February 8, 2021 by
Nick Bonenfant, M.D.'17 and Aamani Chava, M.D.
As a new pediatric resident at UVM Children’s Hospital, Nick Bonenfant, M.D.’17, found himself struggling with how to best support adolescents with mental health issues.
“During my first year of residency, I inherited a panel of primarily adolescent male patients,” he says. “While treating them I felt this disconnect – questioning my ability to connect with them about things like anxiety and depression, worrying about not using the right words, and feeling like I lacked a comfort level and expertise that I needed.”
He’s not alone in this challenge – the number of children presenting with mental health issues is on the rise, and pediatricians are often the first to assess how best to offer support. They can have trouble finding help, as the number of mental and behavioral health specialists hasn’t kept pace with need. As the COVID-19 pandemic continues to rage on, experts see that gap widening even further.
Vermont is experiencing these shortages first-hand. In a state with more than 118,000 children under the age of 18, there are only 32 board-certified child and adolescent psychiatrists, the majority of whom are 50-plus years old, according to the American Academy of Child and Adolescent Psychiatry. With a ratio of one psychiatrist to every 3,867 children, referrals from pediatric and primary care practices to these specialists can take upwards of six months. In the interim, and for those who do not meet the criteria for referral to psychiatric specialists, pediatricians become the first and sometimes only contact and support for caretakers and their children.
That’s why it's crucial for primary care physicians and pediatricians to feel comfortable and be further trained in assessing children for mental, emotional, and behavioral health issues and providing initial care and support, says Bonenfant, now chief resident for the UVM Department of Pediatrics Residency Program. Yet that type of training is not heavily highlighted in an already jam-packed and rigorous pediatric residency curricula.
"You need to integrate the mental health of patients into all aspects of what you do to care for them,” says UVM Professor and Chair of Pediatrics and UVM Children’s Hospital Chief Lewis First, M.D. “You have to understand what it means to be able to recognize the signs of depression, anxiety, or stress as it impacts a child or teenager's ability to deal with whatever their physical illness is. Being able to diagnose and treat common mental health issues in our youth are essential attributes that every pediatric clinician must learn about during their training and then apply to whatever they do with that training."
Spurred by his own experience as a teen who suffered from anxiety and now, as a pediatrician-in-training treating patients, Bonenfant set out to further his own education and that of the pediatric residents who would come after him. Just three years later, two new programs have emerged to enhance training for both pediatric and psychiatry residents.
An elective psychiatry rotation gives second- and third-year pediatric residents a foundation for understanding and assessing child and adolescent mental health. While developing the elective in collaboration with Assistant Professor and Director of the Child Psychiatry Fellowship Program Maya Strange, M.D., and Elizabeth Forbes, M.D., an assistant professor of pediatrics and division chief of the UVM Children’s Hospital Children’s Specialty Center, Bonenfant was not only one of the program’s creators, but its first student as well. “Essentially a crash course on child and adolescent behavioral and mental health,” as Bonenfant describes it, the four-week rotation focuses on shadowing child and adolescent psychiatric physicians and fellows and working with UVM's Vermont Center for Children, Youth, and Families and community organizations such as the Howard Center, a mental health agency in Burlington.
Now, less than a year after he became the first pediatric resident to complete the elective, six out of seven third-year pediatrics residents are taking part in the optional elective.
The connections that Bonenfant made while creating and completing the elective, and his work with 2019-2020 UVM Pediatric Chief Resident Anna Zuckerman, M.D., that ultimately led to the creation of a second new offering, the Mind Body Buddy program.
Officially launched in October 2020, the program is the culmination of a joint effort between the UVM Department of Pediatrics and Department of Psychiatry, specifically Bonenfant, Zuckerman, Strange, Forbes, Associate Professor and Director of the Pediatric Residency Program Jill Rinehart, M.D., Assistant Professor of Psychiatry Haley McGowan, D.O., Clinical Professor of Pediatrics Marshall “Buzz” Land, M.D., Clinical Assistant Professor of Psychiatry Logan Hegg, M.D., and Clinical Instructor of Psychiatry and Child and Adolescent Psychiatry Fellow Aamani Chava, M.D.
The creation of the program and the elective align with the collaborative care model being adopted by the health care system in Vermont and other states. When Rinehart became the new residency program director in September 2019, enhancing pediatric training in regard to mental and behavioral health was at the top of her list of goals. So, when she heard about the work that was already being done by Bonenfant, Strange, Zuckerman, Chava, McGowan, and others, it was a “no-brainer.” Rinehart says she told the group: “Do it—all doors are open! I’ll connect you with anyone you need to connect with and provide any support I can.”
Structured similarly to a program at Maine Medical Center in Portland, Maine, Mind Body Buddy bolsters both the pediatric residency curriculum and the child and adolescent psychiatry fellow training program with real-time peer-to-peer support, cross-specialty lectures, and the opportunity for occasional patient appointments during which both a pediatric resident and a child and adolescent psychiatry fellow are present – something that would rarely happen outside of this environment.
“We wanted to create a program that would not only be high-yield but practical in terms of how much we could offer within existing training structure to improve residents’ preparation for the mental and behavioral health concerns they will encounter frequently with their child and adolescent patients and families,” says Bonenfant. “Initially, we just incorporated more didactics and teaching sessions from child psychiatrists about anxiety, depression, and PTSD.” The curriculum grew from there.
Now, each July, when child and adolescent psychiatry fellows and residents start their training, one fellow is partnered with one first year , one second year, and one third-year pediatric resident. The third-year pediatric resident acts as the liaison between their fellow residents and their assigned child and adolescent psychiatry fellow “buddy.” At least once each month, the pediatric and psychiatric buddy pairs meet to discuss cases and assessments they have questions about. In between monthly meetings, the buddies often text, call, or set up virtual meetings with one another for informal consults, or time-sensitive questions and concerns. The knowledge sharing and benefits are a two-way street, says Chava.
“As child psychiatrists, we can help answer questions about pharmacology, family approaches, and mental and behavioral health resources for our pediatric counterparts,” Chava says. “At the same time, I may be treating a patient for anxiety who also has a chronic disease such as Crohn's. I can ask my pediatric buddy about the facets and treatment of the disease I’m not familiar with and learn more about the history of that patient and their family’s experience with it.”
Although the exchange of information alone is important, the way in which that exchange happens is particularly impactful. Because pediatricians are often with a family from the birth of their child through the time the child reaches adulthood, they often become the family’s most trusted confidant in terms of any medical decisions.
“When you’re bringing in a new provider such as a child psychiatrist, it helps to have the support of a trusted provider who you know is keeping you safe and secure,” says Chava. “Knowing that your new provider is collaborating with your lifelong provider gives families a feeling of safety and security.”
Bonenfant and Chava agree that prior to their training and, specifically, this program, they were not always confident in consulting with their respective psychiatric and pediatric counterparts.
Chava says that the program is enabling the residents and fellows to become better colleagues by teaching them one of the most important skills in their careers — interprofessional communication. “Oftentimes, the biggest mistakes in medicine are made because of something that’s missed – errors in communication,” says Chava. “The program brings us back to the basics and teaches us how to communicate effectively as specialists in our respective fields.”
Pediatricians and child psychiatrists with this training are critical to the future health of children and adolescents in our community, says First, “It’s part of treating the ‘whole child’ – attending to their mental health along with their physical wellbeing,” he explains. “There are not enough cavalry coming into the world of mental health to meet the myriad psychological needs that society has placed on our next generation. This program is an important step in remedying that problem.”