Pediatric hospitals in several states have reported sharp increases in ED visits for anxiety, depression, substance abuse, suicide attempts, self-harm, aggressive behavior, and eating disorders. In a June 4 article in Medscape, Christine Crawford, associate medical director of the National Alliance on Mental Illness, described the current situation as one of "colliding pandemics"-one being the long-standing inadequacy of mental health resources for children coupled with the psychological toll of COVID-19.

Behavioral health ED visits at Yale New Haven Children's Hospital averaged 26 per day in May, compared with one or two visits per day in 2019. Pediatric mental health ED visits across the Children's Hospital Colorado system were up 72% from January to April compared with the same period in 2019. At Connecticut Children's Medical Center, pediatric psychiatrist Jennifer Downs noted in a recent interview with the CT Mirror that the intensity of mental health symptoms of young people coming to the ED is "much greater than is typical"-for example, suicide attempts rather than suicidal thoughts, or episodes of physical rather than verbal aggression.

Even when children are found to need mental health treatment, there can be long waits for both inpatient and community-based care. "This is an unacceptable situation," David Brumbaugh, chief medical officer at Children's Hospital Colorado, told Medscape. "We would never allow a child with leukemia or appendicitis to go several weeks without treatment."

Nurses are often in a position to identify mental health issues in children, especially school nurses who can note changes in students over time, and to gain additional insight through relationships with parents. But the pandemic has multiplied the duties of school nurses, who must monitor students and staff for COVID-19 infection, help with contact tracing, and follow-up with children who test positive for the virus or who may be coping poorly with the stress of the pandemic-all in addition to their usual duties. "We don't have the bandwidth, the staffing, or the capacity" to manage schoolchildren's mental health issues, said Robin Cogan, an AJN editorial board member and nationally certified school nurse for more than 20 years who blogs as The Relentless School Nurse. "There was no [mental health] safety net to begin with" before the pandemic, she told AJN, calling for more staff and resources.

In addition, clinicians and advocates would like to see fewer bureaucratic hurdles in the pediatric mental health system and more mental health screening by pediatric practitioners. Other recommended system improvements include specialty mental health services for children such as eating disorder programs, 24-hour mobile pediatric mental health teams, better insurance coverage, and reimbursement rate equity for telehealth for ongoing mental health management.

These improvements, advocates say, would help to strengthen the behavioral health continuum for children so they are less at risk for becoming adults with chronic behavioral health challenges.-Betsy Todd, MPH, RN