The hidden pandemic
Dr. Sekaran
In the eyes of Anand Sekaran, MD, division head of hospital medicine, and medical director of inpatient services at Connecticut Children’s Medical Center in Hartford, Conn., it’s a hidden pandemic.
Not the physical toll of COVID-19, which blares across cable-television shows and newspaper headlines daily.
It’s the mental toll on children, adolescents, and teenagers.
“I often coin it as the second pandemic, the pandemic of the mental health care crisis in children,” Dr. Sekaran said. “It’s truly occupied my team’s life over the last one and a half to two years now. Our clinical work-life has been dominated by the mental health crisis seen during COVID.”
Pediatric hospitalists aren’t alone.
In October, the American Academy of Pediatrics (AAP), American Academy of Child and Adolescent Psychiatry (AACAP), and Children’s Hospital Association (CHA) declared a “child and adolescent mental health emergency.”
“We are caring for young people with soaring rates of depression, anxiety, trauma, loneliness, and suicidality that will have lasting impacts on them, their families, and their communities,” the statement read in part. “We must identify strategies to meet these challenges through innovation and action, using state, local, and national approaches to improve the access to and quality of care across the continuum of mental health promotion, prevention, and treatment (see sidebar below).
The public statement acknowledges what pediatric hospitalists have endured for more than a year: pediatric patients are filling up emergency departments and hospitals while they wait for a bed in a mental health care facility.
For Dr. Sekaran, that declaration is further validation of what he and his team see on a daily basis. Connecticut Children’s, for example, has seen roughly a 40% increase in eating disorders in children since the beginning of the COVID-19 pandemic in March 2020. He also sees a higher rate of suicide attempts in teenagers, mirroring the national trend.
As a hospitalist in an academic setting, the medical treatment so often tied to mental illness isn’t the issue, Dr. Sekaran said.
“We’re quite good at the medical care,” he said. “We’ve done it, and we know how to do it. The challenge comes when they become medically cleared, and then those children who need further inpatient psychiatric care, unfortunately, have nowhere to go.
“And that speaks to the overall societal crisis in the lack of appropriate and sufficient mental health inpatient beds. So, imagine what happens. We admit many, many more children. We clear them medically, and then they have nowhere to go because they have no inpatient psychiatry placements.”
The situation is even more precarious in community hospitals, where HM practitioners don’t have the staffing or the resources to handle the increased pipeline of pediatric mental health patients.
Pediatric hospitalist and regional clinical director Beth Natt, MD, MPH, SFHM, who practices at several community hospitals in Connecticut, said that one way she’s adjusted is to work with the emergency department for consults to “facilitate the medical clearance of more complex children.” It doesn’t solve all issues, but it can help, especially as she’s seen the number of pediatric mental health admissions for medical treatment such as non-accidental ingestions rise from one every month or two to almost weekly.
Dr. Natt noted that in addition to the medical issues including increased length of stay and inpatient flow, the pediatric mental health crisis also weighs on hospitalists themselves.
“These are difficult situations for families, and we are having to regularly have hard and emotionally challenging conversations on a frequent basis. The intensity of emotional support these situations require, just in terms of the face-to-face kind of conversations, are really tough on our staff,” she said. “In the community hospital setting, those kinds of kids are challenging to support. We don’t have the depth of pediatric resources in the community hospital setting.”
Even with the strength and support of an academic setting, Dr. Sekaran said it’s not enough to keep pace. The pediatric mental health crisis has put a spotlight on the broader issue that even before COVID-19, there were not enough inpatient mental health beds for children. In addition, the reimbursement for those psychiatric services needs to increase, he said.
“If the incentive is there, these beds and programs will get created,” he added. He believes there is also a need for improved “upstream interventions,” such as school-based services and access to outpatient mental health visits.
This leaves the question for pediatric hospitalists: is the current crisis and the formal recognition of it from groups like AAP, AACAP, and CHA enough to move the needle?
“It is my hope,” Dr. Sekaran said, “that this will be the catalyst and the new attention and spotlight that is needed, exacerbated by the pandemic, and ultimately will result in real change.”
Richard Quinn is a freelance writer in New Jersey.
Sidebar: A call for change
The recent crisis declaration from the American Academy of Pediatrics, American Academy of Child and Adolescent Psychiatry, and Children’s Hospital Association calls for policymakers to advocate for:
- Increased federal funding to ensure all families and children can access evidence-based mental health screening, diagnosis, and treatment, with particular emphasis on under-resourced populations.
- Addressing regulatory challenges and improving access to technology to assure the continued availability of telemedicine.
- Increasing implementation and sustainable funding of effective models of school-based mental health care, including clinical strategies and models for payment.
- Accelerating adoption of effective and financially sustainable models of integrated mental health care in primary care pediatrics, including clinical strategies and models for payment.
- Strengthen emerging efforts to reduce the risk of suicide in children and adolescents through prevention programs in schools, primary care, and community settings.
- Address the ongoing challenges of the acute care needs of children and adolescents, including shortage of beds and emergency room boarding by expanding access to step-down programs from inpatient units, short-stay stabilization units, and community-based response teams.
- Fully funding comprehensive, community-based systems of care that connect families in need of behavioral health services and supports for their child with evidence-based interventions in their home, community, or school.
- Promoting and paying for trauma-informed care services that support relational health and family resilience.
- Accelerate strategies to address longstanding workforce challenges in child mental health, including innovative training programs, loan repayment, and intensified efforts to recruit underrepresented populations into mental health professions as well as attention to the impact that the public health crisis has had on the well-being of health professionals.
- Advancing policies that ensure compliance with and enforcement of mental health parity laws.
Source: AAP-AACAP-CHA Declaration of a National Emergency in Child and Adolescent Mental Health
