The hospital where I practice recently admitted a 14-year-old girl with post-traumatic stress disorder, or PTSD, to our outpatient program. She was referred to us six months earlier, in October 2022, but at the time we were at capacity. Although we tried to refer her to several other hospitals, they too were full. During that six-month wait, she attempted suicide.
Unfortunately, this is an all-too-common story for young people with mental health issues. A 2021 survey of 88 children’s hospitals reported that they admit, on average, four teens per day to inpatient programs. At many of these hospitals, more children await help, but there are simply not enough services or psychiatric beds for them.
So these children languish, sometimes for days or even a week, in hospital emergency departments. This is not a good place for a young person coping with grave mental health issues and perhaps considering suicide. Waiting at home is not a good option either – the family is often unable or unwilling to deal with a child who is distraught or violent.
I am a professor of psychiatry and pediatrics at the University of Colorado, where I founded and direct the Stress, Trauma, Adversity Research and Treatment Center. For 30 years, my practice has focused on youth stress and trauma.
Over those years, I have noticed that these young patients have become more aggressive and suicidal. They are sicker when compared to years past. And the data backs up my observation: From 2007 through 2021, suicide rates among young people ages 10 to 24 increased by 62%. From 2014 to 2021, homicide rates rose by 60%. The situation is so grim that in October 2021, health care professionals declared a national emergency in child mental health.
Since then, the crisis has not abated; it’s only gotten worse. But there are not enough mental health professionals to meet the need.
The numbers behind the suffering
The American Academy of Child and Adolescent Psychiatry reported in May 2023 that there is a drastic shortage of child and adolescent psychiatrists across the U.S.
For every 100,000 children in the U.S. – with 1 in 5 of those children having a mental, emotional or behavioral disorder in a given year – there are only 14 child and adolescent psychiatrists available to treat them, according to the American Academy of Child and Adolescent Psychiatry. At least three times as many are needed.
There is also a significant shortage of child therapists – social workers, psychologists, licensed professional counselors – as well. This is particularly the case in rural areas across the country.
Studies show that young people in the U.S. are increasingly stressed and traumatized. The constant barrage of information via social media and the demand to participate in it is complex, and interactions can be harmful to a child’s mental health.
But what children and adolescents see online is not the only problem. Much of life still happens offline, and a lot of it is not good. Millions of young people deal every day with alcoholic, drug-abusing or neglectful parents; peers who drink, vape and use drugs; violence at their schools or in their streets; and overwhelmed caregivers – whether parents or others – preoccupied with financial or other personal problems.
For an adolescent already struggling to make sense of the world, any one of these issues can be overwhelming.
Not enough time or money
The U.S. health care system does very little to support these children or their families. This pattern begins at the moment of birth, and it is baked into the system.
Ideally, prospective parents or those who are pregnant would receive parenting classes that continue through the child’s developmental phases. That generally does not happen. Then, many new parents do not have nursing and maternal care visits or paid parental leave. And for those families struggling financially, there is not an adequate safety net.
Nor can some families afford mental health treatment to support their children’s needs. Many mental health providers don’t take insurance and instead opt for out-of-pocket payments from patients. This is due to the low reimbursement rates from most insurers, which makes it very difficult to sustain a practice. Depending on the service, the cost could be anywhere from US$100 to $600 per session.
To see providers that do take insurance, there are usually co-pays – typically between $20 to $50 a week. But it can often be challenging for the insured to find a suitable in-network provider to meet a child’s needs.
The payments add up, particularly when mental health treatment takes many months, and sometimes years, to have an effect. There is a reason why it takes so long. Unlike medical doctors, mental health professionals do not simply make a diagnosis and provide medication or surgery. Instead, for treatments to work and to change the outcome for young people who are struggling, an ongoing – and lengthy – relationship between the therapist and the patient is needed.
Treating a child is significantly more difficult than treating an adult. That is, in part, because children are constantly developing and changing. But perhaps the most formidable challenges are the multiple entities a child therapist may have to work with: caregivers, the school system, the courts and child welfare agencies. What’s more, getting a diagnosis, treatment or both often involves working with multiple providers, such as a primary care doctor, individual therapist, family-focused therapist and psychiatrist.
In the institute where I work, the psychiatry department loses money on almost every patient we treat. If it weren’t for fundraising and fostering relationships with donors, the department could only provide care to a select few.
Struggling children and teens in the U.S. need earlier interventions. Although schools are ideal places to teach social skills, they still do not offer enough activities to help young people develop resilience to cope with adversity.
Sometimes, young patients see primary care doctors who don’t have enough training in this area. Telephone hotline programs, which offer these doctors free consultations from mental health professionals to help assess problems in young patients, should be available throughout the U.S. But right now, only 19 states have such programs. One bright spot: The 988 Suicide and Crisis Lifeline, which launched in July 2022, is available 24/7.
When a young person needs treatment, parents should prioritize finding a mental health provider right away. Asking the child’s primary doctor and school counselors for a reference is a good start. If the child is already on a waiting list, a parent or guardian should call the provider weekly to check in and make sure the child is not forgotten.
The process can be discouraging and daunting, but in our current environment, which provides limited support, that’s the way it is. And without a heavy lift from parents, the child remains at great risk.
Steven Berkowitz, MD is a Professor of Psychiatry and Pediatrics at the University of Colorado School of Medicine. He is a graduate of the Hahnemann College of Medicine (Now Drexel) in Philadelphia