972453

research-article2020
CCP0010.1177/1359104520972453Clinical Child Psychology and PsychiatryLeff et al.

COVID
Clinical Child Psychology

Changes in pediatric emergency

and Psychiatry
2021, Vol. 26(1) 33­–38
© The Author(s) 2020
department visits for mental Article reuse guidelines:
sagepub.com/journals-permissions
health during the COVID-19 DOI: 10.1177/1359104520972453
https://doi.org/10.1177/1359104520972453
journals.sagepub.com/home/ccp
pandemic: A cross-sectional study

Rebecca A Leff1,2 , Erika Setzer3,

Mark X Cicero2,3,4 and Marc Auerbach2,3,4
1
School of Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer -Sheva, Israel
2
Department of Emergency Medicine, Yale University, New Haven, CT, USA
3
Children’s Emergency Department, Yale New Haven Children’s Hospital, New Haven, CT, USA
4
Section of Pediatric Emergency Medicine, Department of Pediatrics, Yale University School of Medicine, Yale, New
Haven, CT, USA

Abstract
Background: Limited early results indicate that the COVID-19 outbreak has had a significant
impact on the mental health of children and adolescents. Pediatric emergency departments (PED)
play a pivotal role in the identification, treatment, and coordination of care for children with
mental health disorders, however, there is a dearth of literature evaluating the effects of the
COVID-19 pandemic on mental health care provision in the PED.
Objectives: We sought to evaluate whether changes in frequency or patient demographics
among children and adolescents presenting to the PED has occurred.
Methods: This is a cross-sectional study conducted at the Yale New Haven Children’s Hospital
(YNHCH) PED. Data representing the early COVID-19 pandemic period was abstracted from
the electronic medical record and compared using descriptive statistics to the same time period
the year prior. Patient demographics including patient gender, ED disposition, mode of arrival,
race-ethnicity, and insurance status were assessed.
Results: During the pandemic period, 148 patients presented to the YNHCH PED with mental
health-related diagnoses, compared to 378 in the pre-pandemic period, a reduction of 60.84%.
Compared to white children, black children were 0.55 less likely to present with a mental health
condition as compared to the pre-pandemic study period (p = 0.002; 95% CI 0.36–0.85).
Conclusions: Children with mental and behavioral health disorders who seek care in PEDs
may be at risk for delayed presentations of mental health disorders. African American children
may be a particularly vulnerable population to screen for mental health disorders as reopening
procedures are initiated and warrants further study.

Keywords
Pediatric emergency medicine, child psychiatry, COVID-19, pandemics, emergency services,
psychiatric

Corresponding author:
Rebecca A Leff, Department of Emergency Medicine, Yale University, 464 Congress Avenue, Suite #260 New Haven,
CT 06519 USA.
Email: leffre@post.bgu.ac.il
34 Clinical Child Psychology and Psychiatry 26(1)

Introduction
The full extent of the mental health impact of COVID-19 is as of yet unknown. Limited early
results indicate that the COVID-19 outbreak has had a significant impact on the mental health of
children and adolescents (Duan et al., 2020). In the United States, among the measures intended to
mitigate the public health threat posed by the COVID-19 pandemic, nationwide school closures
have been implemented and government policies have supported home confinement (Duan et al.,
2020; Wang et al., 2020). Stressors such as social isolation; prolonged and unknown duration of
social distancing measures, fears of infection, familial financial stress, and parental distress or ill-
ness may represent serious threats to the mental health and well-being of children in both the short
and long term (Duan et al., 2020; Wang et al., 2020). Prior to the COVID-19 pandemic, mental
health-related concerns made up 2% to 5% of all pediatric emergency department (PED) visits in
the United States, with rates increasing nationwide (Lo et al., 2020). A recent analysis of the
Nationwide Emergency Department Sample (NEDS) data set from 2007 to 2016, found a 60%
increase in mental health visits to PEDs (p < .001) despite constant overall PED volumes (Lo
et al., 2020). However, no study has evaluated changes in PED visits for mental health conditions
during the COVID-19 pandemic. While further research on the impact of COVID-19 on mental
health in this population is required in multiple settings (Duan et al., 2020; Wang et al., 2020), there
is a particular need to evaluate whether changes in frequency and/or patient demographics among
children and adolescents presenting to the PED has occurred.
In the following Brief Report, we sought to measure differences in PED mental health visits
associated with the COVID-19 pandemic. Emergency departments play a pivotal role in the iden-
tification, treatment, and coordination of care for children with mental health disorders and often
serve as a safety net for children with mental health disorders seeking care (Morelli et al., 2020;
Sheridan et al., 2015; Zima et al., 2016). Currently, the role of the PED as a safety net is even more
critical in light of decreased access to outpatient mental health services (Cui et al., 2020). If provid-
ers are not made aware of changes in the frequency and patient demographics of PED mental
health visits, they will not be able to identify populations at risk for delayed presentations of undi-
agnosed or untreated mental health conditions. Timely recognition of at-risk children may help
improve children’s and adolescents’ health and well-being as well as develop long-term capacities
for mental health services.

Materials and methods

This is a cross-sectional study conducted at the Yale New Haven Children’s Hospital (YNHCH)
Pediatric Emergency Department using an administrative data set. Yale New Haven Children’s
Hospital (YNHCH) is an acute care hospital in New Haven, Connecticut, and the PED sees over
38,000 patients per year. The study population was identified as all patients who presented to the
PED at YNHCH less than 16 years of age who presented with a chief complaint of “psychiatric
evaluation.” All children presenting with this chief complaint are evaluated with a suicide risk
assessment by the triage nurse, vital signs, a safety assessment, and a medical screening exam
conducted by an ED provider. Data representing the early COVID-19 pandemic time period was
abstracted from the electronic medical record (EMR) system (EPIC™ 2010) from March 10, 2020
to May 20, 2020 and compared using descriptive statistics to the same time period the year prior.
The start date coincides with the date Connecticut Governor Ned Lamont declared a civil prepared-
ness and public health emergency in the state of Connecticut in response to the COVID-19 pan-
demic and the end date corresponds to the date phase one reopening was initiated in Connecticut
(Governor and State Agencies of Connecticut, 2020).
Leff et al. 35

Patient demographics including patient gender, ED disposition [Admit, Length of Stay (LOS),
Discharge], mode of arrival [Emergency Medical Services (EMS), private car], race-ethnicity, and
insurance status, were assessed. As no protected healthcare data attributable to individual patients
was used, the study was reviewed and deemed exempt from full institutional review board review
(IRB Protocol ID: 2000028494).
Descriptive statistics were generated to summarize our results. Percentages are presented for all
categorical variables, and number missing are presented for all. Prevalence estimates were com-
pared between those presenting prior to and during the COVID-19 pandemic using χ2 test. All P
values were two-tailed, and significance was set at a p value less than 0.05. LOS is represented by
a mean value. All analyses were performed with SPSS, version 23 (IBM® SPSS® Software 2015).

Results
During the pandemic period, 148 patients presented to the YNHCH PED with mental health-related
diagnoses, compared to 378 in the pre-pandemic period, a reduction of 60.84% (a reduction of
39.34% as compared to 2018) (Table 1). The mean LOS was 5.13 h, as compared to 5.96 h previ-
ously. The majority of patients were publicly insured (78.4%), consistent with pre-pandemic data.
Compared to white children (51.4%, n = 76), black children (23.6%, n = 35) were 0.55 less likely
to present with a mental health condition as compared to the pre-pandemic study period (p =
0.002; χ2 9.77; 95% CI 0.36–0.85). No other race or ethnicity saw a statistically significant change
in proportion of ED visits for mental health-related diagnoses. No significant change in odds of
admission was identified (OR 1.35, p = 0.08) nor was a significant change in mode of arrival
identified (p = 0.62; χ2 0.25; 95% CI 0.72–1.64). 33.1% of patients were brought by EMS com-
pared to 66.9% from home, consistent with pre-pandemic data. Female gender was noted to repre-
sent a risk factor for presentation to the PED with a mental health diagnosis (p = 0.006; χ2 7.43),
however no significant change was identified between pre-pandemic and pandemic study periods
(p = 0.16; 95% CI 0.54–1.16).

Discussion
Despite identified mental health stressors for children during the COVID-19 pandemic (Duan
et al., 2020; Wang et al., 2020), mental health visits were less frequent in a single PED during the
pandemic compared to the pre-pandemic period. These observations may reflect an increase in
delayed and unmet need and are compounded by decreased access to outpatient mental health ser-
vices (Cui et al., 2020). The authors are not aware of any alternative provisions in the region for
mental health emergencies in this age group during the early phases of the pandemic. Severe men-
tal health conditions warranting EMS transport are still prevalent, despite the closure of schools
which commonly transport to PEDs via EMS. Failure to identify a statistically significant trend for
patient mode of arrival suggests a continual need to support mental health care provision in PEDs
during future phases of the pandemic. Decreases in LOS were observed, and likely reflect decreased
overall PED patient volume (Walker & Tolentino, 2020).
Black children bore a disproportionate share of the decline in PED visits for mental health diagno-
ses as compared to other ethnicities. Though previous studies have demonstrated higher rates of
mental health-related PED visits among black compared to white children (p < 0.05), our study
found that rates of mental health-related PED visits for children of black race/ethnicity significantly
decreased during the COVID-19 pandemic as compared to other ethnicities (Abrams et al., 2019).
The causes of this disproportionate decline in visits by black children is unclear. One potential reason
may be that the decision to seek mental health care in PEDs represents school rather than parent
36 Clinical Child Psychology and Psychiatry 26(1)

Table 1. Patient characteristics of PED visits by children with a mental health disorder, 2020 versus 2019.

Characteristic Patients, no. (%)

Pandemic Control (2019) χ2 p value OR (95% CI)

(2020) (N = 148) (N = 378)
Hospital 54 (36.5%) 113 (29.9%) 3.07 .08 1.35 (0.9–2.01)
admission
Mode of arrival
EMS 49 (33.1%) 118 (31.2%) 0.25 .62 1.09 (0.72–1.64)
Walk-in 99 (66.9%) 260 (68.8%) 0.25 .62 0.91 (0.61–1.38)
Gender
Male 72 (48.6%) 163 (43.1%) 1.91 .16 1.26 (0.86–1.83)
Female 76 (51.4%) 216 (57.1%) 1.91 .16 0.8 (0.54–1.16)
Race/ethnicity
Black 35 (23.6%) 136 (36.0%) 9.77 .002 0.55 (0.36–0.85)
White 76 (51.4%) 172 (45.5%) 2.04 .15 1.26 (0.86–1.85)
Hispanic or 41 (27.7%) 106 (28.0%) 0.008 .93 0.99 (0.64–1.51)
Latinoa
Asian 5 (3.3%) 5 (1.3%) χ2 test not validb χ2 test not validb 2.6 (0.74–9.15)
American Indian/ 1 (0.68%) 4 (1.06%) χ2 test not validb χ2 test not validb 0.64 (0.07–5.74)
Alaska Native
Other/unknowna 28 (18.9%) 61 (16.1%) 0.87a .35 1.21 (0.74–1.99)
Insurance type
Medicaid 116 (78.4%) 277 (73.3%) 1.95 .16 1.32 (0.84–2.08)
Private( blue 31 (20.9%) 97 (25.7%) 1.75 .19 0.78 (0.48–1.19)
cross blue shield,
commercial)
Other 1 (0.68%) 4 (1.06%) χ2 test not χ2 test not 0.63 (0.07–5.74)
validb validb

Note. OR = odds ratio; CI = confidence interval.

a
Estimates for Hispanic/Latino were recorded separately as an ethnicity. Other data were recorded as race. Other data
may include Hispanic/Latino patients.
b
The value of the cell expected was not five or more in at least 80% of the cells, or at least one cell had an expected
value of less than one. Thus, the assumptions of the χ2 test were not met.

preference (McMiller & Weisz, 1996). Consequently, pandemic provoked school closures may mean
disproportionately reduced access to mental health resources for black children. Additionally, the
disproportionate overall effect of COVID-19 on African American communities and related public
messaging may further deter African Americans from seeking care (Yancy, 2020). Alternatively, the
disproportionate decline may reflect discriminatory school discipline practices which disproportion-
ately impact students of color (Anyon et al., 2018; Bottiani et al., 2017).

Limitations
This study has several limitations. The sample examined in our population may not have findings
generalizable to the national population given the study was conducted at a single tertiary, referral
hospital on a small sample set. However, trends elucidated in New Haven are likely to be generaliz-
able to the entire US, considering that the broader New Haven area; which includes neighboring
towns such as West Haven, Milford, and Hamden; all of which are served by the Yale New Haven
Leff et al. 37

Hospital (YNHH) medical system, is highly representative of overall US demographics (Five

Thirty Eight, 2016). For all data points, there may exist significant differences, but the study was
underpowered to detect it. Frequency of Asian and Native Americans presenting to our PED were
not large enough to meet the assumptions of the χ2 test and may require state or national level data
sets to assess. Such variations are clinically significant and warrant further consideration. Future
work is required to assess developing changes in mental health care visits to PEDs as reopening is
initiated. Such continued analysis is critical as local actors plan for both subsequent phases of the
COVID-19 pandemic and post-pandemic management of care.

Conclusion
Providers should be aware that children with mental and behavioral health disorders who seek care
in PEDs may be at risk for delayed presentations of mental health disorders and should take this
into account when conducting clinical evaluations. Community-based mental health providers
such as outpatient clinics, schools, and telepsychiatry services should be prepared for high levels
of unmet mental health need. An appropriate public health pandemic response should include alter-
native interventions and designated resources for mental health in the community setting. These
provisions should include alternative resources for mental health emergencies in this age group in
subsequent phases of the pandemic. African American children may be a particularly vulnerable
population to screen for mental health disorders as reopening procedures are initiated and warrants
further study.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or
publication of this article.

Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD
Rebecca A Leff https://orcid.org/0000-0001-9254-6884

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Author Biographies
Rebecca A Leff is a medical student at Ben Gurion University in Beer Sheva, Israel and an affiliate researcher
in the Department of Emergency Medicine at Yale University.
Erika Setzer, MSN, RN, CEN, CNML, NE-BC is the patient service manager of the pediatric emergency
department at Yale New Haven Children’s Hospital.
Mark X Cicero, MD, FAAP is an associate professor in the section of pediatric emergency medicine at the
Yale School of Medicine. He has served nationally as a consultant for prehospital and hospital pediatric dis-
aster preparedness. He serves as the chair of the pediatrics committee of the National Association of EMS
Physicians, and on the National Biodefense Science Board.
Marc Auerbach, MD, FAAP, MSc is an associate professor of pediatrics and emergency Medicine at the Yale
School of Medicine. He is the Director of Pediatric Simulation at the Yale Center for Medical Simulation and
was the founding co-chair of INSPIRE, the world’s largest simulation-based research network. He has served
as the principal investigator on multiple funded trauma and simulation research projects to ensure the optimal
care for ill and injured children.