Pediatric Emergency Department Visits Associated with Mental Health Conditions Before and During the COVID-19 Pandemic - United States, January 2019-January 2022

The Impact of Social Media Use on the Development of Eating Disorders

Pediatric providers are caring for youth who are digital natives and will spend their lives as online media consumers. Awareness of the risks and benefits, as well as ways to mitigate harm are essential to effectively care for children and adolescents, as well as educate their families. Social media is widely used by youth, with widespread effects, including the potential to influence the development of disordered eating. Higher risk youth can be vulnerable to advertising, body image comparisons, and predatory online eating disorder communities.

Changing Epidemiology of Emergency Medical Services Calls for Children in the United States During the COVID-19 Pandemic and Reopening

OBJECTIVES

The objective of this study was to describe changes in the volume and types of emergency medical services (EMS) calls for children during the COVID-19 pandemic and after availability of the COVID-19 vaccine ("reopening period").

METHODS

A retrospective cross-sectional study of EMS 9-1-1 responses to children under 18 years for all causes over a 4-year period (2019-2022) reported in the National Emergency Medical Services Information System (NEMSIS) dataset. Data was stratified into three periods, Pre-pandemic, Pandemic and Reopening. We used generalized linear models to estimate the effect of the pandemic and reopening on daily call volume trends, on-scene mortality and scene disposition, correcting for seasonality and baseline effects. We performed subgroup analyses based on geographic region and diagnosis (trauma, respiratory, mental health, seizure, diabetes).

RESULTS

A total of 4,612,505 pediatric EMS 9-1-1 responses were included. Call volume for EMS showed an increasing pre-pandemic trend (+25.9%/year) followed by an acute drop in volume (-28.9%) and decreased trend (-13%/year) during the pandemic period and a rebound (+17.5%) during the reopening period that was generally conserved across all regions. Subgroup analysis by diagnosis showed similar trends among a wide variety of illnesses. There were increased odds of on-scene death for calls for traumatic (OR 1.77) and respiratory (OR 2.00) illnesses, with partial reversal in the respiratory group (OR 0.66) during the reopening period. During the pandemic, children were less likely to be transported (OR 0.70) and more likely to be non-transported (OR 1.30) and refuse care (OR 1.32), with partial reversal of these trends during the reopening period.

CONCLUSIONS

The pre-pandemic increase in EMS call volume was disrupted by an acute pandemic-related decline followed by a rebound during reopening. During the pandemic, children were more likely to present with more severe manifestations of disease processes, particularly increased on-scene death for trauma and respiratory illness, and less likely to be transported-with only partial reversal of trends in reopening.

Outcomes Following a Mental Health Care Intervention for Children in the Emergency Department: A Nonrandomized Clinical Trial

Importance

The emergency department (ED) is an important safety net for children experiencing mental and behavioral health crises and can serve as a navigational hub for families seeking support for these concerns.

Objectives

To evaluate the outcomes of a novel mental health care bundle on child well-being, satisfaction with care, and health system metrics.

Design, Setting, and Participants

Nonrandomized trial of 2 pediatric EDs in Alberta, Canada. Children younger than 18 years with mental and behavioral health presentations were enrolled before implementation (preimplementation: January 2020 to January 2021), at implementation onset (run-in: February 2021 to June 2021), and during bundle delivery (implementation: July 2021 to June 2022).

Intervention

The bundle involved risk stratification, standardized mental health assessments, and provision of an urgent follow-up appointment after the visit, if required.

Main Outcomes and Measures

The primary outcome, child well-being 30 days after the ED visit, was assessed using the Stirling Children's Wellbeing Scale (children aged <14 years) or Warwick-Edinburgh Mental Wellbeing Scale (children aged 14-17 years). Change in well-being between the preimplementation and implementation periods was examined using interrupted time-series analysis and multivariable modeling. Changes in health system metrics (hospitalization, ED length of stay [LOS], and revisits) and care satisfaction were also examined.

Results

A total of 1412 patients (median [IQR] age, 13 [11-15] years), with 715 enrolled preimplementation (390 [54.5%] female; 55 [7.7%] First Nations, Inuit, or Métis; 46 [6.4%] South, Southcentral, or Southeast Asian; and 501 [70.1%] White) and 697 enrolled at implementation (357 [51.2%] female; 51 [7.3%] First Nations, Inuit, or Métis; 39 [5.6%] South, Southcentral, or Southeast Asian; and 511 [73.3%] White) were included in the analysis. There were no differences between study periods in well-being. Reduced well-being z scores were associated with mood disorder diagnosis (standardized mean difference, -0.14; 95% CI, -0.26 to -0.02) and nonbinary gender identity (standardized mean difference, -0.41; 95% CI, -0.62 to -0.19). The implementation period involved fewer hospitalizations (difference in hospitalizations, -6.9; 95% CI, -10.4 to -3.4) and longer ED LOS (1.1 hours; 95% CI, 0.7 to 1.4 hours). There were no differences between study periods in ED revisits or care satisfaction.

Conclusions and Relevance

In this study, the delivery of a care bundle was not associated with higher child well-being 30 days after an ED visit. Hospitalizations did decrease during bundle delivery, but ED LOS did not. These health system findings may have been affected by broader changes in patient volumes and flow processes that occurred during the COVID-19 pandemic, which took place as the study was conducted.

Trial Registration

ClinicalTrials.gov Identifier: NCT04292379.

An Investigation of Adolescent Mental Health In a New York City Cohort Before and During the COVID-19 Pandemic in the Primary Care Setting

OBJECTIVES

To investigate differences in the prevalence of positive depression screens before and during the COVID-19 pandemic within primary care and assess patient characteristics based on depression screen results in both time periods.

METHODS

This was a retrospective cohort study of patients ages 12-21 years-old from two urban primary care clinics seen for well-child visits and who had completed depression screens before and during the pandemic. Additional variables evaluated included demographics, substance use, and mental health (MH) conditions such as anxiety, depression, and suicidal ideation (SI). Paired analyses using McNemar's Chi-squared test and paired t-test evaluated differences in variables between time periods. Patients were also categorized into four groups determined by their depression screen result in each period and characteristics between the four groups were compared using the Fisher's exact test.

RESULTS

Of 1621 patient charts reviewed with documented depression screens, there were 232 patients who had screens completed during both time periods. Twenty three (9.9%) patients screened positive for depressive symptoms before the pandemic and 38 (16.4%) screened positive during the pandemic. More patients had SI, depression, anxiety, and substance use during the pandemic. Patients who had at least one positive depression screen had more MH conditions than patients who had negative depression screens during both time periods.

CONCLUSIONS

Among a cohort of adolescents seen in primary care before and during the pandemic, more patients screened positive for depression and there were more MH conditions during the pandemic, demonstrating a need to prioritize MH resources for adolescents in the primary care setting.

Challenges and Opportunities of Pediatric Mental Health Practice in Rural America

Youth living in Rural America have increased rates of mental illness and inadequate resources to address their mental health concerns. Programs and systems are currently available to build capacity in pediatric clinicians to care for youth with mental illness and to recruit and support rural clinicians. Such programs should continue to be supported with federal and state funding and additional novel programs aimed at addressing the youth mental health crisis in North America should be developed and funded.

Implementation of Contraception Care for Psychiatrically Hospitalized Adolescents: A Hybrid Type 2 Effectiveness-Implementation Study

PURPOSE

To examine the implementation and effectiveness of a contraception care intervention for adolescents hospitalized with psychiatric disorders.

METHODS

This prospective, observational, hybrid type 2 effectiveness-implementation study examined the effectiveness of the Contraception Care at the Behavioral Health Pavilion (CC@BHP) intervention in 4 inpatient psychiatric units at a quaternary children's hospital. A multifaceted implementation blueprint guided implementation. CC@BHP is a clinical pathway intervention designed to increase access to contraceptive counseling and initiation during hospitalization. Eligible patients were assigned female at birth, at least 14 years old, and admitted to one of four units between December 2021 and February 2023. Implementation outcomes were provider adoption (documentation of assessing interest in contraception care) and intervention reach (order placed for contraception consultation). Intervention effectiveness outcomes assessed downstream health service access, including patient receipt of contraception consultation and contraceptive prescription/initiation.

RESULTS

Across 1,461 visits, the mean patient age was 15.9 years and 63.4% were White. Forty percent (n = 586) of visits included at least one intervention component. Overall, healthcare providers adopted CC@BHP in 29.0% (n = 424) of visits and ordered contraception consultations in 19.1% (n = 279) of visits (reach). Adolescents received contraception consultations in 16.7% (n = 244) of visits and 116 patients (7.9%) initiated a contraceptive (effectiveness). Later study waves demonstrated greater adoption and reach.

DISCUSSION

Implementation improved over time and CC@BHP delivered contraceptive counseling and initiation, including implants and intrauterine devices, in a large quaternary hospital to interested adolescents. Inpatient psychiatry admissions offer a timely opportunity to address reproductive health needs of adolescents.

Suicidal thoughts and behaviors among gender-minority adolescents in the emergency department

OBJECTIVE

Gender-minority youth, whose gender identity differs from their sex assigned at birth, have elevated suicide risk compared to cisgender youth, yet few studies examine their suicide risk in the emergency department (ED). Our objectives were to determine the prevalence of and assess risk and protective factors associated with prior suicide attempt (SA) and recent suicide ideation (SI) among gender-minority adolescents in the ED.

METHODS

We conducted a secondary analysis of gender-minority adolescents in the Emergency Department Screening for Teens at Risk for Suicide (ED-STARS) multicenter, random-series prospective cohort study. Prior SA and recent SI were based on the Columbia Suicide Severity Rating Scale and Ask Suicide-Screening Questions, respectively. We conducted Firth's logistic regressions to assess risk and protective factors associated with prior SA and recent SI.

RESULTS

Of 6641 adolescent participants in ED-STARS, 280 (4.2%) identified as gender minority. Of the gender minorities, 72% presented with a nonpsychiatric complaint, 37% admitted to a prior SA, and 25% reported recent SI. Prior SA was associated with the number of self-harm methods in the prior 12 months (adjusted odds ratio [aOR] 1.5, 95% confidence interval [CI] 1.3-1.9), sexual minority (aOR 5.0, 95% CI 2.5-10.6), and mother's history of prior SA (aOR 3.6, 95% CI 1.5-9.2). Recent SI was associated with hopelessness (aOR 4.2, 95% CI 1.5-13.9), lower positive affect (aOR 0.9, 95% CI 0.8-1.0), sexual minority (aOR 8.3, 95% CI 2.5-37.8), five or more self-harm events in the prior 12 months (aOR 4.9, 95% CI 2.1-11.6), and number of illicit drug classes (aOR 1.9, 95% CI 1.2-3.2).

CONCLUSIONS

Among gender-minority ED adolescent patients, one in three experienced a SA prior to the ED visit. One in four endorsed SI within 2 weeks of the ED visit. The identified risk and protective factors among gender-minority adolescents may inform future ED-based efforts to detect and reduce suicide risk.

An Analysis of School-Based Mental Health Models and Policies

ABSTRACT

The youth mental health crisis in the United States was exacerbated by the COVID-19 pandemic, as well as in part by widespread, frequent use of the internet and social media. Schools provide an opportune setting for delivering prompt preventative interventions to actively mitigate this crisis. The purpose of this project was to identify policy recommendations for improving school-based mental health services and reducing inequities in care, as well as to produce guidelines on how to advocate for better policies for school mental health services. School policies were analyzed in 3 states at 3 different levels: the state level, district level, and school level. To augment the policy reviews, unstructured interviews were conducted with 5 school nurses from the 3 states. Recommendations for just and sustainable policies for school-based mental health care and strategies on how to advocate for such policies are outlined. This project exemplifies the need for strong policies to support school mental health, with a focus on the role of the school nurse.

Trends in Mental, Behavioral, and Developmental Disorders Among Children and Adolescents in the US, 2016-2021

Introduction

Childhood mental, behavioral, and developmental disorders (MBDD) are common and are associated with poor health and well-being. Monitoring the prevalence of MBDDs among children and factors that may influence health outcomes is important to understanding risk and promoting population health.

Method

We examined trends in parent-reported lifetime MBDDs among children and associated health promotion and risk indicators from 2016 through 2021 by using data from the National Survey of Children's Health. Estimates of prevalence and average annual percentage change were stratified by specific MBDDs and demographic characteristics (eg, sex, age, race and ethnicity). Children with any MBDDs versus none were compared overall and by MBDD subgroup on health care, family, and community indicators.

Results

From 2016 through 2021, MBDD prevalence among children aged 3 to 17 years increased from 25.3% to 27.7%; increases were specific to anxiety, depression, learning disability, developmental delay, and speech or language disorder. Unmet health care needs increased annually by an average of approximately 5% among children with MBDDs. Each year from 2016 to 2021, approximately 60% of children with MBDDs received mental or developmental services in the past 12 months. Each year, a higher percentage of parents of children with MBDDs compared with children without MBDDs reported poor mental health (14.7% MBDD, 5.7% no MBDD) and economic stress (21.6% MBDD, 11.5% no MBDD).

Conclusion

Increasing prevalence of certain MBDDs and MBDD-associated indicators, before and during the COVID-19 pandemic, highlights the need for improved pediatric mental health training for health care providers, for prevention and intervention efforts, and for policies addressing economic stability and equitable access to mental health services.

Trends in Adolescent Depression Screening Outcomes Over the COVID-19 Pandemic at a Large, Integrated Health Care System in Southern California

PURPOSE

Little is known about changes in depression screening outcomes among adolescents in primary healthcare across the COVID-19 pandemic. We describe trends in depression screening outcomes within a large integrated health care system in Southern California.

METHODS

Retrospective electronic health record data from preventative healthcare visits of 11-12-year-olds and 13-17-year-olds screened for depression from March 1, 2017, to August 31, 2022, were extracted in 6-month blocks. The percentages of screens meeting "threshold depression" were reported overall, and by sex, race or ethnicity, and median household income quintiles. We used Poisson regression to estimate rate ratios of threshold depression in 3 winter blocks (September to February) comparing lockdown (2020), reopening (2021) to a pre-COVID (2019) period, and reopening relative to lockdown. Disparities in trends by sex, race, or ethnicity and household income were tested using interaction terms.

RESULTS

Of 735,333 visits with complete screening (183,550 for 11-12-year-olds and 551,783 for 13-17-year-olds), 4.6%, 6.5%, and 7.4% of 11-12-year-olds had "threshold depression" during winter blocks of pre-COVID, lockdown and reopening, respectively. The corresponding rates were 5.8%, 8.5%, and 9.8% for 13-17-year-olds. The rates were higher during lockdown and reopening relative to pre-COVID and higher during reopening relative to lockdown for both age groups (all p-values <.001). Trends differed by sex in both age groups (p-values <.001) and by race or ethnicity (p = .001) in the 13-17-year age group.

DISCUSSION

Californian adolescents demonstrated an increase in threshold depression since COVID lockdown starting March 2020 with further increase observed during reopening in September 2021. Future studies are needed to determine the long-term trends.

Preliminary Evidence for Neuronal Dysfunction Following Adverse Childhood Experiences: An Investigation of Salivary MicroRNA Within a High-Risk Youth Sample

Background/Objectives: Adverse childhood experiences (ACEs) are potent drivers of psychopathology and neurological disorders, especially within minoritized populations. Nonetheless, we lack a coherent understanding of the neuronal mechanisms through which ACEs impact gene expression and, thereby, the development of psychopathology. Methods: This observational pilot study used a novel marker of neuronal functioning (brain-derived micro ribonucleic acids, or miRNAs) collected via saliva to explore the connection between ACEs and neuronal gene expression in 45 adolescents with a collectively high ACE exposure (26 males and 19 females of diverse races/ethnicities, with six cumulative ACEs on average). We aimed to determine the feasibility of using salivary microRNA for probing neuronal gene expression with the goal of identifying cellular processes and genetic pathways perturbed by childhood adversity. Results: A total of 274 miRNAs exhibited reliable salivary expression (raw counts > 10 in > 10% of samples). Fourteen (5.1%) were associated with cumulative ACE exposure (p < 0.05; r's ≥ 0.31). ACE exposure correlated negatively with miR-92b-3p, 145a-5p, 31-5p, and 3065-5p, and positively with miR-15b-5p, 30b-5p, 30c-5p, 30e-3p, 199a-3p, 223-3p, 338-3p, 338-5p, 542-3p, and 582-5p. Most relations remained significant after controlling for multiple comparisons and potential retrospective bias in ACE reporting for miRNAs with particularly strong relations (p < 0.03). We examined KEGG pathways targeted by miRNAs associated with total ACE scores. Results indicated putative miRNA targets over-represented 47 KEGG pathways (adjusted p < 0.05) involved in neuronal signaling, brain development, and neuroinflammation. Conclusions: Although preliminary and with a small sample, the findings represent a novel contribution to the understanding of how childhood adversity impacts neuronal gene expression via miRNA signaling.

Neighborhood-Level Social Determinants of Health and Adolescent Mental Health

OBJECTIVE

Mental health diagnoses among adolescents are increasing in prevalence. Existing literature considers associations between individual-level social determinants of health (SDOH) and adolescent mental health. Neighborhood-level SDOH can have a substantial impact on health. This paper examines associations between neighborhood-level SDOH and mental health diagnoses of anxiety, depression, and suicidal ideation among hospitalized adolescents.

METHODS

We used 2018 and 2019 Texas Inpatient Discharge Public Use Data Files linked to the zip-code level Child Opportunity Index 2.0, a composite measure of subdomains which characterize neighborhood-level SDOH, to examine rates of mental health diagnoses and associations with patient characteristics across opportunity level quintiles.

RESULTS

The sample included 50,011 adolescents ages 10-19 admitted to the hospital with the mental health diagnoses anxiety, depression, and/or suicide. Most had a single diagnosis; anxiety (12.9%), depression (37.5%), or suicide (13.0%). Hospitalized adolescents 10-14 years old were a plurality (44.2%) of the sample. Most adolescents were White (64.2%) and non-Hispanic (67.4%) and lived in rural areas (29.6%). Adolescents from racial minority populations and those in rural communities with mental health diagnoses had lower opportunity-levels. Higher opportunity levels were associated with greater odds of having an anxiety or suicide diagnosis while a depression diagnosis was associated with a lower opportunity-level.

CONCLUSIONS

There are significant differences in adolescent mental health diagnoses associated with neighborhood opportunity-level. While all adolescents can benefit from mental health education, screening, and early interventions, additional resources tailored to neighborhood-level opportunity may prove a more meaningful way to improve population-level mental health outcomes.

Health Service Utilization Patterns Among Medicaid Enrollees With Intellectual and Developmental Disabilities Before and During the COVID-19 Pandemic: Implications for Pandemic Response and Recovery Efforts

OBJECTIVES

To assess the impact of COVID-19 on health service utilization of adults with intellectual and developmental disabilities (IDDs) through an analysis of Medicaid claims data.

DESIGN

Retrospective cohort study of Medicaid claims.

SETTING AND PARTICIPANTS

Medicaid members aged 25 to 64 years from January 1, 2018, to March 31, 2021, from the states of Louisiana, Pennsylvania, and Wyoming.

INTERVENTION

We analyzed data from two 12-month time periods (pre-COVID-19 and during COVID-19) and assessed the potential impact of the COVID-19 pandemic on health service utilization and service intensity for 3 cohorts: (1) IDD with preexisting mental health diagnoses, (2) IDD without mental health diagnoses, and (3) all other Medicaid members.

MAIN OUTCOME MEASURE

Health service utilization determined by specific claims data classifications.

RESULTS

The analysis showed reduced utilization for nonmental health service types with differing utilization patterns for IDD with preexisting mental health diagnoses, IDD without mental health diagnoses, and all other Medicaid members. Change in utilization varied, however, for mental health service types. Measures of service intensity showed decreased numbers of members utilizing services across most service types and increased Medicaid claims per person across most mental health service categories but decreased Medicaid claims per person for most nonmental health services.

CONCLUSIONS

Results suggest a need for mental health services among all Medicaid members during the COVID-19 pandemic. By anticipating these needs, communities may be able to expand outreach to Medicaid members through enhanced case management, medication checks, and telemedicine options.

Mental Health and Suicide Risk Among High School Students and Protective Factors - Youth Risk Behavior Survey, United States, 2023

Adolescent mental health and suicide risk remain substantial public health concerns. High pre-COVID rates of poor mental health and suicide-related behaviors have continued to rise, highlighting the need to identify factors that might foster positive mental health outcomes and reduce suicide-related behaviors at population levels. Using CDC's 2023 Youth Risk Behavior Survey, CDC analyzed the prevalence of mental health and suicide risk indicators and their associations with individual-, family-, and school- or community-level protective factors. Prevalence estimates were calculated for each of the mental health and suicide risk indicators by demographic characteristic. Prevalence ratios adjusted for sex, sexual identity, grade, and race and ethnicity were calculated to examine the association between protective factors and mental health and suicide risk indicators. Overall, 39.7% of students experienced persistent feelings of sadness and hopelessness, 28.5% experienced poor mental health, 20.4% seriously considered attempting suicide, and 9.5% had attempted suicide. Mental health and suicide risk indicators differed by sex, sexual identity, grade, and race and ethnicity. All protective factors were associated with lower prevalence of one or more risk indicators. Findings from this report can serve as a foundation for the advancement of research on protective factors and for the development and implementation of programs, practices, and policies that protect and promote mental health and emotional well-being among youth.

Addressing the Multidimensional Aspects of Trauma in Emergency Department Boarding for Neurodiverse Youth

Psychiatric boarding in pediatric emergency departments is a predictable outcome of escalating psychiatric acuity and inadequate mental health services in hospital systems and the community at large. Guidelines are offered to support initiating treatments in nonpsychiatric hospital settings to reduce pediatric boarding. Treatments call for interdisciplinary approaches, care coordination, and addressing systemic disparities in access and quality of care. Telemental health interventions offer a promising means of reducing inequalities in access. Creating a crisis continuum of care will help minimize strict reliance on inpatient settings, which are increasingly challenging to access and only sometimes fully address the crises, even when used.

Trends in youth acute care hospital visits for anxiety and depression in Illinois

PURPOSE

This study analyzes the trajectory of youth emergency department or inpatient hospital visits for depression or anxiety in Illinois before and during the COVID-19 pandemic.

METHODS

We analyze emergency department (ED) outpatient visits, direct admissions, and ED admissions by patients ages 5-19 years coded for depression or anxiety disorders from 2016 through June 2023 with data from the Illinois Hospital Association COMPdata database. We analyze changes in visit rates by patient sociodemographic and clinical characteristics, hospital volume and type, and census zip code measures of poverty and social vulnerability. Interrupted times series analysis was used to test the significance of differences in level and trends between 51 pre-pandemic months and 39 during-pandemic months.

RESULTS

There were 250,648 visits to 232 Illinois hospitals. After large immediate pandemic decreases there was an estimated -12.0 per-month (p = 0.003, 95% CI -19.8-4.1) decrease in male visits and a - 13.1 (p = 0.07, 95% CI -27 -1) per-month decrease in female visits in the during-pandemic relative to the pre-pandemic period. The reduction was greatest for outpatient ED visits, for males, for age 5-9 and 15-19 years patients, for smaller community hospitals, and for patients from the poorest and most vulnerable zip code areas.

CONCLUSIONS

llinois youth depression and anxiety hospital visit rates declined significantly after the pandemic shutdown and remained stable into 2023 at levels below 2016-2019 rates. Further progress will require both clinical innovations and effective prevention grounded in a better understanding of the cultural roots of youth mental health.

Assessment of Children and Adolescents' Admissions to Pediatric Psychiatric Emergency Department

OBJECTIVE

Emergencies in child and adolescent psychiatry are prevalent, and pediatric psychiatric emergency departments play a crucial role in acute intervention during mental health-related crises. This retrospective cross-sectional study aimed to analyze the characteristics of children and adolescents who were admitted to a pediatric psychiatric emergency department.

METHOD

The data were collected from the records of 8803 patients (females 56.6%, Mage = 15.07 ± 2.6) admitted to our pediatric psychiatry emergency department between 2014 and 2021. Diagnoses were made using the International Statistical Classification of Diseases, 10th Revision. We used descriptive statistics to determine patient characteristics and conducted a regression analysis to compare the changes in the admissions numbers by the year.

RESULTS

It was found that depressive disorder was the highest psychiatric diagnosis, with a percentage of 21.4%. Depressive disorder, autism spectrum disorder, and obsessive-compulsive disorder have shown an increase over the years. In 2020, with the onset of the COVID-19 pandemic, psychiatric admissions reached their lowest level. The percentage of hospitalizations was 21.1% for the total of all years. No significant change was found in the total number of admissions, sex, and age.

CONCLUSIONS

The number of admissions for female adolescents who were diagnosed with depressive disorder to our pediatric psychiatry emergency department is shown to be high. The fact that these patients seek help more frequently should be taken into consideration during the planning of mental health services for outpatient and inpatient clinics as well as pediatric psychiatry emergency services.

Neurodevelopmental and Mental Health Conditions in Children With Medical Complexity

BACKGROUND AND OBJECTIVES

Children with medical complexity (CMC) may be at a high risk of neurodevelopmental and mental health conditions given disease comorbidities and lived experiences. Little is known about the prevalence of these conditions at a population level. In this study, we estimated the prevalence of neurodevelopmental and mental health diagnoses in CMC relative to children without medical complexity and measured associations between these diagnoses in CMC and subsequent health care utilization and in-hospital mortality.

METHODS

We applied the Child and Adolescent Mental Health Disorders Classification System to identify neurodevelopmental and mental health diagnoses using all-payer claims data from three states (2012-2017). Poisson regression was used to compare outcomes in CMC with neurodevelopmental and mental health diagnoses to CMC without these diagnoses, adjusting for sociodemographic and clinical characteristics.

RESULTS

Among 85 581 CMC, 39 065 (45.6%) had ≥1 neurodevelopmental diagnoses, and 31 703 (37.0%) had ≥1 mental health diagnoses, reflecting adjusted relative risks of 3.46 (3.42-3.50) for neurodevelopmental diagnoses and 2.22 (2.19-2.24) for mental health diagnoses compared with children without medical complexity. CMC with both neurodevelopmental and mental health diagnoses had 3.00 (95% confidence interval [CI]: 2.98-3.01) times the number of ambulatory visits, 69% more emergency department visits (rate ratio = 1.69, 95% CI: 1.66-1.72), 58% greater risk of hospitalization (rate ratio = 1.58, 95% CI: 1.50-1.67), and 2.32 times (95% CI: 2.28-2.36) the number of hospital days than CMC without these diagnoses.

CONCLUSIONS

Neurodevelopmental and mental health diagnoses are prevalent among CMC and associated with increased health care utilization across the continuum of care. These findings illustrate the importance of recognizing and treating neurodevelopmental and mental health conditions in this population.

Pediatric mental health emergency department visits from 2017 to 2022: A multicenter study

BACKGROUND

The COVID-19 pandemic adversely affected children's mental health (MH) and changed patterns of MH emergency department (ED) utilization. Our objective was to assess how pediatric MH ED visits during the COVID-19 pandemic differed from expected prepandemic trends.

METHODS

We retrospectively studied MH ED visits by children 5 to <18 years old at nine U.S. hospitals participating in the Pediatric Emergency Care Applied Research Network Registry from 2017 to 2022. We described visit length by time period: prepandemic (January 2017-February 2020), early pandemic (March 2020-December 2020), midpandemic (2021), and late pandemic (2022). We estimated expected visit rates from prepandemic data using multivariable Poisson regression models. We calculated rate ratios (RRs) of observed to expected visits per 30 days during each pandemic time period, overall and by sociodemographic and clinical characteristics.

RESULTS

We identified 175,979 pediatric MH ED visits. Visit length exceeded 12 h for 7.3% prepandemic, 8.4% early pandemic, 15.0% midpandemic, and 19.2% late pandemic visits. During the early pandemic, observed visits per 30 days decreased relative to expected rates (RR 0.80, 95% confidence interval [CI] 0.78-0.84), were similar to expected rates during the midpandemic (RR 1.01, 95% CI 0.96-1.07), and then decreased below expected rates during the late pandemic (RR 0.92, 95% CI 0.86-0.98). During the late pandemic, visit rates were higher than expected for females (RR 1.10, 95% CI 1.02-1.20) and for bipolar disorders (RR 1.83, 95% CI 1.38-2.75), schizophrenia spectrum disorders (RR 1.55, 95% CI 1.10-2.59), and substance-related and addictive disorders (RR 1.50, 95% CI 1.18-2.05).

CONCLUSIONS

During the late pandemic, pediatric MH ED visits decreased below expected rates; however, visits by females and for specific conditions remained elevated, indicating a need for increased attention to these groups. Prolonged ED visit lengths may reflect inadequate availability of MH services.

Disordered Eating/Eating Disorders in Adolescents

The coronavirus disease 2019 pandemic was as tressful time for adolescents, with increased isolation, loss of routines, and changes in access to medical care. In this setting, the medical system saw a significant rise in the number of adolescents seeking care for eating disorders, as well as increased severity of patient presentation. Telehealth treatment for eating disorders was a unique shift during the pandemic, with some benefits but not universally positive experiences among patients, families and providers.

Assessing service usage and protective factors in a pediatric psychiatry clinic during the COVID-19 pandemic

Youth with developmental and pre-existing mental health conditions have been particularly vulnerable to declines in psychological functioning during the COVID-19 pandemic. This study aimed to first, analyze service usage within an outpatient child and adolescent psychiatry clinic in the months preceding and during the COVID-19 pandemic, and second, to examine associations with potential protective factors against mental health concerns in a treatment-engaged sample. Service usage was examined using clinic billing data, and reports on protective factors were gathered via parent survey of 81 children ages 6-17 years who received mental health treatment in an outpatient psychiatry clinic during the pandemic. Protective factors were assessed at the individual, family, and community levels, and included children's use of coping strategies, parental resilience, and parents' perceived social supports. Study outcomes, including mental health concerns, mental health emergencies, pandemic-related distress, and social impact of the pandemic, were analyzed via Pearson correlations and simultaneous multiple linear regressions. Findings suggest increased service usage and child coping, parental resilience, and social connectedness as factors associated with fewer mental health concerns in youth with psychiatric concerns during the pandemic. This study lends support for expanding psychiatric services with continued use of telemedicine platforms. Further, findings suggest a mental health benefit to optimizing individual, parental, and community-based resources to enhance children's psychological functioning, particularly for youth with pre-existing mental health conditions.

Pediatric Emergency Physicians' Knowledge, Attitudes, and Behaviors Regarding Confidential Adolescent Care

OBJECTIVES

More than 19 million adolescents seek care in the emergency department (ED) annually. We aimed to describe the knowledge, attitudes, and behaviors related to confidential adolescent care among pediatric ED physicians.

METHODS

We conducted a cross-sectional questionnaire of US physician members of the Pediatric Emergency Medicine Collaborative Research Committee survey listserv. The 24-item questionnaire assessed familiarity with adolescent confidentiality laws, attitudes toward providing confidential care, frequency of discussing behavioral health topics confidentially, and factors influencing the decision to provide confidential care. We dichotomized Likert responses and used χ 2 to compare subgroups.

RESULTS

Of 476 eligible physicians, 151 (32%) participated. Most (91. 4%) had completed pediatric emergency medicine fellowship. More participants reported familiarity with all sexual health-related laws compared with all mental health-related laws (64% vs 49%, P < 0.001). The median age at which participants thought it was important to begin routinely providing confidential care was 12 years; 9% thought confidential interviews should not be routinely conducted until older adolescence or at all. Their decision to provide confidential care was influenced by the following: chief complaint (97%), time (43%), language (24%), presence of family (23%) or friends (14%), and space (22%).

CONCLUSIONS

Respondents reported moderate familiarity with adolescent confidentiality laws. Although they viewed confidential care as something they were comfortable providing, the likelihood of doing so varied. Barriers to confidential care were influenced by their assessment of adolescents' behavioral health risk, which may contribute to health inequity. Future efforts are needed to develop strategies that augment confidential ED care for adolescents.

The Future of School Health Education in the United States: An Ontology

BACKGROUND

As summarized in this article, the widespread implementation of modern school health education (SHE) could become one of the most effective means available to improve the well-being of people in the United States and in other nations. However, the development and evolution of SHE largely remains unorganized, underdeveloped, and neglected by health and education agencies, policymakers, and the public.

METHODS

Essential to the development of any scientific discipline, scientists today use the word ontology to refer to efforts to organize knowledge in particular domains. A useful working definition of a scientific ontology is an explicit, formal specification of a shared conceptualization-a systematic set of shared terms and an explication of their interrelationships. Nine interdependent questions are outlined to help guide the development of an initial, broad, and actionable scientific ontology for SHE.

RESULTS

Whether and how we respond to these questions arguably will determine the future of SHE research, policy, practice, and equity in the United States.

CONCLUSIONS

An initial ontology might help conceptualize, inform, and facilitate more systematic and strategic local, state, national, and international deliberations and actions to improve SHE.

Identifying Children and Adolescents at Elevated Mental Health Risk Before and During COVID-19

OBJECTIVE

To determine whether the prevalence of psychosocial risk in children and adolescents changed from before to during the COVID-19 pandemic and whether these changes differed by age group, sex, and season, based on a standardized psychosocial measure completed as a routine part of primary care.

METHODS

Children and adolescents aged 5.5 to 17.9 years were screened with a parent report Pediatric Symptom Checklist-17 (PSC-17P) between November 2017 and June 2022. Changes in the prevalence of psychosocial risk (global, internalizing, externalizing, and attention scales) from before to during the pandemic were compared by age group, sex, and season.

RESULTS

In a sample of 459,767 health supervision visits, the prevalence of PSC-17P global, internalizing, and attention risk worsened significantly from before to during the pandemic, especially among female adolescents (ages 12.0-17.9). For a pediatrician seeing a hypothetical sample of 1000 adolescent girls, the expected number at risk would have increased from 103 to 131 on the global scale (26.6% increase), from 189 to 231 on the internalizing subscale (22.0% increase), and from 60 to 82 on the attention subscale (35.7% increase). Seasonality had a large effect, with significantly lower PSC-17P risk in the summer every year.

CONCLUSION

Data from a large, national sample of pediatric visits suggested that global, internalizing, and attention concerns increased slightly overall from before to during the COVID-19 pandemic, with different patterns by age group and sex. Adolescent girls showed substantially increased global, internalizing, and attention problems. These increases support the need for further research and additional individual and system-level interventions.

The Role of Clinic Preparedness to Support Patients and Strengthen the Medical System During and After a Pandemic

Pediatric clinic preparedness is essential to improve the care and health outcomes for children during a pandemic and to decrease the burden on hospital systems. Clinic preparedness is a process that involves a well thought out plan that includes coordination with staff, open communication between the clinic and patient families, and collaboration with community partners. Planning for disasters can decrease some of the risks for our most vulnerable patients, including children and youth with special health care needs. There are plans, coalitions, and community partners that can help clinics in their preparedness journey.

Risk of COVID-19 in pediatric population and the effects of COVID-19 vaccination: A retrospective cohort study

OBJECTIVE

Prior studies have demonstrated the adverse effects of upper respiratory infections on the pediatric population, such as increased risk for acute otitis media (AOM). Other studies have noted decreased otitis media complaints during the COVID-19 pandemic. This project aims to identify whether individuals who tested positive for COVID-19 at the Emergency Department (ED) visit had an increased risk of developing severe complications. Additionally, we will study whether vaccination helped decrease following COVID-19 complications.

METHODS

Utilizing the TriNetX database, we obtained de-identified electronic medical records for children under five and 6-10 years old from 2020-2023 in the United States. The study population was propensity-matched for gender, index age, and comorbidities. Complications within eight weeks of the ED visit were compared between COVID-19 vaccinated and unvaccinated children. Risk ratio was used to measure associations between our groups. A p-value less than or equal to 0.05 was considered significant.

RESULTS

After propensity matching, a total of 211,138 children were identified. Within eight weeks after the ED visit, unvaccinated children <5 years old who tested negative for COVID-19 had a 30 % relative risk reduction for AOM, 52 % for sinusitis, 76 % for multisystem inflammatory system (MIS), 17 % for acute respiratory failure, and 37 % for septic shock when compared to those with a positive COVID-19 result (p ≤ 0.05). Unvaccinated 6-10 years old children who tested negative for COVID-19 had an 18 % risk reduction for AOM, 44 % reduction for sinusitis, 63 % reduction for MIS, and 42 % for acute respiratory failure (p ≤ 0.05) compared to those that tested positive for COVID-19. Vaccinated children with positive COVID-19 results have no significant risk of AOM or acute respiratory failure. Additionally, children 6-10 years old with positive COVID-19 results did not have a substantial risk of sinusitis.

CONCLUSION

COVID-19's effects require continued investigation in children. This study showed that there are some increased risks of severe complications following this viral infection.

Functional Tic-like Behaviors: From the COVID-19 Pandemic to the Post-Pandemic Era

During the COVID-19 pandemic, there have been multiple reports about an unforeseen surge in adolescents and young adults exhibiting sudden onset functional tic-like behaviors. This phenomenon has been mainly associated with the female gender and occasionally after exposure to social media content featuring similar patterns of functional tic-like behaviors. A significant portion of these individuals have been directed to specialist clinics for movement disorders with initial misdiagnoses of late-onset refractory Tourette syndrome. Distinguishing between rapid onset functional tic-like behaviors and neurodevelopmental tics as part of Tourette syndrome can be challenging; however, the differential diagnosis is facilitated by focusing on specific clinical and demographic factors, which we have explored in a systematic literature review. Compared to neurodevelopmental tics, functional tic-like behaviors typically present with a more abrupt and intense manifestation of symptoms, onset at a later age, higher prevalence among females, inability to suppress tics, coexisting anxiety and depression, and sometimes a history of exposure to social media content portraying tic-like behaviors of a similar nature. This novel manifestation of a functional neurological disorder may thus be viewed as an emerging neuropsychiatric condition potentially triggered/exacerbated by the psychosocial repercussions of the COVID-19 crisis.

Reducing firearm access for youth at risk for suicide in a pediatric emergency department

Background

Firearm-related suicide is the second leading cause of pediatric firearm death. Lethal means counseling (LMC) can improve firearm safe-storage practices for families with youth at risk of suicide.

Objectives

This study aims to evaluate the feasibility of pediatric emergency department (ED) behavioral mental health (BMH) specialists providing LMC to caregivers of youth presenting with BMH complaints and to test for changes in firearm safety practices, pre-post ED LMC intervention, as measures of preliminary efficacy.

Methods

Prospective pilot feasibility study of caregivers of youth presenting to a pediatric ED with BMH complaints. Caregivers completed an electronic survey regarding demographics and firearm safe-storage knowledge/practices followed by BMH specialist LMC. Firearm owners were offered a free lockbox and/or trigger lock. One-week follow-up surveys gathered self-reported data on firearm safety practices and intervention acceptability. One-month interviews with randomly sampled firearm owners collected additional firearm safety data. Primary outcomes were feasibility measures, including participant accrual/attrition and LMC intervention acceptability. Secondary outcomes included self-reported firearm safety practice changes. Feasibility benchmarks were manually tabulated, and Likert-scale acceptability responses were dichotomized to strongly agree/agree vs. neutral/disagree/strongly disagree. Descriptive statistics were used for univariate and paired data responses.

Results

In total, 81 caregivers were approached; of which, 50 (81%) caregivers enrolled. A total of 44% reported having a firearm at home, 80% completed follow-up at one week. More than 80% affirmed that ED firearm safety education was useful and that the ED is an appropriate place for firearm safety discussions. In total, 58% of participants reported not having prior firearm safety education/counseling. Among firearm owners (n = 22), 18% reported rarely/never previously using a safe-storage device, and 59% of firearm owners requested safe storage devices.At 1-week follow-up (n = 40), a greater proportion of caregivers self-reported asking about firearms before their child visited other homes (+28%). Among firearm owners that completed follow-up (n = 19), 100% reported storing all firearms locked at one week (+23% post-intervention). In total, 10 caregivers reported temporarily/permanently removing firearms from the home.

Conclusion

It is feasible to provide LMC in the pediatric ED via BMH specialists to families of high-risk youth. Caregivers were receptive to LMC and reported finding this intervention useful, acceptable, and appropriate. Additionally, LMC and device distribution led to reported changes in safe storage practices.

Prevalence of Positive Childhood Experiences and Associations with Current Anxiety, Depression, and Behavioral or Conduct Problems among U.S. Children Aged 6-17 Years

Positive childhood experiences (PCEs) have substantial potential to improve children's mental health. We examined the prevalence of 26 specific PCEs, overall and by demographics, and the individual and cumulative effects of PCEs with current diagnosis of three mental health conditions using nationally representative, parent-reported data on U.S. children aged 6-17 years from the 2018-2019 National Survey of Children's Health (n=35,583). The prevalence of each PCE varied, with a range between 22.6% (gets recommended amount of physical activity) to 92.1% (parent(s) have positive mental health). Accounting for demographics, there were associations between most specific PCEs and lower prevalence of current childhood anxiety (22 of 26 PCEs), depression (22 of 26 PCEs), and behavioral or conduct problems (21 of 26 PCEs). There was a dose-response relationship between children in higher cumulative PCE quartiles and lower proportions of anxiety, depression, and behavioral or conduct problems. Findings generally did not attenuate after further adjusting for adverse childhood experiences. PCEs are common among U.S. children, but vary substantially by type of PCE and subpopulation. This has critical implications for focusing prevention and intervention strategies to bolster PCEs in ways that could improve health equity and children's mental health.

Human-Centered Design to Improve Care for Youths Experiencing Psychiatric Boarding

The number of children and adolescents presenting to hospitals with mental health conditions has increased markedly over the past decade. A dearth of pediatric mental health resources prevents delivering definitive psychiatric care to this population at many hospitals; thus, children and adolescents must wait at a medical facility until appropriate psychiatric care becomes available (an experience described as psychiatric "boarding"). Clinicians caring for youth experiencing psychiatric boarding report inadequate training and resources to provide high-quality care to this population, and patients and caregivers describe significant frustration with the current standard of care. Recognizing these issues and the unique emotional components associated with psychiatric boarding, we employed human-centered design (HCD) to improve our hospital's approach to caring for youth during this period. HCD is an approach that specifically prioritizes the assessment and integration of human needs, including emotional needs, as a means to inform change. We used an HCD framework encompassing 5 stages: (1) empathize with those affected by the issue at hand, (2) define the problem, (3) ideate potential solutions, (4) prototype potential solutions, and (5) test potential solutions. Through these stages, we elicited broad stakeholder engagement to develop and implement 2 primary interventions: A modular digital health curriculum to teach psychosocial skills to youth experiencing boarding and a comprehensive clinical practice guideline to optimize and standardize care across clinical environments at our hospital. This manuscript describes our experience applying HCD principles to this complex health care challenge.

ADHD Prevalence Among U.S. Children and Adolescents in 2022: Diagnosis, Severity, Co-Occurring Disorders, and Treatment

OBJECTIVE

To provide updated national prevalence estimates of diagnosed attention-deficit/hyperactivity disorder (ADHD), ADHD severity, co-occurring disorders, and receipt of ADHD medication and behavioral treatment among U.S. children and adolescents by demographic and clinical subgroups using data from the 2022 National Survey of Children's Health (NSCH).

METHOD

This study used 2022 NSCH data to estimate the prevalence of ever diagnosed and current ADHD among U.S. children aged 3-17 years. Among children with current ADHD, ADHD severity, presence of current co-occurring disorders, and receipt of medication and behavioral treatment were estimated. Weighted estimates were calculated overall and for demographic and clinical subgroups (n = 45,169).

RESULTS

Approximately 1 in 9 U.S. children have ever received an ADHD diagnosis (11.4%, 7.1 million children) and 10.5% (6.5 million) had current ADHD. Among children with current ADHD, 58.1% had moderate or severe ADHD, 77.9% had at least one co-occurring disorder, approximately half of children with current ADHD (53.6%) received ADHD medication, and 44.4% had received behavioral treatment for ADHD in the past year; nearly one third (30.1%) did not receive any ADHD-specific treatment.

CONCLUSIONS

Pediatric ADHD remains an ongoing and expanding public health concern, as approximately 1 million more children had ever received an ADHD diagnosis in 2022 than in 2016. Estimates from the 2022 NSCH provide information on pediatric ADHD during the last full year of the COVID-19 pandemic and can be used by policymakers, government agencies, health care systems, public health practitioners, and other partners to plan for needs of children with ADHD.

A Comparative Analysis of Pediatric Emergency Department Admissions Before and During the COVID-19 Pandemic

Objectives This study aims to evaluate the outbreak's impact on emergency services, with findings obtained from patients who applied to our pediatric emergency service before and during the pandemic period. Methods In this study, the Pediatric Emergency Polyclinic of Hatay Mustafa Kemal University (MKU) Department of Pediatrics was evaluated during the COVID-19 pre-pandemic period and the COVID-19 pandemic period. Demographic features, complaints, discharge situations, diagnostic groups, and diagnoses of 16,730 non-traumatic patients one month to 18 years old were compared retrospectively. Results Comparing the pre-pandemic period and the pandemic period, it was determined that there was a statistically significant difference in the average age of patients, age groups, admission hours, triage classification, complaints, and diagnoses seen. Conclusion According to the findings obtained in the study, pediatric emergency department admissions decreased significantly during the pandemic period. As a result of the pandemic measures taken, the incidence of diseases caused by infectious agents, such as respiratory tract infections, decreased. The change in pediatric emergency service habits with the pandemic highlights the importance of conducting more comprehensive epidemiological studies in terms of more efficient and effective use of pediatric emergency health services in Turkey.

Nurses' perspectives on child-friendly care needs in emergency departments: A qualitative study

BACKGROUND

Children can become anxious when undergoing emergency medical treatment. Therefore, emergency departments should be child friendly. This study explored emergency nurses' perspectives on children's needs during emergency care.

METHOD

This qualitative study employed purposive sampling to recruit 17 emergency nurses from 3 medical centers in northern and central Taiwan. Individual interviews were conducted between January and August 2021. Data were analyzed through qualitative content analysis.

RESULTS

The participants had 2-23 years of experience in caring for children in emergency departments. We identified 208 unique meaning units in the interview data, 79 of which were related to child-friendly emergency care. These were classified into 42 codes across 6 categories and 27 subcategories. The six categories were timely comfort, emotional care, frontline safety, emergency response, human resources support, and treatment efficiency.

CONCLUSION

Emergency nurses have professional competencies, play a crucial role as care providers for children in the emergency department, and ensure the comfort and safety of children seeking treatment. The categories related to child-friendly emergency care identified in this study can serve as a basis for developing child-friendly care emergency guidelines.

Psychosocial Care for Youth with Type 1 Diabetes: Summary of Reviews to Inform Clinical Practice

The intensive demands of diabetes care can be difficult for youth with type 1 diabetes and their families to integrate into daily life. Standards of care in pediatric diabetes highlight the importance of evidence-based psychosocial interventions to optimize self-management behaviors and psychological well-being. The current review summarizes select systematic reviews and meta-analyses on evidence-based behavioral health interventions in pediatric diabetes. Interventions include strategies to strengthen youth psychosocial skills, improve family dynamics and caregiver mental health, enhance health and mental health equity, and address psychosocial factors related to diabetes technology use.

Inpatient pediatric nursing staff experiences treating psychiatric patients: A mixed methods study

PROBLEM

A gap in the literature exists attempting to understand the impact that the influx of pediatric psychiatric patients has had on inpatient general medicine pediatric nursing staff.

METHODS

A mixed-method research study was conducted among full- and part-time pediatric nurses and nursing assistants working on general pediatric units. Quantitative data was collected via an anonymous survey using the Professional Quality of Life Scale version 5 and Support Appraisal for Work Stressors scale. Surveys were followed by semistructured interviews.

FINDINGS

Of the 158 staff eligible, 47 (29.7%) participated in the quantitative portion. [Correction added on 29 September 2023, after the first online publication: In the preceding sentence, the participation rate was revised from 23.5% to 29.7% in this version.] Significant differences were found between roles, with nurses experiencing lower levels of compassion satisfaction and higher levels of burnout. Role differences were seen in supervisor support and nonwork support, with nurses reporting less support from both. Supervisor support showed a significant correlational relationship with compassion satisfaction and burnout. Nonwork support showed similar correlations with compassion satisfaction and burnout. Themes that emerged from the interviews were Barriers to Care, Emotional Impact, and "Help Me Help You."

CONCLUSION

Nurses may be at greater risk for compassion fatigue due to perceived inadequate support from leadership, unclear role expectations, and lack of resources.

COVID-19 and Adolescent Outpatient Mental Health Service Utilization

OBJECTIVE

The COVID-19 pandemic created challenges in accessing mental health (MH) services when adolescent well-being declined. Still, little is known about how the COVID-19 pandemic affected outpatient MH service utilization for adolescents.

METHODS

Retrospective data were collected from electronic medical records of adolescents aged 12-17 years at Kaiser Permanente Mid-Atlantic States, an integrated health care system from January 2019 to December 2021. MH diagnoses included anxiety, mood disorder/depression, anxiety and mood disorder/depression, attention-deficit/hyperactivity disorder, or psychosis. We used interrupted time series analysis to compare MH visits and psychopharmaceutical prescribing before and after the COVID-19 onset. Analyses were stratified by demographics and visit modality.

RESULTS

The study population of 8121 adolescents with MH visits resulted in a total of 61,971 (28.1%) of the 220,271 outpatient visits associated with an MH diagnosis. During 15,771 (7.2%) adolescent outpatient visits psychotropic medications were prescribed. The increasing rate of MH visits prior to COVID-19 was unaffected by COVID-19 onset; however, in-person visits declined by 230.5 visits per week (P < .001) from 274.5 visits per week coupled with a rise in virtual modalities. Rates of MH visits during the COVID-19 pandemic differed by sex, mental health diagnosis, and racial and ethnic identity. Psychopharmaceutical prescribing during MH visits declined beyond expected values by a mean of 32.8 visits per week (P < .001) at the start of the COVID-19 pandemic.

CONCLUSIONS

A sustained switch to virtual visits highlights a new paradigm in care modalities for adolescents. Psychopharmaceutical prescribing declined requiring further qualitative assessments to improve the quality of access for adolescent MH.

Characteristics, disposition, and outcomes of children hospitalized for mental health boarding at a children's hospital

Increasingly, youth experiencing mental health crises present to acute care medical hospitals and "board" on medical units due to inpatient psychiatric bed shortages. We conducted a retrospective cohort study of children experiencing mental health boarding at a US children's hospital from October 2020 to September 2022. We examined associations between patients' characteristics and their disposition and outcomes. Our cohort included 1891 boarding hospitalizations: 53.9% transferred to an inpatient psychiatric hospital and 46.1% discharged home. Characteristics associated with not being transferred to an inpatient psychiatric hospital included age <13 years (adjusted odds ratio [aOR] 0.6; 95% confidence interval [CI]: 0.4-0.7), disruptive or aggressive behavior (aOR 0.6; 95% CI: 0.4-0.8), psychosis (aOR 0.5; 95% CI: 0.3-0.8), COVID-19 infection (aOR 0.3; 95% CI: 0.2-0.6), or a complex chronic medical condition (aOR 0.8; 95% CI: 0.6-1.0). Our findings suggest that certain populations of children experiencing mental health boarding face disparate access to inpatient psychiatric care.

COVID-19 and the impact on psychiatric and suicide-related emergency department visits of 5-18-year-Old youth in Israel

COVID-19 has been found to take a toll on the mental health of children and adolescents worldwide. This study retrospectively evaluated the changes in the number of general and suicide-related visits to a pediatric psychiatric emergency department (ED) at Geha Mental Health Center in Israel and the distribution of sex and age of the 5-18-year-old youth who visited the ED. The study looked at visits from the pre-pandemic years to the first and second years of the pandemic. The findings showed a sharp decrease in visits at the beginning of the pandemic, followed by a significant increase in the first year and a nonsignificant decline in the second year. The proportion of girls' ED visits was higher in the pandemic years compared to the pre-pandemic years. Regarding suicide-related visits, after a sharp decline at the beginning of the pandemic, the number of visits increased at a rate similar to the pre-pandemic period. We conclude that the pattern of change was similar to that of other population-level exposures to continuous stress conditions. Further research on the vulnerability of girls in similar situations is needed.

Monthly correlates of longitudinal child mental health during the COVID-19 pandemic according to children and caregivers

Multiple reviews identify the broad, pervasive initial impact of the global COVID-19 pandemic on the mental health of children, who may be particularly vulnerable to long-term psychiatric sequelae of the ongoing pandemic. However, limited longitudinal research examines persistence of, or change in, children's distress or psychiatric symptomatology. From June 2020 through December 2021, we enrolled two cohorts of families of children aged 8-13 from Southwestern Ontario into a staggered baseline, longitudinal design that leveraged multi-informant report (N = 317 families). In each family, one child and one parent/guardian completed a baseline assessment, 6 monthly follow-up assessments, and one final follow-up assessment 9 months post-baseline. At each assessment, the child and parent/guardian completed the CoRonavIruS health Impact Survey and measures of child anxiety, depressive, irritability, and posttraumatic stress syndromes. Children's mental health, indexed by the severity of multiple syndromes, fluctuated over the study period. Elevated local monthly COVID-19 prevalence, hospitalization, and death rates were associated with monthly elevations in children's reported worry about contracting COVID-19 and stress related to stay-at-home orders. In turn, both elevated monthly worry about contracting COVID-19 and stress related to stay-at-home orders were associated with monthly elevations in child- and parent-/guardian-report of children's emotional distress and psychiatric syndromes. This study illustrates the importance of, and informs the potential design of, longitudinal research to track the mental health of children, who may be particularly vulnerable to broad psychosocial sequelae of health crises such as the COVID-19 pandemic.

Health Consequences of Familial Negative Weight Talk Across the Spectrum of Gender Diversity

PURPOSE OF REVIEW

To synthesize differences in familial negative weight talk and health-related correlates across gender identities and to highlight gaps relevant to the unique experiences and health correlates of boys and transgender and gender diverse youth.

RECENT FINDINGS

Most of the studies included in this review observed no difference by gender in familial negative weight talk health correlates. Gender biases in existing measures, however, may have contributed to underreporting of health correlates in boys. Moreover, transgender and gender diverse youth are severely underrepresented in this research. Future research should consistently examine effect modification across gender identities and include measures that are specific to the weight-based concerns and experiences of boys and transgender and gender diverse youth.

Admission rates and clinical profiles of children and youth with eating disorders treated as inpatients before and during the COVID-19 pandemic in a German university hospital

Introduction

Children and youth at risk for mental health disorders, such as eating disorders (ED), were particularly affected by the COVID-19 pandemic, yet evidence for the most seriously affected and thus hospitalized youth in Germany is scarce.

Methods

This crosssectional study investigated anonymized routine hospital data (demographic information, diagnoses, treatment modalities) of patients admitted (n = 2,849) to the Department of Child and Adolescence Psychiatry, Psychosomatics and Psychotherapy (DCAPPP) of a German University Hospital between 01/2016 and 02/2022. Absolute and relative number of inpatients with or without ED prior to (01/2016-02/2020) and during the COVID-19 pandemic (03/2020-02/2022) were compared. The effect of school closures as part of social lockdown measures for COVID-19 mitigation on inpatient admission rate was explored as it has been discussed as a potential risk factor for mental health problems in youth.

Results

During the COVID-19 pandemic, ED inpatient admission rate increased from 10.5 to 16.7%, primarily driven by Anorexia Nervosa (AN). In contrast to previous reports, we found no change in somatic and mental disorder comorbidity, age or sexratio for hospitalized youth with ED. However, we did observe a shortened length of hospital stay (LOS) for hospitalized youth with and without ED. In addition, non-ED admissions presented with an increased number of mental disorder comorbidities. In contrast to our hypothesis, school closures were not related to the observed increase in ED.

Discussion

In summary, the COVID-19 pandemic was associated with an increased rate of inpatient treatment for youth suffering from AN, and of youth affected by multiple mental disorders. Accordingly, we assume that inpatient admission was prioritized for individuals with a higher burden of disease during the COVID-19 pandemic. Our findings pinpoint the need for adequate inpatient mental health treatment capacities during environmental crises, and a further strengthening of child and adolescence psychiatry services in Germany.

Reduction of Mental Health-Related Emergency Department Admissions for Youth and Young Adults Following a Remote Intensive Outpatient Program: Quality Improvement Analysis

BACKGROUND

Pediatric mental health emergency department (ED) visits are increasing at 6% to 10% per year, at substantial cost, while 13% of youth with psychiatric hospitalizations are readmitted in the following weeks. Hospitals do not have the resources to meet escalating youth's mental health needs. Intensive outpatient (IOP) programs, which provide multiple hours of care each week, have the power to reduce the number of patients in need of hospitalized care and provide a step-down option for patients discharging from ED's in order to prevent readmissions.

OBJECTIVE

The purpose of this program evaluation was to assess (1) whether youth and young adult ED admission rates decreased following participation in a remote IOP program and (2) whether there were differences in readmission rates between youth and young adults by gender identity, sexual orientation, race, or ethnicity.

METHODS

Data were collected from intake and 3-month postdischarge surveys for 735 clients who attended at least 6 sessions of a remote IOP program for youth and young adults. Patients reported if they had been admitted to an ED within the previous 30 days and the admission reason. Over half (407/707, 57.6%) of clients were adolescents and the rest were young adults (300/707, 42.4%; mean age 18.25, SD 4.94 years). The sample was diverse in gender identity (329/687, 47.9% female; 196/687, 28.5% male; and 65/669, 9.7% nonbinary) and sexual orientation (248/635, 39.1% heterosexual; 137/635, 21.6% bisexual; 80/635, 10.9% pansexual; and 170/635, 26.8% other sexual orientation) and represented several racial (9/481, 1.9% Asian; 48/481, 10% Black; 9/481, 1.9% Indigenous; 380/481, 79% White; and 35/481, 7.2% other) and ethnic identities (112/455, 24.6% Hispanic and 28/455, 6.2% other ethnic identity).

RESULTS

Mental health-related ED admissions significantly decreased between intake and 3 months after discharge, such that 94% (65/69) of clients with a recent history of mental health-related ED admissions at IOP intake reported no mental health-related ED admissions at 3 months after discharge from treatment (χ21=38.8, P<.001). There were no differences in ED admissions at intake or in improvement at 3 months after discharge by age, gender, sexuality, race, or ethnicity.

CONCLUSIONS

This study documents a decrease in ED admissions between intake and 3 months after discharge among both youth and young adults who engage in IOP care following ED visits. The similar outcomes across demographic groups indicate that youth and young adults experience similar decreases after the current tracks of programming. Future research could conduct a full return-on-investment analysis for intensive mental health services for youth and young adults.

Pediatric Mental Health Emergencies During 5 COVID-19 Waves in New York City

OBJECTIVES

To describe the proportion of pediatric mental health emergency department (MH-ED) visits across 5 COVID-19 waves in New York City (NYC) and to examine the relationship between MH-ED visits, COVID-19 prevalence, and societal restrictions.

METHODS

We conducted a time-series analysis of MH-ED visits among patients ages 5 to 17 years using the INSIGHT Clinical Research Network, a database from 5 medical centers in NYC from January 1, 2016, to June 12, 2022. We estimated seasonally adjusted changes in MH-ED visit rates during the COVID-19 pandemic, compared with predicted prepandemic levels, specific to each COVID-19 wave and stratified by mental health diagnoses and sociodemographic characteristics. We estimated associations between MH-ED visit rates, COVID-19 prevalence, and societal restrictions measured by the Stringency Index.

RESULTS

Of 686 500 ED visits in the cohort, 27 168 (4.0%) were MH-ED visits. The proportion of MH-ED visits was higher during each COVID-19 wave compared with predicted prepandemic trends. Increased MH-ED visits were seen for eating disorders across all waves; anxiety disorders in all except wave 3; depressive disorders and suicidality/self-harm in wave 2; and substance use disorders in waves 2, 4, and 5. MH-ED visits were increased from expected among female, adolescent, Asian race, high Child Opportunity Index patients. There was no association between MH-ED visits and NYC COVID-19 prevalence or NY State Stringency Index.

CONCLUSIONS

The proportion of pediatric MH-ED visits during the COVID-19 pandemic was higher during each wave compared with the predicted prepandemic period, with varied increases among diagnostic and sociodemographic subgroups. Enhanced pediatric mental health resources are essential to address these findings.

Psychological disorders and suicide attempts in youths during the pre-COVID and post-COVID era in a Taiwan pediatric emergency department

Background

The COVID-19 pandemic has had a significant impact on pediatric patients, increasing their vulnerability to psychological fragility. The aim of this study was to investigate the epidemiology and clinical spectrum of pediatric psychological fragility and suicide attempts in the emergency department (ED) before and after the onset of the COVID-19 outbreak.

Methods

A total of 340 pediatric patients admitted to the ED for psychological fragility between 2019 and 2022 were retrospectively collated and categorized according to three periods: pre pandemic, pandemic, and post pandemic. Epidemiological and clinical information were analyzed and compared among the three groups. Moreover, patients with suicidal ideation or suicidal attempts and types of substance use disorders in children with suicidal attempts sent to the ED were analyzed.

Results

The proportion of psychological fragility increased during the pandemic period (0.4%) and the post-pandemic period (0.8%) compared to that in the pre-pandemic period (0.28%). Suicide ideation was the highest before the pandemic period (0.04%), while suicidal attempts were the highest in the post pandemic period (0.42%). Significantly elevated trends in suicide attempts involving overdose and injury were observed among the three groups (p < 0.05). Intensive care unit (ICU) admission rates increased significantly after the COVID-19 outbreak (p < 0.05), and major depressive disorder was the most common psychological fragility in the ED in all three groups.

Conclusion

An increase in the proportion of pediatric psychological fragility in the ED was noted in the post pandemic period than before or during the pandemic. With higher rates of ICU admissions and an increase in suicide attempts among children and adolescents during the pandemic compared to before or after the pandemic, it is of utmost importance to provide mental health support to this vulnerable population in order to prevent suicide attempts in the event of a new global outbreak of infectious diseases.

Upward trends in eating disorders, self-harm, and suicide attempt emergency admissions in female adolescents after COVID-19 lockdown

INTRODUCTION

Increased mental health problems have been reported in children and adolescents related to the COVID-19 lockdown and its immediate aftermath, especially among adolescent females. However, the longer-term impact of persistent quarantine measures and social restrictions on this population is yet to be further explored.

MATERIALS AND METHODS

We compared the number of children/adolescents admissions to the psychiatric emergency department (ED) of Hospital Clínic de Barcelona during the COVID-19 lockdown and the following year with the numbers of admissions the year before lockdown, adjusting for variations in the population. We also conducted separate analyses by gender, age group, and diagnostic categories. Finally, we also repeated the analyses considering the cumulated deficit/excess since the start of the lockdown. Statistical significance was estimated using binomial tests with Bonferroni correction.

RESULTS

A total of 2425 admissions were recorded. Globally, admission rates decreased during the lockdown (46%) and progressively increased during the one-year aftermath (43% by spring 2021). This increase was particularly high in adolescent females (85%) while unclear in children and/or males. The main diagnostic categories involved were anxiety, depressive, and eating disorders, as well as self-harm behavior, suicidal ideation, and suicide attempts. The increase in eating disorders, self-harm behavior, and suicide attempts admissions in female adolescents remained statistically significant when considering the cumulated deficit/excess.

CONCLUSIONS

We found increased ED admissions during the aftermath of the COVID-19 lockdown among adolescent females. We recommend strengthening the attention to this population to provide adequate specialized care and prevention strategies.

Weight-based discrimination and disordered eating behaviors in a cohort of U.S. sexual minority young adults

OBJECTIVE

Though prevalent, weight-based discrimination is understudied and has been linked to disordered eating behaviors (DEB) among adolescents and adults. Sexual minority populations experience elevated risk of DEB, but little is known about the role of weight discrimination in this elevated risk.

METHODS

Participants were 1257 sexual minority women and men (ages 18-31 years) in the US Growing Up Today Study cohort. We examined cross-sectional associations between weight discrimination victimization and three DEB in the past year: unhealthy weight control behaviors, overeating, and binge eating. Generalized estimating equations, adjusted for potential confounders, were used to estimate prevalence ratios (PRs) and 95% confidence intervals (CIs).

RESULTS

Three in 10 participants (31%) reported weight-based discrimination victimization. Sexual minority young adults who reported weight-based discrimination had greater relative prevalence of unhealthy weight control behaviors (PR [95% CI]: 1.92 [1.35, 2.74]), overeating (3.15 [2.24, 4.44]), and binge eating (3.92 [2.51, 6.13]), compared with those who reported no weight-based discrimination. Associations with overeating and binge eating remained significant after adjusting for BMI.

DISCUSSION

The role of weight-based discrimination, and its intersections with other forms of stressors for sexual minority young adults, must be included in efforts to advance eating disorder prevention for this underserved population.

PUBLIC SIGNIFICANCE

Three in 10 sexual minority young adults in this study had experienced weight-based discrimination, a common but understudied form of discrimination. Sexual minority young adults who experienced weight-based discrimination were at greater risk of disordered eating behaviors than those who had not experienced weight-based discrimination. These findings suggest that weight-based discrimination may be an important-and preventable-risk factor for disordered eating behaviors among sexual minority young adults.

A Review of Telepsychiatry for Pediatric Patients in the Emergency Setting

PURPOSE OF REVIEW

The purpose of this review is to summarize factors contributing to the current state of pediatric mental health access in ED settings and synthesize the existing literature on the use of telepsychiatry to extend access to care, with particular focus on feasibility and sustainability.

RECENT FINDINGS

Children are presenting to emergency departments (EDs) with mental health concerns at an increasing rate, while ED capacity to treat psychiatric needs in children remains insufficient. This growing problem is compounded by decreased access to outpatient care and inpatient psychiatric beds, resulting in exorbitantly long waiting times, or "boarding," of children in crisis. Telepsychiatry has emerged as a strategy to decrease boarding of pediatric patients in ED settings by utilizing remote psychiatric professionals to provide consultation and assessment. Telepsychiatry in ED settings is an effective strategy to increase access to care and decrease length of stay for pediatric patients.