Children presenting for deliberate self-harm tripled over 10-year study period

Kids with mental health disorders landed in the emergency department (ED) with alarming frequency in a 10-year study period, most notably for deliberate self-harm and substance abuse, according to analysis of national data.

The assessment of data from several national databases (2007 to 2016) showed that visits for children (ages 5 to 17 years) shot up by 329% for deliberate self-harm, 159% for substance use disorder, and 60% for all mental health disorders, reported Rachel M. Stanley, MD, MHSA, Nationwide Children’s Hospital in Columbus, Ohio, and co-authors.

“The majority of these visits occur at nonchildren’s EDs in both metropolitan and nonurban settings, which have been shown to be less prepared to provide higher-level pediatric emergency care,” they wrote in Pediatrics.

Some good news: Pediatric ED visits overall remained stable, and alcohol-related disorders fell 39%, they added.

The current study addresses missing data on where there has been an upswing in children seeking mental health care, especially in rural areas that struggle with shortages of qualified mental health professionals, noted Jennifer A. Hoffmann, MD, of the Ann & Robert H. Lurie Children’s Hospital of Chicago, and Ashley A. Foster, MD, Boston Children’s Hospital, in a commentary accompanying the study.

They pointed out that “The National Pediatric Readiness Project… demonstrated that EDs with lower pediatric volume are less likely to have pediatric-specific equipment, policies, and procedures in place that are recommended for emergency care of children.”

But even adopting policies and procedures won’t be enough to “guarantee delivery of high-quality care…Clearly, innovative solutions are needed at a systems level to better meet the needs of children with mental health emergencies,” Hoffmann and Foster stated.

As an example, they cited a toolkit from the Department of Health and Human Services that “offers an adaptable framework with recommendations for triage, screening, assessment, and disposition for pediatric mental health patients in the ED.”

Stanley and co-authors used data from the Nationwide Emergency Department (NED) Sample databases, the Healthcare Cost and Utilization Project, and the Agency for Healthcare Research and Quality.

The children were grouped into three groups: those with any mental health disorders; those with substance use disorders; and those who presented for deliberate self-harm. Pediatric ED volume for each site was classified based on the Pediatric Readiness Survey categories.

The authors reported that mental health ED visits rose 68% among teens (ages 15 to 17 years) and 74% among girls (P<0.001 for both). Also, ED visits for anxiety disorders went up by 117% as did visits for impulse control disorders (111%, P<0.001 for both).

As for pediatric ED volume, “Significant rate increases were observed among nearly all ED volumes, except for medium-volume facilities [4,000 to 9,999], and was most pronounced among facilities with higher pediatric ED volumes [10,000 to 24,999],” Stanley’s group wrote.

Additionally, they found that the absolute rate change among non-children’s hospital EDs increased from 14.6/1,000 to 22.7/1,000, for a difference of 55% (P<0.001). “Similarly, pediatric mental health ED visits rose among all urban-rural locations; although greatest among the large and small metropolitan areas (P <0.001), a 41% increase was observed among EDs classified as neither metropolitan nor micropolitan (P=0.001),” they stated.

Study limitations included lack of NED data on return rates to the ED for mental healthcare, and the potential for missed cases if a child came to the ED without a formal diagnosis for a mental health condition. “However, because we limited our analysis to age 5 years and above, age of onset for these conditions is more likely to have occurred by then,” the authors stated.

Stanley and co-authors also pointed out that “The rate increase in substance use disorders, despite the decline in alcohol use disorders, bears further investigation, especially as the opiate epidemic continues to escalate.”

They suggested that telehealth could be one way that rural, low-volume EDs increase “access to behavioral health specialists who can screen, assist with acute interventions, and support connections to continued care within the community,” adding that research has indicated that telephone consultation programs can lead to kids receiving greater mental health treatment.

  1. U.S. children who presented with mental health disorders, sought care at emergency departments (ED), particularly for deliberate self-harm and substance use disorders.

  2. The majority of visits occurred at non-children’s EDs in both metropolitan and non-urban settings, which have been shown to be less prepared to provide higher-level pediatric emergency care.

Shalmali Pal, Contributing Writer, BreakingMED™

Stanley and co-authors, as well as Hoffmann and Foster, disclosed no relationships relevant to the contents of this paper.

Cat ID: 254

Topic ID: 253,254,254,730,138,192,146,54,55,57