Kids Visiting ER in Mental Crisis Often Get No Follow-Up

A growing number of U.S. kids are landing in hospital emergency rooms for a mental health crisis. Now a new study finds that many do not get follow-up care after they’re discharged.

Experts said the findings, published Feb. 13 in the journal Pediatrics, are yet more evidence of the cracks in the nation’s mental health care system — especially when it comes to helping kids.

Of more than 28,000 U.S. kids discharged from the ER for a mental health concern, only about half had a follow-up health care appointment within a month, researchers found.

More than one-quarter were back in the ER within six months.

The results are, unfortunately, no surprise, the researchers said. Past studies have illustrated the ways in which the system is failing kids in mental health crisis.

“But this puts some concrete numbers on what we’re seeing in practice,” said lead researcher Dr. Jennifer Hoffmann, a pediatric emergency physician at Lurie Children’s Hospital of Chicago.

Kids in mental health crisis can end up in the ER for various reasons. Sometimes they are suicidal or have intentionally harmed themselves. Sometimes they are having a panic attack or a serious behavioral issue. Sometimes they or their parents have nowhere else to turn for mental health help.

For those families, Hoffmann said, the ER is a “safety net.”

“This may be the first time these kids are seeing anyone for a mental health concern,” she said.

In fact, of young people in the study, about one-third had no outpatient mental health visit in the past year. And it’s hard for those kids, in particular, to get a timely follow-up appointment after they leave the ER, Hoffmann said.

Black children are especially underserved, the study found: 49% had a follow-up visit within a month of their ER visit, compared to 59% of white kids.

One central problem is the dearth of child mental health specialists: Many U.S. counties, especially in rural areas, have not a single one.

Hoffmann noted that her team looked at whether kids had a follow-up visit with a health care provider of any kind.

“Timely access to a mental health specialist is probably even worse,” she said.

Simply getting kids a health care appointment is actually a “low bar” to meet, said Hannah Karpman, an assistant professor at Smith College School for Social Work in Northampton, Mass.

“That doesn’t even get at the quality of care,” said Karpman, co-author of an editorial published with the study.

She stressed that health care providers, in and out of the ER, want to do their best for kids. But the system is not there: In addition to the trouble getting outpatient appointments, kids who need a hospital admission sometimes cannot get it because no bed is available.

Outpatient care does not have to be provided by a child psychiatrist — and it usually isn’t. Oftentimes, the provider is a social worker who specializes in mental health care.

While that can expand the mental health workforce, there are issues there, too, Karpman pointed out.

Those mental health providers start out in “community-based” settings — clinics and other facilities where they are supervised and part of a team. Such programs also often serve lower-income families: They cannot, for instance, refuse patients in the way providers in private practice can.

Unfortunately, Karpman said, social workers often graduate in a mountain of student loan debt. So the financial incentive is great to go into private practice as soon as they are eligible, rather than stay in the demanding, underpaid job they have.

As a result, Karpman said, community clinics with the greatest needs are likely to have the least-experienced staff.

To Karpman, one good starting place would be student loan forgiveness for social workers. But those clinicians also need fairer pay, and the care they provide needs to be adequately reimbursed, both experts said.

Medicaid, the government health insurance program for low-income Americans, covers mental health care. But the specifics vary by state, and providers in private practice sometimes refuse to take Medicaid patients due to low reimbursement, Hoffmann pointed out.

The findings are based on medical records from more than 28,500 kids ages 6 to 17. All were enrolled in Medicaid and had at least one mental health-related ER visit between 2018 and 2019.

About one-third had a follow-up health care visit within a week of their ER discharge, and just under 56% had an appointment within a month. Of all kids in the study, about 27% returned to the ER within six months.

The study period predates the pandemic, which has only put more strain on child mental health services, both experts said.

Of course, everyone wants to keep kids from reaching a crisis point in the first place. And that, Karpman said, also requires societal investment — in schools, in communities and toward helping families who are struggling to make ends meet.

“We really need to be thinking more holistically,” she said.

More information

The National Alliance on Mental Illness has more on supporting kids’ mental health.

SOURCES: Jennifer Hoffmann, MD, MS, pediatric emergency physician, Ann & Robert H. Lurie Children’s Hospital of Chicago, and assistant professor, pediatrics, Northwestern University Feinberg School of Medicine, Chicago; Hannah Karpman, PhD, MSW, assistant professor, Smith College School for Social Work, Northampton, Mass.; Pediatrics, Feb. 13, 2023, online