ERs saw huge leap in teens during pandemic

Biggest increase among young girls, new studies show

The number of Canadian adolescents who visited emergency departments or required hospital treatment for self-harm or suicidal thoughts rose significantly during the COVID-19 pandemic, with the greatest increase among preteen and younger teen girls, two new studies show.

The pair of studies, published Monday in the CMAJ (Canadian Medical Association Journal), found higher-than-expected emergency department visits and hospitalizations for these mental-health crises in children ages 10 to 18 compared with the years leading up to the pandemic.

Researchers say the studies provide further evidence of the pandemic’s impact on the mental health of young people. The findings, they say, echo other Canadian and international research that shows similar increases in selfharm among adolescent girls, signalling this group may have been disproportionally affected.

The new research, the authors say, highlights the need for better access and more funding to bolster the already stretched pediatric mentalhealth system, and points to the demand for additional supports for children and youth, including help in identifying early warning signs in preteens and younger teenagers.

“What we didn’t expect to find was that these mental-health crises would be so exacerbated in females and in younger adolescents — girls between 10 and 14 years old — during the pandemic in terms of hospital admissions,” said Dr. Naveen Poonai, an associate professor at Western University’s Schulich School of Medicine & Dentistry and lead author of the Canada-wide study.

“This demographic needs to be on our radar and serious consideration for investment needs to be made.”

Dr. Natasha Saunders, a pediatrician at the Hospital for Sick Children and senior author of the second study published in the CMAJ, said Ontario data showing elevated rates of self-harm among preteen and young teenage girls emphasizes the need to ensure kids have multiple ways to easily and equitably access mental-health care to help prevent them from requiring hospital care.

“We have to, as a system, meet kids where they’re at and where they’re ready to seek care. We need care to be continuous and co-ordinated and not hard to navigate,” she said, adding that timely access is equally important.

“If a kid seeks help, we can’t wait 10 months to get that kid care.”

The first study, conducted by members of the Pediatric Emergency Research Canada Network, a group of health-care researchers working to improve care in pediatric emergency medicine, analyzed anonymized data from the Canadian Institute for Health Information (CIHI). They found that while Canada-wide emergency department visits for all causes in children age 10 to 18 fell considerably during the pandemic compared to the five years pre-COVID, ER visits and hospital admissions for suicidal ideation, self-harm and self-poisoning increased for this group.

Emergency room visits for these crises increased to 6,060 per quarter during the pandemic period (April 1, 2020 — March 31, 2022), up from 5,293 per quarter in the prepandemic period (April 1, 2015, to March 31, 2020) — an increase of 14.5 per cent. Hospitalizations for these conditions in the same age group increased to 1,770 per quarter of the pandemic from 1,590 admissions per quarter pre-pandemic, an increase of 11 per cent.

Previous data from CIHI showed mental illness, including anxiety and mood disorders, was among the top reasons kids and teenagers required hospital care during COVID’s second year.

The second paper published Monday in the CMAJ — a population-based study that analyzed Ontario data from CIHI and the independent research group ICES — found ER visits for self-harm in children age 10 to 17 increased by 29 per cent above expected levels, while hospitalizations increased by 72 per cent.

As in the Canada-wide study, the increases were greatest among girls, particularly those 10 to 13. There was a 62 per cent increase in ER visits among this cohort compared to expected levels modelled from data collected in the three years leading up to the pandemic. As well, hospitalizations among girls 10 — 13 were three-and-a-half times greater than expected levels.

The study also found an increase in adolescents seeking hospital care for self-harm among those who had already entered the mental-health system and among those for whom the visit was their first for mentalhealth concerns, Saunders said. This suggests this issue is not solely due to difficulties accessing care in the community, she said, but may also signal more widespread distress among this age group.

While the pair of studies didn’t examine the reasons for the increases in ER visits and hospitalizations, Saunders said they are likely due to “the chronic, cumulative effects of the pandemic” during a vulnerable time in a child or teen’s development.

“When you have these incredibly stressful periods, at a time when a child’s brain is developing, when they’re developing their sense of identity, they’re developing their independence, and many of the things that usually support normal healthy development have been taken away or curtailed, that can leave a lasting impact on a young teen,” said Saunders.

She said a limitation of the Ontario study is that it only accounts for kids who go to the hospital, meaning it is “likely an underestimate of the true magnitude of effect because many kids may have selfharming behaviours at home who don’t present to acute care.”

Poonai noted that before the pandemic and depending on the school board, many young people had access to school-based counsellors, social workers and even some mental-health nurses. During the pandemic, much of that access ceased.

“Children relied on those people extensively,” he said. “They were available to kids during the day, they heard directly from teachers, they heard directly from parents and they knew the kids.”

“I’m not a public health policy expert, but what I do know is that investments in front-line support staff for kids, whether they be mental-health specialists or counsellors with interests in mental health, such as social workers, needs to be made.”

Dr. Stacey Bélanger, a developmental pediatrician and hospitalist at the Centre Hospitalier Universitaire Sainte-Justine, a large pediatric hospital in Montreal, said the studies’ findings reflect what she and her colleagues saw during the early years of the pandemic.

“My colleagues in the emergency department couldn’t keep up with the influx of patients coming in with mental-health issues,” said Bélanger who specializes in mental health and behavioural pediatrics. “I’ve been practising for almost 25 years, and it was the first time that the majority of the patients in our hospital units were adolescents and the majority of those because of a mental-health crisis or treatment for eating disorders.”

In May, the Canadian Pediatric Society released a statement calling for systemic changes to meet the mental-health needs of the country’s children and youth. The society noted that fewer than 20 per cent of kids with mental-health concerns receive timely treatment and said a lack of access to multidisciplinary care and inadequate government funding, among other things, has “exacerbated a mental health crisis among children and youth.”

Bélanger, a member of the Society’s Mental Health Task Force, said more funding is needed to ensure universal access to community mental-health services, programs and supports to help prevent kids and teens from needing hospital care.

Dr. Rachel Mitchell, a child and adolescent psychiatrist at Sunnybrook Health Sciences Centre and lead author of the Ontario study, said she wants children and adolescents struggling with their mental health — and their parents and caregivers — to know “there is always hope and there is always help.”

“That’s the most important thing to remember. Even when all feels lost, in moments of crisis or despair, that feeling won’t last forever. You may not be able to change the situation, but you can get help to start changing the way you feel. We want kids to reach out for that help.”