In Limbo

dr. Abdallah: In the late summer of 2020, as a pediatric intern in the Solnit Integrated Training Program, I spent a month working with the child psychiatry consultation team that serves patients in the pediatric wards of Yale New Haven Children’s Hospital. Our supervising physician commented on an increase in recent eating disorder cases, which she attributed to the stressors of the pandemic. At that time, we had two patients with eating disorders on our list.

By the time I switched to working in the pediatric emergency department (ED) in November, that increase had increased in size and became more apparent in other psychiatric presentations, namely suicide attempts. The number of children justifying psychiatric admission consistently exceeded the number of available psychiatric beds. For days ten or more children sat in the emergency room waiting for an opening in one of the available psychiatric wards. Some ED employees called the back hallway where many of them waited “Mini Wini” after Winchester 1’s Child Psychiatry.

The backlog soon fell into the children’s wards. Without the usual number of winter respiratory infections, the floors could accept children with psychiatric presentations who initially needed medical care and clearance. This group consisted mainly of patients struggling with eating disorders and patients with suicide attempts due to toxic ingestion. Once these patients were medically cured, it took days to weeks for a bed to open on a psychiatric floor or a diner. They waited in limbo in the pediatric ward, unable to proceed to the next stage of treatment and too ill to go home safely.

The safety risk of their disease meant that under the standard of care model, these patients required regular one-on-one monitoring. During my pediatric ward rotation in February, I watched nurses struggle to find enough babysitters, often filling the role for half an hour on their own. I also saw my colleagues in the psychiatry of the Child Psychiatry Consultation Service hurtling through the wards with three times the usual count.

drs. Abdallah & MacLeod: COVID-19’s toll on children’s mental health is just beginning to manifest. Causes are multifactorial, ranging from decreased social attachment to increased risk of domestic violence and child abuse.1-2 Preliminary studies have shown an overall increase in suicidality, substance use and eating disorders in children, adolescents and young adults since the start of the pandemic.3-5 Of particular concern is that children and adolescents who already belong to disadvantaged and marginalized groups, whether because of race, socioeconomic status, pre-existing mental illness or a number of other factors, are disproportionately affected.1,6

There are several much-needed changes at the system level that will allow for more rapid, appropriate and versatile care in this complex new landscape. Examples include funding to increase inpatient and outpatient capacity for children and adolescents seeking mental health services, medico-psychiatric units in pediatric hospitals that allow for simultaneous treatment of physical and mental health comorbidities, and optimization of telehealth psychiatry to allow wider access. into treatment in pediatric settings.

In the meantime, pediatricians can play a pivotal role in supporting children and adolescents awaiting psychiatric services. While there is no perfect way to handle these impossible scenarios, involving family members and encouraging social support is known to promote resilience to acute and chronic stress.7 Validation, a smile and a listening ear can go a long way. contribute to promoting healing. Most importantly, caregivers should show self-compassion and have realistic expectations of their work in a non-psychiatric environment. It can be discouraging to observe patients in clinical uncertainty, without having the resources to address their primary disease. But helping children survive, both physically and psychologically, while maintaining hope for the coming recovery, is a clinical victory.

More family resources on helping children and adolescents with the COVID-19 pandemic can be found on the American Academy of Child & Adolescent Physiatry website.

Sarah Abdallah, MD, grew up in Ann Arbor, MI, as the oldest of four siblings in a vibrant Lebanese-American family. She moved to New Haven to attend Yale and hasn’t left since, though she’s still a Midwesterner at heart! In college, she studied dual molecular biology and psychology, and along the way discovered her passion for human genetics. Her longstanding research interest lies in applying experimental and computational genomics approaches to better understand the etiologies of complex neuropsychiatric disorders. As a medical student at Yale, she spent a year as an HHMI-ASHG researcher in the Fernandez lab, where she has since continued her work identifying genes and genetic variants that contribute to OCD. She is excited to train as a resident in the Albert J. Solnit Integrated Adult/Child Psychiatry/Research program and to continue to work with the wonderful people at the Child Study Center. Outside of medicine, she enjoys running, traveling and competing with the Yale grad touch rugby team, as well as working on various art and film projects.

Jelena MacLeod, MD, MHS, is a Clinical Fellow in the Albert J. Solnit Integrated Adult/Child Psychiatry/Research program. Originally from Zagreb, Croatia, she has lived in Belgium as well as in the Washington DC area. At the Johns Hopkins School of Public Health, her master’s thesis explored the public health potential of incorporating epigenetics into our understanding of trauma, stress, and PTSD. She then studied neuroendocrinological and behavioral correlates of childhood anxiety disorders as a postdoctoral fellow at the Yale Child Study Center. During her time at the University of Connecticut School of Medicine, she established and developed a Peer Support program to train medical students in basic mental health skills. Her current work focuses on optimizing mental health screening in pediatric primary care through systems design, healthcare data mining, and implementation science.

Comments are closed.