The 988 Lifeline: An Opportunity to Address the Pediatric Mental Health Crisis

two teenagers walking together outside

The number of children suffering from mental health conditions has drastically increased over the past decade. Many of these children experience mental health crises, or situations where they are in danger of hurting themselves or others and need urgent psychiatric evaluation and stabilization. 

Across the country, the health care system is not adequately meeting the needs of children who need this type of help. Children who present to an emergency department with a mental health crisis often experience prolonged waits for transfer to an inpatient psychiatric facility. For those children who can safely be discharged home, significant shortages of pediatric- and adolescent-trained mental health clinicians make it difficult to receive timely, ongoing outpatient mental health care.

Some of these challenges may be alleviated when a new national three-digit crisis number—the 988 Suicide and Crisis Lifeline—goes live on July 16. The 988 number was mandated by Congress in October 2020 as a national service for children and adults facing mental health emergencies. Rather than call 911 or go to an emergency department, children and families will be able to dial 988 on any phone line and be connected to a crisis counselor. There will also be a text option, allowing children or their caregivers to text with a crisis counselor if they prefer or if that option is safer for them. Below, I’ll discuss opportunities and challenges for this new system, and the steps needed to ensure this resource meets the needs of children and adolescents. 

How 988 can make things better

The 988 number has the potential to transform access to pediatric emergency mental health care. First, it can allow families to avoid calling 911 and involving law enforcement in mental health crises in which there is no criminal activity. The 988 number may also help families avoid unnecessary visits to the hospital. For example, a trained crisis counselor may be able to help families or caregivers de-escalate mental health emergencies at home and provide linkages to close outpatient follow-up services. In scenarios where de-escalation by caregivers is not possible, a crisis counselor may be able to send a mobile crisis team to provide onsite evaluation of the child. These services could help families get linked to mental health care earlier and keep children in familiar settings like home and school, freeing up hospital resources for the children who need them most.

However, much of the planning for 988 has focused on adult users. As a pediatrician, I know that 988 will not live up to its promise if we develop an adult-focused service and hope it works for children. We need a service that is trained to meet youth needs, that takes steps to ensure youth safety and that can assist with linkage to ongoing child-focused mental health care.

Ensuring that 988 can meet the needs of youth

There are some specific steps that city and state organizations can take to ensure children’s needs are considered in the 988 roll out. 

First, it is crucial that the crisis counselors staffing the 988 call centers have pediatric-specific expertise. Counselors need training in speaking with children and adolescents, since we know that youth frequently use existing crisis lines, especially over text. It is also crucial that counselors are trained to provide appropriate pediatric referrals. For example, children need to be referred to pediatric- and adolescent-trained mental health providers and/or to crisis evaluation centers with child and adolescent psychiatrists on staff.

We also know that while minors are entitled to privacy in using crisis hotlines, there are limits to confidentiality that should be addressed upfront. If a child discloses a risk to their safety or to the safety of someone else, there must be clear guidelines about who will be contacted to ensure that appropriate care and evaluation of that child will be undertaken. In considering this process, it is critical to think about ways to avoid unnecessary law enforcement involvement in the process of transporting youth for stabilization and evaluation, and to ensure youth rights to confidential care—when safety is not at risk—are maintained.

Schools are often places where children reveal mental health concerns. A school reaching out to the 988 line should result in a different cascade of events than an individual caller, including ensuring that youth requiring transfer to another site of care are supported with a caregiver or trusted adult. Crisis counselors should also assist schools in coordinating school-based mental health services and ensuring that individualized education plans are in place, steps which may prevent future mental health emergencies. 

Finally, we need to bolster the availability of pediatric mental health crisis care to meet increased demand. The need for pediatric mental health crisis and inpatient services already far exceeds supply. Ideally, children who are in need of help and are not currently getting services will use the 988 number. This is likely to result in increased mental health needs being identified and more crisis psychiatric evaluations being necessary. It is critical to develop local and national strategies to ensure that these youth can get connected to timely, evidence-based care.

As we recognize Mental Health Awareness Month, millions of children across the country are suffering because of inadequate access to mental health care. By ensuring that youth needs are being prioritized in the 988 roll out, we can help to address this national crisis.