Tip of Children’s Mental Health Iceberg

For emergency room doctors, they are a sad and familiar sight: Children returning again and again in the grip of mental health crises – From NYTimes articles;  “Mental Health Crisis + Emergency Rooms” (full article below) is just the tip of the iceberg. It shows the exponential increase in chemical restraints and Emergency Room mental health visits by children. Yet it misses the crisis at the heart of the story, and what we could do to save the huge costs and terrible failure our policies repeat for at-risk children and our communities every day.

• Approximately 33% of youth involved with child welfare visited the ED at least once for mental health problems during their involvement with CPS.
• Children who remain at home after a CPS evaluation are at high risk for ED use, with 35.6% of those receiving CPS services and 37.4% of those not receiving services using the ED.

Children in CPS care who use the ED for mental health reasons are more likely to:

• Have a history of sexual abuse
• Have parents with mental illness
• Have experienced placements outside of the home

The most common reasons for ED visits among CPS-involved youth include:

1. Suicidal ideation
2. Substance use
3. Suicide attempts

Gender differences exist, with males predominantly visiting for substance use problems and females for suicidal ideation.

ED visits for CPS-involved youth are most commonly initiated by:

1. Police (35% of cases)
2. Child welfare services (27%)
3. Parents (19%)

Three main trajectories of ED use have been identified:

1. ED contact initiated by child welfare workers for suicidal ideation/attempts
2. ED contact initiated by police for substance use and externalized behaviors
3. ED contact initiated by parents for suicidal ideation/attempts
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• Mental health-related ED visits for children have been increasing, with a 24% rise for ages 5-11 and a 31% rise for ages 12-17 in 2020 compared to 2019.
• The average length of stay in the ED for psychiatric admissions is 18 hours, compared to 5 hours for non-psychiatric admissions

  Mental health treatment was initiated in only 24% of cases within 30 days following an ED presentation.

• For 16% of ED users, their ED visit represented their first ever lifetime contact with the mental health system.

EDs face several challenges in providing optimal care to CPS-involved children with mental health emergencies, including:

• Lack of personnel, capacity, and infrastructure
• Difficulties in timely access to mental health professionals
• The busy ED environment
• Limited outpatient post-ED discharge resources

Children’s mental health is not delivered by the stork or subduing them with powerful drugs in emergency rooms. It comes from nourishing parents, skill-building and a safe home environment.

Absent this, children of young moms without parenting skills, drug habits, and violent boyfriends struggle every day to live with their trauma, abuse, and neglect.

Some escape the chaos, but most don’t. Only the very worst cases of trauma and abuse make it into Child Protective Services and Foster Care. Between 10 & 12 million children are reported to CPS every year (pre-COVID)

Fewer cases were reported during COVID, but more stress, domestic violence, and trauma occurred. There were 3.9 children per family in MN’s child abuse reports last year. This is about the national average (3.5 million reports nationally per year – pre-COVID).

This is a topic that most of us avoid. There is little appetite for knowing the living conditions or mental health of or how traumatized fostered and adopted State Ward Children succeed or fail.

Child self-harm and attempted suicide are common in child protective services but rarely reported.

Only successful child suicides make the paper.

Abused children have no voice in their homes and little understanding or support in the media or the State House.

Decades of working in the field of Child Protection have made it clear to this CASA volunteer guardian ad Litem that mental health requires a safe, skill-building environment. Otherwise, too many children go on to live a life missing critical skills, crushing depression, and recurring feelings of failure and inadequacy born out of the traumas they have suffered.

Child self-harm and suicide attempts are everywhere in child protective services, but nowhere are they transparent or reported.

Suicide is now the 2nd leading cause of death among teens

Our ability to avoid and ignore the data and stories has filled our jails, broken our schools, and made our communities unsafe and unhappy.

Almost 1/2 of LGBTQ youth have seriously considered suicide this last year

Children raised in homes filled with rape, violence, crime and substance abuse suffer from self-hate, depression. Their trauma-induced behaviors often set them apart from their peers and leave them without the skills necessary to succeed in school or society.

ER Physician Dr Anna Cushing (the quoted DR in this article) has no way of knowing how many of her patients are traumatized children who come from foster or adopted homes.

Children locked into toxic homes during COVID with no escape or access to mandated reporters might lessen their need for Emergency Room mental health visits and the behaviors that need medicating.

A striking number from the JAMA study;

308,000 emergency mental health visits in the 38 hospitals reported in JAMA’s study equates to 8026 emergency health visits per hospital.

This equates to 48,904,342 emergency room mental health visits in the 6,093 hospitals in the U.S. from 2015 to 2020. The COVID lockdown has kept many millions more children locked in toxic homes over long periods without access to safety or healing.

Caregivers fearful of kids in mental health crises turn to ERs
BY ELLEN BARRY NEW YORK TIMES
For emergency room doctors, they are a dispiriting and familiar sight: Children who return again and
again in the grip of mental health crises, brought in by caregivers who are frightened or overwhelmed.

… surge in pediatric mental health emergency visits in recent years, as
rates of depression and suicidal behavior among teens surged. Patients often spend days or weeks in
exam rooms waiting for a rare psychiatric bed to open up, sharply reducing hospital capacity.

…a large study published Tuesday found a surprising trend among adolescents who repeatedly visited
the hospital. The patients most likely to reappear in ERs were not patients who harmed themselves, but
rather those whose agitation and aggressive behavior proved too much for their caregivers to manage.

In many cases, repeat visitors had previously received sedatives or other drugs to restrain them.
“Families come in with their children who have severe behavioral problems, and the families really just
are at their wit’s end, you know,” said Dr. Anna Cushing, a pediatric emergency room physician at
Children’s Hospital Los Angeles and one of the study’s authors. “Their child’s behavior may be a danger
to themselves, but also to the parents, to the other children in the home.”

The findings, published in the journal JAMA Pediatrics, analyzed more than 308,000 mental health
visits at 38 hospitals between 2015 and 2020.

…The results suggest that researchers should focus more attention on families whose children have
cognitive and behavioral problems, and who may turn to emergency rooms for respite, Cushing said.
“I’m not sure we’ve been spending as much time talking about these agitated and behaviorally
disregulated patients, at least on a national scale,” she said.

The frequency of revisits suggests that the care they receive in emergency rooms “is really not
adequate,” she said.

Guidelines recommend that so-called chemical restraints — benzodiazepines or antipsychotics
administered by injection or through an intravenous drip — be used as a last resort because they can be
traumatizing or cause physical injury to the patient, medical staff or caregivers, said Dr. Ashley Foster,
assistant professor of emergency medicine at the University of California, San Francisco.

The use of these drugs in pediatric emergency rooms has increased in recent years. Between 2009 and
2019, chemical restraint use increased by 370%, while mental health emergency room visits increased
by 268%, according to a study that Foster and her colleagues published last year.

The drugs were used more often on Black patients, as well as on male patients between 18 and 21, the
study found. Foster described those disparities as “concerning, and motivation for thinking about how
to enhance equitable care.”

Dr. Christine Crawford, a child and adolescent psychiatrist at Boston Medical Center, said caregivers for
children with behavioral disorders often turn to ERs when “it gets to the point where someone could get
hurt.”
“They enter sixth, seventh, eighth grades — that’s when we see those families that have been
struggling for a long time,” said Crawford.

Families in this situation, she said, “are quite isolated,” often hiding their struggles from friends and
relatives. ER treatment is comforting to caregivers but offers little long-term benefit, she said.

“Families come in with their children who have severe behavioral problems, and the families really just
are at their wit’s end.”

Dr. Anna Cushing, ER physician at Children’s Hospital Los Angeles and study co-author

KIDS AT RISK ACTION/KARA/INVISIBLECHILDREN.ORG

 

#childhoodtrauma

#childabuse

#Emergencyrooms,#doctors,mentalhealthcrisis,#kidsatrisk,#kara,#lgbtqyouth,#DRannaQushing,#caregivers