Calming the Crisis

Published in Hopkins Children's - Spring 2023

Mental health problems among children and adolescents across the United States started ticking up even before the COVID-19 pandemic, with a shortage of mental health practitioners, a lingering stigma surrounding mental health conditions and a lack of access to care. Then, the pandemic brought school shutdowns, changes in routine and social isolation, compounding the issue.

When crises escalate, young people can find themselves in hospital emergency departments for days while waiting for inpatient placement, also known as “boarding.” Those with neurobehavioral conditions such as autism may wait even longer.

At Johns Hopkins Children’s Center, approximately 2,000 patients per year with mental health concerns are now coming to the emergency department, says Leticia Ryan, division chief of pediatric emergency medicine. Three of the 28 beds in the unit are allocated for acute mental health needs, she says, yet sometimes more than 12 patients at a time have been awaiting admission.

“We saw increases in the numbers of patients, particularly adolescents, presenting with suicidality, suicidal thoughts and behaviors — and that was prior to COVID,” Ryan says. “The main challenge, here and across the nation, is that there are not enough inpatient psychiatric beds for children and adolescents in crisis, and there are many challenges with obtaining outpatient and ongoing care.”

“To respond to this national crisis, we’re working on a whole child/adolescent psychiatry redesign initiative,” says Dawn Luzetsky, senior director and associate chief nursing officer for pediatric nursing for the Children’s Center.

“We’re looking at the physical environment, we’re looking at the complement of staff that we have and their training, because what we’re realizing is we’re seeing more higher acute patients who come with a quite complex presentation of their illness, and we’re realizing we have to relook at how we train our staff,” Luzetsky says. “That’s from clinicians to nurses to our psych assistants to security.”

Johns Hopkins Hospital and health system leaders, and those working with Maryland’s Health Services Cost Review Commission, are also advocating for better access to care for the pediatric and adult mental health populations, Luzetsky adds. “We’re feeling as if the state is hearing us, and hopefully we’ll be able to see some further programmatic support,” she says.

Meanwhile, clinicians at Johns Hopkins are taking action. Here are four innovative ways that Children’s Center experts are bringing therapeutic interventions to children and adolescents with mental health needs.

1. Starting Intervention in the Emergency Department

Typically, children going to an emergency department with a mental health crisis experience a long wait for inpatient placement while receiving little active treatment, says John Campo, director of the Division of Child and Adolescent Psychiatry at Johns Hopkins.

Taking action quickly is crucial, says Campo. “We know that if you actively manage some of these kids — having their medications looked at, and maybe having a family meeting — after a day or two, you might be able to send them home and get them into outpatient treatment.”

Looking to kick-start mental health services earlier, the Children’s Center has begun moving toward CALM (Crisis Assessment, Linkage and Management), a model Campo previously helped develop at an Ohio children’s hospital to try to proactively manage children who present to the ED in need of high acuity psychiatric services. An interdisciplinary mental health team works to front- load care and stabilize the patients within 48 hours, with the goal of sending them home if possible with strong outpatient follow-up care.

At the Children’s Center, which has begun to implement CALM, social workers who meet with new patients experiencing a mental health crisis call for a psychiatry consult and get a dedicated team that includes licensed psychologist Mackenzie Sommerhalder, psychiatrist Vamsi Kalari, and mental health nurse practitioner Abitha Priya Perumal. Together, they work with young people to adjust medications, develop behavior management strategies and hold family meetings to discuss tools for managing aggression or other issues in the home environment.

Sommerhalder also connects with nursing and the child life department to determine what activities patients might enjoy to keep them calm, like playing with sensory toys or moving around. “We try to incorporate as many items as we can that they would find pleasant in their day,” she says.

Patients who are stable and waiting for inpatient placement may be escorted to other areas of the hospital for a change of scenery, or they can join in play activities offered by the child life department. And rather than standard meals, these patients can choose foods they like from the hospital menu.

As young patients start to improve but remain in the ED, Kalari says, the team discusses with parents whether the family would be comfortable having the child go home, with referrals to outpatient psychiatrists if needed. Families can return to the ED if necessary.

Some patients who are discharged can be transitioned to an outpatient bridge clinic at Johns Hopkins that is directed by Sommerhalder to help ensure children remain stable until they find another treatment option such as a day hospital or outpatient program. “We work really hard to do a ‘warm hand off,’” she says about the process of introducing a patient and family to the next caregiver or contacting a community-based clinician.

To help ease wait times, “we are trying to make the setting as comfortable as possible,” Ryan adds. Volunteers in the pediatric ED, many of whom are undergraduate Johns Hopkins University students, help engage and comfort patients by bringing blankets, snacks and coloring books.

2. Increasing Inpatient Staff Members and Beds to Meet Complex Needs

Before the COVID-19 pandemic, the 15-bed inpatient pediatric psychiatry unit on 12 South at the Children’s Center was mostly full during the school year, with open beds during school breaks and over the summer, says Brian Wise, nurse manager for child and adolescent psychiatry. “For the last couple of years,” he says, “we’ve just been full the whole time, and we’ve got as many as 20 to 25 kids in line just within the Johns Hopkins network waiting for an inpatient bed.”

It’s not just volume but acuity of patients that has grown, Wise says. Some patients are thinking about or have attempted suicide. Others are presenting with psychiatric illnesses such as early-onset schizophrenia or mania as part of bipolar disorder. Clinicians are also seeing a dramatic increase in young patients with catatonia, Wise says, which has led researchers to investigate if there is a causal link to lingering COVID-19 effects.

The pandemic also led to shortages in the foster care system, with some children staying in the unit days after their psychiatric illnesses have been ameliorated while staff wait for a safe place to send them after discharge.

As a result of all of these factors, length of stay has increased from an average of seven to eight days pre-pandemic to 10 to 12 days now.

To meet the burgeoning need, Wise and others increased nursing ratios, hired more staff (and some traveling nurses), and designated four beds in the unit for high-acuity patients. A philanthropic gift from investment management and financial services organization Morgan Stanley will support adding at least three inpatient beds designed to help alleviate the ED backlog.

“Our goal is being able to increase capacity, offering access to care for patients who need that level of psychiatric or mental health treatment,” Luzetsky says, “as well as to build an interdisciplinary health care team that complements that level of complexity. So when patients are ready to go to a lower care facility or go home, we have a well-coordinated plan for the patient and get them connected back into the community with the right resources.”

3. Intervening to Address Suicidal Thinking

Increasingly, one of the most common mental health crises that bring young people to the Children’s Center emergency room and other pediatric ERs is suicidal ideation.

“Most EDs aren’t well-equipped to handle suicidal thinking, and many of the kids who present don’t always get best-practice standards met when they’re seen,” Campo says.

“Even when they are properly assessed, we know it’s difficult to successfully link them with ambulatory services later.”

With a $5.5 million grant from the Patient-Centered Outcomes Research Institute, Campo, Johns Hopkins psychiatric epidemiologist Holly Wilcox, and colleagues at the Children’s Hospital of Philadelphia and Columbia University in New York, are conducting a comparative effectiveness study of two interventions for young people at risk for suicide who go to the ED — strategies that could be scaled in hospitals throughout the United States.

The first involves meeting with patients and parents to create a personalized written safety plan that patients can use when they are suicidal. It starts with recognizing warning signs that may trigger a suicidal crisis, and identifying and employing internal coping strategies. If these steps do not help, the patient is advised to contact family members or friends who may help in a crisis. The list then addresses what to do in an emergency, like calling the patient’s therapist or going to an ED. It’s important to have a plan written down, Campo says, because rational thinking can become difficult during times of emotional distress.

After discharge, patients receive text messages or phone calls from a clinician who checks in, reminds them to review their safety plan, and makes sure they have followed up with their therapist or other mental health services.

Recognizing that interpersonal difficulties such as romantic breakups or fights with friends or family members can be triggers for suicidal thinking, the other intervention includes five sessions of interpersonal psychotherapy (IPT) — short-term treatment for these types of scenarios, with intense focus on how to make adjustments in interpersonal situations to help reduce depressive symptoms and the risk of suicidal behavior. The first session is conducted in the ED by a psychologist or therapist and includes making a safety plan. Follow-up sessions can be conducted in person or by telemedicine, depending on the patient’s preference.

Researchers hope to enroll up to 840 participants ages 12 through 19 over a four-year period, Wilcox says. The team will track suicide-related return visits to the ED in three to six months, use of mental health services and how the IPT sessions impacted overall quality of life, among other variables.

4. Tapping Outpatient Programs to Keep Children Out of the Hospital

The Expanded School Mental Health Program places master’s-level therapists in over 120 public schools in the Baltimore area. The therapists support children from preschool age up to 12th grade who have conditions such as anxiety or attention-deficit hyperactivity disorder, maximizing their productivity in school. Psychiatrists who rotate around the schools help consult on cases and prescribe medications.

“One of the reasons the program is successful is because it doesn’t necessitate that kids and families jump through all of those logistical hoops to try to get treatment,” says Johns Hopkins psychiatrist Hal Kronsberg, a former middle school teacher who works with the program, which started about 30 years ago. “A kid can go during a free period, for instance, and see their therapist, and it doesn’t wind up totally disrupting their day,” Kronsberg says.

In fiscal year 2022, Johns Hopkins therapists saw 576 students for services deemed medically necessary and over 3,400 students for prevention services across 21 schools, says program manager Annastasia Kezar.

Therapists are fully integrated in the school culture, Kronsberg says, and their work includes participating in teacher training and providing informal consults for students having a difficult time in the classroom. A therapist at the Baltimore School for the Arts has helped students contact teachers for academic help and apply for jobs and work permits, mediated peer conflicts, and attended senior recitals and other milestone events.

The child mobile treatment program, in place for 25 years, brings therapists into the home for children and families who may need more intensive services as a bridge after leaving an inpatient program and returning to the community. Currently, six therapists, one psychiatrist and one nurse practitioner see upward of 75 clients each month, generally once per week, Kezar says.

“It’s a unique program to Maryland,” says Kronsberg. “We work with kids and families where children experience not just psychiatric illness but face other considerable psychosocial challenges.”

Children qualifying for the program are those at risk for multiple hospitalizations or for being placed outside the home. They may have bipolar disorder, depression, anxiety, post-traumatic stress disorder or other conditions, Kronsberg says, and at times may face housing instability or educational challenges.

“We spend a lot of time not just practicing therapy and prescribing medication, but also making sure there’s food in the home and that housing and school issues are being addressed,” he says. “The goal is to keep kids within their families. The therapist plays a really important role not only in the child’s life but in the whole family system.”