Jennifer Axelband, DO, FACOEP, President-Elect
As I pen my first Pulse communication as President Elect, I must thank the membership, my mentors and the board for all the support and encouragement I have received as I embark into this new role. Leading a college is challenging, communicating with the written word with a goal to strike a sense of importance is humbling. In my attempt to write, a flight of ideas crossed my mind, what does the membership want to read? Do I write about the year ACOEP has had with our accomplishments and goals? Should I write about what my focus and aspirations are? Do I address current events such as healthcare news, legislation, and advocacy? I then realized the deluge of topics in my head was not a flight of ideas, it was writers block. An overwhelming feeling of being stuck in the writing process without the ability to move forward and write anything new. Everything that came to mind has been highlighted in the past. The solution, I need to get personal.
On September 14, 2023 my son came home from school, he’s 16 years old and attends a public high school. As a teenager, he sees me and my husband as annoying adults who he cannot have a meaningful conversation with because we do not understand his generation. His daily routine after school is to come into the house, eat every morsel of junk food he can find and then take a nap after an exhausting day of school and socializing. Usually I get a “Hi mom” or “What are you making for dinner?” from him. I ask how his day was and his reply is typical, alternating between “fine” or “boring”. September 14, a Thursday afternoon was different. My son called me from the bus and asked if I was home and said he needed to talk to me. My first thoughts were, how many days of detention, how much money or which class is he failing. I was not prepared for what came next.
As he entered the house he said “She’s dead”, those were his words. I must have looked confused and shocked because he kept talking, talking and pacing, as he told me the story of his friend. They have known each other since middle school. They “dated” for a brief time in 6th grade, the equivalent of holding hands in school and calling each other boyfriend and girlfriend. With the pandemic and changes in school attendance they stayed friends, stayed in the same friend group and social media circles. They texted or snapped or whatever regularly. He told me he was talking to her in school earlier in the week. He then told me what happened at the end of the school day. Her close girl friends were brought into the administrative office during the last period of school, 30 minutes later he and some other friends saw her friends leave the office crying hysterically and yelling “she’s dead”. His friend was not in school that day and no one had heard from her. My son’s face was a picture of disbelief, sadness and anger. My first thought was, is this true?
The loss of a young bright life is tragic, you wouldn’t think it could get worse, but it did. That day the news channels and the internet exploded with the reality of the event, a double homicide. As the hours passed and one day lead into another more information was released to the public and formal announcements were made at school confirming his friend’s death. Sharp force trauma, the cause of death, was stated by the coroner and reported in the local news, to both his friend and her mother. A suspect was identified a few days later and shortly after identification was taken into police custody, his friend’s former boyfriend. Forthcoming were more details from the authorities and with more details my son became retreated in his conversations with me.
My son did not talk as openly about how he was feeling or what he has encountered at school. I watched the news to try to keep up on the information stream he was experiencing. The local news reported on how a Go Fund Me account was active to assist in the funeral expenses with additional proceeds to be donated to a local charity for survivors of domestic and intimate partner abuse. I asked my son about attending the funeral. He planned to go alone, we disagreed about this plan, and he grew angry with me. He’s never been to a funeral, I expressed my “mom” concerns and eventually he agreed. September 23, 2023, I took my teenage son to his first funeral, a family funeral for a friend and her mother.
At the funeral, I gave my son space and was just present for him if he needed me. I cried as the sadness was just overpowering. The music playing in the background was slow and deliberate for the loss of 2 young lives. Summertime sadness and tears in heaven replayed on a loop. I watched my son and his friends interact and my heart broke for them. Some of his friends were tearful and sad, others were stoic with unemotional faces, others seem to be coping with conversation and socializing. I asked my son how are you doing? He replied consistently, unemotional “I’m fine” and “I can’t do anything about it anyway”. The lack of expressed feelings crushed me emotionally as I am thinking is he depressed, is he ok, does he need more than I can give?
Sitting at a funeral allows you to think and be introspective. Who is there to address the mental wellness for these teenagers, not yet adults and not truly children? What resources do the schools provide? Who was there for his deceased friend? My son was able to look past his normalcy of superficial conversation to talk to me initially and now he seems to be closing off. What resources do today’s teenagers and children have aside from each other in shared grief?
These questions all have answers, but the answers are not uniform or consistent and vary from school district to state to nationally. The mental health of everyone but more strikingly of teenagers has been impacted by the pandemic, by the regular exposure to violent events and by the stressors associated with everyday life. As adults it can be difficult to navigate the mental health system, as a teenager it is likely more confusing. Now consider a different perspective, do you as an emergency physician know how to traverse the complexity of the mental health system for adolescents? Do you know their rights? Do you know the resources and legislation?
In short, the system is daunting and complex. Federal policies have been revised and newly accepted that apply to childhood and adolescent mental health include the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA), the Patient Protection and Affordable Care Act of 2010 (ACA), the 21st Century Cures Act of 2016 (Cures Act), and the Supporting Children’s Mental Health Act of 2021 (SCMHA). On a state level, since the onset of the pandemic, 38 states have enacted nearly 100 laws focused on supporting schools in their role as one of the primary access points for pediatric behavioral health care. Consent for treatment has also been evolving as more adolescents are seeking mental health support independently. Maryland, California, and Illinois allow adolescents to consent for mental health treatment at age 12 independently. Not all states have the same provisions, to date, 18 states still require a person to be 18 years of age to consent to mental health treatment or have no law giving a right to consent to minors seeking mental health services.
Unfortunately, we as a community of parents, family, physicians and healthcare providers are encountering tragic and violent events like my son and his classmates have experienced. As a parent we want to be that person who knows it all and can help our child, as a physician we need to know how to help all the children. There are some resources in the column on the right to assist you in knowing your state’s mental health laws.
RESOURCES:
When Your Child, Teenager, or Adult Son or Daughter has a Mental Illness or Substance Use Disorder, Including Opioid Addiction: What Parents Need to Know about HIPAA. US Department of Health and Human Services Website. https://www.hhs.gov/sites/default/files/when-your-child.pdf . Published January 2018. Accesses September 30, 2023.
Improving Access to Children’s Mental Health Care. Center for Disease Control and Prevention Website. https://www.cdc.gov/childrensmentalhealth/access.html . Last reviewed March 8, 2023. Accessed September 30, 2023.
Rates of Mental and Behavioral Health Service Providers by County, 2015. Center for Disease Control and Prevention Website. https://www.cdc.gov/childrensmentalhealth/stateprofiles-providers.html . Last reviewed March 8, 2023. Accessed September 30, 2023.
Randi O, Gould Z, States Take Action to Address Children’s Mental Health in Schools. National Academy for State Health Policy Website. https://nashp.org/states-take-action-to-address-childrens-mental-health-in-schools/ . Published February 14, 2022. Accessed September 30, 2023.
Marianne Sharko, Rachael Jameson, Jessica S. Ancker, Lisa Krams, Emily C. Webber, S. Trent Rosenbloom; State-by-State Variability in Adolescent Privacy Laws. Pediatrics June 2022; 149 (6): e2021053458. 10.1542/peds.2021-053458https://publications.aap.org/pediatrics/article/149/6/e2021053458/187003/State-by-State-Variability-in-Adolescent-Privacy?autologincheck=redirected
Sharko article table 1: State-by-State Policies on the Ability for Minors to Consent for Medical Services https://publications.aap.org/view-large/9694715?autologincheck=redirected