Kids and Covid-19: A Mental Health Crisis Looms
By Abigail Kramer
Every Friday morning, Dr. Wanda Fremont logs onto her computer to video-conference with patients. Most are teenagers who have recently attempted to commit suicide. Some attacked family members during episodes of out-of-control aggression. A few have eating disorders that have gotten so bad, doctors fear they could die of self-neglect.
They have all been admitted to the adolescent psychiatric unit at SUNY’s Upstate University Hospital in Syracuse, New York, where, since the coronavirus arrived, Fremont has conducted weekly rounds by video. As always, the unit's eight beds are full, with several kids waiting in a medical ward for a spot to open up. Patients usually stay for one to two weeks—just long enough to get them out of the immediate crisis and discharge them, making space for young people who show up in the hospital's emergency department daily from all over Central New York.
In the past month, Fremont and other doctors across New York State say that—after plummeting in the weeks after schools closed—the number of young people coming to hospitals with dangerous psychiatric emergencies is climbing back up.
It is a first sign, they say, of a looming mental health crisis among children and adolescents, as fallout from the Covid-19 pandemic continues to rain down across New York. And doctors warn that—unless the State makes radical changes—many young people will not be able to get the mental health care they need.
"We're still in the honeymoon phase now," says Fremont, who is a professor and vice chair of child psychiatry at SUNY Upstate. "Over the next year, we'll see the real psychological impacts."
Even before the coronavirus drove New Yorkers into their homes, suicide was the second-leading cause of death in the state for youth aged 15-19, and the third-leading cause of death for children aged 5-14.
Despite Federal and State laws requiring insurance companies to make mental health services as affordable and easy to obtain as medical care, doctors and advocates say that New York's mental health system has been starved by decades of stingy insurance reimbursements and underinvestment by the State.
Medicaid, which covers close to two million New York kids, often does not reimburse mental health care providers enough to cover the costs of offering services, providers say. Commercial insurance plans pay even less.
The consequence is that sick kids regularly sit on wait lists for months to see a therapist or child psychiatrist. More than half of children diagnosed with mental health conditions in New York receive no treatment or counseling at all—including 55 percent of kids with major depression, according to data from national surveys.
Now, as the coronavirus isolates families in their homes, young people face an onslaught of circumstances that damage mental health. At best, they are cut off from friends, routines, school counselors, and the sense that life is orderly or predictable. Thousands have lost a parent or grandparent to the virus. Many are home with parents who've been laid off, or who risk their health at work because they can't afford to miss a paycheck. Domestic violence has become more common—as, almost certainly, has child abuse. Parents drowning in their own addictions are cut off from help, and likely pulling their children under. Thousands of families have been or soon will be pushed into poverty—a fact that, in and of itself, increases a child's risk for mental health disorders.
"It feels like we're seeing a pressure cooker," says Dr. Christopher Lucas, who is the vice chair for intensive services at SUNY Upstate, and who sees most of the young people who come through the hospital's ER with psychiatric problems. "Many of the resources that kids use to cope aren't available. And there's a knock-on effect, with parents under their own stressors. Things come to a head."
In recent weeks, Lucas has seen an influx of young people who’ve made serious suicide attempts. "Some are kids who were already thinking about suicide and have decided that life's not worth living," he says. Others have taken overdoses while live streaming on Facebook, or written suicide notes, or spent weeks researching painless ways to die.
Lucas has treated multiple teens with special needs who overdosed after learning by email that they were failing classes. "They're even getting bad news remotely," he says.
He's also seen a notable increase in young people with life-threatening eating disorders, especially anorexia. "It may be seen as something a kid can control when everything else is out of control," Lucas says.
Data from other countries and past pandemics support doctors’ fear that the problem will only get bigger. In a survey of kids aged 6 to 12 in Wuhan and the nearby city of Huangshi, in China, more than one in five children reported symptoms of depression after coronavirus quarantines lifted, while nearly as many experienced ongoing anxiety. In previous studies of children in parts of the U.S., Canada, and Mexico who were quarantined during outbreaks of H1N1 (in 2009) and SARS (in 2003), researchers found that 30 percent met clinical criteria for PTSD—a rate similar to that among child abuse victims.
‘IT’S A DISASTER’
In New York, doctors both downstate and upstate report that kids’ psychiatric emergency visits dropped sharply in the first few weeks after schools closed. While spring is usually a time when hospitalizations go up, the children's psychiatric emergency program at Bellevue Hospital was nearly empty in the first month of stay-at-home orders, when most New Yorkers were avoiding hospitals for fear of Covid, says Dr. Jennifer Havens, who directs child and adolescent psychiatry for NYC Health + Hospitals, which runs Bellevue and New York City's other public hospitals.
As April rolled into May, however, young people began showing up again, and their cases tended to be extremely serious. "It's very sick kids," Havens says.
Doctors on Long Island saw the same trend. In the first week of March, 82 young people came to the emergency department of Cohen Children’s Medical Center because of a psychiatric emergency. That number is typical in springtime, says Dr. Vera Feuer, who directs pediatric emergency psychiatry at the hospital. (Feuer also runs the hospital’s behavioral health urgent care, which saw 72 young patients during the first week of March.)
The numbers began a nosedive the week before Long Island schools shut down, reaching a low of just 11 pediatric mental health ER visits during the first full week of April. A month later, however, visits had more than tripled, going up to 37 in the first week of May.
That number is still much lower than during a typical spring week, but Feuer says that the cases coming in are more likely to be very acute, and that she—as well as colleagues at other hospitals—are seeing an increase in serious suicide attempts that require medical treatment in addition to psychiatric care.
Data from Syracuse follow a similar trajectory. Psychiatric emergencies brought an average of 36 kids per week to Upstate University Hospital's emergency department during the three weeks immediately preceding school closures, says Dr. Lucas from SUNY Upstate. In the three weeks after, visits dropped to an average of just 12 per week. Then in May—as in New York City and Long Island—the numbers began climbing again, and the kids showing up tended to present with very serious conditions.
Doctors say that many of the young people who come to emergency departments would never have gotten so sick in the first place if they had access to mental health treatment in their communities.
Decades of underpayment have created chronic shortages of providers and care, says Dr. Fremont of SUNY Upstate. “There’s a shortage of child psychiatrists. There’s a shortage of hospital beds. The average wait to get into a child mental health clinic is six months."
"Why is that? ” Fremont asks. “Again, because there's not much [insurance] reimbursement. It's a money-losing clinic for a hospital."
According to a 2019 study published in Pediatrics, New York State has just 20 child psychiatrists per 100,000 kids. That number is significantly higher than in many states, but it still leaves sick kids with nowhere to turn before they end up in crisis, says Havens of Health + Hospitals.
"It's a disaster at every point in the chain," Havens says. "It's a disaster that kids have to get that sick to get any care."
THERAPY ON THE SCREEN
The world of mental health care has seen one hopeful development come from the coronavirus shutdown: Soon after schools closed, the State changed regulations to temporarily allow providers to conduct many services via video conference—fast-forwarding changes that might normally take years to spool through State and Federal regulatory bureaucracies.
Telemedicine does not work for everyone. Many people who badly need mental health care do not have reliable internet connections or devices. And it can be very difficult to hold the attention of young children via video screen, as many homeschooling parents have recently learned. Video conferencing also doesn't work for people experiencing serious psychosis or paranoia, providers say.
But it does help providers connect with patients who live far from clinics, or whose lives are too chaotic to show up at a weekly appointment. And, to many therapists’ surprise, it often works well for adolescents. "Teenagers are really comfortable with this medium. This is what they live and breathe," says Dr. Fremont. "I have some kids who I can't get to stop talking on video, whereas in person they cross their arms and say 'I don't know.'"
Advocates for children with behavioral health needs have begun asking the State to extend telehealth flexibility beyond the shutdown. But they say that regulators and providers must make sure that low-income families have access to the technology they need to connect to the internet and benefit from the changes.
“We also need to make sure we reach families who speak languages other than English and those who might mistrust the healthcare system,” says Alice Bufkin, the director of policy for child and adolescent health at the Citizens’ Committee for Children of New York, which leads a statewide “Healthy Minds, Healthy Kids” campaign to increase young people’s access to behavioral health care.
“We have such clear racial inequities in how our healthcare system operates now," Bufkin says. "We need to make sure the digital divide doesn’t widen them.”
The campaign is calling on the State to order insurance companies to waive mental health copays and fees for the children of essential workers. They are also asking for funding that will allow schools to address mental health needs when students return, including resources to identify children who have experienced trauma or have a behavioral health need, and to connect them with clinical services in schools and communities.
Most importantly, Bufkin says, the State needs to invest in shoring up and expanding services so that all young people can get mental health care when they need it. Such investment, Bufkin says, is essential to keeping kids out of emergency rooms and hospital beds. In the long run, it can also prevent a range of debilitating—and expensive—problems, including homelessness, incarceration, and adult mental illness. “When children don’t get the services they need, they become sick adults,” Bufkin says. “When you invest up front, you see positive impacts for years to come.”
When New York State passed its budget for the current fiscal year (which began in April), legislators largely protected children’s behavioral health care from cuts that hit many Medicaid-funded services. However, Governor Andrew Cuomo has warned that the State may be forced make deep, across-the-board cuts of 10 to 20 percent if the Federal government doesn't provide a great deal more aid.
That would be a disaster for children’s mental health care, says Andrea Smyth, the director of the New York State Coalition for Children's Behavioral Health, which represents provider agencies across the state.
"Almost every single service would go out of business," Smyth says. "If they cut 10 percent, we don't even know how that would work."
In Syracuse, Dr. Fremont has a prediction. Not long ago, she sat in on an online conference sponsored by the American Psychiatric Association, at which she watched a presentation by the head of disaster psychiatry for the U.S. Armed Forces.
"He showed a picture of a little footprint. Next to it was a huge footprint, 10 times the size," Fremont says. "The speaker said the little footprint is Covid. The big footprint is what's coming psychologically. You can't see it yet."
Abigail Kramer is a senior editor at the Center for New York City Affairs at The New School.