Why children's mental health is viewed as a national emergency

[00:00:00] Host Amber Smith: Upstate Medical University in Syracuse, New York invites you to be "The Informed Patient" with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith. Rates of mental health challenges are soaring among children, adolescents, and their families throughout the pandemic, so today I'm talking about this important issue with two experts in caring for children from the Upstate Golisano Children's Hospital. Pediatrician Greg Conners, MD, is professor and chair of pediatrics at Upstate, and child psychologist Jennifer Rapke is the chief of the child psychiatry consult service at Golisano. I welcome both of you back to "The Informed Patient" podcast.

[00:00:39] Gregory Conners, MD: Thank you.

[00:00:39] Jennifer Rapke, PsyD: Thank you for having us.

[00:00:41] Host Amber Smith: Now suicide is the second leading cause of death for young people between the ages of 10 and 24. And I think it's tempting to believe that this can't be happening here in our community. So please, tell us what you're seeing. Dr. Conners, what percent of pediatric emergency department visits are for mental health emergencies?

[00:01:00] Gregory Conners, MD: Sure, thanks for bringing up that important topic. The fact is that suicide is happening among young people, even though we don't want to always believe it is happening among young people in both the Central New York area and across the country. But much more than that for every completed suicide, we see a large number of incomplete suicides, where someone didn't actually die, or discussion of suicide gestures, or just talk about,"I'd like to die," or "maybe the world would be better off without me." So we see large numbers of children like that, and it ends up being about 10% or so of the children who come to our emergency department these days, our pediatric emergency department, are there for mental health related reasons. It's not just a Central New York phenomenon. Across the country, there have been large increases in emergency department visits too, especially during the COVID era. During the last couple of years, the number of ED (emergency department) evaluations for suicide attempts in adolescent girls has increased 50% and,

[00:01:59] Host Amber Smith: Wow.

[00:02:00] Gregory Conners, MD: Yeah. And children under 12, even those young kids, 24% increase in emergency department mental health visits during the COVID era. Teens 31% increase. So we're seeing the increased locally and nationally,

[00:02:14] Host Amber Smith: And that's huge. And do you attribute it to the stress of all of the pandemic? Dr. Rapke?

[00:02:21] Jennifer Rapke, PsyD: Uh, we definitely have seen an increase with COVID. However, our community, as well as many communities nationally, were seeing an increase in numbers before COVID even hit. Actually, prior to -- we consider March of 2020 really, the beginning of COVID because that's when schools closed -- February was our busiest month in the last three years prior to that. In the couple months before COVID really shut everything down, we were already seeing a significant increase in kids coming in. Over the last three years, we've had a 400% increase at Upstate in the number of kids presenting with mental health complaints.

[00:02:58] Host Amber Smith: When you talk to these kids, what are some of the things, do you see any trends in what they point to? Are they able to say "this is what's causing stress in my life?"

[00:03:10] Jennifer Rapke, PsyD: During COVID, we definitely saw most of the kids talking about isolation as being a primary factor that was driving their symptoms. Since COVID has morphed over time and the kids are being able to be back in school, we're not hearing as much about isolation as just everything in their world is changing all of the time. Parents are feeling very stressed and unable to handle things like they normally would be able to. And certainly, academic stress now for those kids that are struggling to get back into the routine of life and academics as they were previously.

[00:03:45] Host Amber Smith: Let me ask you for kids who had a pre-existing issue before the pandemic, let's say an eating disorder, has the pandemic had an impact on things like that?

[00:03:56] Jennifer Rapke, PsyD: I think we've seen an increase in eating disorders as well. It's harder to tell if that was already happening prior to COVID or if COVID really put that into overdrive, but we certainly have seen an increase in presentations for eating disorders. Many of those cases used to go to Rochester to Strong Memorial, and now that we have so many cases that we're having to hold kids here at Golisano as well for those issues, and really trying to manage. Again, one of the primary drivers in eating disorders is needing a sense of control. And as everybody can imagine, the world feels very out of control for most people the last few years. And so that really triggers something like an eating disorder, even further.

[00:04:36] Gregory Conners, MD: And I'm going to repeat a point that we heard earlier, which is that this is not new during COVID. It certainly increased, but it was already way on the upward trend. In fact, it's become the number two cause of death in children, age 10 to 24 is suicide in the United States. This is something that came on a few years ago. And so it was already present, and people are already worrying quite a lot about it. And then COVID has just amplified the rate. So it's two phenomenon on top of each other.

[00:05:06] Host Amber Smith: So COVID didn't cause it, but COVID seems to be making it worse?

[00:05:10] Gregory Conners, MD: That's right.

[00:05:11] Host Amber Smith: Can you describe how these children present when they come to the emergency department?

[00:05:16] Gregory Conners, MD: Sure. And just for background, I'm a pediatric emergency physician, so that's where I work clinically. And I'm also the chairman of a national committee on pediatric emergencies through the American Academy of Pediatrics. So I sort of have this national perspective too. Children, they present with a variety of ways all the way from actual suicidal act -- taking pills or hurting themselves in some other way -- that we see some of that, for sure. But that's really not majority. The majority are people who make some kind of a suicide gesture, perhaps cutting themselves, or discussing suicide, or maybe "the world would be better off without me," words like that, or some other form of severe anxiety talking about hurting someone else at school or hurting someone in family. So, a wide variety of ways, or presentations. Schools are seeing more and more kids acting out and are getting less and less willing to accept that until the kids go back to class. These days, there's a lot more of what you might call zero tolerance because of concern that this might actually end up resulting in an actual suicide or an aggressive act. So lots of those kids are coming to the emergency department these days.

[00:06:26] Gregory Conners, MD: Once they come to the emergency department and are recognized as having mental health issues, we do the same kind of intake that we do on any other patient, getting their history and that sort of thing, physical examination, making sure that there aren't multiple things going on, that we're not missing something. And then we're fortunate that we at Upstate are able to turn to mental health colleagues. Dr Rapke and colleagues are able to come to the emergency department and assess these patients. Then we make a decision about if they need to be admitted to our hospital or to a mental health facility, or are able to go home and be connected with a counselor or psychologist, something of that nature. In fact, many of them already have those, some of those resources in place, but it hasn't been as effective as it could be, or they're having a crisis. So we're often able to reconnect those patients with their previously existing sources of mental health care.

[00:07:16] Host Amber Smith: So, let me ask you a little bit more about that. How do you decide who gets admitted and who is okay to go back home?

[00:07:24] Gregory Conners, MD: Yeah, so fortunately we're able to rely on the expert opinion from mental health professionals, psychiatrists, and a whole mental health team, including child psychologists and child psychiatrists. And we're really lucky to have Dr. Rapke not only with us today, but able to take care of our patients on a regular basis and really give us advice as emergency physicians. We can recognize certainly some, some of the basics, but it's great to have a real in-depth expert team as well. And so they help us deciding if patients are okay to go home safe or need extended stay in the hospital. And there are also inpatient mental health specific centers. We have only eight beds here at Upstate ,but there are other inpatient mental health facilities for children in the region. And so they can help us place the patient in one of those facilities if they need that. Although almost always they're full, and so it's hard to find them a room in the inn.

[00:08:20] Host Amber Smith: This is Upstate Medical University's "The Informed Patient" podcast. I'm your host, Amber Smith. My guests are from the Upstate Golisano Children's Hospital -- pediatrician, Dr. Greg Conners and child psychologist Jennifer Rapke. So Dr. Rapke, it was challenging for parents to find a good child psychologist or counselor or therapist before COVID. And with the demand for mental health services being so high, what's being done to help kids who need help?

[00:08:47] Jennifer Rapke, PsyD: That's a really challenging question and something that as a society and a nation we're struggling with currently. There's a lot of advocacy points that are out there of things that are needed that are certainly not enough right now. But one of the things that concretely happened in respective to COVID was telehealth was something that got used much more frequently. So we were able to offer those services more remotely, especially to people that were at a distance. As some people may know, Golisano serves a large region. It's not just the local area. So we serve a lot of counties, some of which could be hours away and not able to physically come to appointments and things. So telehealth expansion was a big thing that happened over the last two years. The other thing that happened was an investment in school-based mental health. So there is money and efforts out there to, just like we tried to put that into primary care over the last 10 years, now there's a lot more efforts to put that into school-based mental health care, where we can access kids. Kids are at their primary care doctor and they're at school generally. And so we can try to meet them where they're at a little better. And so most of the districts in our region are trying to involve mental health care in some way in their district. So that was a big change as well, but it's still, unfortunately not enough. And a lot more work is needed in that area.

[00:10:07] Host Amber Smith: Many children have lost parents, and sometimes both parents, to COVID. What is happening to those children? And in general, what sorts of mental health challenges are these kids facing?

[00:10:20] Jennifer Rapke, PsyD: So bereavement is a natural course of life for most people. Many kids, their first loss is a pet or a grandparent. So it is part of a developmental process that most of us go through to lose, a family member or a loved one. Unfortunately, a loss due to COVID was complicated by a lot of things and can lead to complicated bereavement in that, many people weren't able to have memorials or ceremonies or religious practices in response to the loss. So it didn't give us these opportunities to grieve in the ways that we normally would. And it also created just an added factor into things. Certainly COVID is something that's become politicized and has social implications. And so that complicates bereavement too. That can cause anger, frustration in the way that things were handled, or maybe they felt their loved one didn't get the correct medical care that they needed because of strapped resources. So it certainly can breed complicated bereavement. The difficult thing is we have to respect people's bereavement process for what it is. There is data out there that says, if we try to give care too soon before the person is ready, it can actually cause worse bereavement for them or cause more symptoms. So we don't want to make something that's normal abnormal, but it is certainly something we have to keep an eye on and watch a little more closely because a loss due to COVID can cause what's called complicated bereavement or a bereavement that lasts longer or has more mixed feelings or mixed emotions that are caught up in there as well.

[00:11:47] Gregory Conners, MD: The children of families of color, and also families in poverty, have been especially hit by losses of parents or caregivers during COVID. And many of them already had decreased access to other kinds of mental health resources. So although the mental health crisis has been across the board, it has especially hit families, including children of color.

[00:12:14] Jennifer Rapke, PsyD: Absolutely.

[00:12:15] Host Amber Smith: What are some of the reasons for that? Why our youth of color are disproportionately affected by this?

[00:12:22] Gregory Conners, MD: Yeah. As Dr Rapke was saying, we have had increased loss of parents and guardians during the COVID pandemic. Also, as a background, there's been less resources available, including mental health resources to kids in the school districts and in primary care settings, all across the board, available to children and families of color. and then also in areas of poverty. Central New York has a high poverty rate, especially in Syracuse, and often that's associated with decreased mental health resources. But I am going to tell you that the largest provider of primary care to children in the area, pediatric primary care, is here at Upstate Golisano Children's Hospital. And there we have, I think, especially good resources embedded in primary care for children with mental health needs. So we are helping to address that right here at Upstate Golisano Children's Hospital.

[00:13:20] Host Amber Smith: I wanted to ask you also, are you seeing children with physical ailments that are brought on by stress? I know we hear about adults that, you know, ulcers that are brought on by stress. Do you see things like that in kids?

[00:13:33] Gregory Conners, MD: I'll start that, and Dr. Rapke can amplify. I'm sure. I'll say that as an emergency physician, we will see children with some of the classic things including, well, you mentioned ulcers, but in children it tends to be more headaches, stomach aches, and also some unusual kind of rhythmic behaviors that can look like seizures, but seem not to be seizures. And then also we see kids will often have cutting behaviors. Fresh cuts or even scars on usually on their forearms, but other places as well. They can tell us that there's mental health issues, stress going on. I'm sure Dr. Rapke sees a lot more.

[00:14:07] Jennifer Rapke, PsyD: We actually have an entire separate team, Amber, that handles that, led up by Dr. (Anne) Reagan and a team of pediatric psychologists. So the numbers that we were citing about children with mental health complaints don't even include that entire population of kids that comes in with medical complaints, and they're seen by Dr. Reagan and her wonderful team of colleagues. So it's a whole separate group of folks that we are seeing as well, that's on top of, the traditional mental health crises that we're talking about today, and they try to be embedded in every subspecialty at Upstate. So they're involved in the pulmonary clinic for children, with pulmonary illness cystic fibrosis. They're embedded in the hematology oncology population where we can see medical symptoms that are, exacerbated by stress. And then all the kids here in the hospital that Dr. Conners just mentioned. So there's a whole nother section of kids that aren't even really who we're talking about today that are being served by a whole another team of people. So that if you add all that together, it's even bigger than we're describing..

[00:15:05] Gregory Conners, MD: It can be hard to untangle physical elements and mental health ailments. I think it's well known that they are, that there's an interplay back and forth. A great example is children with asthma. They may well have increased problems with their asthma as a result of stress and mental health. It's not to say they don't have asthma, but they're working together, in this case against that child.

[00:15:28] Host Amber Smith: We've been talking mostly about kids from 10 on up. I wonder, does the pandemic have an effect on babies and toddlers? Do you see that they're picking up on tension in the household or not?

[00:15:42] Jennifer Rapke, PsyD: Our service has seen kids as young as three presenting with mental health chief complaints, which just sounds really intense. But if you think about, three-year-olds can be in preschool, and so they're being seen in those environments, and people are noticing something is different, something is unusual, this kid is not functioning in the way that they normally do. We certainly see kids as young as you know, 12 to 18 months for developmental delays and concerns, and the Center for Special Needs here at Upstate serves some of those kids in recognizing early intervention and early issues. So absolutely we see changes as early as newborns primarily because they are very keen observers of the environment around them. They learn based on their family, their parents, their caregivers, and all of us as adults are stressed as well. And so they absolutely pick up on that. I think we often underestimate how much kids observe and notice about the people around us. We used to call them the little barometers of the family because they let us know what's going on in the family based on their behavior and how they're acting.

[00:16:41] Host Amber Smith: This is Upstate's "The Informed Patient" podcast host Amber Smith with my guests, Dr. Greg Conners, who is the professor and chair of pediatrics at Upstate, and child psychologist Jennifer Rapke, who is the chief of the child psychiatry consult service at the Upstate Golisano Children's Hospital. We're talking about how the pandemic has affected children and their mental health. So I'd like to talk about some solutions. I know the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry and the Children's Hospital Association have jointly declared a national state of emergency in children's mental health. Dr. Conners, can you explain what these groups are hoping to accomplish?

[00:17:36] Gregory Conners, MD: Sure. And thanks for mentioning that. I think that was a really important statement that these three professional societies highlighted by the American Academy of Pediatrics, which is the number one professional group of pediatricians in the United States, that they all got together and declared this a national state of emergency and children's mental health. I think that's a big deal that I would recommend that people take a minute or two to take a look at, easy to find on the internet. I think what the goal of this state of emergency was really twofold. Number one was to bring awareness, and I think that although you and I, and Dr. Rapke know that this is going on, there quite a few people who don't really appreciate the importance and the magnitude of the mental health crisis that we're seeing in children and teens right now. And then also to help to bring resources to help make it right. As you said, solutions. What I think that they're looking for is increased both to access to mental health care and then quality of mental health care. And we can get into specifics, but I think it has to do with working with policy makers mostly to help bring increased financial resources to the mental health community to help things like treatment and prevention, school and community-based care, community-based mental health programs and increased workforce mental health -- pediatric in particular -- mental health workforce really needs increased resources there. And then increased hospital beds, clinic beds, that kind of just room for patients to come. It's really, I consider it an investment inpediatric mental health, really similar to that, and probably more important, than the investment that we're making in roads and bridges and that sort of thing, because this is our future.

[00:19:18] Host Amber Smith: Dr. Rapke mentioned, I think, telemedicine before, or telehealth. Are there regulatory challenges that threaten telehealth or telemedicine that need to be fixed?

[00:19:28] Host Amber Smith: So we talk about insurance payments and insurance coverage for physician visits. And before the pandemic, the rate at which a treating physician or psychologist was paid was much, much smaller if a visit was made by telemedicine than in person. And so there, there was really an incentive not to do that and to have patients come in, and so very few folks were actually taking advantage much of telemedicine, offering or being able to get appointments through tele-medicine. Well, with the pandemic, the recognition that many visits -- medical, mental health, all sorts of visits -- could be just as efficiently done through telemedicine has led to equal reimbursement, whether it's via tele medicine or in person or close to it in many cases. And that's really tied to the state of emergency that's been declared by the government through the pandemic, and it also is slated to go away once the pandemic subsides. And so one of the requests from this state of emergency in children's mental health is to continue the availability, at full payment, of telemedicine for mental health visits for children and teens, so they don't necessarily need to travel a long way to get connected with their therapist. It helps to remove some of the barriers to mental health treatment.

[00:20:49] Host Amber Smith: I wonder -- kids being, digital natives, they're so good on their phones and electronic devices -- are they responding very well to the option for telemedicine, for mental health visits at least?

[00:21:00] Jennifer Rapke, PsyD: I think like most everything it's one way or the other. So there's half of the kids that really prefer that, they benefit from it, they don't feel as comfortable coming in, especially kids that have really high anxiety or, are even struggling to get out of the house because of their mental health challenges. This offers them a window and a way to do that that's more comfortable to them. And for families that are struggling to get their kids to come to an appointment, this is maybe a better platform. There's another group of kids that have said I absolutely hate telemedicine. It's awkward. It's weird. I don't like it. I don't feel as connected to the person. I, I don't even want to do it anymore unless I can come back in the office. So it's equally, depending on the kid's personality and depending on the challenges that they're facing.

[00:21:44] Gregory Conners, MD: And by the way, that's not just limited to mental health. We're seeing similar pros and cons and all kinds of chronic illnesses for check-ins and stuff. It's great. Check in with somebody in six months, see how their kidney or liver disease is doing, for example. Telemedicine's really a benefit for those kind of visits.

[00:22:02] Host Amber Smith: You're listening to "The Informed Patient" podcast from Upstate Medical University in Syracuse, New York. I'm your host, Amber Smith, talking with Dr. Greg Conners and child psychologist Jennifer Rapke about the impact the pandemic has had on children.

[00:22:17] Host Amber Smith: Dr. Rapke do schools in Central New York communities offer school-based mental health care?

[00:22:24] Jennifer Rapke, PsyD: So we have quite a few districts in the local area, and each one of them is in a different phase of development. Some of them are fully integrated and every one of their schools is offering school-based mental health of some kind. Other schools are a little bit earlier on in their development and their process, and they do that a little differently. We have schools of all sizes shapes and colors going on right now. And everyone has to apply it in the way that makes sense for their district and the way that is feasible for their district. And like we talked about earlier, there just aren't necessarily enough providers to go around. And so trying to find people to come into those settings and come into them at the frequency that's needed is a little bit challenging at the moment. But I think all of them are trying to address it in some way, shape or form. And the county and the state have offered some reimbursement opportunities for folks that are trying to offer that.

[00:23:15] Host Amber Smith: Dr. Connors what role do the professional organizations see community pediatricians playing in making sure that kids get the mental health care that they need?

[00:23:24] Gregory Conners, MD: Primary care pediatricians like those in the community are really well-trained to do physical exams, give immunizations and talk about those with families, check on developmental stages, safety counseling, all sorts of things in a limited period of time so that they can move on to the next checkup. And adding in mental health screening is really important, but it's difficult time-wise, and many of the pediatricians aren't really as well-trained because it hasn't traditionally been part of pediatric training -- although that's changing -- to do that kind of mental health screening. So the American Academy of Pediatrics and other groups are calling for increased reimbursement, increased training, and maybe embedding of mental health resources right in with primary care pediatric settings. And we're fortunate to have that ability to do at Upstate, but certainly we could do more in the primary care setting. And then also helping people identify good sources of referral for patients who are screened and found to be in need of additional mental health care, so helping people connect up with resources for which to refer the kids.

[00:24:29] Host Amber Smith: Thinking long term, I'd like to talk about what the pandemic is doing to normal child development. Dr. Rapke, you mentioned a lot of the kids mention isolation. Has that had a lasting impact?

[00:24:43] Jennifer Rapke, PsyD: I think it's a little early to say confidently what it's going to do. There's data and studies just starting to come out about the effects that we are seeing. There's some concern about, interestingly enough, even with masks up, are kids understanding emotional reactions appropriately? Are they understanding social cues in the same way? You know, because if half of our face is missing, basically, do they understand and interpret things in the same way that they would? There is some concern about delays in social skills and social mannerisms that kids are not understanding or lagging in a little bit, because they haven't been in schools, or they haven't been around social situations as much. So there's certainly some early concern about some of those issues, but I don't know that we completely understand yet the effect that it might have long term, and will those things last, now that they're back in their typical school, or for the most part or will they bounce back pretty quickly? Kids are extremely resilient, wonderful creatures. And we don't know if that sort of a temporary effect right now that we're seeing, or if it's something that will remain.

[00:25:48] Host Amber Smith: Yeah. I was wondering, the anxiety, the depression that so many kids are dealing with these days that the pandemic has made worse, do you think it will automatically subside once this crisis ends?

[00:26:03] Jennifer Rapke, PsyD: I don't think anything in medicine or psychology automatically, I'm sorry to say. Our fields of psychology as a field of "it depends," and we, it really depends on a lot of factors in their world. Are the people around them recovering in a healthy, appropriate way? Are the resources around them back to where they were or back to a new normal that's good? Are they surrounded by good, healthy influences, or have they really gotten off track, during those couple of years of difference. We also don't know what the pandemic has in store for all of us. There's some warning signs right now of rising rates and rising concerns again about new variants, and so we don't know if things are going to head in a positive, healthy direction, or if we're going to be struggling with this for a while. So it's hard to say honestly about what to expect. Our hope is that, particularly with school, I think that was something that I harped on quite a bit. The conversations I had through COVID was getting the kids back in school because that is a huge sense of normalcy for them and a huge part of their life and their world. So my hope is that with that mostly back for them and mostly heading back to a baseline that will be a positive thing. But I don't know.

[00:27:15] Host Amber Smith: Before we wrap up, I want to ask you, Dr. Conners, how do you think this generation will be shaped by COVID?

[00:27:21] Gregory Conners, MD: Dr. Rapke just mentioned some of the concerns, at least that are on the table or potential concerns for the future about developmental growth and especially in young children. And so we have concerns about that there will be long-term mental health effects, but I also want to look at some positives. I think that there's nothing but good in and appreciating and letting people know in a more general way that there are mental health concerns in children and in teens. You opened by saying something like "we don't like to think about it," and maybe we don't like to think about it, but we need to. And I mentioned the considering mental health expenditures as investments in our future. And I think that the recognition that this is important, remember that this was so prevalent even before COVID, that if some kind of good can come out of this, but by investing more in mental health and children, maybe we'll end up with stronger and resilient adults as a result.

[00:28:18] Host Amber Smith: Well, I want to thank you both for making time to discuss this important topic. My guests have been Dr. Greg Conners, who's professor and chair of pediatrics at Upstate, and Dr. Jennifer Rapke, who's a child psychologist at Upstate and the chief of the child psychiatry consult service at Golisano. Both of them see patients at the Upstate Golisano Children's Hospital.

[00:28:37] Host Amber Smith: "The Informed Patient" is a podcast covering health, science and medicine brought to you by Upstate Medical University in Syracuse, New York. This is your host, Amber Smith, thanking you for listening.