Changing Well Child Visits to
Whole Child Visits:
A new vision for effective
childhood mental health.
A 12-year-old boy I’ll call Sam sits in my office, giving the me the side-eye. It’s his
first appointment, and Sam doesn’t want to be there. He’s getting C’s and D’s at school
and being reprimanded by his teachers. At home, there are 3-hour homework battles,
slammed doors and frequent arguments. And he’s no longer getting invitations to
birthday parties. Sam is constantly getting the message that he’s the problem, and his
self-talk—I’m no good. Everybody hates me —has gotten very negative. Sam is angry
and depressed. But he’s also hanging in. He’s still going to school, keeping his head
above water. He’s resilient but not in a positive way. And the only coping mechanism
Sam is practicing is avoidance, which video games provide. Nothing like being
successful at Fortnite to help Sam feel like he’s fitting in.
Now if we could wave a magic wand and go back to when Sam was very young,
what we’d likely see is a boy who was really motivated. But then Sam started to run into
an invisible wall. It could be undiagnosed ADHD that stops his momentum and causes
him a lot of frustration. When Sam experiences this frustration enough times, he starts
to anticipate failure and develops a sense of learned helplessness – I can’t. This
situation leads to a host of other issues: academic failure, family arguments,
depression. So by the time I see twelve-year-old Sam, I am attempting to untangle
problems that have become like a tightly knotted fishing line.
Imagine giving a child a bike helmet AFTER she’s gotten a concussion instead of
while she’s learning to ride her bike. This is the way we currently deliver mental
healthcare to our children.
And nationwide surveys are not encouraging about how well that’s going .... The
median age for the onset of anxiety is 6 and for ADHD it’s 11. Yet, only 15 to 25% of
children with a mental health disorder receive treatment. And why is that?
While dedicated pediatricians follow well-established Well Child guidelines,
respond to parent concerns, and check for developmental disorders at annual wellness
visits, there are ZERO required mental health checks until a child is 12. And then only
for depression.
Considering over half of all mental health issues occur BEFORE the age of 14.
To borrow and outdated term from my industry, that’s just plain crazy.
But at least we’re catching depression, right? Nope. Even for those kids who
have depressive disorders, only 40% receive treatment. The director of a large, local
pediatric practice confirms the problem, “We routinely check developmental progress
but from 30 months to 12 years we don’t screen for mental health issues. We just don’t
have the time,” she said.
The current healthcare system is failing our children, and we can do better. The
solution? I propose we turn child wellness visits into Whole Child Visits that include a
mental health check with an experienced mental health professional. Mental health
providers could relieve the unfair burden put on schools and pediatricians and offer
more support for families.
These annual visits would allow an on-site psychotherapist to track a child’s
mental health in the same way a pediatrician tracks a child’s physical health and
development. And because these mental health checks would become a routine and
accepted part of wellness, this would go a long way in alleviating the stigma of mental
health issues. Plus, they would help normalize children talking about their feelings. But
most importantly, children and their parents would get the treatment and support they
need when they need it, so common mental health problems don’t go undiagnosed or
become engrained and more complex. So families wouldn’t have to say, as I’ve heard
them say so often after years of struggle and frustration, that they wish they’d come to
see me much sooner.
A pediatric office that integrated physical and mental health checks could have
helped David before he started having suicidal thoughts. This sensitive, intelligent
young man was pale, anxious, and depressed. David ran track and complained about
being tired all the time and said that his heart raced even when he was resting. What
looked like depression, anxiety, or both turned out to be a failing thyroid. After
collaborating with his doctor, David’s anxiety and depression disappeared. He’s now
excelling in school.
And consider Becca who had yelled at her teacher and had pushed several other
students to the ground. Every week Becca had long tantrums and repeatedly went to
the nurse for stomach aches. But Becca could also be motivated, polite, and funny. As it
turned out, Becca felt panicked in large groups. The slightest hint of rejection cascaded
her into fight or flight response. Becca was practicing the only coping mechanism she
had and asking for help the only way she knew how. Imagine if Becca had been able to
share her feelings of anxiety earlier and if we’d been able to teach her age-appropriate
techniques to better manage her stress.
Let’s enable therapists to get ahead of problems instead of being left to react to
them. Enable them to help families identify early signs of concern, even before a crisis
makes a problem diagnosable by looking at a child’s response to ordinary situations at
home.
Therapists, for example, could help families spot their child’s emotional and
behavioral tells. A tantrum, for instance, is a child’s language of distress but can easily
be dismissed as normal. A therapist could help parents and children decode this
language by asking them to describe their child’s behavior 1 minute, 15 minutes, 60
minutes before a meltdown. Instead of focusing on the tantrum, they could get at its
cause--possibly, hunger, lack of sleep, or overstimulation.
Or a therapist could ask what happens when their child is sent to get ready for
bed on her own. If she’s reluctant to go up alone, it could be an indicator of anxiety. Or if
she goes up alone but then doesn’t get ready for bed, it might indicate she needs help
with Executive Function skills—those cognitive abilities that allow us to have control
over our behavior.
An integrated Whole Child Visit would allow psychotherapists not only to identify
potential problem but also help address them. They could work collaboratively with
pediatricians and parents to be a resource, offering advice and strategies, making
referrals, prioritizing treatment options, and checking back in about the effectiveness of
the suggested strategies.
This is particularly important now. We are in the middle of an epidemic of anxiety.
Our children are living in a world of constant “on” and their brains and bodies get
fatigued. They fall into patterns of anticipating failure, reacting to minor signs of distress
with a flight or fight response. What is far worse, they don’t know how to practice
responding to problems by pushing forward and problem solving.
Let’s return to Sam. If Sam had gotten Whole Child Visits, a psychotherapist
might have asked his parents to describe what it was like for him to learn to ride a bike.
Learning to ride a bike takes courage, determination and multi-tasking. There are
almost always falls. A question like this could reveal Sam’s difficulty with what’s called
“frustration tolerance.”
The therapist could then offer Sam tools for better success, helping him slow
down, step back and try out other possibilities when he’s frustrated. This would help
change Sam’s self-talk from, “It’s impossible” and “I can’t” to a new, more positive story.
Faced with his next challenge, Sam could build on his previous success and develop
more positive resilience.
Identified early enough, barriers that children face can offer wonderful
opportunities for them to develop useful life tools, like emotional intelligence, flexibility,
frustration tolerance, safe risk taking, delayed gratification, and the ability to learn from
their mistakes. Whole Child Visits could support children in this practice and better
prepare them for the stressors in their lives, especially as in today’s fast-paced online
world, kids are exposed to cyberbullying, pornography, and sexting that they are not
developmentally ready for and have limited time to process.
Giving our kids the right tools at the right time can avoid more serious,
complicated problems from developing, change their narrative from negative to positive,
and build their resilience. But the timing matters.
Whole Child Visits that integrate medical, emotional, and educational support
would facilitate early and effective mental health care for our children and provide the
greatest long-term benefit.
Let’s give our children that helmet as they learn to ride not after the concussion.
© Benjamin Hillyard 2019
AloftNH.com
Centerforcollaborativechange.com
