State of Emergency: A Crisis in Children’s Mental Health Care

In this issue of Pediatrics, Hoffmann et al¹  present follow-up rates after a pediatric mental health emergency department (ED) visit using a Medicaid claims data set. Their analysis reveals a follow-up rate of 56% for any outpatient mental health visit within a 30-day window. If we consider an ED visit for mental health care a clear indicator of need for specialty mental health care, this study suggests that only about half of the young people who need such care receive it.

Although the authors rightly focus their discussion on this striking gap between need and access to mental health care, their analysis uncovers other important indicators of a pediatric mental health system of care in crisis. Twenty-seven percent of all children in this sample returned to the ED for mental health-related symptoms within a 6-month period, implying that even those who did receive outpatient treatment were not adequately held in that setting. Twenty eight percent of children presented with >4 distinct mental health diagnoses, suggesting poor diagnostic specificity or perhaps inadequate diagnostic categories to characterize their needs. Twenty percent spent >48 hours in the ED for their index mental health visit, demonstrating that the kind of follow-up care required was unavailable. The analysis by Hoffmann et al, in all areas, documents critical problems in our pediatric outpatient mental health treatment system.

As Hoffmann et al and others^2–7  have shown repeatedly, our country is not meeting the behavioral health needs of our young people. Although problems with the pediatric mental health system have been known for decades, recent factors, including the coronavirus disease 2019 pandemic,⁸  accelerated its breakdown. EDs are the last stop when all else has failed, and they, too, lack the resources to support, or even discharge, these patients. The factors driving this crisis are complex, but not insurmountable. Two pressing issues require our immediate attention: First, our community-based mental health support system needs an immediate and massive overhaul. As Hoffmann et al and others have demonstrated, youth and their families lack access to high-quality comprehensive mental health services that provide enough support for children to remain in their homes, out of EDs and out of other 24-hour levels of care. As a result, young people are shuttled between inadequate outpatient services and the ED. When they become too acute to return home, they are stuck boarding in the ED,⁹  often for days, because higher levels of care are inaccessible or do not exist. The shuttling between inadequate services leaves the burden of care on ill-equipped parents with no formal training and little resources. These problems are exacerbated when a young person has multiple areas of need; for instance, a developmental disability coupled with a mental health disorder.¹⁰  Minoritized children also experience more profound disparities in access to and quality of care received.^4,7  We need a massive investment in innovative, holistic, and comprehensive community-based support models, particularly those that can adequately support parents who are caring for their children at home. Second, the pediatric behavioral health workforce has been decimated. The current workforce is young, has little experience, and receives little to no ongoing supervision or training. Two decades ago, community-based mental health care clinicians were largely trained in medical schools or lengthy psychology doctoral programs, both with extensive internship requirements. They worked in organizations with structured and well-funded training departments and under supervisors with significant tenure in the field. Today, the deprofessionalization of the field driven by cost-containment efforts have left us with clinicians that have, at most, 2 years of graduate training in social work of counseling psychology.^11,12  Such clinicians often graduate with an enormous amount of debt, forcing them to make economically driven career decisions. Before they can become independently licensed, they work in community mental health settings. After 2 years of experience, they become eligible for independent licensure. As a result, just as their skills begin to increase, they exit community mental health for private practice to increase their salaries. Our least-experienced clinicians staff the clinics with the highest need. Low rates of reimbursement and lack of pay parity in community-based mental health settings, coupled with a thriving private practice sector driven by insurance expansion through the Affordable Care Act, are to blame for this migration. A massive investment in the education and training, and adequate payment of the behavioral health care workforce are long overdue.

The findings from the study by Hoffmann et al¹  are unfortunately unsurprising and consistent with the literature. They also are not new. As pointed out by Campo et al,¹³  despite epidemiologic data released in 2005 that suggested that 1 in 5 young people met the criteria for mental disorders, a decade later, in 2015, <50% of youth were able to access treatment. This new analysis adds to the overwhelming evidence that there is an urgent need for a dramatic change in our pediatric mental health care system. We believe it is time for a “child mental health moonshot,”¹⁴  and call on the field and its funders to come together to launch the next wave of bold mental health research, for the benefit of these children and their families who so desperately need our support.

ED

emergency department