In the fall of 2021, on the heels of a joint declaration of a state of emergency in children’s mental health by the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry and the Children’s Hospital Association, the U.S. Surgeon General Dr. Vivek Murthy issued a public health advisory regarding the “looming mental health crisis” among children and adolescents.
At the time, omicron was surging nationwide, only to be supplanted this past year by the “tripledemic” of COVID, RSV or respiratory syncytial virus, and influenza. Hospitals heroically increased staffing, added beds and took other necessary steps to address acute medical needs for children and adults.
In contrast, during this same period, the response to the children’s mental health crisis was grossly inadequate. As a pediatric emergency physician and a child and adolescent psychiatrist, we witness the results of this inadequate response on a daily basis.
America’s children have experienced steadily escalating rates of mental illness, including depression, anxiety, and suicidality for over a decade. The pandemic only worsened these trends. In the first six months of 2021, children’s hospitals experienced a 45% increase in self injury and suicide cases in 5–17-year-olds, compared to the same period in 2019. In Oregon, these trends have been particularly stark. Oregon has the nation’s highest rates of depression, substance use disorder, and other mental health disorders among our youth.
Where is the sense of urgency to address these problems?
For years, children’s mental health services have been marginalized and underfunded. Oregon’s pediatric mental health infrastructure has been hampered by ill-coordinated funding, lack of infrastructure and workforce shortages. For example, as recently highlighted in The Lund Report, despite the state increasing funding for substance use disorder treatment, it is still near impossible to find care for youth with serious substance use problems. As the Oregon Capital Chronicle reported, the children’s mental health system strands children with urgent mental health needs on interminable waiting lists, provides wildly disparate services depending on insurance and region, and is bafflingly difficult for parents to navigate. Too often – without mental health services available and their children’s symptoms worsening – parents resort to the final common pathway for society’s failed systems: the emergency department.
When children and parents arrive, they encounter a chaotic environment in which they have to tell their story repeatedly to different providers, many of whom are not mental health specialists. Clinicians are forced to act as gatekeepers to psychiatric services that are mostly unavailable or nonexistent. If patients are deemed safe enough to send home, they are typically discharged with a list of providers who may or may not have openings. Those assessed as too unstable are typically referred to inpatient psychiatry programs and kept in the ED. Unfortunately, in Oregon, inpatient pediatric psychiatric care options are incredibly limited: Only two hospitals provide the highest level of care and offer approximately 40 beds. These programs are often at capacity, resulting in youth boarding in the ED for days or weeks. If a youth has co-occurring mental health and substance use problems, the options dwindle even more. For youth and families, having to wait in an ED for days to weeks to access needed care is often crushing. For providers on the front lines of the mental health epidemic, witnessing their patients failed by the system again and again leads to disillusionment and burnout.
In 2022, the U.S. launched a new 988 mental health emergency response system. Oregon has adopted 988 as well as expanding its mobile response system and adding a crisis stabilization program for youth called stabilization services. These are undoubtedly seeds of hope; but for these seeds to grow into effective programs, they must be bolstered with adequate funding and staffing. Furthermore, we must create a true continuum of care by increasing options across both outpatient and inpatient care, so that any child’s or adolescent’s mental health needs are appropriately addressed.
This continuum of care must be user-friendly, with clear points of entry and with replicable, consistent and effective pathways. Services must be available uniformly across all regions and coordinated with the educational system. And, most importantly, insurers must be held accountable for covering these services, in parity with medical services.
Children’s mental health deserves no less than a pandemic-level response; while uneven, our national response to COVID-19 proves the U.S, health care system can address crises when it chooses to. We have a limited amount of time with our current generation before they progress into adulthood, where they will either be able to function as healthy adults, or not. In the words of Murthy, “It would be a tragedy if we beat back one public health crisis only to allow another to grow in its place.”
Rebecca Marshall is a medical doctor and an associate professor of child and adolescent psychiatry and pediatrics at Oregon Health & Science University. She works in the pediatric emergency department as well as the children’s hospital with youth who are having mental health crises. She is the director of the data evaluation and technical assistance team, which partners with Oregon Health Authority and community agencies to evaluate and improve statewide youth mental health programs, and the immediate past president of the Oregon Council of Child and Adolescent Psychiatry.
Rob Cloutier is a medical doctor and professor of emergency medicine and pediatrics as well as the assistant dean for admissions at Oregon Health and Science University’s School of Medicine. He has over 20 years of practice and academic experience at the forefront of the pediatric mental health crisis. He is also a member of the board of directors for Portland Street Medicine, an organization delivering medical care to unhoused populations in the Portland area.
This Commentary first appeared in the Oregon Capital Chronicle. It may or may not reflect the views of The Corvallis Advocate, or its management, staff, advertisers or donors.
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