Out of control: Solving the child and youth mental health crisis

The scenario is all too familiar. It is Friday night. I am on call and asked to see 11-year-old “Jenna,” who has been brought to the emergency department by her mother because she is “out of control.” Jenna was raging at home, throwing things, destroying her room, hitting, kicking, and biting, and threatening to kill herself. This behavior has increased over the past few weeks and her mother is worried that Jenna will commit suicide or harm her little brother. 

Now in the ER, Jenna is tearful but cooperative. She is systemically well, with no history of chronic illness. Her mother refuses to take her home be­cause someone has to “fix” this. Is she psychotic, depressed—perhaps she has an anxiety disorder? Is she truly suicidal? Jenna requires stabilization and observation and, though she does not need an acute care bed, she cannot go home either. 

Consequently, Jenna is admitted, by default, to the general pediatric ward with one-on-one nursing care. The child and youth psychiatrist is consulted and Jenna is referred to the Child and Youth Mental Health Team but, as it is Friday evening,  she remains in hospital until Monday morning when these services become available. 

Here are some facts:   
• Approximately 20% of children and youth experience mental disorders that cause significant distress and impair their day-to-day functioning.[1] 
• Suicide is the second-leading cause of death among 10- to 24-year-olds.[2] 
• Canada has the third worst suicide rate in the world for 15- to 19-year-olds.[2]
• 40% to 50% of office visits to pediatricians are for mental health problems.[3] 
• Approximately 140000 BC children and youth are currently experiencing mental disorders.[4]
• Only 5% of children and youth receive any form of psychological care and a mere 1% to 2% are treated by mental health specialists.[5]
• Every $1 spent on psychological ser­vices yields a savings of $5 in medical costs.[5] 
• The average cost of treating children’s mental health problems in community-based agencies is less than $2500 per child per year. The cost of a pediatric hospital bed is more than $2500 per day.[2]

Mental health services provided to children and youth in BC are fragmented, largely due to the ministerial split of duties. The care of children and youth falls under the jurisdiction of the Ministry of Children and Family Development (MCFD) but they also receive mental health services from physicians, hospitals, and schools. 

MCFD services are provided Monday to Friday, 8:30 a.m. to 4:30 p.m. Children and youth requiring services outside of these hours default to the medical system and are often, like Jenna, inappropriately hospitalized, receiving treatment from emergency and family physicians and pediatricians who often have limited training and ex­pertise in mental health issues. 

As we know, MCFD is widely known for its Child Protection Services and, as a result, many families refuse to access important non-protection services that MCFD offers such as child and youth mental health.

MCFD Minister Tom Christenson recently delivered a progress report on the Child and Youth Mental Health Plan that was implemented in 2003.4 Significant accomplishments have occurred in the last 5 years; however, more needs to be done: 

• Improve collaboration and coordination of services provided by all components of the mental health team to include not only the MCFD services but also services provided by physicians, hospitals, and schools. 
• Make child and youth mental health services consistent and coordinated between communities.
• Work to remove child and youth mental health’s current stigma as being synonymous with Child Protection Services.
• Use multidisciplinary teams, since they are more successful than individual interventions in responding to the mental health needs of children and youth.[5] 
• The Ministry of Health must develop recruitment and retention strategies to increase the number of child and youth psychiatrists. Remunerate physicians appropriately.
• Develop therapeutic (and cost-effective) respite beds for children and youth to avoid inappropriate admission to an acute care bed.
• Continue developing and implementing prevention and early intervention strategies ensuring that more children and youth will receive appropriate and timely care.

Mental health problems are “arguably the leading health problems that children face after infancy.”[6] The situation is critical, and the suffering of patients and their families is significant. If we do not adequately address the child and youth mental health crisis, we will continue to fail thousands of young British Columbians like Jenna. 

—Wilma Arruda, MD
Chair, Child and Youth Committee

References

1. Child and Youth Mental Health: Population Health and Clinical Service Considerations, A Research Report Prepared for the British Columbia Ministry of Children and Family Development, April 2002.
2. Gibson, J. Northern Life. 2 May 2008.
3. Canadian Pediatric Society.
4. Child and Youth Mental Health Plan for B.C.—Progress Report 2008, MCFD.
5. Strengthening Primary Care, CPA.
6. Dr Charlotte Waddell, director, Children’s Health Policy Centre, SFU.