Officials and experts have sounded the alarm over the state of children’s mental health as the second pandemic year comes to a close, warning a crisis is emerging – but advocates, hospitals and schools say it may have already arrived.

Short-staffed children’s hospitals were slammed with increased emergency department visits for mental health, suicide and self injury cases in the first nine months of 2021 compared to the same period last year.

At the same time, already strained schools with limited resources have been left to face a growing need for mental health assistance as many children returned to in-person school this fall with increased symptoms of depression and anxiety after COVID-19 flipped their worlds upside down.

The American Academy of Pediatrics (AAP), the American Academy of Child and Adolescent Psychiatry (AACAP) and the Children’s Hospital Association declared a national emergency for children’s mental health in October shortly after the back-to-school season.

But AACAP President Warren Yiu Kee Ng said the situation has “gotten worse” since that declaration, with the scope being “even larger than we imagined.”

“I think that we are in the deep end of a mental health crisis, and I think that the COVID-19 pandemic is only making it worse,” he said.

Children’s hospitals recorded almost 38 percent more emergency department visits for mental health cases and nearly 54 percent more suicide and self-injury cases in the third quarter of 2021 compared to 2020, according to the Children’s Hospital Association (CHA).

CHA President Amy Wimpey Knight said some hospitals saw suicide and self-injury cases in the emergency department triple and even quadruple. Many hospitals are also seeing between 20 and 50 boarders daily, or patients kept in emergency beds until spots in psychiatric treatment programs open up, who ultimately have their care delayed.

“I think the pandemic has taken everyone to the max really, and so children’s hospitals are no different,” she said. “We are also extremely short-staffed.”

According to experts, the pediatric mental health crisis was already emerging in the decade before the pandemic, which “exacerbated” and “accelerated” the problem.

“What we kind of expect right now is the next five to 10 years, we’ll see an escalation of this because of what’s happened to kids, primarily in the five to … 18 range right now,” Wimpey Knight said.

Still, Alysha Thompson, the clinical director of the psychiatry and behavioral medicine unit at Seattle Children’s Hospital, pointed out action is also needed to address the current problems.

“There are a lot of things that we can do that will put out fires a year from now, five years from now, 10 years from now, which are really exciting and need to be put in place now,” she said. “And the reality is those things take time. They’re not gonna address the current fire. And so, as we are addressing all of these things for youth mental health, we need to think about how to do both.”

The two months on record with the most emergency department mental health visits at Seattle Children’s Hospital were October and November this year, with more than 360 and 380 patients, respectively. In total, the unit has 41 beds for inpatient care.

December numbers are not finalized but are “in line” with the previous two months, although around the holidays generally there’s a drop in mental health emergency visits, a hospital spokesperson said.

“I think on the one hand, there’s been a lot more attention to youth mental health needs than I think I’ve ever seen before, which makes me feel hopeful,” Thompson said. “I also think that even with that people aren’t realizing really, truly what a crisis it is.”

The Biden administration has called more attention to youth mental health in recent weeks, with Surgeon General Vivek Murthy issuing a rare advisory in December, cautioning of a looming mental health emergency among young people.

“It would be a tragedy if we beat back one public health crisis only to allow another to grow in its place,” he wrote in the advisory.

The widespread death and disease over the past two years have impacted the emotional state of the country’s children. During the pandemic, more than 120,000 children lost a primary caregiver, and another 22,000 endured the death of a secondary caregiver – defined as a co-residing grandparent that provides housing – according to a study published in October.

With the disproportionate effect of the pandemic on minority communities, Ng of AACAP noted that the consequences have been even “more particularly challenging” for children of color.

The overall resulting mental toll on children has ramped up pressure on not only hospitals, but also on child psychiatrists and psychologists who face overwhelming requests for appointments and help.

“As a mental health provider in the child psychiatrist, I can’t think of a time that it’s been busier for such a long period of time, and no one is immune to that and working in the setting,” Ng said.

“Access to care is a significant challenge because we weren’t designed and/or built to accommodate and think about such a pandemic of mental health issues for adults as well as for children,” he added.

The burden has also extended to schools, with Judy Styer, the director of health and wellness for the Framingham Public Schools in Massachusetts, said her district is dealing with an unseen “level of escalation of behaviors.”

This includes a rise in depression, anxiety and suicidality among middle and high school students and “over-the-top” behavioral concerns among younger students, she said.

“I can tell you quite honestly, after being in the position I’m in for almost 15 years, I’ve never seen anything like the mental health issues that our student population is experiencing,” she said. “It’s tragic, and it’s challenging, and it’s exhausting.”

“We can’t sustain this, and our kids are suffering,” she added.

Advocates and experts are calling for more support and recognition for both those struggling with mental illness and behavioral health professionals. These requests range from prioritizing increasing capacity in hospitals, integrating mental health in schools and improving the recruitment and retainment of mental health workers.

“In my opinion, it’s already another pandemic, and I think it’s going to get worse, and we need to do something about it,” Thompson of Seattle Children’s Hospital said.