National Guidelines for Child and Youth Behavioral Health Crisis Care: Why Are They Needed?

Children are not small adults. This is obvious, but when it comes to crisis services, it seems the development of these services has focused mainly on adults, causing a lack of child-specific programs. Despite the recent rollout of the nationwide 988 system, an increase in emotional and behavioral health problems is occurring in children and adolescents. Young people of color, economically marginalized children and LGBTQI+ youth are disproportionately affected according to the Centers for Disease Control and Prevention (CDC) Youth Risk Behavior Survey (2021). Because of this, the Substance Abuse and Mental Health Services Administration (SAMHSA) released National Guidelines for Child and Youth Behavioral Health Crisis Care in 2022.

As David Covington, CEO of RI International and leader in the 988 effort has observed:

“As with everything, we just take the adult version and stamp with children and adolescents and we're done, right? No. That's not what we did. We've learned kids are not micro adults. We've got to come up with something that is unique and appropriate for them.”

The problems affecting young people are significant. Data from the CDC Youth Risk Behavior Survey (2021) shows the following trends:

• High school students reported a 50% increase in feelings of sadness and hopelessness (from 28% to 42%) since 20011

• Suicidal behaviors in students have increased 44% from 2009 to 2019 with almost one in five students reporting having made a suicide plan.

These trends were present pre-pandemic but were made worse by it.

Traditionally, youth in crisis were often taken to hospital emergency departments. Loe, et al (2020) reported that while pediatric emergency visits remained stable overall from 2007 to 2016, visits for all mental health disorders rose 60% and pediatric substance use visits rose 159% (while alcohol related visits fell 39%). Arguably the most concerning trend identified by the authors was that emergency department visits for deliberate self-harm increased 329%.

Youth who are not discharged from an emergency department following a behavioral health evaluation usually follow one of three paths: admission to an inpatient psychiatric bed, remaining in the emergency department until a psychiatric bed becomes available (a process referred to as “boarding”) or admission to a traditional medical hospital bed to await transfer to a psychiatric bed (another form of boarding). While there are many reasons why boarding is not ideal, one is the use of seclusion and physical and chemical restraint in environments not appropriate for pediatric psychiatric cases.

Like their adult counterparts, youth in crisis often interact with law enforcement officers either through 911 calls or with school resource officers. Responding to Youth with Mental Health Needs: A CIT for Youth Implementation Manual by the National Alliance on Mental Illness (NAMI) states, “too many youth with mental health needs are encountering law enforcement officers that are not trained to respond effectively to a mental health crisis and as a result, youth in crisis often do not get to the services and supports they need.” Black, Indigenous and other people of color (BIPOC) and LGBTQI+ youth experience higher levels of discrimination, profiling and violence from law enforcement than their white counterparts, according to SAMHSA’s National Guidelines for Child and Youth Behavioral Health Crisis Care, which highlights the need for crisis care that serves diverse populations.

In the next installment of this series we will discuss the new guidelines and how they were tailored to youth in crisis.