Stress and adversity early in life may lead to overall poor health outcomes later on . Physiologically speaking, the pediatric and adolescent populations have immature endocrine systems, nervous systems, and hypothalamic-pituitary-adrenal axes, which are necessary to help deal with physical and psychological stress . Given the uptick in mental health issues facing adolescents and young adults prior to the pandemic, we postulated that COVID-19 would exacerbate and worsen mental health for our patients.
While many mental health screeners exist, our screener was easy to use and implement quickly because our institution already had an established mental and behavioral health screener in place (ED-DRS) . We used this as the framework for questionnaire content, and tailored the questions to COVID-19. Our PED providers were already accustomed to using a mental health screener. Therefore, it was quickly accepted as a time-efficient screening tool, taking 2-5 minutes to complete.
Our findings are consistent with existing literature, that is, evidence of patient anxiety, depression, and even suicidality. Almost half of screened patients admitted to feeling scared regarding their risk of getting COVID-19 and the risk of their family members catching it as well. Patients also had concerns about financial security and food insecurity. While the long-term downstream effects of COVID-19 on mental health in the pediatric population are still unknown, there is likely to be an effect on their mental or behavior development from the strain of living through this pandemic .
The majority of those who suffer from mental and psychiatric illnesses identify as female, compared to their male counterparts , and gender plays a role in how a person deals with stress . Interestingly, this was not illustrated in our findings. Although the majority of those who were distressed and answered yes to many of our screener questions were female, gender was not a statistically significant finding. However, males tend to be less inclined to seek care or admit to psychological issues , a possibility in our study as well.
Of patients admitting to having difficulties coping during the pandemic, a substantial number of them were seen and evaluated by social workers; most notably, patients who screened positive for food insecurity, depression, and suicidality.
Interestingly, age did not play a role in whether a patient responded yes or no to screening questions and age was not salient in whether or not a social work consultation occurred. We thought that the younger the patient, the more likely they would be distressed by COVID-19 and would thus require social work assessment and intervention. We had intuitively believed younger patients would be more frightened, understand less, feel more isolated from their peers, and have immature coping abilities in a time of crisis. Our questionnaire data clearly do not depict this, perhaps suggesting some protective effect or support by their caregivers.
In a recent study performed at Yale New Haven Children’s Hospital PED, investigators tracked the frequency of patients presenting with mental health issues , and found a 60% reduction in visits related to mental health issues. This could be due to many reasons, including a lack of universal screening for mental and psychosocial issues at their institution. In another study performed at a tertiary care children’s hospital in Portland, Oregon, researchers found a sharp decline in pediatric mental health visits to their PED . This was largely attributed to the stay-at-home order that was enacted just a week prior to their data collection. In contrast, although not formally studied, we have anecdotes suggesting an increase in patients presenting for mental health issues.
Based on ED-DRS data  previously published, 30.4% of patients 12 years or older screened positive for anxiety at our institution pre-COVID-19. In our current study, however, 47.3% of patients admitted to feeling anxious during this pandemic. This is likely attributed to the immense uncertainty throughout the COVID-19 pandemic, such as when children will return to school, when businesses will reopen, when parents will be gainfully employed, when families will be able to gather for celebrations and religious gatherings, and when travel and entertainment will resume regular operations. Living under such ambiguous and ill-defined conditions is certainly contributing to the increase in anxiety, as shown by our questionnaire.
In review of the literature, we have not seen other pediatric or general Emergency Departments screen for COVID-19 related stress and its effects on the mental, emotional, and behavioral health of presenting patients, despite providers and clinicians acknowledging its pervasive presence. Emergency Departments serve as a safety net for patients of all ages, and mental health screening should be incorporated into medical screening in order to recognize, diagnose and provide treatment for patients early on. Given limited access to outpatient mental health services, it is even more crucial for PEDs to screen for and help patients presenting with mental health concerns .
Our questionnaire was created in “yes/no” format instead of Likert or qualitative formats, which limited our descriptive findings. The questionnaire was administered verbally by a provider, rather than through self-report without clinician interaction. Patients may not have felt comfortable being honest and sharing their responses with providers due to the long-standing stigma associated with mental health conditions. Also, some providers may have proceeded to administer the questionnaire in the presence of parents who declined to temporarily exit the room. Furthermore, our questionnaire served as a screening tool, not a diagnostic tool. Lastly, it is important to note that our screener was implemented in a single PED at an inner city, tertiary children’s hospital, and therefore, our results may not be generalizable to other PEDs, populations, or setting