COVID-19: don’t be fooled, the kids are not okay

THE mental health effects of COVID-19 lockdowns and restrictions on children and adolescents may have been hard to pin down, but at the pointy end of the stick – paediatric intensive care units (PICUs) – it’s hard to deny the data.

Research published late last week from the Australian and New Zealand Intensive Care Society Paediatric Study Group (ANZICS PSG) and the ANZICS Centre for Outcome and Resource Evaluation (ANZICS CORE), has highlighted an increase in PICU admissions following deliberate self-harm, coinciding with the COVID-19 lockdowns and social restrictions of 2020 and 2021.

The study analysed registry data for 1 January 2015 through to 30 June 2021. In that period, 813 patients aged 12–17 years were admitted to intensive care units (ICUs) following deliberate self-harm.

“At the onset of the pandemic, monthly incidence of [deliberate self-harm] ICU admissions per million children and adolescents increased from 7.2 admissions in March 2020 to a peak of 11.4 admissions by August 2020, constituting a significant break in the temporal trend,” the authors wrote.

That occurred “while the rate of all-cause admissions to pediatric ICUs of children and adolescents of all ages (ie, ages 0–17 years) per 1 million children and adolescents decreased from a long-term monthly median of 150.9 admissions to 91.7 admissions in April 2020”.

Dr Felix Oberender, medical director of the paediatric ICU at Monash Children’s Hospital, and lead author of the research, told InSight+ that while the study was observational and therefore it was not possible to assume causality, the numbers were concerning.

“This is an intensive care study, and we are not mental health experts. We really only see the tip of the iceberg,” he said.

“The main burden and knowledge rests with the families, the mental health experts, our emergency department colleagues, the paramedics.”

While the study is observational, the numbers were loud and clear, according to Professor Patrick McGorry, Executive Director of Orygen and professor of youth mental health at the University of Melbourne.

“What else would be causing that increase [other than the lockdowns, social restrictions and other measures necessary to control the COVID pandemic]?  These impacted much more heavily on young people than any other age group, with harmful disruption of the protective scaffolding supporting mental health and development,” he told InSight+.

“It’s a robust finding that matches data from the Department of Health and what we’ve been seeing anecdotally – a massive surge in mental health problems for young people during the pandemic.

“headspace’s waiting lists have also blown out, and so far we haven’t yet seen a proportional government response to these issues.”

Professor McGorry said the peak of the COVID pandemic had turned Chief Health Officers in to “Chief COVID Officers”.

“That’s understandable given the shock and urgency of the situation early on, but, as the pandemic evolves you have to be able to walk and chew gum at the same time,” he said.

“What is now clear is that lockdowns and social restrictions such as we had are justified until vaccination rates increased.

“What is now clear is that lockdowns and social restrictions such as we had were justified until vaccination rates reached a stable plateau and the public were protected as much as possible.

“But you simply cannot continue to force people to stay home indefinitely, and in the case of young people, stay away from schools and their social networks.

“There are competing health priorities and trade-offs here and we’ve got to get the balance right from the beginning in any future pandemics.

“Young people don’t start off with well developed coping mechanisms – that’s a key task of emerging adulthood – to learn safer and more effective strategies. This transition is an exquisitely sensitive period of life and young people’s mental health depends on a stable family environment, engagement with peer groups, and progress within educational pathways.”

Federal Government support has been mainly about “sand-bagging” the pandemic-related surge. They now need to urgently step up with new investments in workforce growth and new platforms of expert care for the “missing middle” – young people too complex for headspace and primary care but not severe enough for acute State mental healthcare, Professor McGorry said.

Dr Oberender told InSight+ that in the event of future pandemics “we have to look beyond the immediate impact of the society-wide crisis”.

“In 2020, I think many of us comforted ourselves thinking at least the kids are okay,” he said. “What we’re seeing now in 2022 is a broad acknowledgement, in fact, that they’re not okay.”

At the same time, he stressed that “the study didn’t compare Australia with countries that had less robust approaches to public health and where children instead experienced the trauma and burden of COVID-related disease and death in their families”.

“And it’s not just the people who get COVID-19. It’s the ripple effects.

“The overriding theme for me is that mental health these days is a real issue when society is in crisis, particularly for the vulnerable amongst us.”

Other findings from the JAMA Network Open study included:

• Of the 813 study patients, 230 individuals (15.2%) were admitted during the first 15 months of the COVID-19 pandemic in Australia, between 1 April 2020 and 30 June 2021.
• Ingestion of a drug was the predominant diagnosis (657 patients, 80.8%), followed by hanging or strangulation (80 patients, 9.8%] and non-drug ingestion (40 patients, 4.9%).
• Other self-injuries (36 patients, 4.4%) included admission diagnoses of isolated trauma, multiple traumas, and burns.
• The rate of all-cause ICU admissions of children and adolescents of all ages remained below pre-pandemic levels throughout 2020.
• The incidence of ICU admission with deliberate self-harm per million children and adolescents aged 12–17 years increased after this time, from 7.2 admissions in March 2020 to a peak of 11.4 admissions in August 2020.
• Nearly half of the children and adolescents aged 12–17 years admitted to pediatric intensive care with deliberate self-harm required mechanical ventilation (400 patients, 49.2%).
• ICU mortality was 4.9% (95%CI, 3.5–6.7%), and hospital mortality was 5.2% (95%CI, 3.7–6.9%).

“The coronavirus pandemic in Australia was associated with a significant increase in admissions of children and adolescents to intensive care with deliberate self-harm,” the authors concluded.

“Addressing this challenge in the pediatric population during the current health crisis may require perspective, policy, and resourcing beyond direct COVID-19 morbidity and mortality.”

The authors noted the limitations of their study, including:

• actual patient-specific factors associated with triggering of DSH, details regarding presence or absence of suicidal intent, and complexities of individual circumstances remained unknown, as did socioeconomic and ethnic data;
• coding did not allow the authors to unequivocally identify or classify self-injury. While the literature broadly supports the assumption of self-harm in the selected diagnostic codes in this age group, misclassification of true accidents cannot be excluded;
• the analysis did not include patients with deliberate self-harm who did not present to hospitals, who were admitted to hospitals but did not require intensive care, or who died prior to arrival in ICUs. Also not included were children and adolescents admitted to adult ICUs not contributing to the pediatric registry. A significant number of older adolescents may therefore have been missed, potentially skewing the data.

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