Deborah Hagler, MD, MPH, FAAP attended Duke University and Cornell Medical College and did her pediatric training at the Children’s Hospital of Philadelphia. Throughout her educational journey, she has been involved in collaborative efforts to educate her community. As a resident in Philadelphia, she worked with at-risk youth at a local homeless shelter and helped organize a series of talks for residents to educate herself and colleagues about social determinants of health. For these efforts receiving the Nancy Barnhart Community Service Award and the Senior Resident Humanitarian award. In 2021 she completed a Masters of Public Health at the Bloomberg School of Public Health at Johns Hopkins University focusing on child and adolescent mental health and is using many of her new skills working with a multi stakeholder coalition to improve children’s mental health and spearheading the creation of additional resources to treat youth with substance misuse and substance use disorders through the TREATME NOW program at Day One.
Dr. Hagler is an active member of the community, serving as the school physician for many years and working with many local organizations on issues pertinent to children’s health and wellbeing.
She has been the recipient of several Community Builder Awards from the local United Way.
Dr. Hagler recently retired from her clinical practice at Maine Health Pediatrics Brunswick. She is a past President of the Maine Chapter of the American Academy of Pediatrics and remains on the AAP board as a co-chair of the Healthy Mental Development Committee. She is an active board member of the MidCoast Youth Center and, in 2024, was honored by the Maine Children’s Alliance with the Giraffe Award.
What drew you to working with youth, particularly youth at risk who experienced both mental health and substance use challenges?
Since I was very young, I knew I wanted to be a doctor and enjoyed working with young people. My dad was a surgeon, and he visited my fifth-grade classroom to talk about being a doctor and sewed 2 pigs’ ears together to demonstrate the work of surgeons. From that moment on, I knew I wanted to pursue medicine. I didn’t know what kind, but I wanted to work with children, and I had experience as a camp counselor when I was young. I did a lot of activities with other kids, and I’ve just always enjoyed being around young people, and that hasn’t changed as I’ve grown older.
I went to medical school, and I even knew more that I wanted to go and work with kids. I really enjoyed working with families, teaching families, and working with children. During my residency, I had some fantastic mentors, Drs. Ken Ginsberg, Marc Gorelick, Steve Ludwig, and Jane Lavelle, who have worked extensively with teens. All were true mentors during my training, working with higher-risk youth and inspiring me to think about that area. I had always appreciated the complexity, and I saw a need. I still remember in medical school when a very sick child would come into the ER, and you’d get that feeling that many people would shy away from such tense situations. I learned that I need to lean into those moments more, not less.
From my own family’s teachings, if people are running away, sometimes that means you really need to lean in and help. I also learned that from my mentors. Complexity lets you build deeper relationships with the family, the patient, and your colleagues. Despite its challenges and discomfort, the process ultimately leads to stronger relationships. I was really drawn to all of it. You learn a lot; you develop rich, complex relationships with your patients and your colleagues. And even though it can be difficult, I really liked the layered nuance of it all.
How has your work in collaborations and collaborative care models been helpful when working with youth and the various organizations that interface with youth?
Honestly, it helps youth feel better to know they’re supported and that many people are thinking about them. It helps you because more brainpower is going into thinking about these complex situations, and that is always better for the patient. Also, there’s this own secondary trauma I’ve realized over the years of working with the kids with traumatic backgrounds and multiple complexities, and secondary trauma is managed better when you are collaborating with people and talking about hard problems as a team.
Very early on, something that has always stuck with me from my psychiatric training: one of the psychiatrists said, “Never worry alone.” I expanded that to “never care for people alone.” The problems are a lot bigger than one person often can manage alone. Even for the individual patient, that’s why they come to a doctor, to share what they need and cultivate a circle of support. And the same with caregivers, if we can all work on things together, a community of care makes things better for the individual. It’s taken me a while to grow and lean into that, but the further along the road you get in your career, you realize that the more collaboration you can have around a patient, and particularly the more you can develop relationships with other clinicians around patient care, the better off your patients will be in the end.
Unfortunately, our system is not set up for that. The [computer] screen has siloed in many ways – It ‘harder to have a team meeting about patients because the day is so scheduled. It’s harder to find time during the day to talk to people because of your busy schedule, charting, and inbox demands. In clinical practice, at lunchtime, you try to connect with people or write emails to people so you can have the whole team approach. When you cross-disciplinary communication, you can put everybody on the same track around a patient, so everybody’s hearing the same thing. Screens have been useful when you are able to pull a team together. Meeting on Zoom / Teams around a patient takes a lot of effort to collaborate, but it’s much better for the patient, and it’s better for the team when you’re able to do that. I really like that model.
What are the various needs for youth regarding substance use and mental health issues that you have seen or that have evolved over time?
The biggest thing is the need to build community and to keep it established around youth. There are still places where kids are expelled from school, and then they are more at risk of using substances. It further stigmatizes them, pushes them away from the community, isolates them, and disengages them from the supports that could be there, such as trusted adults. That is what’s needed: access to caring adults who will be around to keep them engaged in protective factors. There is a need for access to evidence-based therapies such as Functional Family Therapy, Contingency Management, and others. However, you have to keep them engaged, rather than increasing shame and punishing behaviors; instead, discuss it and support them in comfortable, safe places to sort through multiple issues that are going on and where that use comes from. Use is just one piece of the puzzle to deal with.
Schools and the provider community need to and are trying to figure out how to keep young people engaged both in school, treatment, and community. Harm reduction was so anathema when I was growing up in training, but it’s about keeping them in the ecosystem rather than pushing them out. They need their whole ecosystem to avoid isolation, further substance use, and further spiraling into other issues that could get them into trouble. This is what the whole system has to move toward.
There are so many things that can further isolate kids. It can be whatever’s going on with their family. Support for the family system is needed, to have access to all the things a family needs, mental health treatment, substance use treatment in the home, housing, food, all the basics, so the family doesn’t get isolated, can stay intact to support their kids.
The medical part is just one piece of that ecosystem. It has to be a safe space for them to continue in or a champion for them, one of those trusted adults that they can connect to, that can keep them connected to other things in the ecosystem that are going to pull them away from the use. For some kids, their whole social structure is built around their use, and we need to help build in other structures that will pull them away from their risky use.
That is where effective, evidence-based therapy like ACRA comes in to help build a social support network. Connecting them to community, school, and activities that steer them away from substances is really, really, really important for many youths. Just further isolating them isn’t helpful.
What is the role of the pediatrician or family practitioner?
Youth need a safe space to talk and disclose. Sometimes that’s with someone at school, sometimes a parent, or your pediatrician or family doctor. It’s about having a relationship where you feel safe enough to open up. Pediatricians or family providers often have ongoing relationships that can be helpful. Screening helps, and many kids will share things, but we must ensure we interpret the results correctly and follow up. Some kids won’t say anything on a screener, but when they are ready to talk, you need to listen. The pediatrician’s role is to ask questions, be curious, give accurate information, and sometimes intervene by saying, “I am concerned about the amount of drinking you’re telling me about,” or “Have you thought about making a change?” “What have you tried before? Has anyone said anything?” You can gently follow up with other questions and keep your door open. Sometimes, just suggesting something might be too much, like “Why don’t you decrease that?” or “Here are some tricks,” or “Do you want to talk to someone else about this?” Offering these options allows some kids to seek help, while others may not. The goal is to plant the idea of change, give them a bee in their bonnet. Many kids don’t realize their use is problematic, especially with cannabis and alcohol. Sharing a small piece of information might help them recognize the issue or consider a change. This is a very important role for primary care.
If they need more help or if you really need to have a conversation with a supportive parent, especially since you might have a relationship with them if you’ve been part of the community for a while. You can start that discussion. You can assist them in communicating with a parent, which is often very hard when you’re young. Talking with loved ones and family about this can be so difficult because parents often have high expectations for their children, which they should. Most of the time, kids don’t want to disappoint their parents, so they hide things and avoid sharing everything. But most parents want the best for their kids, and if they’re struggling, they want to know.
Sometimes there is a mismatch between what young people and their families expect and want. Having tough conversations can be hard, but the primary care provider can help, especially if they have a good relationship with the youth. That is a big role primary care can play for young people. They can act as a coach, talk to a parent if needed, or simply help a young person navigate a system on their own. If you’re 16, an emancipated minor, and you’ve decided you need to act, it can feel overwhelming. You can assist them in finding resources that establish a support system around them.
You often know resources in your town. You know who to contact at the school, who to reach out to at your local youth center, Y, Boys and Girls Club, or who to talk to when you want to say, “Can we put some support in place for this kiddo? They like to do X, Y, and Z. Can you help them connect to the local community garden, the bike club, or other opportunities beyond the exam room?”
Many kids also need mental health resources, such as psychiatric evaluations, more intensive medication management, and primary care providers can also start medication management. There is strong support for this, thanks to solid partnerships with pediatric and behavioral health providers and many adolescent psychiatry partners. Primary care and pediatric providers can do a lot to support youth.
What else would you like to share for those working with youth?
It’s important to remember that among youth, some are really struggling with their families, and it may not be safe for them to engage with them. Therefore, having processes in place to discuss confidentiality and what counts as confidential for adolescents seeking care is good practice. Youth can receive care for substance use, mental health, and sexual health on their own without their parents’ consent. Sharing this, understanding the rules of confidentiality when you really need to disclose information, and how you’ll disclose it are critical. You’re not going to say, “I’m going to run out and tell your mom.” Instead, you will have a conversation about it. You want the adolescent to feel safe and trusted with you; otherwise, they might leave and not come back. The goal is often to get adolescents to return and reconnect. That’s why maintaining a long-term relationship is important: it helps ensure that adolescents and parents understand the boundaries of interaction.
Also, another important tip is to understand that your goal is to help a thriving, healthy adult who can leave your house and handle things independently. Youth need to be empowered. They should be educated and encouraged to manage much of their own medical care, which is part of your role as a provider, as well as for the parents. They need to take charge by making appointments themselves, discussing issues directly with the doctor, and allowing adolescents to handle some of these matters and make decisions with the physician or clinician. Sometimes, you might ask the youth if they want to bring in their mom or someone else into the discussion, or if they prefer to decide on their own. Don’t be shy about talking about all of this. Just don’t hold back. It’s easier than you think, even if it feels overwhelming. Ultimately, you’re doing your best for the young person in front of you and helping them grow up and learn how to navigate their challenges on their own.
What are some resources for providers?
There are excellent resources on the maine.gov website for adolescents, the AAP, TreatMe, the ME SUD Learning Community, Helping Families Help, and Day One websites. We still need more, but they are steadily growing. I believe everyone has come together as a team within the community. People are focusing more on youth and families and on gathering resources. There obviously needs to be more, but change doesn’t happen overnight. It takes time, but we will get there. It requires people to commit themselves to the process.