We found significant variation across sociodemographic groups of children in crisis and post-crisis health care use over a 6-year period in Alberta. The largest increase in visits to the emergency department for mental health crises was among First Nations children. First Nations children and those from families receiving subsidy from government-sponsored programs had more return visits to emergency departments over time compared with other children. First Nations children also had disproportionately less follow-up care with a physician after an emergency department visit and had longer times to follow-up care. Sociodemographic status, diagnosis and illness acuity were significant predictors of time to post-crisis health care use.
Multiple studies have shown that race and ethnic background influence access to mental health services and emergency care for children.3,4
To the best of our knowledge, our group is the first to report on the use of emergency mental health care among First Nations children. We currently have a poor understanding of the prevalence of mental illness among these children. In the 2002/03 First Nations Regional Longitudinal Health Survey, 17% of First Nations parents reported a modest percentage of behavioural and emotional problems among their children.21
Other studies suggest more substance use,8
more symptoms of conduct disorder9
and higher completed suicide rates among First Nations children than among other children.10
We found that more First Nations children presented to emergency departments for disorders secondary to substance abuse and intentional self-harm than other children, and that, compared with other children, First Nations children returned more quickly to the emergency department and had a longer time before visiting a physician in the post-crisis period. These findings suggest that investments in culturally based, community- and school-based resources targeting the high-risk behaviours seen in the emergency department may help to reduce crisis events and foster the use of mental health resources.22
Although such resources would not have been captured through physician billing in our study, the high rates of emergency department use suggest that if such services do exist and are being used, they may not be specific or comprehensive enough to reduce crises.
Our findings also reflect access and utilization issues. In the 2002/03 Regional Longitudinal Health Survey, parents reported long waits for health care (91.4% of respondents) and lack of service coverage by the First Nations and Inuit Health Branch (10.6% of respondents) as significant barriers to health care access.21
To what extent these barriers limit access to and the use of mental health services is not known. In our study, First Nations children had the longest times to physician follow-up care, but First Nations status alone did not predict time to most follow-up visits. To reduce mental health crises and tailor care, more investigation is needed to better understand the relation between crisis-oriented patterns of care, delays in receiving follow-up care, and the services desired and sought in a post-crisis period by First Nations children and their families.
Consistent with our hypotheses, children from families receiving subsidy (welfare and other government-sponsored programs) also had some of the highest rates of emergency department visits and revisits, with government-sponsored subsidy status predicting a quicker return. Contrary to one of our hypotheses, however, these children, in general, did not have longer times to follow-up than other children for a follow-up physician visit. Our findings of increased use of health services among a lower socioeconomic group of children are similar to other Canadian studies examining the use of community-based mental health services23
but dissimilar to research on return visits to the emergency department.19
Whether high rates of visits by children in our study reflect a lack of access to pre-crisis care, delays in seeking care until crises emerge or other factors (e.g., geography) could not be answered with the Ambulatory Care Classification System, but these factors are important to determine. A lack of access has implications for the availability of services in neighbourhoods that differ by socioeconomic status. Delays in mental health care for children have been linked to time lags between generalist care and specialist referrals24
and service proximity.25
Our study has several limitations. First, we were limited by diagnostic reporting. Although recent studies using Ambulatory Care Classification System data indicate diagnostic accuracy,15,16
no formal assessment of mental health diagnostic coding in ambulatory care has been conducted.
Second, the databases used do not identify all Aboriginal children; non-Treaty Status, Inuit and Métis children were not included.
Third, we could not determine the influence of either pre-crisis mental health care, contact with non-physician resources in the post-crisis period or other variables hypothesized to influence the use of health care. Higher rates of visits to emergency departments may be the result of a disproportionately high use of emergency services over other medical services or a preference for emergency care. Longer times to physician follow-up in our study may reflect access to other mental health services in the child’s community (private clinics, community-based programs designed for specific sociodemographic groups). Child- or family-specific determinants (e.g., stress, stigma, family constellation and psychiatric history) likely further explain both crisis and post-crisis health care use, but these were not available in the Ambulatory Care Classification System. Although this database limitation is not unique to our study, it does point to important considerations for administrative data-capture parameters and how to increase the contributions of these repositories for health care decision-making.
Finally, although others have reported the same socioeconomic proxy definition,26
our use of health care premium subsidy may not have always accurately reflected a child’s socioeconomic status.
Visits to the emergency department for mental health care should be considered a “stop gap” solution in the full suite of mental health services. For many children, these visits reflect a need for earlier intervention to prevent illness destabilization into crisis. Further, children with longer times to follow-up care in the post-crisis period may also be disadvantaged because they likely require continued support for stabilization. We found that sociodemographic status plays an important role in the post-crisis use of health care services.
A recent US-based study reported continued use of emergency departments for pediatric mental health care despite linkage to community-based services,27
which suggests that seeking health care is not solely patterned by features of the health care system. Factors such as stigma and discrimination,28
and parent unemployment29
are linked with service use and should be a priority for understanding predictors of the time to and use of mental health care. Such a line of investigation may help to explain the varied patterns of emergency department use and follow-up physician care observed among the different sociodemographic groups in our study.
Although recent treatment in an emergency department has been shown to be a strong predictor of follow-up mental health care for suicide-related behaviours,30
our study also suggests that the time to post-crisis care is affected by age, sex, diagnosis and clinical acuity. Future studies that determine why the risk for repeat crisis events increases with age are worthwhile and could query, for example, whether youth are particularly vulnerable because of their developmental struggles for autonomy. Moving ahead, our findings that when a child leaves the emergency department with an unspecified diagnosis they are more likely to return sooner in crisis or that certain diagnoses (substance abuse, anxiety) and less urgent presentations (e.g., lower triage scores) involve longer times to follow-up care could inform current discharge planning processes in Canada’s emergency departments without fiscal or human resource impact.