Addressing Mental Health Needs in Children Before They Reach the ED

Across the country, hospital emergency departments (EDs) are experiencing a sharp increase in the number of children and teens seeking treatment for mental health conditions.

It’s a sign that children and teens aren’t getting the help they need for behavioral health conditions until these conditions reach a critical state. It’s also a reflection of both the stress children and teens face—particularly in an era of rapid-fire social media exposure—and their increased awareness of the impact of anxiety and depression on their health.

In Colorado, 25% of ED visits by children and teens in 2018 were mental health-related, an increase of 4% in two years, a recent report found. What is more shocking is that the percentage doesn’t include juveniles who present with a secondary diagnosis related to mental health or whose conditions involve substance abuse.

Colorado isn’t the only state experiencing higher rates of youth with behavioral health conditions in the ED. In California, for example, the number of adolescents and young adults ages 13 to 21 who came to the ED with a primary diagnosis that was mental-health related rose 42% from 2012 to 2018. This compares to just a 4% increase in ED encounters for other diagnoses.

But EDs are ill-prepared to treat youth who struggle with mental health challenges. They typically lack the specialized expertise to properly diagnose and assess treatment options for adolescents in mental health distress. Even when children with anxiety and depression are properly identified, a shortage of behavioral health specialists means kids may not get the help they need in a timely fashion, especially if they live in rural areas or are economically disadvantaged. The impact: repeat ED visits by teens for mental health challenges and high rates of ED-to-inpatient admissions.

Behind the numbers

Recent data point to the complexities of treating mental health issues among youth who present in the ED:

• Major depressive disorder was the most common diagnosis among youth 18 and younger in Colorado, according to a three-year review of commercial, Medicare and Medicaid claims.
• Nearly 60% of mental health-related ED visits among teens and young adults in California involve self-harm.
• Teens who come to the ED with self-harm injuries face increased risk for repeat ED visits for self-harm or suicide attempts and are eight times more likely to die from suicide. They are also three times as likely to die within five years of any cause, one study shows.
• Rising rates of mental health ED visits among kids in California correspond with higher rates of suicide among teens and young adults.

Given the number of children and teens who attempt suicide and the increased violence by which suicides occur, it’s clear that health professionals must work to pair youth with the right resources when they present in the ED with a mental health condition. But without mental health training, ED professionals often face challenges accurately diagnosing a child’s condition.

For example, one reason that major depressive disorder is such a common diagnosis may be that there isn’t a category for coding self-harm behavior, so “major depressive disorder” tends to be a catch-all diagnosis. Lack of mental health expertise also contributes to ED repeat visits for mental health conditions as well as a high percentage of mental health-related inpatient admissions stemming from ED visits.

Additionally, the stigma related to behavioral health conditions—particularly among parents of children and teens, but also among some teens—often means youth are coming to the ED are dealing with more acute behavioral health conditions. The longer they take to get treated, the worse the future outcome. This is especially true if children and teens aren’t paired with the appropriate resources on first point of contact in the ED—and EDs typically are hard-pressed to make these connections.

Providing the right support

How can EDs more effectively meet the needs of children and teens in crisis—and how can healthcare organizations partner with schools, parents and communities to address mental health conditions before they require emergency assistance? Here are three approaches to consider.

Equip the ED with 24-hour access to behavioral health specialists and support. Establish partnerships with behavioral health specialists—whether in person or online, such as via a telehealth platform. Designate team members to be paired with children and teens who present with suspected mental health conditions or self-harm injuries. Doing so not only helps these patients receive the right care in the ED, but also ensures parents and their children are connected with optimal resources that help protect children’s health. At UNC Medical Center in Chapel Hill, N.C., forming a division of emergency psychiatry positioned the health system to provide ED patients with access to a psychiatrist within two hours.

For EDs in rural areas or in towns with limited access to behavioral health specialists, virtual care can help bridge the gap. Another option: digital mental health modules that make it easy for children and their parents to access behavioral health services jointly and independently. It’s an approach that eases convenience for children and teens in working families, as barriers such as lack of transportation and work conflicts can impede access to mental health services.

Build relationships with community groups focused on mental health or youth services. Developing relationships with community mental health service providers gives EDs greater bench strength in addressing adolescents’ mental health conditions effectively and steering teens toward therapies and tools that could make a deep impact. One example of a unique approach to behavioral health treatment for children and teens: equine therapy, which can help youth manage feelings of anxiety and depression. In Loudon County, Va., a community service group called Project Horse Empowerment gives seventh- through ninth-graders a less-pressured environment for therapy.

In reaching out to community service groups, make sure to include substance abuse specialists. Four in 10 high school students say they have tried marijuana, and those that use it regularly are more likely to experience depression. Faith-based organizations, too, could help meet the demand for mental health care, such as by pairing adolescents with access to counselors who can help youth work through emotional challenges.

Reach out to local schools to deepen the front-line defense. With 27% of teens to rating their mental health as “fair” or “poor,” it’s clear that schools are experiencing a rise in behavioral health scenarios, too. With lack of connection to an adult cited as a risk factor for suicide, some states are equipping teachers with training on how to spot youth who are suffering from mental health issues such as anxiety, panic disorders or depression and respond quickly and effectively. Colorado, for example, developed a toolkit for promoting mental health in schools. The toolkit includes tips on how to reduce the stigma around suicide prevention. In Indiana, Hamilton Southeastern Schools near Indianapolis partnered with Community Health Network to offer in-school therapy services, which are billed to parents’ insurance. The school system also founded a club to help teens learn to better manage stress, drawing on the power of peer-to-peer support to destigmatize mental health offerings.

Rethinking ED approaches to kids in crisis

As children and teens become more exposed to adult-level stresses and more aware of the impact these stressors can have on their mental health, it is no surprise that EDs are seeing a surge in demand for mental health care among youth. But few EDs are prepared to address this demand. Given the dangers that at-risk youth and their communities face when access to mental health services is limited, now is the time to empower EDs with the right resources to respond in the right way at the right time—ultimately saving lives.

Diane J. Felder, MD, is the medical director for Magellan Healthcare of Texas.