians avoid overlooking signs of mental-health disorders. Yet despite AAP recommendations that all children be universally screened for social-emotional concerns every year starting at birth, a 2022 report<\/a> found that only around 30 percent of children receive the proper behavioral and developmental screening at recommended intervals.<\/p>\n After the SCARED form indicated that Margot had anxiety, \u201cwe had a long appointment with the pediatrician, without Margot present, where she laid out our options, including medication,\u201d says Anna. \u201cI felt we were not there yet. She recommended getting a therapist for Margot, and that my husband and I participate in SPACE, a parenting program.\u201d SPACE<\/a>, which stands for Supportive Parenting for Anxious Childhood Emotions, is a therapy program in which parents learn to stop reinforcing their child\u2019s anxieties and help them cope. Margot began therapy, her parents attended SPACE meetings, and they checked in with the pediatrician as they progressed.<\/p>\n As far as Anna knew, Margot\u2019s pediatrician didn\u2019t have any specialized training in mental health. What she had instead, Anna said, is a practical understanding of how to be helpful. She listened with curiosity and used standardized tools (the SCARED) to harness the parents\u2019 insights and make an informed determination. She explained what she could explore (medication) and what a specialist could provide (therapy), and she shared a means for the child\u2019s parents to educate and empower themselves (SPACE) if therapy was not immediately available or affordable. (About one-third<\/a> of psychotherapists do not accept insurance, and it often isn\u2019t feasible to see someone out of network, for whom services are typically paid out of pocket.)\u00a0Margot\u2019s pediatrician also provided ongoing support.<\/p>\n When I asked Anna how Margot\u2019s doing these days, she told me that her daughter now sleeps in her bedroom alone. Might this \u2014 supplementing one\u2019s own capabilities with accessible resources that circumvent the specialist shortage and put parents in the driver\u2019s seat \u2014 be a model for success in the pediatric setting?<\/p>\n Each of the experts I spoke with proposed different ways to potentially shrink pediatricians\u2019 blind spots and ensure that kids get needed care. They advised deeper education during medical training. They advocated for continued self-driven education over time. They spoke of collaborative models in which pediatric practices install behavioral-health experts on-site. They described better systems to connect school psychologists with pediatricians \u2014 a connection that, while historically fraught with HIPAA concerns, is now being addressed by platforms like Unite Us<\/a>, says Berger-Jenkins, who also mentioned hotlines provided by the National Network of Child Psychiatry Access Program<\/a>s, on which any primary-care provider can connect with a mental-health professional to run a case past them. Nearly everyone spoke about the need to alleviate the financial pressures that force pediatricians to churn through patients in 30 minutes or less.<\/p>\n But for now, the onus is on pediatricians to embrace their increasingly significant role in childhood mental health \u2014 and to make sure they\u2019re ready for it.\u00a0\u201cThe knowledge is not going to come to you,\u201d Mirzaian says.<\/p>\n That day at the Los Angeles training session, clinical psychologist Stephanie Marcy and Mirzaian shared case studies of anxiety and depression and how they can manifest as physical symptoms and complaints.\u00a0Marcy provided practical guidance for parents and caregivers for when a child is struggling with anxiety, as well as grounding and breathing exercises that can help everyone involved. Mirzaian offered evidence-based guidelines for when to start an SSRI. The pair went over the basics of identification and diagnosis, but went deeper into screening for suicidality and discussed ways to approach a patient who reports thoughts of suicide.<\/p>\n Marcy and Mirzaian say they often receive questions from physicians after the training has ended. They want to know how to treat patients who may have two conditions \u2014 ADHD and anxiety or ADHD and PTSD, for example \u2014 and which to tackle first. But by and large, the pair tends to observe a post-training surge of confidence in their pupils. Mirzaian told me that after the teaching sessions she\u2019s led, \u201cthere\u2019s a little bit of like, \u2018Hey, I can do this. Other people are doing this. It\u2019s okay\u2019\u201d among attendees.<\/p>\n Added Marcy, \u201cI continue to see physicians prescribing more over time. I see them continuing to build their competence, comfort, and willingness.\u201d<\/p>\n Stay in touch.<\/p>\n Get the Cut newsletter delivered daily<\/p>\n Vox Media, LLC Terms and Privacy Notice<\/p>\n