Threefold Rise in Mental Health Referrals From Paediatric Emergency During COVID-19 

Becky McCall

June 25, 2021

Acute mental health presentations to paediatric emergency care increased significantly over the three pandemic lockdowns, according to preliminary results of an audit of paediatric emergency services at one of the UK’s leading centres for child and adolescent emergency care.

Of particular concern are data showing a dramatic rise in cases of intentional overdose in teenagers, and the finding that most presentations did not have pre-existing mental health diagnoses.

"The incidence of CAMHS [Child and Adolescent Mental Health Services] referrals among under 18-year-olds presenting to the paediatric emergency department was significantly greater in all three lockdowns and represented nearly a threefold increase on 2019," reported Dr Jonathan Temple, junior clinical fellow, at King’s College Hospital (KCH), London, who carried out the work with senior researcher, Dr Sreena Das, consultant paediatrician, and Dr Lala Asim, paediatric emergency consultant lead, both also at KCH.

Dr Temple presented the findings at the recent virtual annual conference of the Royal College of Paediatrics and Child Health (RCPCH).

Depression, Anxiety, Self-harm

The incidence of overall CAMHS referrals in lockdown two (5 November – 2 December 2020) and lockdown three (5 January - 11 April 2021) were both significantly higher compared with those in lockdown one (23 March - 31 May, 2020).   

Children under 13 were most often referred for depression and anxiety, while intentional overdose or deliberate self-harm was the most common referral in 13- to 17-year-olds, the preliminary data showed.

Females formed the vast majority of cases, with over 80% of CAMHS referrals in lockdowns two and three being girls.

Dr Sofia Manolesou, consultant child and adolescent psychiatrist who practices at the Maudsley NHS Foundation Trust, South London, and in Athens, Greece, welcomed the research, noting that it helps gauge the true extent of the effects of the pandemic on young people's mental health and confirms what has been seen in daily clinical practice over the last months. "Mental health services were unprepared to deal with the first wave," she said. "They closed down, or some were transformed to COVID-related services, and for a long time there was very little provision of services in outpatient CAMHS."

Dr Karen Street, consultant paediatrician, Royal Devon & Exeter NHS Foundation Trust, and RCPCH mental health lead also commented on the findings, in particular, the outcomes in the teenage years. "This reflects a stage of life and development that involves separating from the dependence on parents, as well as developing self-identity, risk taking, pursuing aspirations and so on. This is all dependent on being able to be away from family, socialising, extra-curricular interests, and academic progress among other things. All of this was taken away from young people through lockdown measures."

Regarding younger children, she added: "They would have had their own issues, but generally it is not a retrograde step for them to be family-centred for the prolonged period of lockdowns."

True Effects of the Pandemic on Mental Health in Young People 

Emergency care settings have continued to act as key contact points for young people and healthcare professionals with acute mental health crises during the three COVID-19 lockdowns, but, Dr Temple pointed out, we are only now beginning to appreciate the impact of this phenomenon.

"There are growing concerns that the psychosocial health and wellbeing of young people has been adversely affected by increasing social isolation and uncertainty during lockdown," he said. "This may have included disruption of educational and social activities, isolation from peer support networks, reduced safety-netting and surveillance by schools and community services, emotional trauma and disruption of specialist and community support services for young people with pre-existing behavioural issues such as autism, placing increasing strain upon caregivers and their relationships with their children."

Audit Across, and Comparing Between, the Three Lockdowns 2020-2021

The study aimed to determine whether lockdowns correlated with incidence of referral to CAMHS of 0- to 17-year-olds from the KCH paediatric emergency department during the three lockdown periods. In addition, it aimed to explore and evaluate underlying health inequalities, and to identify evidenced-based areas suitable for pathway adaptation and clinical service provision. Only preliminary results were presented at the RCPCH meeting last week.

The retrospective, matched cohort study audited every patient who attended the KCH paediatric emergency department across all three lockdowns, totalling 8763 young people and compared these data with corresponding time periods in 2019 (n=23,459 total, CAMHS referrals n=231).  

Electronic patient records provided data on age, gender, ethnicity, pre-existing safeguarding alerts, clinical outcomes, diagnoses, and CAMHS referral outcomes (n=191). These data were also compared with the national secondary schools’ census 2019.

"We can see a substantial reduction in the number of young people [overall] presenting to the paediatric emergency department, which is consistent with findings elsewhere," said Dr Temple. But the incidence of CAMHS referrals from the paediatric emergency department in under 18s appears to have been significantly greater during lockdowns.

Specifically, in under-18s, the incidence of CAMHS referrals in lockdown two (3.1% of total patients, compared with 0.5% during the same time period pre-COVID) was significantly higher compared with lockdown one (1.2% of patients versus 1.3% pre-COVID), and likewise CAMHS referrals in lockdown three (2.3% of patients versus 1.2% pre-COVID) were also higher compared with lockdown one.  

Importantly, Dr Temple stressed that most young people referred to CAMHS appeared not to have been previously known to mental health services, and that the majority of 0- to 17-year-olds referred to CAMHS presented out-of-hours.

"Among 13- to 17-year-olds, 1 in 3 referrals to CAMHS were admitted in lockdowns two and three, compared with 1 in 4 during lockdown one. During lockdown three, 73% (80 patients) presented out-of-hours," he said. Also, fewer than one-fifth of CAMHS referrals triggered a pre-existing safeguarding alert.

Behavioural issues, intentional overdose, eating disorders and anxiety, all increased over the three lockdowns but there was a reduction in deliberate self-harm. "The clinical significance of this remains to be understood," Dr Temple remarked.

The vast majority of CAMHS referrals were from ethnic minority groups (74% lockdown one, 76% lockdown two, and 50% lockdown three), which was in keeping with the general paediatric population for Southwark and Lambeth. "However, the majority of CAMHS referrals were female, with 88% and 85% being female in the second and third lockdowns respectively." 

Serious Implications for Service Provision 

Turning to mental health service provision, Dr Temple said: "The preponderance of out-of-hours presentations across all three lockdowns has significant implications for service provision and emphasises the importance of developing robust clinical pathways for young people presenting to paediatric emergency department out-of-hours with acute mental health issues."

He added that because most children were not known to services previously, and with the trends seen so far, high levels of clinical suspicion needed to be maintained throughout every stage of assessment. "The long-term impact upon mental and social health of young people has likely yet to be fully appreciated."

Adding comment on the need to consider clinical service provision going forward, Dr Street remarked that this was a key and multi-layered issue. "The children’s workforce as a whole have to upskill and be able to promote mental well-being, offer early intervention and recognitions, mental health first aid and appropriate sign posting and onward referral."

But she highlighted that CAMHS services are under-resourced compared with adult services, even despite the promises in the NHS Long Term Plan. "Better resources and a national programme of recruitment and training are needed, as well as integrated working across organisations, which is essential to move forward."

Dr Temple explained that he and his colleagues were keen to discover whether their findings were reflected in the findings of other paediatric emergency departments in the UK, as well as data from community services. He also acknowledged the need for caution among healthcare professionals in attributing the preliminary findings of this study to the transient phenomenon of national lockdown. "We don’t yet know how much of this apparent trend is due to the Sars-CoV2 pandemic and how much represents a continuation of the upward trend in psychosocial health issues among young people in the UK that has been observed over recent years."

Presented at the virtual annual conference of the Royal College of Paediatrics and Child Health (RCPCH), June 15-17, 2021.

COI: None declared by Dr Temple, Dr Street or Dr Manolesou.

No abstract available.

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