‘Canaries in a coalmine’: Children and adolescents in EDs with mental health issues

The number of people under 19 seeking mental health help at emergency departments (EDs) shot up by 46% in seven years, according to a new Medical Journal of Australia study, ‘Paediatric mental and physical health presentations to emergency departments, Victoria, 2008–15’.
 
The major causes for presentation were self-harm, drug and alcohol-related issues, depression and anxiety, and behavioural disorders. Mental health presentations rose by 6.5% a year, more than three times the rate of physical health presentations, which rose by 2.1%.
 
Self-harm presentations accounted for 22.5% of cases, making it the most frequent reason children and adolescents came to the ED. These cases increased by 53% over the study period, from 1412 to 2157 cases. Drug-linked mental health problems were the second largest category.
 
The study, by Melbourne-based Murdoch Children's Research Institute researchers, is the first to track trends in children and adolescents presenting at EDs.
 
Lead author Professor Harriet Hiscock told newsGP she was surprised and disturbed to find that the numbers had risen so significantly, particularly among primary school-aged children. 
 
‘We’d heard anecdotally that the numbers were on the rise, but we didn’t expect by so much or that patients would be so young,’ she said.
 
‘A lot of money has been poured into treatment of mental health, but very little into prevention in these early stages. Often we see these problems emerging in kindergarten and early primary school. Kids don’t just wake up suicidal. It’s been coming a long time.’
 
A previous survey undertaken by Professor Hiscock’s institute of 2000 parents found that parents of teenagers are well attuned to signs of early mental illness in their child, while parents of younger children pick up on the signs significantly less.
 
‘Parents can think their child will grow out of it. They think, they’re only eight, how could anxiety be a problem? It can be confronting for many parents,’ Professor Hiscock said.
 
One reason for missing the warning is that mental health issues often manifest differently in children and young people compared to adults. 
 
Professor Hiscock said many families she interviewed did not realise the underlying issue was mental health until they went to an emergency department seeking help for the physical manifestations of the illness, such as persistent headaches, stomach aches without a cause, loss of appetite, or sleeping all the time.
 
‘If they don’t recognise it’s a mental health problem and don’t address it, that’s when things reach a crisis point and end up in the ED,’ she said.
 
‘EDs can help young people who self-harm. But they’re not set up for young people with anxiety and depression, or behavioural issues.’
 
One of the major reasons so many families take their children to emergency is the cost of private care.
 
‘GPs often refer patients to very good paediatricians or psychologists, but unless you can afford private fees, you might have to wait up to 12 months,’ she said. ‘We have a good private system, but not so much in the way of a public one.
 
‘We’ve interviewed parents who came to the ED who say the waiting list is much too long.
 
‘We want to help GPs, educators and maternal and child health nurses to better recognise the signs of early mental health problems with children, and then help them have conversations with parents, to help them want to get help.’
 
Professor Hiscock said a longer-term solution would be the funding of prevention initiatives and low-cost or free care targeting younger people. 
 
‘GPs need to familiarise themselves with the signs of mental health and behavioural issues in young children and be aware of where to go to get support in the community, such as community health centres which often have the low cost solutions,’ she said.
 
Over a year, an estimated 14% of Australians aged four to 17 – 580,000 people – experience issues of mental health, according to the study.
 
An MJA editorial accompanying the new study states it is likely that ‘current mental health services are failing to provide alternatives to emergency departments for adolescents in crisis’.
 
‘The emergency department data reported in this issue of the MJA should be seen as canaries in a coalmine. Despite major investments in the mental health service system, it is failing to provide alternatives to emergency departments for adolescents in crisis. There is a pressing need to understand why, particularly in the context of persisting high prevalence rates,’ the editorial states.
 
The study comes after news that mental health issues now account for 3.6% of all ED presentations in Australia.

childrens-health mental-health MJA