When distressed children come to the ER, I wonder about their life paths

by Dr. Sabreen Akhter

On the afternoon that the world found out about the brutal slayings of 19 elementary schoolchildren in Texas, I was trying to sleep.

I work nights as a physician in a children’s emergency department, and I had a shift later that evening. When I awoke and checked my phone before starting the bedtime routine for my two young children, I saw the news. Fifteen dead. Later, that number ballooned to 19 children plus two beloved teachers. The weight of it was sickening, and I knew that soon, 19 little faces would begin to show up on my social media feeds, faces that would be reflected back to me in the kids I would see that night in the emergency department. I couldn’t bring myself to read more, and so I turned off my phone and turned up the music as I drove into work that night.

It was a busy night in the children’s ED. The viral season is surging hard and late, and hand in hand with this, there is a surge in children presenting with mental health or behavioral issues. This surge has been building, one that we are unlikely to see any respite from in the years to come. These children come in with stories of harming themselves, of ingesting pills or running into traffic or hanging themselves, of having injured or threatened their families, and on and on. They often sit for many hours boarding in our ED because my state, like many others, has an abysmal support model for children in these kinds of crises, with only 94 inpatient psychiatric beds for the over 1 million children in the state, chronic disinvestment and underfunding of mental health services, along with high rates of turnover of mental health staff and facility closures.

When children come to the ED in a mental health or behavioral crisis, they sometimes come alone, sometimes with police or a state caseworker, but most often, they come with their families. Families who are often exasperated and who are looking for some kind of tangible help. While some of these children will get admitted, most will go home. Our mental health providers will do a thorough assessment of their needs and offer various outpatient support for them.

Sometimes, by the end of their visit, this will feel like a viable path forward, but too often, the mental health provider and I will look at each other and wonder, given the constraints of our system, how much have we really been able to help these children and their families.

My older child is 8. He is curious, gregarious, hyper and full of joy. He is un-self-conscious still, unafraid to bust into frenetic and uncoordinated dance moves, not yet embarrassed by how his r’s sound like w’s. He is at a precious age, an age that feels at a precipice, only 10 years away from the age of the perpetrators of the two most recent mass shootings.

I wonder — what happens between the ages of 8 and 18 to a child, to a boy, in this chasm of time when so many influences are beyond my control? I try to comfort myself in thinking that he has loving and constant parents, that he is privileged to not want for much in his childhood. But I know, from talking with so many tearful and desperate parents in the ED, that, often, all of that is not enough.

I worry — is it possible to keep my own children safe in this world that seems increasingly violent? And is it possible to find safety for their mental well-being if they ever do need help in a system that is overwhelmed by the needs of so many?

Around 4 a.m., when the ED had slowed down, I looked at my board and started counting. Eighteen. There were 18 children in our ED at that moment with mental or behavioral health concerns, and, as I was looking, a 19th popped up in the waiting room. Nineteen young people, with a lifetime of love and worry behind and hopefully in front of them, 19 children searching desperately for safety in this world.

I reflected on that number as, later that morning, I pulled my 8-year-old aside before he left for school and, in fumbling phrases, tried quickly to tell him about what had happened in Texas before he heard about it at school. He looked at me with worried eyes. “Is this going to happen in my school?” he asked. Parenting is full of these pressing conundrums: How much should I explain to a child about the deep and pervasive history of guns, of violence, of racism and of mental health disinvestment in the two minutes that I had before shuttling him off to school? I floundered. I told him not to worry, that his school is safe and that he will be safe, but as I spoke it, my voice faltered. Children have a way of discerning quickly when adults are telling them untruths or half-truths, and as my child stepped out the door, I knew he could sense this.

There is no way for me to assure my children of safety, in their schools, in their places of worship, in their communities and, ultimately, even in their minds. But as a parent and a pediatrician, I have no option other than to hope, to struggle and to advocate for better.

We are all bound together in this fight. And we are bound to do so with the same urgency and heartbreak that we feel today in our emergency departments, in our communities and in our homes.

Dr. Sabreen Akhter is a pediatric emergency physician in Seattle.