Pediatrics

The aftermath of the COVID-19 pandemic on pediatric mental health: A pediatric emergency department’s perspective

a b s t r a c t

Background: pediatric mental health visits in the United States has become a public health crisis. Pediatric emer- gency departments (PED) encounter these patients during mental health emergencies. The COVID-19 pandemic disrupted the social environment of pediatric patients which potentially lead to new and worsening mental health issues. This study examined the proportion of mental health visits to PED around the first wave of the COVID-19 pandemic.

Methods: This retrospective cohort study assessed the proportion of mental health visits at a urban, PED between September 2019 to February 2022. Inclusion criteria were subjects aged 6 to 18 years with a holding order assigned, and one of identified mental health International Classification of Disease, Tenth Division (ICD-10) codes: F01-F99, T14.19, R45, R46.89. Proportion of mental health visits were compared in 6-month periods with the first 6-months representing the pre-COVID-19 period. Secondary analysis compared demographic infor- mation and ICD-10 codes.

Results: A total of 1036 charts were studied: 126 charts from 2019 to 2020, 512 from 2020 to 2021, and 398 from 2021 to 2022. The proportion of mental health visits from September 2019 to February 2020 was 1.4%, and for the following 6-month periods, the proportion of mental health visits was 1.2%, 7.5%, 4.9%, and 5.7%. There was a sta- tistically significant difference (p < 0.001) demonstrating a higher proportion of mental health visits after the start of the COVID-19 pandemic. Secondary analysis demonstrated statistically significant difference in both me- dian age (p < 0.001) and median length of hospitalization (p < 0.001).

Conclusion: This study demonstrated a significant increase in pediatric mental health visits following the start of the COVID-19 pandemic. We believe further investigation into the needs and management during acute surges will improve the care we provide to this vulnerable population.

(C) 2023

  1. Introduction

Emergency departments (ED) play a vital and important role during acute mental health concerns such as suicidal ideations, self-harming behaviors, depression, and anxiety. In the pediatric emergency depart- ment (PED), mental health concerns have been on the rise over the past several years [1,2]. One study showed an over 60% increase in men- tal health disorders presenting to the PED over a 10-year period, with a 326% increase in self-harming behaviors [3]. In 2018, suicide became the second leading cause of death in patients ages 10-24 [4]. This rise in

* Corresponding author at: Department of Emergency Medicine, Maimonides Medical Center, 4802 10th Avenue, Brooklyn, NY 11219, USA.

E-mail address: [email protected] (D.T. Guernsey).

mental health visits to PED has created a public health crisis that re- quires resources to help provide adequate and reliable care.

In March 2020, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) lead to the pandemic of coronavirus disease 2019 (COVID-19). In the early spring of 2020, Brooklyn, NY was one of the epicenters of the COVID-19 pandemic with one of the earliest and lon- gest periods of lockdown and public-school remote learning [5,6]. Di- sasters such as the COVID-19 pandemic disrupt the social framework and negatively impact mental health [7].

Psychiatric patients often have prolonged ED length of stays because of the paucity of mental health beds nationwide straining the limited re- sources in the ED [8]. Excessive boarding in the ED >4 h can increase Medical errors, decrease patient safety and privacy, and increase mor- tality [9]. A systematic review found pediatric mental health Boarding patients may wait 2-3 days in PED for inpatient placement [10].

https://doi.org/10.1016/j.ajem.2023.06.021

0735-6757/(C) 2023

Moreover, pediatric mental health visits in the ED require significant amount of ED, mental health, and inpatient resources in the manage- ment to ensure not only the proper treatment but also the safety of the patient and team [11].

The pediatric mental health crisis was a Public health concern before the COVID-19 pandemic. As one the hospital centers at the epicenter of the first wave of COVID-19 with a prolonged Lockdown period, vulnera- ble populations including pediatrics patients had the greatest potential for impact from the COVID-19 pandemic [7]. The objective of this study was to determine the impact made by the first wave of COVID- 19 on the proportion of pediatric mental health visits between academic school years.

  1. Methods

This was a retrospective cohort study performed at an urban, aca- demic hospital in Brooklyn, NY from September 2019 until February 2022, divided into 6-month periods. We selected September as the start period as it coincides with the start of a new academic year. We di- vided into 6-month periods for analysis since September 2019 to Febru- ary 2020 would represent a pre-COVID-19 pandemic period as well as identifying an overall trend. The PED is staffed by pediatric emergency medicine physicians with child psychiatry available with roughly 35,000 annual visits prior to the pandemic.

Inclusion criteria were subjects aged 6 to 18 years old with a holding order applied and one of the specific International Classification of Dis- ease, Tenth Division (ICD-10) codes, as listed in Table 1. ICD-10 are assigned both by the ED team and psychiatry team, including primary and secondary diagnoses. We used holding order as an inclusion criteria because when placed in the EMR it requires psychiatric clearance prior to discharge. All patients who did not meet these criteria were excluded from the study. We included all patients presenting directly to the pedi- atric ED or as a transfer from an outside hospital. We did not exclude re- peat visits for patients as each visit required repeat evaluation and assessment by psychiatric team. All charts with a holding order were queried, and study investigators reviewed each chart and extracted the relevant information.

Data was extracted directly from the EMR and assigned a subject ID. The data collected included: age in years, date of birth, gender, race, eth- nicity, insurance, disposition, ICD-10 codes, and length of hospitaliza- tion. Length of hospitalization was calculated from time of registration until discharge from the ED or hospital. To maintain confidentiality, medical record number (MRN) or name was not provided which prevented any chart review or assessing the number of repeat visits. Those involved in data extraction were blinded from the patient’s chart to control bias. All data was managed in Research Electronic Data Capture (REDCaps) database without any identifiable information hosted at Maimonides Medical Center.

The primary outcome was the proportion of mental health visits compared to all ED visits. We extracted the number of all ED visits for the 6 to 18 years-old who presented to the ED during the time periods of interest in order to calculate the proportion of mental health visits for each time period. We divided our time period into 6-month periods, for a total of 5 periods, and compared for difference. Our secondary out- comes included differences in subjeCT characteristics between study pe- riods including age, gender, language, race, ethnicity, disposition, and

median length of hospitalization. Additionally, a secondary outcome in- cluded the incidence of ICD-10 codes as listed in Table 1.

We summarized continuous variables with medians and inter- quartile (IQR) ranges while categorical variables were summarized with frequency and count. Kruskall Wallace was used to compare con- tinuous variables. Chi-square or Fisher exact test was used when com- paring categorical variables. All statistical analysis was performed using SPSS software. Alpha was set at 0.05. Sample size was not calcu- lated for this study given the restriction of studying the impact of an emerging disease. This study was approved under expedited review by the institutional review board.

  1. Results

We queried 1036 charts from the EMR with 126 charts pulled for 2019-2020, 512 charts pulled for 2020-2021, and 398 for 2021-2022. After exclusion of charts, we were left with 119 charts for 2019-2020, 459 charts from 2020 to 2021, and 330 charts from 2021 to 2022 which is demonstrated in Fig. 1, including the breakdown of mental health visits per 6-month periods. The study characteristics for each 6- month period is demonstrated in Table 2.

For the 2019-2020 year, there were 6191 PED visits from September to February and 2658 PED visits from March to August. The proportion of mental health visits was 1.4% (95% CI: 1.1%-1.7%) for September to February and 1.2% (95% CI: 0.8%-1.7%) for March to August. For 2020-2021, there were 3164 PEDS visits for September to February and 4506 PED visits for March to August. The proportion of mental health visits was 7.5% (95% CI: 6.7%-8.5%) for September to February and 4.9% (95% CI: 4.3%-5.6%) for March to August. For September 2021 to February 2022, there was a total of 5782 PED visits with a pro- portion of mental health of 5.7% (95% CI: 5.1%-6.3%). When compared across time, there was a statistically significant difference (p < 0.001) between the 6-month time periods with the rise in proportion of mental health visits after the first wave the COVID-19 pandemic.

When comparing the ICD-10 codes between 6-month periods, we

found the same top 5 ICD-10 codes. Those codes are F32.9 (Major de- pressive disorder), R45.851 (Suicidal ideations), R46.89 (Other signs and symptoms involving appearance and behavior), F41.9 (Anxiety dis- order, unspecified), and F43.20 (Adjustment Disorder), presented in Table 3. There was no statistical difference between the 6-month periods (p = 0.14).

Image of Fig. 1Table 1

Description of International Classification of Diseases-10 Codes. ICD-10? Code: Description:

F01-F99 Mental, Behavioral and NeurodevelopMental disorders

T14.19 Suicide attempt

R45 Symptoms and signs involving emotional state

R46.89 Symptoms and signs involving appearance and behavior

* International Classification of Diseases, Tenth Revision. Fig. 1. Flow Diagram for Included Patients.

Table 2

Descriptive statistics for included subjects.

Variable Sept 19 – Feb 20

Mar 20 – Aug 20

Sept 20 – Feb 21

Mar 21 – Aug 21

Sep 21 -Feb 22

p-value

(n = 87)

(n = 32)

(n = 237)

(n = 222)

(n = 330)

Median Age

(years)

15.0 (13.0-16.0)

15.0 (13.25-17.0)

15.0 (13.0-17.0)

14.0 (12.0-16.0)

14.0 (12.0-16.0)

<0.001+-

Gender

Female

49 (56.3%)

13 (40.6%)

142 (59.9%)

143 (64.4%)

192 (58.2%)

0.109

Male

38 (43.7%)

19 (59.4%)

95 (40.1%)

79 (35.6%)

138 (41.8%)

Language

English

61 (70.1%)

23 (71.9%)

178 (75.1%)

149 (67.1%)

234 (70.9%)

0.46

Non-English

26 (29.8%)

9 (28.1%)

59 (24.9%)

73 (32.9%)

96 (29.1%)

Race

White

31 (35.6%)

7 (21.9%)

75 (31.6%)

83 (37.4%)

120 (36.4%)

0.337

Asian

13 (14.9%)

7 (21.9%)

45 (19%)

41 (18.5%)

81 (24.5%)

Black or African American

14 (16.1%)

5 (15.6%)

31 (13.1%)

31 (14%)

38 (11.5%)

Unknown/Not Reported

29 (33.3%)

13 (40.6%)

86 (36.3%)

67 (30.2%)

91 (27.6%)

Ethnicity

Hispanic or Latino

25 (28.7%)

9 (28.1%)

76 (32.1%)

78 (35.1%)

86 (26.1%)

0.059

NOT Hispanic or Latino

55 (63.2%)

20 (62.5%)

135 (57%)

133 (59.9%)

199 (60.3%)

Unknown / Not Reported

7 (8%)

3 (9.4%)

26 (11%)

11 (5%)

45 (13.6%)

Disposition

Discharge

74 (85.1%)

30 (93.8%)

208 (87.8%)

205 (92.3%)

309 (93.6%)

0.126

Admit

13 (14.9%)

2 (6.3%)

28 (11.8%)

17 (7.7%)

21 (6.4%)

Transfer

0 (0%)

0 (0%)

1 (0.4%)

0 (0%)

0 (0%)

Median Length of Hospitalization (days)

8 (4-23)

4.5 (3-11)

13 (4-30)

7.5 (4-21)

6.0 (4-16.5)

<0.001+-

Age and length of hospitalization was summarized with median and IQR and compared across groups with a Kruskill-Wallis test. All other variables summarized with frequency and per- centage, and compared across groups using a chi-square or fisher exact test if needed.

+- Represents statistically significant result.

For our secondary aim, we compared different subject characteris- tics between the 6-month periods. We discovered a statistically signifi- cant difference in median age between the 6-month periods (p < 0.001). We also discovered statistically significant difference in median length of hospitalization (p < 0.001) with September 2020 to February 2021 demonstrating the longest median length of hospitaliza- tion. We did not find any statistical significance between gender (p = 0.11), language (p = 0.46), race (p = 0.337), ethnicity (p = 0.06), or disposition (p = 0.13).

  1. Discussion

The COVID-19 pandemic had a profound impact on the proportion pediatric mental health visits to our emergency department. We dem- onstrated a 4-fold increase in pediatric mental health visits between 2019 and 2020 and 2020-2021, and moreover, there continues to be a significant higher proportion of visits continuing into the 2021-2022 year. Prior to the pandemic, a documented increase in these mental health visits created a burden due to extended length of stay and specific resource utilization [12]. This increase in mental health visits has the potential to have a larger impact on under resourced, safety net hospital. The noticeable spike in proportion of mental health visits and median length of stay warrants additional attention to the acute period following disasters and need for allocation of resources for pediatric mental health.

Stressful events in the developing child, akin to adverse childhood experiences (ACEs), can lead to physical changes in the brain and change neurodevelopment [13]. The impact COVID-19 has had on the development of children and adolescents is multifactorial and includes direct, Psychological effects. The pediatric mental health crisis has only worsened during the COVID-19 pandemic. We must advocate for addi- tional resources and funding to provide the Specialized care these patients require.

As an urban PED that is a safety net hospital for New York City serv- ing a primarily low socioeconomic community, we are limited by the re- sources affecting the care we provide. The challenges our institution faces in providing pediatric mental health care are not uncommon. Ac- cording to the US Surgeon General Advisory statement issued in Decem- ber of 2021, the COVID-19 pandemic significantly impacted children already at increased risk for psychiatric illness for high-risk individuals including racial and Ethnic minorities, LGBTQ+ youth, and low socio- economic status [14]. This study did not obtain statistical significance with race or ethnicity and did not examine LGBTQ+ youth. While we obtained a statistically significant difference in median age between the 6-month periods, we do not see any clinical difference in the median age in the different time periods.

It is vital to document and report these findings about the overall state of mental health after the pandemic. The government and non- profit organizations must see this information in order to provide justi- fication to increase funding for mental health resources and continue

Table 3

The top 5 most frequency ICD-10 Code by time period.

Sept 19

Feb 20

Mar 20

Aug 20

Sept 20

Feb 21

Mar 21

Aug 21

Sep 21

Feb 22

p-value

ICD-10 Code

0.14

F32.9, Major Depressive disorder

13 (14.9%)

6 (18.8%)

49 (20.7%)

43 (19.4%)

48 (14.5%)

R45.851, Suicidal ideations

18 (20.7%)

3 (9.4%)

29 (12.2%)

27 (12.2%)

65 (19.7%)

R46.89, Other symptoms and signs involving appearance and behavior

9 (10.3%)

1 (3.1%)

17

18

25

(7.2%)

(8.1%)

(7.6%)

F41.9, Anxiety disorder, unspecified

5 (5.7%)

1 (3.1%)

14

11

21

(5.9%)

(5%)

(6.4%)

F43.20, Adjustment Disorder

2 (2.3%)

2 (6.3%)

4

16

13

(1.7%)

(7.2%)

(3.9%)

Variable summarized with frequency and percentage, and compared across groups using a chi-square or fisher exact test if needed.

research in this field. The COVID-19 pandemic continues to evolve and what was once considered to be a brief period of time has extended to over 2 years, and we continue to be impacted by its effects. Researchers continue to work and discover the impact the COVID-19 pandemic has had on stress, mental health, neurodevelopment, and post-traumatic stress disorder [15-17]. As this the pediatric mental health crisis con- tinues to grow, this study along with several others help to provide the framework for understanding the impact the pandemic had in order to advocate in the future for specific resource and funding to improve the care we provide in our burdened system.

This study does contain several limitations. We did conduct this as a retrospective cohort study; however, as the purpose of this study was to understand the impact the first wave of the COVID-19 pandemic had on pediatric mental health, it is the appropriate study design. We only con- ducted the study at a single-institution which limits sample size and in- creases potential for error. As a referral center and the only children’s hospital in Brooklyn, it is standard of care in our department to place holding orders and consult child psychiatry on all behavioral or psychi- atry complaints; however, we do acknowledge the potential for varied practice. This varied practice may have prevented the capture of all mental health visits, but we believe it is a minor limitation. Our measure was proportion of mental health visits which was impacted by the de- crease in pediatric visits. However, looking at the absolute numbers of visits it was still significantly larger in the post-COVID-19 time period further support overall increase in mental health visits. Those who re- turned as repeat visits were unable to be examined due to the way data was collected and analyzed to protect patient information. Since we attempted to understand the overall burden on the hospital, we be- lieve this does not limit our study. Lastly, our institution provides pedi- atric psychiatry in the ED with no inpatient pediatric psychiatric service. The lack of a robust service able to provide inpatient care may deter- mine who present to the ED. We are the only children’s hospital in Brooklyn with a large catchment area; however, we are unclear the impact the lack of inpatient service contributes to our data.

The access and availability of mental health care, in particular for children and adolescents, in the United States is in crisis, and due to the COVID-19 pandemic, this public health crisis has only worsened. We emphasize the increased demand in mental health visits have brought upon PED associated with the COVID-19 pandemic and the concern that it will not only continue but also worsen without specific interventions. We hope this study will encourage additional research that will improve our understanding as well as develop and establish solutions to improve the mental health care we provide to children in the United States.

Presentations

None.

Funding/support

No funding was secured for this study.

Author disclosure

DG conceptualized and designed the study, designed the data collec- tion instruments, and collected data. ES, LC, and AA conceptualized the study and collected data. MS designed data collection instruments and carried out the initial analyses. AT and JZ conceptualized and designed the study and coordinated and supervised data collection. DG drafted the initial manuscript. All authors critically reviewed and revised the manuscript for important intellectual content. All authors approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

CRediT authorship contribution statement

David T. Guernsey: Writing – review & editing, Writing – original draft, Project administration, Methodology, Data curation, Conceptuali- zation. Elina Slobod: Writing – review & editing, Writing – original draft, Investigation, Data curation, Conceptualization. Michael Silver: Writing – review & editing, Writing – original draft, Formal analysis, Data curation, Conceptualization. Lea Cohen: Writing – review & editing, Writing – original draft, Investigation, Data curation, Conceptu- alization. Ayesha Ali: Writing – review & editing, Writing – original draft, Investigation, Data curation, Conceptualization. April Toure: Writing – review & editing, Supervision, Investigation, Data curation, Conceptualization. Jessica Zerzan: Writing – review & editing, Supervi- sion, Investigation, Data curation, Conceptualization.

Declaration of Competing Interest

All authors have no conflicts of interest to disclose.

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