Throughout the pandemic I have sometimes felt I could split myself in two and still not treat all the children and teenagers whose parents call me every day asking whether I can see them. Sometimes I add hours and work later into the night, knowing that I too am being stretched.
I worry about an 11-year-old girl who was struggling with terrible mood swings before the pandemic and then lost a grandparent to Covid and told me that she cannot breathe wearing a mask. It causes her to have panic attacks, on top of her being terrified that her parents will soon die from the latest variant.
I worry about a teenager I treat who told me if he had access to a gun, he would shoot himself, and another who climbed up on a roof, planning to jump, and at the last minute had second thoughts. Suicidal behavior is often preceded by a trigger, and for many youth, the unique stresses associated with Covid have provided that catalyst, particularly when combined with a mental health system that was overburdened even beforehand.
In the past few months, my patients and I were just starting to interact again in person. This laid bare the damage caused by Covid, as their emotional pain seemed all the more poignant in three dimensions as opposed to on Zoom. This reality was recently highlighted in a surgeon general’s advisory about pediatric mental health and emergency declarations by the two major medical organizations that oversee the care of children. These pronouncements may fall aground, awash in the many advisories we are all immersed in daily. But they are a call to arms to develop more effective mental health screening and intervention strategies, and they highlight the disproportionate impact of Covid on youth, especially young people of color. We must listen.
With Omicron, it is clear that anxiety is starting to spiral out of control even further, in a sort of PTSD response, as people are flashing back to traumatic memories of the beginning of the pandemic. Until a few weeks ago, I could almost feel that things were getting better. Kids were back in school both locally and at college, playing sports and attending after-school activities, and everyone seemed to be adapting to what clearly is an endemic. Now what?
In the past several weeks, I have gotten more and more calls from extremely depressed and overwhelmed college students who are taking medical leaves from school and need me to email professors or fill out the necessary paperwork. I can’t find clinicians near their colleges to treat them, and their college health services are often limited in the amount of regular mental health care they can provide.
One young man was going to overdose in his dorm room, and his R.A. called campus security and he was taken to the local emergency room. He was discharged the next morning, withdrew from school and returned home. He refused further hospitalization, and there were no intensive outpatient programs near his home that were seeing patients in person, and he had had a negative experience with a virtual “day program” in the past.
Several days later, his mother called the police after he locked himself in the bathroom planning to overdose. He was taken to the emergency room, where he waited for hours for an inpatient hospital bed at another hospital.
Things got better after that: He was discharged from the hospital and entered a residential facility. He is doing extremely well and asking to return to college after the residential treatment is over. Still, I wonder if there had been more suitable intensive outpatient options whether he would have been hospitalized in the first place, let alone whether he would have needed to experience the trauma of the emergency room stay that preceded his hospitalization.
Long wait times and insufficient resources for youth mental health are tragically common. Recently, in our emergency room at NewYork-Presbyterian Morgan Stanley Children’s Hospital, children and teenagers could wait an average of three to four days for an inpatient bed. This improved to a still unacceptable two- to three-day wait thanks to an obvious solution: Six more beds were added at one of our inpatient units — which was no easy task.
There are currently logjams at every portal to mental health care for inpatient and outpatient care, in person and over Zoom. I often cannot find other clinicians to refer children to or to treat alongside me using other types of therapy, because everyone is already too busy.
This shortage predates the pandemic. A 2019 study found that nearly half of the 7.7 million pediatric patients in the United States with a mental health disorder were not receiving treatment. The American Academy of Child and Adolescent Psychiatry estimatesthat there should be 47 child and adolescent psychiatrists for every 100,000 youths in the United States, but the national average is just 11 such doctors per 100,000.
The increased need for care has turned this shortage into a full-on crisis. Among emergency department visits by girls ages 12 to 17 in early 2021, there was a more than 50 percent increase in suspected suicide attempts compared with the same period in 2019. In the first six months of this year, children’s hospitals across the country reported a 45 percent increase in the number of self-injury and suicide cases in 5- to 17-year-olds compared with the same period in 2019.
Both the American Rescue Plan of 2021 and Build Back Better, which has yet to be passed, have substantial allocations for pediatric mental health. The Substance Abuse and Mental Health Services Administration is distributing $3 billion in funding for mental health and addiction, with 25 percent for children, youth and families, focusing mainly on crisis care. Build Back Better would provide $165 million.
The open question is how to allocate this money. We need more clinicians in schools, more child psychiatrists, better screening, more crisis services and 72-hour emergency evaluation units, more inpatient beds, and intensive outpatient programs designed to keep children out of the hospital and for them to transition into following hospitalizations. Repeat suicide attempts by teenagers, for example, are most common in the month after discharge from a psychiatric hospital.
We also need to improve access to care and preventive services, especially to reach suicidal teenagers. Although there has been a large expansion of remote-based mental “telehealth,” we need more mental health “boots on the ground” in our schools and pediatricians’ offices. Fewer than 40 percent of schools in our country had full-time nurses in 2017. Psychologists are responsible for an average of 1,211 students. We need to recruit and train more clinicians and enhance our arsenal for treating pediatric mental health. A colleague suggested developing an AmeriCorps-type program to train college graduates to provide school-based mental health services.
I’ve seen firsthand how good, consistent care can transform the lives of youths with mental health problems. I just received a holiday card from a former patient expressing thanks. I met him when he was a youngster who had been expelled from several schools. During the time I treated him, I managed his medication and hospitalized him twice, and he was treated in an intensive outpatient program. He then spent three years in a residential treatment center before being mainstreamed back into his hometown’s district high school.
Upon graduation, he earned two associate degrees and a bachelor’s, and is now a student in a master’s degree program in occupational therapy. He lives with his girlfriend and their two dogs, wearing “Happy Hanukkah” bandannas in the picture he enclosed. All children and adolescents who need it should have access to care like this. Will we learn from this crisis and finally invest in the well-being of our young people?
Jonathan Slater is a child and adolescent psychiatrist at NewYork-Presbyterian Morgan Stanley Children’s Hospital.
Pandemic Impacts on Children’s Mental Health
Return to School During COVID-19: Considerations for Ontario’s Child and Youth Community Mental Health Service Providers draws on existing knowledge about the impacts of previous infectious outbreaks and emerging evidence and theories about COVID-19. Scholars have identified interrelated sources of distress young people may be experiencing currently. These include, but are not limited to:
Stress associated with fear that family members, friends or they themselves will become ill/infected by the novel coronavirus
Stress associated with uncertainty around the duration of the pandemic, vulnerability to infection, physical distancing measures, and longer-term impacts of the social and economic upheaval both locally and globally.
Stress resulting from intensified media coverage (risk-elevating messages can amplify anxiety; social media can be a source of misinformation).
Potential neurological effects of COVID-19 itself.
Adverse social and economic impacts of physical distancing, quarantine and isolation including:
Loneliness; grief and bereavement complicated by physical distancing measures.
Stigmatization – particularly for individuals infected with – or believed to have been exposed to – the virus (including health care and other essential services workers).
Financial insecurity and challenges in accessing basic needs.
Tensions in relationships and domestic violence related to household confinement.
Access to health, community and social supports – e.g. many children access supports through schools, which have been closed in order to contain the disease.
Another consideration is the impact on children and youth who have been receiving additional support services (e.g. OT, PT, speech-language, special education, mental health) while schools have been closed. They may require a transition plan to ensure there is no disruption in supports and continuity of care.
9 ways of protecting your child’s mental health in face of COVID's Omicron variant
Read here for ideas on how to help kids manage though this difficult time. Daily mindfulness, as a core practice, is a great start.