Introduction
Children of Latin American descent (i.e., Latine) are the second largest racial/ethnic group in the United States and the largest group in California, Nevada, Arizona, New Mexico, Texas, and Puerto Rico.1 When compared with the non-Latine, White population, the Latine community has elevated rates of poverty, food insecurity, exposure to violence, discrimination, and racism. These factors are all associated with poor health and educational outcomes and a higher risk of developing mental disorders.2,3 Relatedly, pediatric mental health visits in emergency departments (EDs) have increased in recent years, with Latine children having prolonged ED stays compared to non-Latine White children.4 Complicating matters is a severe shortage of child and adolescent psychiatrists, with only 11 child and adolescent psychiatrists per 100,000 children across the United States.5 In this context, community-based resources that are accessible and practical are essential, which makes schools an ideal setting to screen for, diagnose, and treat mental health issues in children and adolescents.
Unfortunately, multiple systemic factors hinder the implementation of school-based mental health programs in Latine communities, including access to care, language barriers, and inadequate funding.6 School-based mental health models of care provide a unique and flexible approach, allowing for increased access and valuable advocacy efforts.6 According to Alegria et al, even when racial and ethnic minorities can access care, there is significant undertreatment, and linguistic minorities report worse care than English-speaking racial and ethnic minorities.6 Therefore, bilingual and bicultural providers and case managers are critical. Herein we describe a school-based mental health program that seeks to address barriers to mental health care in the Latine pediatric population and presents an exemplary patient history that illustrates how these services are coordinated across systems of care.
In the NewYork-Presbyterian/Columbia University Irving Medical Center (NYP/CUIMC) School-Based Mental Health Program (SBMHP), a team comprised of psychiatrists, psychologists, social workers, and case managers partners with the New York City Department of Education to provide mental health services to students in the community. The NYP/CUIMC SBMHP strives to overcome the aforementioned barriers to mental health care and, therefore, meet the needs of Latine patients and families in neighboring communities.
Clinical Vignette
C is a 12-year-old female who lives with her mother and maternal grandmother in Washington Heights (Upper Manhattan, New York City) and attends grade 7 in a bilingual program at a local public middle school. She moved to New York from the Dominican Republic 5 months ago. Her mother brought her to the pediatric ED after the patient disclosed to her school guidance counselor that she was having thoughts of killing herself, although she denied having a suicide plan or intent. On psychiatric examination in the ED, the patient described depressive symptoms and frequent suicidal ideation (multiple times per week), last experienced on the day she presented to the ED. Her presentation was concerning for major depressive disorder or adjustment disorder, given her recent and difficult move to the United States. She did not meet inpatient psychiatric hospitalization criteria, and both the patient and her mother wished to pursue outpatient psychiatric treatment. As both mother and grandmother worked outside the home, a school-based program with bilingual clinicians was the ideal disposition for this patient. Therefore, the ED team connected C with the SBMHP clinic at her school.
She was scheduled for an intake within the same week and continued weekly treatment for several months thereafter. Both the patient and her mother noted how helpful it was to have her mental health treatment embedded in her school, as it minimized disruption in both the school day and the mother’s work schedule. The SBMHP therapist communicated with C’s teacher, working together to support C’s adjustment to school and the United States.
Summary of the School-Based Mental Health Program
The NYP/CUIMC SBMHP provides comprehensive, community-based mental health services to school-aged children, primarily in Upper Manhattan, with the goal of increasing access to care while keeping children like C in mainstream educational settings whenever possible. The school-based clinics provide comprehensive evaluation and treatment to children (ages 4–13, grades pre-K through 8) and families onsite at 14 schools in neighborhoods such as Washington Heights-Inwood and Harlem. Participating families are largely Latine, many of whom are of Dominican origin, monolingual Spanish speaking, and live below the federal poverty line.
The program offers multidisciplinary and comprehensive services, encompassing a broad span of interventions within pediatric psychiatry. These include psychological and psychiatric evaluation and management; parent guidance; case management; teacher/school consultation; classroom observation; preventative services for patients, families, and school staff; psychoeducation and outreach; and linkage to other resources, including referrals for neuropsychological evaluation. The most common diagnoses for participating students are attention-deficit/hyperactivity disorder, adjustment disorder, and anxiety disorder. For a child to enroll in the SBMHP, a referral system is utilized in collaboration with the serviced schools, with referrals made by parents, school-based staff, or clinicians.
Clinical Recommendations
Mental health disparities in the Latine pediatric population disproportionately and adversely impact children in myriad ways. Equitable access to mental health services is key to the development and growth of all children. The span of services must include access to appropriate medical care, mental health services in all settings (including schools and EDs), as well as educational resources. The provision of easily accessible services in under-resourced communities is critical given the multiple barriers to care. In addition to financial barriers and limited access to resources, the Latine pediatric population faces potential language barriers. Coordination across multiple systems of care, including community-based programs such as the SBMHP and acute care services including the ED, is crucial to addressing mental health disparities in the Latine population. In addition, including bilingual and bicultural providers as key members of the treatment teams is essential to providing effective care. In conclusion, school-based mental health programs that help provide more equitable mental health services to children and adolescents in under-resourced communities are crucial in addressing health disparities among Latine youth.
About the Authors
Aiyana Rivera-Rodriguez, MD, Assistant Professor of Psychiatry at Columbia University Irving Medical Center; Director of Outpatient and Community Services in Child and Adolescent Psychiatry/ Medical Director—Child and Adolescent Psychiatry Outpatient Program (CHONY-6); NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, USA.
Sebastian Cisneros-Trujillo, MD, Instructor in Psychiatry at Columbia University Irving Medical Center; Program Medical Director—School-Based Mental Health Program; NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, USA.
Maya Hubert, MD, Assistant Professor of Psychiatry at Columbia University Irving Medical Center; Attending Psychiatrist—School-Based Mental Health Program; NewYork-Presbyterian Hospital/Columbia University Irving Medical Center, New York, USA.
Megan M. Mroczkowski, MD, Associate Professor of Psychiatry at Columbia University Irving Medical Center; Program Medical Director, Pediatric Psychiatry Emergency Service, New York, USA.
Acknowledgement
The patient case described in the article is fictionalized for teaching purposes.
Correspondence to:
Aiyana Rivera-Rodriguez, MD; email: aer21@cumc.columbia.edu, 646-599-6521.
Funding
The authors have reported no funding for this work.
Disclosure
The authors have reported no biomedical financial interests or potential conflicts of interest.