'This is our epidemic': Mental health crisis is kids' long-haul COVID, children's hospital leaders say

In the summer of 2020, the average number of weekly visits to the emergency department for suspected suicide attempts among adolescents 12 to 17 was up 22.3 percent from 2019. By winter 2021, the increase in these suspected attempts from winter 2019 was even higher: 39.1 percent, according to the CDC's June 11 Morbidity and Mortality Weekly Report.  

At St. Louis Children's Hospital, the number of pediatric patients presenting to the ED seeking mental or behavioral health treatment is up 30 percent to 35 percent compared to pre-pandemic levels, hospital president Trish Lollo told Becker's Hospital Review. Back in April, visits hit a peak. The hospital internally declared a state of emergency and created an incident command infrastructure to manage the situation.

State of emergency 

It's a phrase — state of emergency — that has come to define not only the COVID-19 pandemic, but a coinciding mental health crisis afflicting the nation and its children's hospitals. In late May, Children's Hospital Colorado in Aurora publicly declared a state of emergency in pediatric mental health, with CEO Jena Hausmann saying EDs and inpatient units were "overrun with kids attempting suicide and suffering from other forms of major mental health illness." The North Carolina Healthcare Association declared its own state of emergency in behavioral health June 14. As of December 2020, 40 percent of all ED discharges in the state for children were for behavioral health concerns.

From April to October 2020, hospitals nationally have seen a 24 percent increase in the proportion of mental health ED visits for kids ages 5 to 11, according to data from the Children's Hospital Association. That increase is even higher for kids ages 12 to 17, at 31 percent.

An old problem, turned up

A consensus among children's hospital executives is that while mental health care has long been an escalating issue, the COVID-19 pandemic has made it unmanageable. 

Back in 2011, when Kurt Newman, MD, took over as president and CEO of Children's National Hospital, he was asked what pediatric health concerns the Washington, D.C.-based hospital should be watching. He told Becker's that when he responded "mental and behavioral health," it surprised administrators.

"The reason it was in my mind so much is, even as chief of surgery, I'd get a call from a friend or family or somebody that I knew, at least once a week, desperate to find services for their child with a mental health issue," Dr. Newman said. It "pulled back the curtain" on the issue for him.

Fast forward to 2020. The problem, well-observed and documented, was exacerbated, largely by isolation caused by social distancing measures taken during the pandemic, hospital executives said. Additionally, the pandemic has removed children from some of the places where early signs of mental illness are identified, such as schools and during extracurricular activities. 

"Throughout COVID, we always thought how lucky we were, how fortunate we were that children weren't as significantly affected by COVID," Ms. Lollo at St. Louis Children's said. "And then, all the things we did to protect ourselves — shut down schools, shut down community centers, shut down access to social situations — those helped basically exacerbate our mental health crisis. I've been calling this our epidemic. This is ... the children's pandemic."

What's the role of children's hospitals?

The state of emergency has called to question children's hospitals' role in the crisis. 

Paul King, president and CEO of Stanford Children's Health in Palo Alto, Calif., told Becker's that children's hospitals have been focused on the mental health crisis for years, but "trying to solve this as a hospital problem is never going to work."

Children's hospitals are trying to find "which swim lane" they are in, Mr. King said, recognizing that collaboration with mental health experts, community programs and others is necessary.

Adding to the complexity is the market variance of mental health care in the nation, which was constructed differently by state, Amy Wimpey Knight, president of the Children's Hospital Association, told Becker's. Crumbling state-run psychiatric infrastructures, low Medicaid reimbursement rates and increased demand are key reasons pediatric mental health patients are being pushed to children's hospitals and EDs, Ms. Knight said.

"A lot of children's hospitals are trying to figure out how do we work effectively in this space," she said. "Because they also recognize we're not the only answer." 

Telehealth and accessibility

One way children's hospitals have extended a limited mental health infrastructure and pediatric psychiatric workforce is through behavioral telehealth visits.

Psychologists at Children's National see the service as mainstream, Dr. Newman said. Patients have responded positively to virtual visits. The hospital saw no-show rates for behavioral health visits drop from 16 percent to 6 percent, Dr. Newman said. At Stanford Children's, Mr. King said the hospital plans to keep 65 percent of its mental health-related telehealth visits remote. Part of the reason is the accessibility aspect, while another is the ability to see into children's home lives. 

But telehealth and pediatric mental health services aren't accessible for all, especially uninsured populations, Medicaid patients and people of color, the executives said. Lack of accessibility is in large part why some populations disproportionately use EDs for long-term behavioral health services. It's an issue the Children's Hospital Association aims to address in its recent legislative proposal to Congress, which requests extended financial relief for the pediatric healthcare safety net.

In that legislative proposal, the Children's Hospital Association also called on lawmakers to permanently extend telehealth flexibilities under Medicare that lifted site restrictions and geographic limitations on telehealth coverage. The association said changes made in the Medicare program may drive Medicaid and commercial payers to do the same. 

Without some of these long-term solutions to the pediatric mental health infrastructure and its workforce, payment models and accessibility, states of emergency will persist.

"We spend a lot of time talking about adults with long-haul COVID," Ms. Knight said. "I think the behavioral mental health crisis is going to be the long-haul for kids."

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