Journal of Psychology & Psychotherapy
Open Access

Social and Community-level Risk Factors Among Adolescents Presenting in Mental Health Crisis to an Urban Pediatric Emergency Department

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Abbreviations

Socioeconomic Status (SES); Emergency Department (ED); Community Statistical Area (CSA); Baltimore Neighborhood Indicator Alliance (BNIA)

Introduction

Social inequalities afflict countless communities across the nation and manifest in different areas of life such as income, educational level and employment status. These inequities affect patterns of health and disease within communities. Several pediatric studies reveal that children with low Socioeconomic Status (SES) suffer from mental health problems more frequently than their peers with high SES and have higher rates of unmet mental health needs [1].

Emergency medicine providers gain a unique perspective of a community’s mental health needs as the Emergency Department (ED) often serves as a safety net for patients in mental health crisis, which are rising in number. Understanding a patient’s community context carries high importance for mental health patients as studies demonstrate that lower-income areas are more likely to have shortages of office-based practices providing outpatient mental healthcare along with overall shortages of mental health professionals. Furthermore, low-income populations face a range of barriers to care such as lacking reliable transportation and inability to pay. Considering the effects community-level factors may have on mental health, this study aims to describe the socioeconomic and community characteristics of high-risk pediatric mental health patients who present for emergency care [2].

Materials and Methods

A retrospective cohort study was conducted including pediatric patients who presented to the pediatric ED at an urban quaternary care children’s hospital in Baltimore, Maryland, from September 2015 to August 2018. The hospital has an annual ED volume of approximately 37,000 patients, of which 2,000 patients present with primary mental health related concerns. The study population included preadolescents and adolescents, aged 9 yrs to 18 yrs, who were evaluated for a mental health chief complaint and recommended inpatient psychiatric hospitalization with an ED length of stay greater than 24 hours. Patients presenting with active medical problems were excluded [3]. For the study patients who resided in Baltimore City, the home addresses were used to identify the Community Statistical Area (CSA) where each patient lived at the time of presentation. Using census data from the Baltimore Neighborhood Indicator Alliance (BNIA), various socioeconomic characteristics associated with each CSA were evaluated including income level, high school graduation rate, violent crime and unemployment rate using BNIA data from 2018. Descriptive statistics including frequencies, proportions, means and standard deviations and medians and interquartile ranges were calculated. This study was approved by The Johns Hopkins university school of medicine institutional review board [4].

Results and Discussion

The study population, 61% were Black/African American, 27% White/Caucasian, 6.5% Hispanic/Latino, approximately 61% had public insurance and 56% resided in Baltimore City. For patients residing in the city, community-level census data was accessed to evaluate various socioeconomic characteristics [5]. These patients had a mean household income level of $48,988, considerably lower than the state average of $80,766. The average proportion of children living below poverty was 32.1% compared to the state average of 11.7%. Educational status, evaluated by high school completion rate and chronic absenteeism for grade levels 9^th-12^th, showed rates of 78.0% (below the state average of 88.7%) and 35.0% (above the state average of 15.2%), respectively [6]. Violence measured by violent crime rate per 1,000 residents and number of gun-related homicides per 1,000 residents had mean values of 17.9% (above the state average of 4.7%) and 0.4% (above the state average of 0.11%), respectively. Lastly, the mean unemployment rate of the represented CSAs (5.3%) was higher than the state average (4.2%) (Table 1).

Table 1: Study patient demographics.

A strong correlation exists between social risk factors (e.g. poverty, low-quality home environment, low educational status and exposure to community violence) and risk for poor mental health. Finding that most high-risk mental health patients who resided in Baltimore City lived in neighborhoods with high poverty rates and low high school graduation rates supports previous studies showing the negative impact of low income and low parental education on children’s mental health [7-10]. Potential explanations for this relationship suggest that children with low SES face a range of barriers that impede their access to mental health services and ability to maintain treatment [11-13]. For instance, fewer office-based practices were found in lowerincome areas and many mental health agencies have limited hours which may not accommodate people working in low-wage shift positions with less time flexibility (Table 2) [14,15].

Table 2: Community-level characteristics associated with adolescent patients who reside in Baltimore city and presented in mental health crisis to the ED.

Although exposure to violence affects all SES groups, children and adolescents from lower SES backgrounds tend to have increased exposure. Numerous studies reveal the association between experiencing violence, either directly or indirectly and worse mental health outcomes. Adolescents who know victims of crime or have seen violent crime are more likely to have both internalizing and externalizing behavior problems. Here, we found that study patients lived in neighborhoods with more than three times the rate of violent crime compared to state averages. These findings underscore the crucial task providers have in assessing patients’ exposure to violence as part of gaining a comprehensive view of the factors impacting their mental health outcomes. A key aspect of this assessment includes understanding the community context in which patients live as both social and environmental factors may affect patients’ mental health needs.

With the rising number of child and adolescent patients with mental health illness, future work should focus on optimizing the care and resources available. Research efforts exploring personal-level data on barriers to attaining and maintaining mental healthcare may help direct efforts in enhancing resources for patients with mental illness living in low-resource areas. Furthermore, work focused on causal studies and investigating into the effects of various types of violent crime exposures on the mental health of children and adolescents may help direct further preventive strategies.

While this study is limited in that it reports community-level data at one point in time, the information presented elicits further discussion about how negative community-level factors and scarcity of resources may affect children’s mental health. Pediatric providers should recognize that their role as advocates for child health extends beyond their place of practice. Advocating for child health means understanding the sundry factors directly impacting patients’ wellbeing and creating change in communities where disparities exist.

Conclusion

The present study reveals the diverse psychosocial factors related to the adolescence mental health issues, as individual issues, family related, school related and community related to the others as predictors of health deterioration in this population. These factors should be examined in promotion programs proposals, prevention and mental health treatments in adolescents.

In synthesis, the analyzed scientific production provided indication that in some situations that are typical from adolescence as depression, suicidal ideation and dissatisfaction with life. Rather than that, precursor factors that lead to adolescence mental health issues were identified as psychosis, anxiety, conduct or eating disorders and toxic substances abuse. In relation to the risk factors with higher probability to adolescence mental health issues, physical, psychological and violence that affects within the family environment constitutes the most severe factor and can lead to psychopathologies, especially in the initial phase of adolescence.

So, the health professional, especially the nurse, as of solid knowledge, should commit to the community services effectiveness subsidized by guidelines, legislations and public politics in mental health. In scheduled visits to high risk families, the professional should stimulate the good intra familiar relationship aiming to identify by cultural and social changes that splits the physical violence nature. This action contributes to the precaution of all types of violence suffered by adolescents.

It is important to mention that the adolescence mental health protection starts with the parents and the family, the school and the community. It important that health and education professionals to be sensitized and prepared to adopt avoidance and health promoter strategies that take in consideration the adolescents’ biopsychosocial and cultural aspects.

Acknowledgment

There are no potential conflicts of interest including no financial relationships or commercial interests to report. No funding was secured for this original research work. All persons who have made a substantive contribution to the study have been included as authors.

Data Availability Statement

Data are available upon reasonable request and will be provided by the corresponding author or senior author of this study.

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