Two distinguished clinicians, Mona Potter, M.D. and Kathryn Boger, Ph.D., ABPP, both Harvard-trained and with nearly two decades of experience in academic medicine, embarked on a mission to revolutionize the pediatric mental health system. Their journey began when they co-developed the McLean Anxiety Mastery Program (MAMP) at McLean Hospital, and then they were determined to apply what they had learned to a larger scale.
Dr. Potter, a board-certified child and adolescent psychiatrist, saw firsthand the positive impact of effective treatment for children and adolescents struggling with anxiety and OCD. “Providing children and teens with the right treatment can be “life-changing,” says Dr. Potter.
Together, they co-founded InStride Health, which provides mental health treatment for children, teens, and young adults based on a program rooted in academic medicine to make high-quality care more accessible to families. Since its inception, InStride’s program has made significant strides, operating in eight states. With a recent influx of Series B funding, the company is poised for further expansion, forging new partnerships with health plans to extend its insurance-based virtual specialty treatment for pediatric anxiety and obsessive-compulsive disorder (OCD).
InStride integrates clinical expertise, exposure coaching, and support into daily life to engage kids, teens, and young adults. It pairs them with a psychiatrist, a therapist, and an exposure coach, who provide real-time support using everyday tools like text, video, and a chat-enabled mobile application.
InStride takes a three-pronged approach to supporting youth struggling with anxiety disorders and OCD:
- Addressing gaps in mental health treatment
- Incorporating care into everyday life
- Delivering lasting results
In honor of National Children’s Mental Health Awareness Day, Daily Nurse spoke with Dr. Potter and Dr. Boger about their work at InStride Health and the role of nurses in championing pediatric mental health. What follows is our interview, edited for length and clarity.
Nearly one-third of youth in the U.S. will struggle with anxiety disorder or OCD by the age of 18, creating significant economic challenges for kids and their families. Talk about how InStride Health is addressing gaps in their mental health treatment.
We built InStride Health to increase access to quality pediatric anxiety and OCD treatment. Over our two decades of clinical work, we witnessed firsthand the challenges that anxiety and OCD can bring to the lives of children and their families. We’ve also seen how the right treatment can change lives and, sadly, how hard it is for families to access this treatment for their children.
Here are some ways in which we at InStride are addressing the gaps:
- We take insurance. Much of specialty pediatric anxiety and OCD care is private pay. We aim to ensure that all kids and families have access to high-quality care.
- We have no waitlist. For the limited specialty pediatric anxiety and OCD clinics that do take insurance, the waitlist can be up to 6-12 months long. We get these kids and families into treatment rapidly so the problems don’t get bigger while the family waits.
- We can work with the full spectrum of acuity/severity. Our model is built to support individuals whose anxiety or OCD is causing significant impairment in life (i.e., school avoidance, social isolation, family disruption, physical symptoms, etc.); we can also work with individuals with mild presentations.
- Our care meets families where they are. Many specialty pediatric anxiety and OCD treatments are not accessible to families due to location. Our fully virtual model allows families to access care no matter where in the state they live and offers flexibility in when and how we engage.
- We operate as a multidisciplinary care team. Our psychiatrist, therapist, and exposure coach work closely with the child, teen, or young adult and with their family and outpatient team (school, pediatrician) to ensure that everyone is on the same page.
- Our treatment is purposefully time-limited. We work with families for up to a year through three phases of care. This allows us to have a more intensive start, in which we work hard to build new skills, followed by step-down and maintenance phases, where we empower the child and their environment to integrate those new learnings into their lives so they can continue to make gains beyond graduation.
What are other difficulties patients and their families encounter getting treatment?
It’s hard enough managing the myriad of day-to-day decisions, stressors, and competing obligations of parenthood; navigating the mental health treatment world to find the right care for a child can get overwhelming very quickly. Each decision point has its unique challenges.
These are some of the common questions families ask:
- Where should we start? Who can we turn to for help? How do we know that we are getting the correct information and guidance?
- I can’t find a therapist who takes insurance. Do I have to pay out of pocket to get good mental health care for my child?
- We need help now, but most therapists have a long waitlist! What can we do while we wait?
- How do we know if treatment is working?
- What is my role as a parent or caregiver?
- What kind of coordination should happen between the school and the pediatrician? And what is our role in that?
- How do we know if we need to consider medication? How will that impact our child’s development?
- How will we know when we’re finished with therapy?
What can be done to provide the best care for patients?
The good news is that there are known treatments that work. To provide the best care, however, we must ensure that we use them. When treating pediatric anxiety and OCD, research and clinical experience demonstrate that cognitive behavioral therapy (CBT), with an emphasis on exposure therapy, is highly effective. Yet many youth with anxiety and OCD do not receive exposure therapy. CBT should be active and goal-oriented, with clear goals and a system for tracking progress.
In addition, we need to appreciate the degree to which kids are impacted by their environment and ensure that we incorporate parents/caregivers into care. We also need to make sure that we are providing a “surround-sound experience” for the youth by communicating closely with the school, pediatrician, and any other outside providers.
Kids, teens, and young adults do best when they are seen and understood as individuals with unique strengths and abilities. Taking a strengths-based approach can help empower youth to actively engage in treatment and to step outside of their comfort zone as they try out new skills and strategies to manage their emotions and build resilience.
Your work at InStride Health is based on your decade of experience at McLean Hospital. What makes your treatment model unique?
While at McLean, we had the privilege of designing a program based on what the kids and families needed and then iterating on that model for almost a decade, reviewing the outcome data and incorporating feedback from patients, families, and clinicians.
While many aspects of our treatment are effective, three that stand out are:
- Parent/caregiver involvement, with close communication with schools and pediatricians.
- There is an emphasis on exposure therapy out in the real world where fears occur, with coaching between sessions to reinforce learning and build skills.
- Our deliberate recruitment and training of talented clinicians and coaches who care deeply about doing right by these kids and their families.
How does real-world, real-time exposure coaching benefit patients?
The young brain struggles with generalizing learning across different environments, making applying knowledge from one setting to another difficult. Engaging in exposure therapy in real-world scenarios, where anxiety and OCD triggers manifest, facilitates more effective acquisition of new learning and skills building. InStride exposure coaches support virtual exposures out in the real world- at stores, restaurants, schools, or in the neighborhood- during scheduled sessions, and they are also available for between-session coaching to support effective skill use in the moment. This proactive, real-world approach aids in developing new neural pathways in the brain.
Nurses, nurse practitioners specifically, have a significant opportunity to provide appropriate treatments for patients with mental health needs, specifically kids and young adults with anxiety and OCD. What must they know to make informed judgments about assessment, treatment, and referral?
An important initial step is to conduct an assessment to determine the diagnoses and biopsychosocial evaluation, coupled with education about the manifestations and behavioral impacts of anxiety and OCD. Anxiety and OCD can present in a variety of ways, and having a solid understanding of the presentation and contextual factors helps to determine the right treatment plan.
When considering whether medication should be part of the treatment plan, it is generally recommended to try therapy (CBT) as the first-line intervention for mild to moderate presentations. If the youth is having difficulty engaging in therapy, or if the symptoms persist despite engagement in therapy, it is reasonable to consider adding medication to help access the therapy, with SSRIs as the first line. For youth with more severe presentations for whom the intensity of the anxiety is causing significant impairment in life, it is recommended to start both therapy and medications together. In addition, when there is a greater impact on functioning and/or distress in the family system, they may benefit from more intensive services that include multiple touch points per week to help stabilize symptoms and gain momentum in treatment.
Measurement-based care provides visibility into whether and how individuals are responding to treatment, allowing for more informed decision-making. This entails collecting data from the child and parents throughout treatment, discussing progress directly with them, and adjusting treatment according to the data and conversations.
What role should nurses play?
Data are clear that there are not enough mental health clinicians (psychiatrists, therapists, counselors) to meet the psychiatric needs of youth. Nurses offer relief to this stressed system through the multiple roles they can play in providing mental health support, including advocating, educating, prescribing, and triaging. Because nurses often serve as trusted points of contact for youth and their families, they can identify signs of mental health concerns, provide education, and support prompt intervention planning. Nurses can conduct assessments with children and families and refer them to other mental health professionals or provide direct support, depending on their training and interests. For example, school nurses can provide critical contributions to health curricula and can educate students, parents, and school faculty and staff about mental health conditions, symptoms, and available resources. They can also help coordinate with community providers to create a support system for the student.
By raising awareness, understanding, and support, nurses contribute to reducing stigma, improving overall mental health literacy, and helping children and families receive essential care.
What should we be doing to improve mental healthcare for children?
We need to treat mental health problems in the same way that we treat physical health, and we need to improve access to effective care. We’ve witnessed so many children and families encounter barriers to accessing mental healthcare. We’ve seen parents waiting on long waitlists while their child’s condition worsened. Families have also shared their sacrifices, including draining their retirement savings and depleting their child’s college funds to get their child the right mental healthcare. Some families also resort to traveling long distances, crossing state lines, or temporarily relocating. We’ve also worked with families whose children can access treatment, but it hasn’t been backed by research or provided relief. It has been heartbreaking to witness.
Similar to heart health, we need to think about intervention at all stages, including prevention, early intervention, active intervention, and maintenance. As mentioned above, a school nurse can contribute to a health curriculum to help educate students on how overall health includes attention to mental health, as well as ways to build resilience and identify when it might be helpful to seek support. This same school nurse will often be the first point of contact for a student who might be struggling, and that relationship could be the difference in identifying needs and seeking support.
We also need to understand that mental health is a continuum, and the brain is susceptible to disorder just as any other organ in the body. We often talk about how we wish that anxiety disorders had a different name from the worry, stress, and fear that most people feel at some point – noting that when a youth meets the criteria for an anxiety disorder, typical management approaches that usually work for those everyday worries, stresses, and fears (e.g., get reassurance, cut down or avoid stressful situations) can perpetuate an anxiety disorder. The brains of those with anxiety disorders process the world differently. There is an attention bias to threat (they are more likely to see and respond to the threat in a situation) that requires a more active, behavioral approach for treatment to be effective (and, at times, biological intervention through medication). Being able to help parents recognize in themselves, as well as their children, the difference between worry, stress, and anxiety disorders can help tailor interventions to be effective for the whole system. Helping them understand that treatment can improve functioning and reduce suffering can help them know what they are working toward.
Is there anything else to share?
Nurses are the glue that holds together the support system for pediatric mental health. With their robust medical training, compassionate relationship building, and steadfast commitment to advocating for their patients, nurses play an essential role in championing pediatric mental health.
The post Meet Two Harvard-trained Clinicians Championing Pediatric Mental Health first appeared on Daily Nurse.
