Children's mental health emergency department visits have skyrocketed over last decade

Children with mental health disorders are seeking emergency medical care at an increasing and alarming rate, and many hospitals are not adequately prepared to treat them, according to a new study published today in Pediatrics.

"We're seeing more and more children presenting with mental health disorders," said Dr. Rachel Stanley, senior author of the study and Chief of Emergency Medicine at Nationwide Children's Hospital.

Her emergency department in Ohio typically sees "20 or 30 kids a day" for mental health reasons, she said.

To determine if this is a nationwide trend, Stanley and her team gathered data from the Nationwide Emergency Department Sample, one of the largest databases used to produce national estimates about emergency department visits. They used data from 2007 to 2016, analyzing patient demographics, mental health conditions, and emergency department characteristics for children aged 5 to 17 years old.

The data confirmed Stanley's suspicions: Emergency department visits for mental health disorders rose by 60% from 2007 to 2016 -- despite the total number of ED visits remaining relatively stable during that period.

The children seeking help experienced a wide range of mental health disorders, including mood disorders, behavior problems, anxiety, substance use disorders, and more. But the most serious of these diagnoses saw the most dramatic increase: visits for intentional self-harm more than tripled, increasing by 329%.

The increase was true across all age groups and both sexes, although it was more pronounced in females and in 15- to 17-year olds. Noting that suicide rates are higher among males, Stanley speculated that although boys feel just as much stress as girls, they might be less inclined to seek help.

There was only one mental health diagnosis that decreased, taking researchers by surprise: alcohol-related disorders. But even as alcohol-related disorders declined by 38%, substance-related disorders rose significantly, by 159%.

While the database the researchers used does not specify which specific substances children and teens were using, Dr. Charmaine Lo, epidemiologist at Nationwide Children's Hospital and co-author of the study, suspects the opioid crisis may be responsible.

"Right around 2014 there was a big increase in substance-use disorders," said Lo. "We can speculate [the opioid crisis] has to do with that uptick," she said. Stanley believes marijuana is also a culprit, as e-cigarette use increases and laws become liberalized.

While these changes are striking, Lo and Stanley acknowledge that they may not tell the full story. The Nationwide Emergency Department Sample database relies on billing codes, so any problem not captured by this system may not be counted.

"We think we missed a lot of kids," Stanley conceded.

Even so, there could be an upside to the staggering numbers. With more awareness of mental health disorders, it's possible more parents and kids are seeking care and getting properly diagnosed.

And while both Lo and Stanley worry that social media may be fueling some of the distress felt by teens, Lo notes that stigma-reducing public messaging may have a positive impact -- May, for example, is designated as Mental Health Awareness month.

But as more children are diagnosed with mental health disorders, experts worry that emergency departments may be falling behind, particularly in places where it is most needed.

Prior research shows that emergency departments that tend to see few pediatric patients are not as prepared to treat children.

Worse still, fewer than half of the country's emergency departments have policies specifically for children with mental health disorders -- dropping to fewer than one-third in rural areas.

"Most of the emergency departments are not actually prepared," said Stanley, who added that smaller emergency departments are among the most frequently visited and the least equipped to handle mental health issues.

Emergency departments that are ill-prepared to handle pediatric patients might refer them to an outside clinic that is miles away, which can have multiple ramifications.

"When a child gets admitted or transfers 50 or 60 miles away -- how are they going to find a [long-term] specialist?" said Lo.

Mindful of these gaps, Stanley has simultaneously been working with the federally-funded Pediatric Emergency Care Applied Research Network (PECARN) to develop tools to identify and treat high-risk children. A large component of PECARN's work is dedicated to disseminating these tools to under-resourced hospitals.

"We want to make sure our decision-making tools are being used where kids are actually seen," Stanley said, who points out that institutional partnerships, education, and funding are all desperately required to make this happen.

In the meantime, to bridge the gap made even wider by the national shortage of mental health providers, Stanley and Lo say telemedicine is an option. Virtual consultations with experienced mental health providers can help train rural providers to manage these cases, which in turn could prevent unnecessary transfers.

Ultimately, the research group hopes that this data drives change, saying that -- aside from resourcing hospitals -- medical training needs to ramp up.

"There are tools for screening these kids and for getting them more care," Stanley said. "These are tools that anyone can learn."

For families, the crucial component in fighting the increasing burden of mental health disorders among children -- even young school-age kids -- is awareness.

"Being aware that this is an issue," said Stanley, "and being aware that there is help out there."