A National State of Emergency in Child and Adolescent Mental Health

Disclaimer: The content of this podcast may be emotionally challenging. Youth mental health is discussed, including self-harm, which may make some audience members feel uncomfortable. Listener discretion is advised.

In this episode of Perspectives 360, we are going to examine the increase in serious mental health issues faced by our nation’s young people and the resulting implications for healthcare and parenthood. In future episodes, we will dive deeper into these implications and what needs to be done to reverse this trend. 

During this episode you will: 

• Explore the scope of the national state of emergency in youth mental health 
• Learn that mental health problems affect 1 in 5 young people 
• Listen to a discussion regarding the rise of suicidality among young people 
• Hear key takeaways on methods that may help to reverse the trend of suicidality among young people 

Link to Transcript

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The information provided through this activity is for educational purposes only. It is not intended and should not be construed as legal or medical advice. Opinions of the panelists are their own and do not reflect the opinions of Coverys or Med-IQ. 

Music and lyrics: Nancy Burger and Scott Weber

Transcript

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Geri Amori: Before we begin, because this podcast is discussing pediatric mental health, including suicide, it might be disturbing to some listeners. 

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Hello, everyone, and welcome to Healthcare Perspectives 360, a podcast dedicated to exploring contemporary healthcare issues from multiple perspectives. I'm Geri Amori, and today, I'm joined by Dr. Cara Pratt, a psychologist who works with all age groups and specializes in clinical anxiety disorders; Dr. Neil Bruce, a psychiatrist who specializes in child and adolescent affective disorders; and Mary Kisting, a clinical nurse specialist who works primarily with the inpatient pediatric population at a Level 1 trauma teaching hospital. Welcome. 

Today, we're talking about the increase in serious mental health issues faced by our nation's young people. The literature supports that mental health problems affect 1 in 5 young people, which is a full 20% of our youth. One sadly shocking marker of the need for intervention is that suicide is the second-leading cause of death for young people ages 10 to 24. Nonetheless, two-thirds of those who need treatment do not have access to it. And while there are many contributors to the increase in mental health treatment needs, research suggests that exposure to racism, both individual and systemic, contributes to both mental health symptoms and healthcare inequities. 

We are experiencing annual increases in mental health service utilization of 6 up to 10% a year, which, over time, has a very large cumulative effect. In 2021, the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Children's Hospital Association jointly declared a national state of emergency in child and adolescent mental health, citing dramatic increases in mental health conditions and emergency room utilization. In today's episode of Perspectives 360, we are going to examine the scope and the range of the problem and implications for healthcare and for parenthood. In future episodes, we will dive deeper into the implications and what needs to be done. 

So to begin, our panelists have told me I can use their first names, and I'm going to give you a quick setup with some statistics so that you have a frame of reference for what we're going to talk about. So, the 2023 data published by the CDC in their Youth Risk Behavior Survey Summary and Trends report states that—get ready for this—40% of kids, that we've been talking about, report persistent feelings of sadness or hopelessness. The increases in the percentage of students who were threatened or injured with a weapon at school went from 7% up to 9%. Increases in the percentage of students who were bullied at school went up from 15% to 19%. And increases in the percentage of students who missed school because of safety concerns, either at school or on the way to school, went up from 9% to 13%. 

Now, I'd like to really ask our panelists what they're experiencing. So Neil, what have you seen in your practice? Do these stunning numbers match what you see? Does it feel like these rates have increased over the last 10 years?

Neil Bruce: I would say, in my practice, I have definitely noticed the numbers have gone up. I think, with COVID and the pandemic, obviously, everyone's lives were uprooted, and our regular routines and ways about going through life were uprooted. But especially for children, where going to school is a big place where you socialize, with the pandemic, things switched to virtual for many of us, but virtual school for kids was very isolating. I think it was a matter of kind of just getting through it, maybe not excelling or learning as much, but also not socializing, which is a big part of child development and also how kids enjoy life, how they interact with others and build friendships, really gets them out of the house, gets them active. And I think being at home was very disruptive for their development and for their mental health well-being. 

Now that kids are back in school, I do think there are some social skills deficits that lead to bullying. Kids might not feel like they can interact with other kids as well, which can also kind of make them easy targets of bullies as well. And in terms of the weapons and school safety concerns, it does seem like that's gone up a lot as well, and it is scary. You hear about guns being brought to school. You hear about threats, as well, and since those weapons are fairly easily accessible, you do have to take those threats seriously, too, which means shutting down schools, suspending kids that can be further disruptive to their education.

Amori: That's a lot. Cara, what about in your practice? The number of young people who are threatened by a weapon [at] school or miss school because of safety concerns seems huge. Do you see a lot of this?

Cara Pratt: I do. I agree with a lot of what Neil said, and I'm seeing the same things. It just seems to be getting more and more common. At my practice, I don't see as much of the direct threats with weapons at school, but bullying and, like, really violent fights are pretty common to hear. I've even seen videos of violent fights that have happened at schools. And bullying threats on social media is a big one I see a lot. And overall, I tend to work with people who are more on the anxious side of things, so I might see more of this than others, but there's really significant anxiety about bullying at school, safety concerns, and even things like bomb threats or mass shootings. I've even worked with, like, really, really young kids who are really worried about mass shootings at their school, and it's absolutely heartbreaking. 

And then also working with their parents, too, on how to address this with your kids because it is a real fear. But it affects a lot, and I'm seeing a lot of the anxiety. Honestly, the sadness and hopelessness that you've talked about as well is something I see quite a lot with really, really, quite depressed kids who are quite young, and their parents as well trying to know what to do with all of that. So really, I'm not surprised by those numbers, unfortunately.

Amori: Let's move to Mary. Mary, I'm struck by the number of youth expressing signs and symptoms of depression. I hear it from grandparents who are worried about their grandchildren. I see it on the media. I hear about it. And I seem to remember, though, that the teens were a time of dysphoria for everybody. I mean, everything from acne to relationship problems to feeling like a total loser. But it seems different now. How do you see it as different now?

Mary Kisting: Geri, the most striking difference that I have seen over the past number of years in the hospital setting, is that the children that we're seeing in the acute care areas are younger. It was really interesting to see children come at such an age where they are really still developing their coping skills, and then have the onslaught of all of the things that have just been discussed about—COVID and bullying and violence and all of those things. And I think the consequence of that has been in the inpatient setting that we're seeing children come in at a very much younger age, and that's really different. 

And I think the other thing that we've seen is that there's just more children coming in with suicide attempts, depression. And it's really not unusual to have numerous children in the emergency department, who have come in with a suicide attempt, awaiting placement. And that's not unique, I think, to our area. I think that's across the country. There's just more patients, more children coming in with these issues, and they're younger than they used to be.

Amori: Like how young? Like how young are we talking? Are we talking 13, or are we talking 6? What are we talking?

Kisting: The NIH has a screening tool that they use for suicide. It's called the ASQ—Ask Suicide Questions. They suggest screening as young as 8, but the data that they have from their studies that they've done goes down as young as 3, for children that are starting to show signs, clinical signs of depression, and those kids are even at greater risk when they get older. So it's very young, and there's more of them.

Amori: Oh, that makes me so sad. Thank you. Neil, among all the mental health cases identified, using the Child And Adolescent Mental Health Disorders Classification System in 2023, suicide attempts and ideation and self-injury has seen the greatest increase, and it has become the most common ED mental health condition in children's hospitals. Since 2019, the ED cases of suicide and self-injury, it says, has risen 50%, and inpatient cases have risen 30%. And since 2016, they've nearly tripled. More than half the children who make a suicide attempt or die by suicide have had a visit to a regular health provider, physical health provider, in the 6 months before their death or their attempt. And what is that about? How are we missing it? How were they getting the means? I mean, this scares me as a grandparent. It must be horribly frightening for parents. What are your thoughts? 

Bruce: Suicidality and suicide rates were increasing prior to the pandemic, and then it seemed like the pandemic did accelerate that somewhat, especially with all the social isolation, worsening depression, and anxiety during the pandemic. I do think one of the points you made is that more than half of the kids did have a visit with a physical health provider in that time prior to attempt or prior to the behavior. And I think that speaks a lot to screening, which Mary had talked about. She had mentioned the ASQ, or Ask Suicidal Questions. But you see more and more that healthcare organizations are building in screening tools into the emergency room and also into primary care pediatric visits, which is one way that we can prevent missing these in the future. Also educating schools, teachers about signs that they can notice in kids, as well as educating the kids themselves at school. 

I think it's a lot more prevalent than we even know, and then even more so than parents might think, too. I think a lot of times parents might think, oh, not my kid. Or, mental health is something other people deal with, but really it can affect anyone, any age, any demographic, any kind of socioeconomic status. So it is something everyone should be screened for during those primary care visits and emergency room visits. I think in terms of means, these could be anywhere from over-the-counter pills, like Tylenol, some medications, and then also sharps. So if you do have a kid who's showing signs of depression or seems to be at risk for that, you do have to consider just regular household items. They can be dangerous. You might not even recognize it.

Amori: Well, that's pretty scary. Cara, do you see a lot of suicidality among your patients? I mean, building on what Neil said, what kind of means do they have, and can't parents help? Or do you think most parents are disbelieving or clueless? 

Pratt: I absolutely see this quite a bit, and, unfortunately, I agree it seems to be increasing over time. At least where I'm practicing, most of the parents are really wonderful and very involved. I think sometimes there's maybe some degree of denial about the severity of what's happening, but they're absolutely not clueless, for sure, and they want to help, but sometimes just unsure of what to even do or how to even assess, as a parent, how severe the symptoms are for their kids. 

As far as means, and I kind of will tell parents this, too, if you're at a place, depending on an age and cognitive level, if a child is at an age where they want…if they're feeling like they want to harm themselves or to kill themselves, it's kind of hard to limit access to anything that might allow them to do that. I've heard means used before that I never would have even thought of. And so that's part of it is just talking with the parents and caregivers about how to manage risk as much as possible and teaching about discussing this. Or even if I talk with the kids separate from their parents, a lot of times, they will tell me it's a lot more severe than they've told their parents because they don't want to upset or scare their parents as well. So having a different person to talk to that feels safe might be a way of addressing this a little bit. Yeah, it's very disheartening.

Amori: Mary, what about you? Anything unique in the last few years? 

Kisting: You know, Geri, there's not anything particularly unique that we have seen, but it's become more common to see mental health issues as children are coming in for medical care. It's really kind of the usual to have a child admitted with a medical diagnosis, asthma or a trauma, and then they have a mental health medical history on top of that. The uniqueness isn't the types of suicides that we've seen. There's most commonly we are seeing firearms, but I know that there's also cases where there's hangings, and things that…and then kids get real unique, and ingestion of pills is a whole, whole other grouping that's relatively common. And so those have sort of stayed consistent, I think, over time. But it's seeing those kids that come in with all, generally, other medical problems, sometimes somewhat straightforward, also having a pretty robust medical health history as well.

Amori: Wow. Thank you, Mary. I do want to ask Neil one more question. We have a really bad situation, and you work in the inpatient situation. In the Surgeon General's advisory, Protecting Youth Mental Health, it says the best protection is prevention, but that feels almost like a platitude. That horse has left the barn, obviously. And so, do you see any hope? And then I'm going to ask all of you what you want everyone to remember.

Bruce: Yes. So I definitely still think there's hope in this situation. I agree, prevention is the best protection, but if you're currently in a psychiatric crisis or you're currently in a depressive episode, you need more than just prevention. You need treatment. And I think it's important to know that there are treatments for depression in children, adolescents, young adults. We have a lot of evidence that shows that these treatments work. I think a hard part is the resources or finding the right help. There was a lot of bad stuff that happened in the pandemic, but one good thing is, like how we're talking on Zoom right now, telepsych has really opened up a lot of resources for patients. If you're in a state here in the United States, lots of times people practice based on their state and their state medical board, but I guarantee that you will be able to find someone who can treat you through telepsychiatry. So I think that is one benefit of the pandemic we found. 

Amori: I’m glad we found one benefit, Neil. As we come to a close today, I know that we've talked about a lot of really heavy stuff. I'd like to ask each of our panelists: if they have one point they'd like our audience to take away from our discussion today, what would that be? And I guess I'd like to start with Mary.

Kisting: I think the one takeaway that I would have is that providers, healthcare team members, anyone who has an opportunity, we should be using evidence-based screening tools at every single chance. I think that's a great way to, with a minimal amount of time and an evidence-based tool, provide resources to parents and families and children quickly before things escalate. And so that's my one idea that I have. 

Amori: Okay. Thank you. Neil, you got one takeaway?

Bruce: I would say I would like to provide reassurance to the parents. Mental health problems are very common in children and adolescents, but the treatment is out there. Sometimes it's hard to navigate, but I think a good starting point would be asking your pediatrician or primary care doctor for any resources out there, therapy, typically cognitive behavioral therapy. And then lots of pediatricians do feel comfortable prescribing antidepressants, and if they don't, they should be able to provide you a referral to a child psychiatrist.

Amori: Okay, good. And Cara, what are your thoughts?

Pratt: I agree with both of what they said, so far. Trying to think of what to add on, I would say just feel okay asking even young kids about how they're feeling and if they have thoughts about not wanting to be around anymore, or if they ever think that they hope they don't wake up in the morning. I think that's scary to ask—a lot of people I think with COVID, our mental health awareness, in general, is increasing—but I think there are still people who think if you ask about suicide, that you might be increasing that risk, and there is no evidence that that's what happens. And it's scary to ask about, but it's okay to ask about. Kids are willing to talk about this stuff if you ask. That would be my main my takeaway.

Amori: Well, thank you, Cara. And thank you, all of you. This has been a great discussion. You've certainly educated me. I really want to thank our panelists for participating, and I hope our audience has found this valuable as well. I want to thank you for joining us and invite you to join us again next time on Perspectives 360.

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