Study shows increase in admissions, Emergency Department (ED) visits among children, adolescents

Niall Brennan, Clarify’s chief analytics and privacy officer,

According to research by Clarify Health Institute, mental health inpatient admissions for children and adolescents spiked 61 percent and emergency room visits increased by 21 percent between 2016-2021. During this period, however, in-person office and outpatient mental health services rose by only five percent, although significant declines can be partially attributed to the first year of the pandemic.

Clarify Health conducted an on-going investigation of trends in children’s mental and behavioral health using a national sample of insurance claims from more than 20 million children ages one to 19.

The results were compiled into a report entitled, “The Kids Are Not Alright: Pediatric Mental Health Care Utilization 2016-2021,” released in September.

The study looked at services for children with at least one primary mental health diagnosis during the calendar across several disorders including depressive, mood, anxiety and fear-related, obsessive-compulsive related, trauma and stressor related, disruptive, impulse-control and conduct, feeding and eating disorders, suicidal ideation/attempt/intentional self-harm, and neurodevelopmental disorders.

Among the findings:

Adolescents ages 12 to 15 showed the fastest increase in use of inpatient mental health services. Utilization levels for girls 12-15 were more than 2.5 times higher than admission rates for boys in the same age group in 2021.

Inpatient admissions increased seven percent for boys one to 11 years old compared to a 64 percent spike among girls and 68 percent among boys ages 12-15.

The researchers also discovered higher rates of inpatient admissions and emergency department visits among teenagers compared to younger children.

There were also higher rates of mental health emergency department (ED) visits for behavioral health conditions among children covered by Medicaid compared to those with private insurance.

On the flip side, there were fewer children on Medicaid making use of outpatient and doctor’s office visits than those with commercial insurance (32 percent/commercial versus -2 percent/Medicaid).

Researchers point out this discrepancy may be attributed to issues with the number of mental health professionals willing to accept Medicaid patients. It also reflects a general failure to integrate health into the primary care and school-based supports provided to these children, according to the authors.

Niall Brennan, Clarify’s chief analytics and privacy officer, found the results showing the disparities between boys and girls and the fact that emergency departments primarily admit low-income children particularly striking.

Noting that mental health utilization has historically been higher for girls than boys, their research cannot explain why girls 12-15 had the fastest rate in increase of IP utilization with certainty, Brennan said.

However, Brennan said, “Research suggests adolescent girls may have a higher propensity for mental health issues because of factors like earlier development, a higher level of response to external stressors like school and the pandemic, as well as areas where their peer groups differ from their male counterparts—like increased use of social media and lofty beauty standards.”

He noted Medicaid programs and Medicaid managed care plans typically experience a wide variation in the generosity of insurance benefits and the set of providers with whom they contract with ‘in-network.’

“These specific policies can create substantial barriers to access of mental health treatment for some children with Medicaid coverage,” Brennan said. “It’s also worth noting these differences in the Medicaid population contribute to ongoing racial and economic disparities, given that children with Medicaid are more like to be Black, Latino, Asian, and Native American, as well as from lower-income families, compared to children with commercial insurance.”

When broken down by regional trends, the findings showed the Middle Atlantic and New England areas experiencing substantially faster growth of inpatient admission rates with a primary mental health diagnosis when compared with other parts of the United States.

The span goes from a low of 27 percent in IP admissions in the West North Central region to a high of 137 percent in the Middle Atlantic. New England’s increase is at 100 percent.

The study authors noted that the major findings aligned with a joint declaration by three pediatric medical societies and the Surgeon General’s advisory about protecting youth’s health, improving data collection, and monitoring their mental health and having clinicians, health systems, and insurers prioritize addressing the crisis.

“Our findings suggest that these are long-term trends and not solely due to the pandemic,” said Brennan. He said that psychologists and other mental health professionals must be cognizant of the “slew of factors that could be attributing to these alarming jumps in mental health-related medical events in our youth.”

Brennan noted that behavioral health screenings are crucial for identifying mental and behavioral health needs. “By increasing their prevalence, we can connect more children with the care they need.”

He added that despite a recommendation from the U.S. Preventive Services Task Force, screening rates for anxiety and depression are far below 100 percent.

Promoting screening rates through improved access, utilization, and quality of pediatric behavioral health services should be a national priority for every stakeholder in the U.S. health system, according to Brennan.

Additional research to improve and better treat pediatric mental health and wellbeing and leveraging existing resources—including school-based programs—will help the country’s health system better respond to the growing pediatric mental health patient population, he said.

As for limitations of the study, the authors noted their analyses primarily rose from the use of insurance claims data, relying on patient self-reporting and mental health professionals’ diagnosis of mental health conditions within a clinical setting.

Further consideration of data from non-clinical settings like school and community-based programs or those paid for by families out-of-pocket rather than through health insurance would be helpful in establishing the full picture of adolescent mental health, the study authors said.

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