The Shadow Pandemic: Our Nation’s Pediatric Behavioral Health Crisis

MISSOURI - As we near two years of being locked inside a worldwide pandemic, we approach the first anniversary of pretending impassive gestures like flipping a calendar from one year to the next will cure what ails us.

This time last year, we were ready to put 2020 behind us and looked forward to the promise of 2021. For children’s hospitals, 2021 has been more frustrating than its predecessor as the pandemic has accelerated a youth mental health crisis years in the making – one we cannot effectively manage without help.

On July 13, we sounded the alarm about the crisis that is rampant across our state and the nation. We demonstrated that the demand for services far exceeds the available supply, explained how children’s hospitals are not designed to care for kids with mental health needs at scale, and illuminated the impact of the crisis on kids we are caring for and the dedicated health care professionals caring for them.

On October 19, the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, and Children’s Hospital Association declared a national emergency in youth mental health, echoing our concerns and urging policymakers to take action. They pointed to a 45% increase in self-injury and suicide cases among 5- to 17-year-olds at children’s hospitals during the first six months of 2021, as well as more than 140,000 U.S. children having experienced the death of a primary or secondary caregiver during the pandemic, with children of color disproportionately impacted.

On Dec. 6, a new poll highlighted the pandemic’s outsized impact on anxiety and stress among children and adolescents. On Dec. 7, the U.S. Surgeon General issued an advisory on the youth mental health crisis, calling for “a swift and coordinated response to this crisis.”

We hope that will be the case – at both federal and state levels of government. Because in the meantime, children’s hospitals continue to see an overwhelming demand for mental healthcare. An unprecedented number of patients are seeking outpatient care for concerns such as anxiety, depression, disruptive behaviors, academic problems and eating disorders. The resources needed to provide this care are grossly insufficient.  As a result, we’re seeing largely two categories of children in crisis:

1. Kids with a psychiatric diagnosis, resulting in psychosis or imminent risk of harm to self or others. These children present to our emergency department initially because they have hurt themselves, whether cutting themselves, consuming pills, or perhaps broken their hand when punching something – these children need medical stabilization.
2. Kids presenting to us who are “dually diagnosed” – meaning a combination of a developmental disability and a psychiatric crisis. When in crisis, they can be a danger to themselves and others, so they are often brought to us because they have nowhere else to go. Often their families have exhausted resources to keep their loved ones safe and feel like they need protection.

Children from both groups end up at our hospitals after arriving at our emergency departments and being stabilized medically. They stay with us because there is no “step down” service, or for the more acute cases, placement available, whether that means facilities specializing in residential stabilization, partial hospitalization programs, or a therapeutic foster family.

On any given day our emergency department rooms are home to significant numbers of kids with mental health concerns, most of whom languish for days for access to a treatment facility. When we get to the point that there is no hope of transfer to an appropriate facility after holding these children for multiple days in our emergency department, we end up admitting them to a hospital room – filling medical beds with children who do not have medical or surgical care needs – and therefore consuming resources that would otherwise be used to care for medically complex, very ill children. These children with behavioral health needs and no options for placement outside our hospitals stay with us for weeks and sometimes months, with no access to the outdoors and very limited access to education, socialization, and leisure activities essential for youth development.

While mental health has been trending away from residential care facility use for decades, there is a small population of kids who are so severely impaired that they cannot live in a less restrictive setting. Our state continues to lose beds at that level of care, resulting in the burden being shifted to the community, often in parents needing to stop working to care for their child, and then in acute care hospitals when care for these kids at home becomes untenable.

While there is no easy fix to this crisis, we as health care providers are interested in joining policymakers and other key stakeholders to develop the best, most comprehensive policy package we can. Our children and families deserve no less from us.