Mental health ER visits among children rising — experts point to a broken system

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Multiple emergency room visits for children experiencing mental health crises are on the rise, according to a new study. Experts say that a broken system is to blame.

The study, published in the journal JAMA Pediatrics in December, looked at more than 200,000 patients between the ages of 3 and 17 who visited an emergency room with a mental health concern across 38 U.S. hospitals between 2015 and 2020.

Such emergency room visits increased by 8% annually, according to 300,000 visits that were assessed. The number of revisits increased by 6% annually. Young patients with psychotic disorders such as schizophrenia were 42% more likely to revisit the emergency department within six months, according to the study, with 13.2% of the patients having a mental health revisit within six months.

“The psychiatric emergency room can be a lifesaver for young people who are acutely suicidal,” Dr. Harold S. Koplewicz, president and medical director of the nonprofit Child Mind Institute, said in a statement to Yahoo News. “This study speaks volumes about the lack of school-based or outpatient programs. The system is broken.”

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The study points to overwhelmed caregivers of young patients with behavioral or psychological disorders who are increasingly relying on the emergency room for care.

“Families come in with their children who have severe behavioral problems, and the families really just are at their wit’s end, you know,” Dr. Anna Cushing, a pediatric emergency room physician at Children’s Hospital Los Angeles and a co-author of the study, told the New York Times. “Their child’s behavior may be a danger to themselves, but also to the parents, to the other children in the home.”

The study found that young patients with suicidal thoughts or those who were self-harming made up almost 29% of the diagnosis group, followed by patients with mood disorders (23.5%), anxiety disorders (10.4%) and disruptive or impulse control disorders (9.7%). Overall, 13.2% of patients revisited the emergency room for a mental health emergency within six months. But patients with psychotic disorders, disruptive or impulse control disorders and neurodevelopmental disorders were more likely to revisit than those with suicidal thoughts or who were in danger of self-harm.

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“When a child is having a meltdown or is in crisis at home, a lot of them don’t have a child psychiatrist to call to get advice on or to bring them to see the next day,” Michael Enenbach, a psychiatrist and the clinical director of the Child Mind Institute, told Yahoo News. “Oftentimes, it’s just a cycle of behavior disorders at home. They come to the hospital, they’re fine, then they get discharged. Then the whole thing happens a couple days later because they don’t have access to care. So parents’ only option, if they're feeling unsafe, is to go to the emergency room.”

But experts are concerned that the psychiatric emergency room or general hospital emergency departments are not designed or equipped to provide ongoing support needed for young people with chronic behavioral problems.

“There’s no bible on parenting. So when you have a kid who's really challenging, it’s hard to know what to do,” added Enenbach, who has also worked in behavioral emergency rooms for children for 14 years.

“ERs are too busy already, especially with COVID and everything. They’re not really equipped to deal with kids. There’s child psychiatrists on call for the ER, but they get really stressed with a kid having a tantrum or having an episode and they don't know what to do. Our ER doctors don’t know what to do. Pediatricians don’t know what to do. It’s hard because it’s really disruptive to the entire emergency room.”

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The study revealed that most patients with mental health ER visits were girls (56.0% vs. 44.0% boys); non-Hispanic white (50.4% vs. 1.6% Asian American, 17.3% Hispanic and 22.3% non-Hispanic Black). The research also found that predisposing social constructs linked to revisits included race and ethnicity, with non-Hispanic white patients more likely to revisit the ER and Asian American patients, Hispanic patients and other races less likely to revisit. The use of medications in emergency rooms, such as benzodiazepines or antipsychotics, has also increased in recent years and are disproportionately used on Black patients and young men between the ages of 18 and 21, according to the study.

Mental health revisits, the study found, can be linked to the lack of access to health care, with both public insurance and a certificate of insurance being associated with shorter time between revisits.

“Access to outpatient care is really hard, especially if you have Medi-Cal or Medicaid,” Enenbach said. “Very few insurances provided out there are providing services. Then, that disproportionately affects lower socioeconomic groups. So it just clogs up the emergency rooms.”

According to the Child Mind Institute — whose teams of psychologists and other specialists offer evaluation and treatment for ​​a wide range of conditions and concerns — about 70% of U.S. counties do not have one child and adolescent psychiatrist and that the average time it takes between the onset of symptoms and treatment is over eight years, due to stigma, misinformation and lack of access to care.

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“It would be helpful to train pediatricians more in mental health so they can address key issues in these patients,” Enenbach continued. “Currently, pediatricians get very little training in mental health. We need to find a way to educate the population, get more providers out there, get more child psychiatrists through medical schools, hire mental health professionals and educate pediatricians and doctors better.”

He added that “improving collaboration between pediatrics and mental health” is also important. “That’s getting better, but we still have a long way to go,” he said.

The study highlighted Enenbach’s observation, signifying that the trends surrounding the problem of increasing mental health emergency room visits “has not abated.”

“Improved intervention services for patients with a behavioral health crisis are needed on a hospital and systems level to reduce pediatric mental health ED use and ensure access to appropriate follow-up care, with a particular focus on those patients most likely to revisit,” the study’s authors concluded.