Children's Hospital Colorado's 1st mental health-in-chief on the now or never moment facing the US

Last May, Children's Hospital Colorado declared a state of emergency in pediatric mental health after seeing its emergency department and inpatient units "overrun with kids attempting suicide" and suffering from other mental health conditions. As part of the declaration, the hospital made a commitment that it would address the worsening crisis. One of the major shifts included creating a new leadership role, the mental health-in-chief.

K. Ron-Li Liaw, MD, assumed the inaugural role at Children's Hospital Colorado in September 2021. In her role, which is on the same level as a pediatrician-in-chief or surgeon-in-chief, she is tasked with ensuring pediatric mental health is top of mind in every decision made at the hospital. 

Dr. Liaw, a pediatric psychiatrist, also serves as chair of the organization's Pediatric Mental Health Institute. She previously spent 14 years as a clinical associate professor for the department of child and adolescent psychiatry at NYU Langone in New York City. During her tenure, she was the director of the Sala Institute's Child-Family Services and Resilience Programs and chief of service for child and adolescent psychiatry.

Here, Dr. Liaw shares with Becker's more about the inaugural mental health-in-chief role, her top goals for 2022, the biggest challenges we need to overcome and the "now or never" opportunity to create the mental health infrastructure needed to address the pediatric mental health crisis. 

Editor's note: Responses were edited for length and clarity.

Question: The role, mental health-in-chief, is a unique C-suite role for health systems in the U.S. How did this position materialize?

Dr. K. Ron-Li Liaw: Looking at how children's hospitals are structured, especially the executive leadership team, you're 100 percent right that this is very unique and I think a first-of-its-kind role. I do applaud Children's Hospital Colorado's leadership under our CEO Jena Hausmann and department chair for psychiatry, C. Neill Epperson, MD, at the university's medical school. Because of the elevated awareness of the pediatric mental health crisis in Colorado and nationally, these two leaders and the executive team at Children's Hospital Colorado really raised this as a priority to make sure we have the right mental health leadership in every conversation. That meant creating a new role, the mental health-in-chief, who would sit at all of the decision-making tables for strategy, partnerships with state and local agencies, and the federal government. The role is designed to bring mental health research and discovery to our clinical continuum of care, training programs and workforce development initiatives. Those leaders really placed mental health at the center of everything that we do in children's healthcare, which I, as a child psychiatrist, am so grateful for. I am excited for the opportunity to step into this role, because there's not one like it in the country.

Q: What are the main goals and priorities for you as mental health-in-chief in 2022?

KL: I just finished month five here in Colorado. I moved from New York. We just kicked off an envisioning and planning process for children's mental health for both Children's Hospital Colorado as well as Colorado University Anschutz Medical Campus. Our goal is to build a best-in-class, high-quality, highly-coordinated children's mental health system for Colorado in partnership with local, state and federal agencies as well as community partners.

We are obviously facing an incredible mental health crisis, particularly at our emergency department and our higher levels of care. There is a new behavioral health administration for Colorado. I'm meeting with the new director of that agency as well as other members of Governor [Jared] Polis' leadership team to really think about how we can reimagine and redesign children's mental healthcare as part of child well-being and children's healthcare at large. That redesign and the way in which we think about mental healthcare means not just investing in acute and emergency services but really thinking about prevention and early intervention. That upstream mentality is where we'll be focusing our strategic plan. 

Also, we have a critical shortage of mental health providers, child physiatrists and care team members nationally. I think the stat is 9.75 child psychiatrists per 100,000 kids. But what we really need is, at a minimum, 47 child psychiatrists per 100,000 kids. Even with 47, that means for me as a child psychiatrist, I would be caring for or overseeing the care of 2,000 children. It's just shocking. So another priority for me is addressing this. There's a really diverse workforce of potential to bridge the gap. For example, we could tap masters-level clinicians, social workers, licensed professional counselors, nurse practitioners, physician assistants and community mental health folks to create a diverse mental healthcare team that represents the diversity that we see in our society.

Mental health professions are different from being a cardiologist or an ophthalmologist. There's very unique things that you have to understand. People come from different backgrounds and face different challenges. It's very local, so it is important to have people who are from the community helping. So, in short, I am really focused on systems design, partnerships and really building a different kind of mental health workforce that reflects the diversity in our communities.

Q: What do you anticipate being your biggest challenges in trying to accomplish these things?

KL: There's the vision and then there's the reality. I think the biggest challenge will be making sure that we are moving in the same direction in the advancement of our children's mental health system with our state partners in creating this new behavioral health administration, working with child welfare and the Education Department. It'll take all of our systems working in concert and investing in concert to really change the lives and trajectories for other kids who have been dealing with a COVID-19 pandemic, increasing rates of depression, anxiety, suicide and disruptions to learning.

It's going to take all of us and I think those will be some of the big challenges and really getting aligned, and it will take coordination and investment. I think the workforce issue that I mentioned also poses a challenge. If I could magically wave a wand and staff all of the critical roles that we have available on our mental healthcare team, those direct-care staff as well as those working in the community, as well as our specific leadership program development, we'd be in a really great space. But we don't have that pipeline where we have those programs that we've needed to really build a robust mental healthcare workforce for this country. There's not been the same investments in mental healthcare, especially for kids, that we've seen on the physical health side. We have a couple of big challenges, I think, to really tackle in a longer-term investment. 

Q: So you're saying the workforce challenges for mental healthcare are not new? Can you discuss this in more detail?

KL: Absolutely. This has been a problem for decades. I think the pandemic has really exacerbated children's mental health conditions, challenges and struggles. I think the need is higher now than it's ever been, and the workforce is exhausted and burned out and joining in on the great resignation. People are rethinking what's really important to them and to their families.

So my job as new mental healthcare leader here in Colorado is to really create roles that are so compelling and so meaningful and so sustaining that you're contributing a positive impact in a day-to-day way in children's lives; but also that we're transforming our system and you know how your contribution counts, so that it's just as compelling as leaving to work in a different industry, or in telehealth; or that you want to be part of this team because it's dynamic work, and it's work that won't happen anywhere else.

Q: Do you think this is going to be a decades-long process in terms of building up an infrastructure that fosters solid mental healthcare throughout our country? How long do you think that will take?

KL: I think this is going to be a decades-long process. In my career so far, I can tell you, 20 years in the mental health field, this moment is the moment. I have friends at the surgeon general's office and they put out a mental health report not too long ago. This is the point in which we need to pivot to see mental health as integral to the general health and well-being of our society, particularly investing in our children and in early intervention. We should have done the workforce diversification, the early intervention, the community partnership pieces decades ago to build the mental health infrastructure we need for kids. If we miss this opportunity, it won't be decades. It will be never.

Q: What suggestions do you have for other hospitals and health systems that are perhaps overwhelmed by the increased prevalence of mental health disorders and don't know where to start when it comes to addressing it?

KL: I really don't know any systems that are not sitting in the same boat that we are. There are lots of ongoing conversations with leaders across these systems. You have to start where you have strengths and partners. You have to start where the most critical needs are in the system. In terms of planning a big transformation and roadmap for how we think about children's mental health, I think that's something that we all have to partner on to be able to do. There are other health systems that are at different places in this evolution. We want to be partnering with folks in every type of setting, like rural communities and urban communities, in our Rocky Mountain region and across the country as well. We all have to start with our local partners and our local strengths in addressing the current challenges. But in this big reimagining of children's mental healthcare, I think it's going to take a group of leaders who are aligned to create a different vision for kids.

Q: What would you say are some of the most common mental health issues you're seeing among children right now?

KL: Even this past week we've seen 30 children in our emergency department throughout our network of care, and many of them are presenting fairly severe presentations of depression due to isolation and severe anxiety — so much so that they can't attend school, or extracurricular activities or maintain friendships. I think we're seeing a lot of suicide attempts, self-injury, as well as substance use and alcohol use. Eating disorders also have been on the rise through the pandemic.

Then, certainly, kids who used to receive special-ed services and support through their schools, a lot of them have been disrupted. So kids with disability, autism, intellectual challenges — many of them are struggling in the community due to disruptions in their services.

We had a couple days here, just as an anecdote, where because of the omicron variant it was almost like a post-traumatic stress reaction for certain kids, especially in high school or younger. They've been so excited to be back at school and they've been craving just being kids. So with the omicron variant we saw the extra stress come back. 

Q: You're not the first person who says eating disorders are on the rise or have been on the rise since the beginning of the pandemic. Do you know why that is?

KL: I think this is a trend we've been seeing across the country. When I was in New York, we actually developed the eating disorders clinical pathway because of the volume we were seeing. We were partnering with other children's hospitals to understand why we were seeing this. Early in the pandemic, I think, when society was locked down, kids were at home and literally everybody was on their phones and comparing themselves to others via social media and not seeing people in-person. That mixed with the lack of control and uncertainty in their life made it just an unhealthy time. I think, for some kids, that [gave them a] sense of control around their eating and power, in a way, where they didn't have any in the rest of their lives.

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