Trends in referrals to psychosocial services in a pediatric emergency department before and after the onset of the COVID-19 pandemic.

Trends in referrals to psychosocial services in a pediatric emergency department before and after the onset of the COVID-19 pandemic - PMC Skip to main content An official website of the United States government Here's how you know Here's how you know Search Log in Primary site navigation Search Log in Search PMC Full-Text Archive Search in PMC Journal List User Guide As a library, NLM provides access to scientific literature. Inclusion in an NLM database does not imply endorsement of, or agreement with, the contents by NLM or the National Institutes of Health. Learn more: PMC Disclaimer | PMC Copyright Notice Soc Work Health Care . Author manuscript; available in PMC: 2026 Jun 6. Published in final edited form as: Soc Work Health Care. 2026 Apr 8;65(6-7):293–307. doi: 10.1080/00981389.2026.2648200 Trends in referrals to psychosocial services in a pediatric emergency department before and after the onset of the COVID-19 pandemic Mihoko Maru 1, 3, * , Elizabeth R Boskey 1, 2, * , Christina S Lee 3 , Melissa Deane 1 , Pamela Chamorro 1 , Thomas Byrne 3 , Elizabeth Holleran 5 , Mary Elizabeth Collins 3 , Sara M A Donahue 4 , Hiu-fai Fong 5, 6 Author information Article notes Copyright and License information 1 Department of Social Work, Boston Children’s Hospital 2 Division of Gynecology, Department of Surgery, Boston Children’s Hospital 3 Center for Innovation in Social Work & Health, Boston University School of Social Work 4 Department of Accountable Care and Clinical Integration, Boston Children’s Hospital 5 Child Protection Program, Department of Pediatrics and Department of Social Work, Boston Children’s Hospital 6 Department of Pediatrics, Harvard Medical School * Mihoko Maru and Elizabeth Boskey contributed equally to this work. Author Note Mihoko Maru, 2430 Campus Road, Honolulu, HI 96822 Elizabeth R. Boskey, 300 Longwood Ave, Boston, MA 02115 Christina S. Lee, 264 Bay State Road, Boston, MA 02215 Melissa Deane, 300 Longwood Ave, Boston, MA 02115 Pamela Chamorro, 300 Longwood Ave, Boston, MA 02115 Thomas Byrne, 140 Commonwealth Ave, Chestnut Hill, MA 02467 Elizabeth Holleran, 300 Longwood Ave, Boston, MA 02115 Mary Elizabeth Collins, 264 Bay State Road, Boston, MA 02215 Sara M. A. Donahue, 300 Longwood Ave, Boston, MA 02115 Hiu-fai Fong, 300 Longwood Ave, Boston, MA 02115 Mihoko Maru is now at the Thompson School of Social Work & Public Health, University of Hawai’i at Mānoa. Thomas Byrne is now at the Boston College School of Social Work. Elizabeth Holleran is now retired from the Department of Social Work at Boston Children’s Hospital. ✉ Correspondence concerning this article should be addressed to Hiu-fai Fong, 300 Longwood Ave, Boston, MA 02115, hiu-fai.fong@childrens.harvard.edu Issue date 2026. PMC Copyright notice PMCID: PMC13238946  NIHMSID: NIHMS2164669  PMID: 41952442 The publisher's version of this article is available at Soc Work Health Care Abstract The COVID-19 pandemic upended healthcare in the United States, profoundly impacting the mental and physical health of children and adolescents. This study examined how referrals to psychosocial services in a freestanding children’s hospital emergency department changed during the initial COVID-19 state of emergency period in Massachusetts when compared to a previous period of similar length. While the total number of emergency department encounters decreased during the COVID-19 period, there were significant increases in rates of referrals for social work support across general, psychiatric, and child protection needs. Social workers played a critical role addressing children’s needs during the COVID-19 crisis. Keywords: COVID-19, psychosocial, pediatric emergency department Introduction Social workers are uniquely important in health care services generally, and in hospital-based care particularly, due to their role in addressing problems related to social determinants of health ( Vohra-Gupta et al., 2025 ). A recent scoping review on the role of hospital social workers ( Petruzzi et al., 2023 ) highlighted their work in areas such as case management, behavioral health, care coordination, and transitional care. Social workers also have expertise in mental health, family dynamics, and social factors impacting hospital care ( Andrews et al., 2013 ). They are trained to navigate complex health care systems and conduct comprehensive assessments, which can facilitate effective referrals and utilization of hospital and community resources. Social workers may be particularly valuable in emergency departments (EDs), which often serve as a medical and mental health care safety net for persons who are uninsured or lack consistent access to health care ( Moe et al., 2017 ). Social workers fill multiple roles within the ED, including: investigator, gatekeeper, resource broker, care coordinator, problem solver, crisis manager, advocate, and discharge planner ( Moore et al., 2017 ). They are often the first mental health providers to work with individuals who arrive in the ED actively in mental health crisis (e.g., endorsing suicidal ideation or other mental health concerns) and provide assessments, interventions, or referrals to higher level care. They also frequently serve as the connection between the hospital care team and public agencies – e.g., taking primary responsibility for referrals to state child protection services and assessment of patients in acute need of psychiatric care, including an involuntary commitment. The essential role that social workers play in health care settings is only enhanced or increased in times of crisis. Social workers are often at the forefront in addressing human needs brought on by a range of disasters. There is ample evidence from the early days of the COVID-19 pandemic, as well as from various natural or man-made disasters, of the roles that social workers have taken on ranging from providing psychological first-aid in response to acute stress and grief to coordinating services such as the tracking of the missing and dead ( Kamrujjaman et al., 2023 ; Pockett 2006 ; Ross et al., 2021 ; Schneider et al., 2022 ). Emergency Social Work and the COVID-19 Pandemic The COVID-19 pandemic had extraordinary impacts on the social, economic, and health status of individuals across the globe, causing illness, death, and suffering, and increasing rates of anxiety, depression, and suicide risk ( Kim et al., 2024 ; Witteveen et al., 2023 ). Studies also report increases in health-related social needs, including housing, food, and safety, after the onset of COVID-19, particularly among low-income and other disenfranchised populations ( Benfer et al., 2021 ). When lockdowns and distancing brought a halt to many aspects of modern life, EDs served as a vital lifeline to physical and mental health care. During COVID-19 emergency periods across the United States, EDs often served as the sole access point for individuals to address their social and medical needs, particularly for disenfranchised populations ( Anderson et al. 2023 ; Cutler et al, 2022 ). At the same time, the COVID-19 pandemic heightened the risk that children and families would be exposed to psychosocial challenges (e.g., housing insecurity), require psychiatry support (e.g., suicidal ideation), or have child protection needs (e.g., suspected child abuse and neglect) ( Coughlin et al., 2020 ; Hill et al., 2021 ; Rebbe et al., 2023 ). In the United States, a few studies have explored the role that social workers played during the COVID-19 pandemic in health care settings ( Dennelly, et al., 2021 ; Paul, et al., 2020 ). However, an empirical study measuring the role of social work in a pediatric hospital during the pandemic has not been conducted. There is a need for more data on utilization of ED-based psychosocial services through the different phases of the COVID-19 pandemic. Understanding these patterns can help identify service gaps, inform resource allocation, and strengthen preparedness for future public health crises. Present Study The objective of this study was to examine temporal trends in referrals to psychosocial services in a freestanding children’s hospital ED around the time of the COVID-19 pandemic. First, we aimed to compare the volume, rate, and types of psychosocial referrals to three social work services (general, psychiatry, and child protection social work) for ED encounters before and after the onset of the COVID-19 pandemic. We hypothesized that the volume and rate of psychosocial referrals would increase after the onset of the pandemic, during the initial state of emergency period. Second, among ED encounters with a psychosocial referral, we aimed to compare the clinical acuity of encounters before and after the onset of the COVID-19 pandemic. We hypothesized that the clinical acuity of ED encounters with a psychosocial referral would increase after the onset of the pandemic. Materials and Methods We conducted a retrospective analysis of demographic and clinical data from ED encounters for children under 18 years old at a freestanding children’s hospital, comparing psychosocial referrals before and after the onset of the COVID-19 pandemic. The hospital ED is situated within a large, pediatric academic medical center and serves as a regional referral site for pediatric emergency care. Psychosocial referrals can be made during ED encounters to three social work services – general social work, psychiatry social work, and/or child protection social work. Time periods used for comparison of psychosocial referrals were defined as March 10, 2018 to June 15, 2019 (before the pandemic) and March 10, 2020 to June 15, 2021 (after the onset of the pandemic) respectively. The latter dates correspond to the official COVID-19 State of Emergency period in Massachusetts, where the ED was located. Time periods spanning equivalent months were chosen to minimize seasonal variation in our comparative analyses, as there is an established seasonal variance in ED utilization, particularly for pediatric EDs ( Christoffel, 1985 ). All data were abstracted from the hospital’s electronic medical records (EMR), except for data on referrals to child protection, which were abstracted from a separate child protection team database maintained in a secure instance of REDCap ( Harris et al., 2009 ). Demographic data included child date of birth, sex, race and ethnicity, and insurance type. Abstracted race and ethnicity data were based on child and/or parent report during the most recent encounter at the time of data abstraction on March 1, 2024. Clinical data abstracted from the EMR included the presence of notes for referrals to general and psychiatry social work, structured data present in those notes, and clinical acuity measures. Case-level entries for referrals to child protection social work were matched to ED encounters based on a combination of medical record number, referral and encounter dates, and referral source (i.e., ED). The primary clinical acuity measure for ED encounters at this hospital is the Emergency Severity Index (ESI; Gilboy et al., 2005 ). ESI scores were assigned by ED triage nurses at the time of triage based on perceived acuity of medical presentation and anticipated resources required for care. Scores range from 1 (most acute) to 5 (least acute). The ESI has been shown to be a valid and reliable measure in the pediatric ED setting ( Green et al., 2012 ). Data Analysis We generated descriptive statistics (means, standard deviations, and frequencies) and ran two-sample t -tests and chi -square tests to compare demographic characteristics our study sample before and after the onset of the COVID-19 pandemic. Age and insurance type for these analyses were based on data from a child’s first ED encounter during the given time period. We then compared the volume, rate, and types of psychosocial referrals before and after the onset of the COVID-19 pandemic using chi -square tests. We examined three types of psychosocial referrals, including referrals to: 1) general social work, 2) psychiatry social work, and 3) child protection social work. These referral types were not mutually exclusive. We also examined the presence of any psychosocial referral, defined as a referral to at least one of the three social work services (general, psychiatry, and child protection social work). Given the non-mutually exclusive nature of these three specific referral types, we created the binary variable ‘Any psychosocial referral’ as our primary, encounter-level outcome measure to mitigate bias toward ED encounters with multiple referrals and to assess the overall change in utilization of social work services during the study period. Rate ratios (RR) were also calculated by dividing the rate of referrals after the onset of the pandemic by the rate before the pandemic. Referrals to general social work and psychiatry social work were defined by the presence of clinical notes time-stamped during or up to 24 hours after the ED encounter. We chose this time window to align with hospital standards for documentation. A referral to child protection social work was defined by the presence of a case-level entry in the child protection team database for the identified child on the same date as the ED encounter. Finally, we compared the clinical acuity (ESI) of ED encounters with a psychosocial referral before and after the onset of the COVID-19 pandemic, in total and stratified by type of psychosocial referral, using two-sample t -tests and chi -square tests. Statistical significance was assessed at α=0.05 for all analyses. The study was reviewed by the Boston Children’s Hospital Institutional Review Board and determined to be exempt research that met criteria for a waiver of informed consent (IRB-R00042772). Results Sample Characteristics The study sample included 48,087 children with 70,204 unique encounters before the COVID-19 pandemic and 33,724 children with 44,534 unique encounters during the pandemic. There were statistically significant differences in demographic characteristics between children who presented to the ED before and after the onset of the COVID-19 pandemic ( Table 1 ). During the state of emergency period, the proportion of female children increased slightly (46.7% vs. 47.4%, p =0.04). The proportion of non-Hispanic White children also increased, while the proportion of non-Hispanic Black, Hispanic, non-Hispanic Asian, and non-Hispanic Other race children declined ( p <0.0001). Across both time periods, approximately 8-9% of the children had missing data for race. Insurance types also differed between the two time periods. There was a significant decrease in the number of international children (partially due to the closure of the international care office) and children with no or unknown insurance, a slight decrease in children with public insurance, and a corresponding increase in children with private insurance ( p <0.001). Although there were statistically significant differences in characteristics of children who presented to the ED before and after the onset of the pandemic, most of these differences were small in magnitude and not necessarily clinically significant. Table 1. Demographic Characteristics of Children with an Emergency Department Encounter Before and After the Onset of the COVID-19 Pandemic Demographic Variable Before COVID-19 Pandemic (Children with an ED encounter=48,087) COVID-19 State of Emergency (Children with an ED encounter=33,724) n % n % χ 2 p Sex (Female) 22,437 46.7 15,976 47.4 4.05 0.0441 * Race and Ethnicity 297.89 <0.0001 *** White, non-Hispanic 18,700 38.9 14,647 43.4 Hispanic 11,247 23.4 7,381 21.9 Black, non-Hispanic 6,856 12.3 4,122 12.2 Other race, non-Hispanic 4,547 9.5 2,625 7.8 Asian, non-Hispanic 2,004 4.2 1,198 3.6 Unknown 3,893 8.1 3,138 9.3 Insurance 374.48 <0.001 ** Public 22,091 45.9 15,309 45.4 Private 24,554 51.1 18,066 53.6 International 957 2.0 234 0.7 Unknown 485 1.0 115 0.3 M SD M SD t p Age 6.7 5.5 7.2 5.6 −12.99 <0.001 ** Open in a new tab Note . ED=Emergency Department. Median age was 6 at both time periods. * p <0.05, ** p <0.001, *** p<0.0001 Volume, Rate, and Types of Psychosocial Referrals There was a total of n =70,204 ED encounters in the period before the COVID-19 pandemic. This number decreased to n =44,534 during the corresponding COVID-19 state of emergency period. While the total number of ED encounters decreased, the rate of psychosocial referrals significantly increased (RR=1.40, p <.001). Before the pandemic, 10.9% ( n =7,623) of all encounters included a psychosocial referral to one of three social work services (general, psychiatry, and child protection social work). During the state of emergency period, 15.2% ( n =6,779) of encounters included a psychosocial referral. The rates of referrals increased across all referral types – general social work (RR=1.31), psychiatry social work (RR=1.59), and child protection social work (RR=2.46), with the highest rate ratio increase seen for child protection social work referrals (all increases significant at p <0.001) ( Table 2 ). Table 2. Volume, Rate, and Types of Psychosocial Referrals for Emergency Department Encounters Before and After the Onset of the COVID-19 Pandemic Referral Type Before COVID-19 Pandemic (Total ED encounters=70,204) COVID-19 State of Emergency (Total ED encounters=44,534) n % n % χ 2 Rate Ratio Any Psychosocial Referral 7,623 10.9 6,779 15.2 472.71 1.40 * General SW 5,075 7.2 4,205 9.4 179.56 1.31 * Psychiatry SW 3,013 4.3 3,036 6.8 348.00 1.59 * Child Protection SW 195 0.3 304 0.7 103.15 2.46 * Open in a new tab Note . ED=Emergency Department, SW=Social Work; Psychosocial referral types included referrals to: 1) General SW, 2) Psychiatry SW, and 3) Child Protection SW. These referral types were not mutually exclusive. Any Psychosocial Referral was defined as a referral to at least one of the three social work services. * p <0.001 Clinical Acuity of ED Encounters with a Psychosocial Referral While the overall ESI scores for encounters with any psychosocial referral did not increase after the onset of the COVID-19 pandemic, they did change significantly for encounters involving psychiatry and child protection social work referrals. Clinical acuity for encounters with a psychiatry social work referral decreased slightly, as reflected by increased ESI scores during the state of emergency period ( M =2.22±0.47 vs. M =2.25±0.49, p <0.01). In contrast, clinical acuity for encounters with a child protection social work referral increased, as reflected by decreased ESI scores ( M =2.87±0.70 vs. M =2.70±0.76, p =0.02) ( Table 3 ). ESI scores of 2 represent high-risk, potentially life-threatening situations requiring emergent attention (e.g., head trauma), while ESI scores of 3 represent serious situations in need of urgent, timely care involving multiple resources (e.g., fractures) ( Gilboy et al., 2005 ). Table 3. Clinical Acuity of Emergency Department Encounters with a Psychosocial Referral Based on Emergency Severity Index Scores Before and After the Onset of the COVID-19 Pandemic Referral Type Before COVID-19 Pandemic COVID-19 State of Emergency n M SD n M SD t p Any Psychosocial Referral 7,595 2.49 0.75 6,755 2.48 0.73 0.91 0.3648 General SW 5,055 2.63 0.83 4,187 2.63 0.81 0.19 0.8497 Psychiatry SW 3,004 2.22 0.47 3,031 2.25 0.49 −2.46 0.0141 * Child Protection SW 193 2.87 0.70 301 2.70 0.76 2.42 0.0157 * Open in a new tab Note . ED=Emergency Department, SW=Social Work. Clinical acuity is based on Emergency Severity Index (ESI) scores, which are rated on a 5-point scale from 1 (most acute) to 5 (least acute). ESI scores (means and standard deviations) are presented for encounters with available ESI data and stratified by type of psychosocial referral. Psychosocial referral types include referrals to: 1) General SW, 2) Psychiatry SW, and 3) Child Protection SW. These referral types were not mutually exclusive. Any Psychosocial Referral was defined as a referral to at least one of the three social work services. * p <0.05 Discussion During the COVID-19 state of emergency, when school and business closures and social distancing restrictions were in place, there was a statistically significant increase in the rate of psychosocial referrals for children presenting to the ED of a freestanding children’s hospital. This increase in psychosocial referrals occurred in the context of an overall drop in the number of pediatric ED encounters, similar to research in adult hospitals ( Venkatesh et al., 2022 ), and spanned general, psychiatry, and child protection needs. Beyond the increased need for all types of social work support during the pandemic, there was also an increase in the clinical acuity of pediatric ED encounters with a child protection social work referral. These findings are consistent with the anecdotal experiences of social workers serving children and families during this crisis period, which was part of the genesis for this project. Child maltreatment received particular attention at this time due to COVID-19’s impact on school and daycare closures, the other lockdown effects which left families isolated, and the broad and deep stressors on family life. All of these factors threatened to increase the risk of child maltreatment and limit the ability of mandated reporters and other safeguards to prevent and protect children ( Katz et al., 2022 ; Katz et al., 2024 ). In a study focused on infants, Rebbe et al. (2023) found an increase in infant maltreatment medical encounters during a 21-month period following the onset of COVID-19. The increase in clinical acuity among ED encounters with child protection referrals occurred simultaneously with a modest decrease in the clinical acuity of encounters with a psychiatry social work referral. This may suggest that there was a shift towards emergency mental health services for care that may have been met through other types of outpatient and inpatient services during the pre-pandemic period ( Nicholas et al., 2025 ; Wical et al., 2022 ). However, it is notable that the average clinical acuity for ED encounters with any and each type of psychosocial referral remained well within the range requiring urgent to emergent attention ( Gilboy et al., 2005 ), underscoring the overall acuity of encounters for which these health care based social workers were involved. The decrease in overall ED volume in our study aligns with prior reports of decreased volume of 16% to 50% during the initial months of the pandemic ( Wieck et al., 2022 ). The increase in relative proportion of psychosocial need seen in ED encounters in this study is not unique to this hospital, or to pediatric hospitals in the United States. Concerns about increased mental health challenges caused or exacerbated by COVID-19 have also been reported in EDs internationally. A recent, international meta-analysis reported increases in youth presenting to the ED with attempted suicide, suicidal ideation, and self-harm ( Madigan et al., 2023 ). The minor yet statistically significant shifts in the race, ethnicity, and insurance type of children presenting to the ED during the COVID-19 pandemic may be due to worsening disparities in health care access or mistrust of health care systems among racial and ethnic minority populations. Some of the shifts in the insurance type of children during the pandemic may also be reflective of the loss of international patients due to lockdowns and travel bans. Historically, race, ethnicity, and insurance type have been used as proxies for socioeconomic status and thus would be expected to co-vary ( Makkad et al., 2025 ; Wang et al., 2024 ). For many patients and their families during the COVID-19 pandemic, the physical and emotional strain of the disease and the psychological impact of isolation compounded already heightened psychosocial stress. For example, economically strained families accessing weekly specialized care for their child with medical complexity experienced new and exhausting challenges of navigating safe transportation, infection transmission risk of the waiting room, and amended policies limiting visitors including siblings at the bedside ( Driansky et al., 2022 ; Mitchell, 2021 ). Already strained by complex relationship dynamics—including various forms of intimate partner violence-many families found themselves with little to no relief as schools, daycares, and workplaces shut down or shifted to remote operations ( Letourneau et al., 2022 ; Prime et al., 2020 ; Rahman et al., 2022 ). At the same time, social distancing measures limited support from extended family, friends, and faith communities. In this context, social workers were increasingly called upon-not only to assist families in managing the concrete stressors of daily life, but also to provide emotional presence amid overwhelming fear, sadness, and anger ( Nicholas et al., 2023 ; Plunkett et al., 2021 ). Medical providers in the pandemic were also more attuned to the psychosocial issues that their patients were facing and had a renewed desire to collaborate and reach out for support and not do this work alone. These factors may all contribute to the higher rates of psychosocial referrals seen during the pandemic. In the United States, social workers are the primary resource for meeting psychosocial needs in EDs for a number of reasons, including the broad scope of their training and its focus on person-in-environment and social determinants of health ( de Saxe Zerden et al., 2016 ; Moore et al., 2017 ; Steketee et al., 2017 ). In recent years, there has been a growing recognition of the value of including social workers in ED roles ( Auerbach & Mason, 2010 ; Moore et al., 2017 ; Rehman et al., 2022 ). However, social work in the ED setting often requires additional training and experience which should be a strong consideration in responsive scaling of staffing to support volume in both the acute and chronic phases of a disaster ( Beltran et al., 2023 ). The pandemic underscored the urgent need for more farsighted and proactive disaster response policies across systems. It is essential that social work be included in the development of these policies, given the profession’s critical role not only in immediate disaster response, but also in postvention care for both families and staff. During the pandemic, many staffing shortages were addressed through costly temporary solutions such as hiring travel nurses or contracting with third-party agencies to bring in traveler social workers ( Ziemann et al., 2023 ). These measures, while necessary in the moment, revealed a lack of long-term planning. Moving forward, staffing needs of this nature can and should be anticipated and integrated into future emergency preparedness strategies. While the initial response to the pandemic often involved siloed decision-making and fragmented strategies, those instincts quickly gave way to more open communication across communities. Grassroots mutual aid networks emerged organically, fostering collaboration and shared resource distribution ( Roy et al., 2023 ). In response, community resource mapping efforts were initiated-valuable tools that should continue to be supported and expanded. Maintaining these efforts ensures that state and local officials, as well as other key stakeholders, have a clear understanding of both the resources available and the critical gaps that must be addressed in future crisis planning ( Fernandes-Jesus et al., 2021 ; Kenworthy et al., 2023 ). Social workers can be useful liaisons between hospitals and community organizations, often taking on leadership roles in both settings. While the acute phase of the COVID-19 pandemic has subsided, there remains an ongoing mental health crisis in the United States. Furthermore, catastrophic climate events and other public health disasters may only increase in frequency in the coming years, and systems need to be put in place to manage the increase in psychosocial need likely to occur as a result ( Reichelt et al., 2025 ). One of the most important lessons of the COVID-19 pandemic was the need for alternate systems of support when the primary social safety net becomes unavailable. The strengths of this research include its setting in a large, pediatric academic medical center that serves as a regional resource for care, extensive data on resource utilization, and the use of a control period designed to adjust for seasonal variations in need. Limitations include its retrospective design and its reliance on documentation practices to determine types of referrals. The study data are also limited in their generalizability – particularly to states where there was not an extended emergency period in the early pandemic. Furthermore, ESI scores may be limited as a measure of clinical acuity, as they are determined early in an ED encounter (at the point of triage). We also did not conduct analyses to examine psychosocial referral patterns by race, ethnicity, or insurance type before and after the onset of the COVID-19 pandemic. Future analyses could address possible confounding by demographic factors through employing multivariable adjustment or stratified analyses. Interrupted time series analyses could provide a more fine-grained examination of patterns of change throughout the different phases of the pandemic. In addition, mixed-effects models or generalized estimating equations could be used to address issues resulting from children having multiple encounters within a period as well as allowing for inclusion of potentially important contextual variables, such as community-level stressors. Further studies using methods like latent class analysis may also help us understand the sociodemographic factors that influence ED visits during public health crises. Our future research goals include an extensive cost-benefit analysis of emergency social work services during the COVID-19 emergency period and in the following years, with a particular focus on unaddressed psychiatric need in the pediatric population. There is also a need for longitudinal studies to assess long-term trends post-disaster and to explore the effectiveness of specific social work interventions deployed during the pandemic and in other disaster settings. Furthermore, qualitative and mixed-methods studies that include a detailed review of clinical notes or direct exploration of social workers’ perceptions would be particularly useful for understanding how social workers assess risk and need, and for identifying facilitators and barriers to service expansion in times of crisis. . Conclusions This study investigated the utilization of ED-based social work services in a large, freestanding children’s hospital by comparing patterns of psychosocial referrals and clinical acuity for ED encounters before and after the onset of the COVID-19 pandemic. Despite an overall decrease in the volume of encounters seen in the ED, there was a significant increase in the need for psychosocial support – including general, psychiatry, and child protection social work services. During the COVID-19 state of emergency, the clinical acuity of ED encounters involving child protection referrals increased. Social workers in the ED assumed a critical role during this crisis, and there is an ongoing need to consider how to appropriately scale up their services during future emergency periods. Preparedness and responsiveness were key to supporting the needs of children and families during the early phase of the COVID-19 pandemic. Hospitals may want to consider cross-training other social workers in emergency protocols to respond to future emergency needs. Acknowledgements We gratefully acknowledge Allison Scobie-Caroll for initiating our inter-institutional collaboration and Tami Gouveia and Aaron Grey for providing continued support. We thank Endy Imam for help with data abstraction, Asha Kiirikki and Jennifer Cummings for input on psychiatry data; and Daniel Miller for input on study design and data management. Funding Statement This research did not receive any specific grant. Mihoko Maru was supported by the Center for Innovation in Social Work & Health at Boston University School of Social Work and the Department of Social Work at Boston Children’s Hospital. Hiu-fai Fong is supported in part by the National Institutes of Health (K23MD016171). The content is solely the responsibility of the authors and does not necessarily represent the official views of Boston University School of Social Work, Boston Children’s Hospital, or the National Institutes of Health. Footnotes Declaration of Interest Statement The authors report there are no competing interests to declare. Data Availability Statement The data that support the findings of this study were derived from hospital records and databases and contain limited identifiers and restricted information. Due to institutional and legal privacy restrictions, these data are not publicly available. Researchers may request data access from Boston Children’s Hospital’s Clinical Trials Business Office, subject to institutional approvals and a data use agreement. References Anderson KN, Johns D, Holland KM, Chen Y, Vivolo-Kantor AM, Trinh E, Bitsko RH, Leeb RT, Radhakrishnan L, Bacon S, & Jones CM (2023). Emergency department visits involving mental health conditions, suicide-related behaviors, and drug overdoses among adolescents - United States, January 2019-February 2023. MMWR Morbidity and Mortality Weekly Report, 72(19), 502–512. 10.15585/mmwr.mm7219a1 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Andrews CM, Darnell JS, McBride TD, & Gehlert S (2013). Social work and implementation of the Affordable Care Act. Health & social work, 38(2), 67–71. 10.1093/hsw/hlt002 [ DOI ] [ PubMed ] [ Google Scholar ] Auerbach C, & Mason SE (2010). The Value of the Presence of Social Work in Emergency Departments. Social Work in Health Care, 49(4), 314–326. 10.1080/00981380903426772 [ DOI ] [ PubMed ] [ Google Scholar ] Beltran S, Yalim A, Morris A, & Taylor L (2023). Emerging social workers during COVID-19: Exploring perceived readiness and training needs. Journal of social work (London, England), 23(3), 428–442. 10.1177/14680173231162490 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Benfer EA, Vlahov D, Long MY, Walker-Wells E, Pottenger JL Jr, Gonsalves G, & Keene DE (2021). Eviction, Health Inequity, and the Spread of COVID-19: Housing Policy as a Primary Pandemic Mitigation Strategy. Journal of urban health, 98(1), 1–12. 10.1007/s11524-020-00502-1 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Christoffel KK (1985). Effect of season and weather on pediatric emergency department use. The American Journal of Emergency Medicine, 3(4), 327–330. 10.1016/0735-6757(85)90058-0 [ DOI ] [ PubMed ] [ Google Scholar ] Coughlin CG, Sandel M, & Stewart AM (2020). Homelessness, Children, and COVID-19: A Looming Crisis. Pediatrics, 146(2), e20201408. 10.1542/peds.2020-1408 [ DOI ] [ PubMed ] [ Google Scholar ] Cutler GJ, Bergmann KR, Doupnik SK, Hoffmann JA, Neuman MI, Rodean J, Zagel AL, & Zima BT (2022). Pediatric mental health emergency department visits and access to inpatient care: A crisis worsened by the COVID-19 pandemic. Academic Pediatrics, 22(6), 889–891. 10.1016/j.acap.2022.03.015 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Dennelly L, Sousa C, & Roberts K (2021). Shaping the Future of Social Work Practice in Healthcare: Addressing COVID-19 Needs through Integrated Primary Care. Social work, 67(1), 41–47. 10.1093/sw/swab046 [ DOI ] [ PubMed ] [ Google Scholar ] de Saxe Zerden L, Jones A, Lanier P, & Fraser MW (2016). Social Workers: Continuing to Address the Social Determinants of Health. American Journal of Public Health, 106(6), e15. 10.2105/AJPH.2016.303147 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Driansky A, Pilapil M, & Mastrogiannis A (2022). Updating the healthcare maintenance visit for children with medical complexity: applying lessons learned from the coronavirus disease 2019 pandemic. Current opinion in pediatrics, 34(2), 248–254. 10.1097/MOP.0000000000001116 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Fernandes-Jesus M, Mao G, Ntontis E, Cocking C, McTague M, Schwarz A, Semlyen J, & Drury J (2021). More Than a COVID-19 Response: Sustaining Mutual Aid Groups During and Beyond the Pandemic. Frontiers in psychology, 12, 716202. 10.3389/fpsyg.2021.716202 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Gilboy N, Tanabe P, Travers D, Rosenau AM, & Eitel DR (2005). Emergency Severity Index, version 4: Implementation handbook (AHRQ Publication No. 05-0046-2). Agency for Healthcare Research and Quality. [ Google Scholar ] Green NA, Durani Y, Brecher D, DePiero A, Loiselle J, & Attia M (2012). Emergency Severity Index version 4: a valid and reliable tool in pediatric emergency department triage. Pediatric emergency care, 28(8), 753–757. 10.1097/PEC.0b013e3182621813 [ DOI ] [ PubMed ] [ Google Scholar ] Harris PA, Taylor R, Thielke R, Payne J, Gonzalez N, & Conde JG (2009). Research electronic data capture (REDCap)—A metadata-driven methodology and workflow process for providing translational research informatics support. Journal of Biomedical Informatics, 42(2), 377–381. 10.1016/j.jbi.2008.08.010 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Hill RM, Rufino K, Kurian S, Saxena J, Saxena K, & Williams L (2021). Suicide Ideation and Attempts in a Pediatric Emergency Department Before and During COVID-19. Pediatrics, 147(3), e2020029280. 10.1542/peds.2020-029280 [ DOI ] [ PubMed ] [ Google Scholar ] Kamrujjaman MD, Demetriou C, Cuartas Álvarez T, & Castro Delgado R (2023). The Role of Social Work for Emergency Medical Services (EMS): A Systematic Review. Prehospital and Disaster Medicine, 38(5), 628–635. 10.1017/S1049023X23006143 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Katz C, Cohen N, Attrash-Najjar A, Glucklich T, Jacobson M, Varela N, Priolo-Filho SR, Chang OD, Haffejee S, Kaawa-Mafigiri D, Katz I, Maguire-Jack K, Massarweh N, Tarabulsy GM, Levine DT, & Wekerle C (2024). The remote work of child protection professionals during COVID-19: A scoping review and thematic analysis. Child abuse & neglect, 106759. 10.1016/j.chiabu.2024.106759 [ DOI ] [ PubMed ] [ Google Scholar ] Katz I, Priolo-Filho S, Katz C, Andresen S, Bérubé A, Cohen N, Connell CM, Collin-Vézina D, Fallon B, Fouche A, Fujiwara T, Haffejee S, Korbin JE, Maguire-Jack K, Massarweh N, Munoz P, Tarabulsy GM, Tiwari A, Truter E, … Yamaoka Y (2022). One year into COVID-19: What have we learned about child maltreatment reports and child protective service responses? Child Abuse & Neglect, 130, 105473. 10.1016/j.chiabu.2021.105473 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Kenworthy N, Hops E, & Hagopian A (2023). Mutual Aid Praxis Aligns Principles and Practice in Grassroots COVID-19 Responses Across the US. Kennedy Institute of Ethics Journal 33(2), 115–144. 10.1353/ken.2023.a904080. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Kim S, Hwang J, Lee JH, Park J, Kim HJ, Son Y, Oh H, Smith L, Kang J, Fond G, Boyer L, Rahmati M, Tully MA, Pizzol D, Udeh R, Lee J, Lee H, Lee S, & Yon DK (2024). Psychosocial alterations during the COVID-19 pandemic and the global burden of anxiety and major depressive disorders in adolescents, 1990-2021: challenges in mental health amid socioeconomic disparities. World journal of pediatrics: WJP, 20(10), 1003–1016. 10.1007/s12519-024-00837-8 [ DOI ] [ PubMed ] [ Google Scholar ] Letourneau N, Luis MA, Kurbatfinski S, Ferrara HJ, Pohl C, Marabotti F, & Hayden KA (2022). COVID-19 and family violence: A rapid review of literature published up to 1 year after the pandemic declaration. EClinicalMedicine, 53, 101634. 10.1016/j.eclinm.2022.101634 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Madigan S, Korczak DJ, Vaillancourt T, Racine N, Hopkins WG, Pador P, Hewitt JMA, AlMousawi B, McDonald S, & Neville RD (2023). Comparison of paediatric emergency department visits for attempted suicide, self-harm, and suicidal ideation before and during the COVID-19 pandemic: a systematic review and meta-analysis. The lancet. Psychiatry, 10(5), 342–351. 10.1016/S2215-0366(23)00036-6 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Makkad H, Saini A, Manning ER, Duan Q, Colegate S, & Brokamp C (2025). Racial Fairness of Individual- and Community-Level Proxies of Socioeconomic Status Among Birthing Parent-Child Dyads. Journal of racial and ethnic health disparities, 12(4), 2293–2298. 10.1007/s40615-024-02050-9 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Mitchell SM (2021) True Resilience: A Look Inside COVID’s Effect on Children with Medical Complexity and Their Families. Curr Pediatr Rep 9, 171–177. 10.1007/s40124-021-00254-9 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Moe J, Kirkland SW, Rawe E, Ospina MB, Vandermeer B, Campbell S, & Rowe BH (2017). Effectiveness of interventions to decrease emergency department visits by adult frequent users: A systematic review. Academic Emergency Medicine, 24(1), 40–52. doi: 10.1111/acem.13060 [ DOI ] [ PubMed ] [ Google Scholar ] Moore M, Cristofalo M, Dotolo D, Torres N, Lahdya A, Ho L, Vogel M, Forrester M, Conley B, & Fouts S (2017). When high pressure, system constraints, and a social justice mission collide: A socio-structural analysis of emergency department social work services. Social Science & Medicine, 178, 104–114. 10.1016/j.socscimed.2017.02.014 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Nicholas DB, Samson P, Hilsen L, & McFarlane J (2023). Examining the COVID-19 pandemic and its impact on social work in health care. Journal of Social Work, 23(2), 334–349. 10.1177/14680173221142767 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Nicholas DB, Zulla RT, Cielsielski J, Zwaigenbaum L, & Conlon O (2025). COVID-19 Pandemic Experiences of Families in Which a Child/Youth Has Autism and Their Service Providers: Perspectives and Lessons Learned. Journal of Autism and Developmental Disorders, 55(8), 2706–2717. 10.1007/s10803-024-06402-6. [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Paul TJ, de Bruin M, & Taylor TA (2020). Recasting social workers as frontline in a socially accountable COVID-19 response. International Social Work, 63(6), 786–789. 10.1177/0020872820949623 [ DOI ] [ Google Scholar ] Petruzzi L, Ewald B, Covington E, Rosenberg W, Golden R, & Jones B (2023). Exploring the efficacy of social work interventions in hospital settings: A scoping review. Social Work in Public Health, 38, 2, 147–160, DOI: 10.1080/19371918.2022.2104415 [ DOI ] [ PubMed ] [ Google Scholar ] Plunkett E, Broadbent A, Fien S, & Cardona M (2021). Impact of COVID-19 social distancing on the quality of dying: A call for discretionary application of rules. Journal of Social Work in End-of-Life & Palliative Care, 17(2-3), 132–136. 10.1080/15524256.2021.191592 [ DOI ] [ PubMed ] [ Google Scholar ] Pockett R (2006). Learning from each other: The social work role as an integrated part of the hospital disaster response. Social Work in Health Care, 43(2-3), 131–149. 10.1300/J010v43n02_09 [ DOI ] [ PubMed ] [ Google Scholar ] Prime H, Wade M, & Browne DT (2020). Risk and resilience in family well-being during the COVID-19 pandemic. The American psychologist, 75(5), 631–643. 10.1037/amp0000660 [ DOI ] [ PubMed ] [ Google Scholar ] Rahman R, Huysman C, Ross AM, & Boskey ER (2022). Intimate Partner Violence and the COVID-19 Pandemic. Pediatrics, 149(6), e2021055792. 10.1542/peds.2021-055792 [ DOI ] [ PubMed ] [ Google Scholar ] Rebbe R, Reddy J, Kuelbs CL, Huang JS, & Putnam-Hornstein E (2023). The Impact of COVID-19 on Infant Maltreatment Emergency Department and Inpatient Medical Encounters. The Journal of pediatrics, 262, 113582. 10.1016/j.jpeds.2023.113582 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Rehman T, Pidgeon H, Chimileski B, Parker S, & Hsieh D (2022). Scoping Review: Medical Education Interventions Optimizing Social Workers in the Emergency Department. The western journal of emergency medicine, 24(2), 201–205. 10.5811/westjem.2022.10.55693 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Reichelt P, Schumacher A, Meyer N, & Zenclussen A (2025). Climate Change and Child Health: The Growing Burden of Climate-related Adverse Health Outcomes. Environmental research, 122502. Advance online publication. 10.1016/j.envres.2025.122502 [ DOI ] [ PubMed ] [ Google Scholar ] Ross AM, Schneider S, Muneton-Castano YF, Caldas AA, & Boskey ER (2021). “You never stop being a social worker:” Experiences of pediatric hospital social workers during the acute phase of the COVID-19 pandemic. Social Work in Health Care, 60(1), 8–29. 10.1080/00981389.2021.1885565 [ DOI ] [ PubMed ] [ Google Scholar ] Roy MJ, Bynner C, & Teasdale S (2023). The Third Sector and COVID-19: A Rapid Realist Evidence Synthesis of Third Sector Responses to the COVID-19 Pandemic. https://www.gcu.ac.uk/__data/assets/pdf_file/0019/150733/Report_The_Third_Sector_and_Covid_19_21277.pdf [ Google Scholar ] Schneider SE, Ross AM, & Boskey ER (2022). ‘We are essential:’ Pediatric health care social workers’ perspectives on being designated essential workers during the COVID-19 pandemic. Social Work in Health Care, 61(1), 36–51. 10.1080/00981389.2022.2028696 [ DOI ] [ PubMed ] [ Google Scholar ] Steketee G, Ross AM, & Wachman MK (2017). Health Outcomes and Costs of Social Work Services: A Systematic Review. American Journal of Public Health, 107(S3), S256–S266. 10.2105/AJPH.2017.304004 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Venkatesh AK, Janke AT, Kinsman J, Rothenberg C, Goyal P, Malicki C, D’Onofrio G, Taylor A, & Hawk K (2022). Emergency department utilization for substance use disorders and mental health conditions during COVID-19. PLOS ONE, 17(1), e0262136. 10.1371/journal.pone.0262136 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Vohra-Gupta S, Petruzzi L, Cherian A, Chow C, Unzueta M, & Joachimi R (2025). A narrative review on shifting practice and policy around social determinants of health (SDOH) screenings: Expanding the role of social workers in healthcare settings in the US. Healthcare 13(10), 1097; 10.3390/healthcare13101097 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Wang P, Zhu Y, Jin Z, & Deng W (2024). Medical mistrust in racial minorities during the COVID-19 pandemic: Attitudes, actions and mental health outcomes. PLOS Global Public Health, 4(12), e0003871. 10.1371/journal.pgph.0003871 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Wical W, Harfouche M, Lovelady N, Aguilar N, Ross D, & Richardson JB (2022). Exploring emergent barriers to hospital-based violence intervention programming during the COVID-19 pandemic. Preventive Medicine, 165(Pt A), 107232. 10.1016/j.ypmed.2022.107232 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Wieck MM, Silva T, & Kohler JE (2022). Changing Patterns of Pediatric Trauma During the COVID-19 Pandemic. Pediatric annals, 51(7), e286–e290. 10.3928/19382359-20220504-07 [ DOI ] [ PubMed ] [ Google Scholar ] Witteveen AB, Young SY, Cuijpers P, Ayuso-Mateos JL, Barbui C, Bertolini F, Cabello M, Cadorin C, Downes N, Franzoi D, Gasior M, Gray B, Melchior M, van Ommeren M, Palantza C, Purgato M, van der Waerden J, Wang S, & Sijbrandij M (2023). COVID-19 and common mental health symptoms in the early phase of the pandemic: An umbrella review of the evidence. PLoS medicine, 20(4), e1004206. 10.1371/journal.pmed.1004206 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Ziemann M, Strasser J, Krips M, Yang YT, & Pittman P (2023). How Governor Directives Changed Health Workforce Flexibility in Response to the COVID-19 Pandemic. Public health reports (Washington, D.C.: 1974), 138(1_suppl), 78S–89S. 10.1177/00333549221132534 [ DOI ] [ PMC free article ] [ PubMed ] [ Google Scholar ] Associated Data This section collects any data citations, data availability statements, or supplementary materials included in this article. Data Availability Statement The data that support the findings of this study were derived from hospital records and databases and contain limited identifiers and restricted information. Due to institutional and legal privacy restrictions, these data are not publicly available. Researchers may request data access from Boston Children’s Hospital’s Clinical Trials Business Office, subject to institutional approvals and a data use agreement. ACTIONS View on publisher site PDF (348.8 KB) Cite Collections Permalink RESOURCES Similar articles Cited by other articles Links to NCBI Databases Follow NCBI NCBI on X (formerly known as Twitter) NCBI on Facebook NCBI on LinkedIn NCBI on GitHub NCBI RSS feed Connect with NLM NLM on X (formerly known as Twitter) NLM on Facebook NLM on YouTube National Library of Medicine 8600 Rockville Pike Bethesda, MD 20894 Web Policies FOIA HHS Vulnerability Disclosure Help Accessibility Careers NLM NIH HHS USA.gov Back to Top

Related documents

• A Psychoeducational Intervention to Prevent the Psychological Impact of COVID-19 Pandemic in Primary Care Workers#918476
• Screening, Brief Intervention, and Referral to Treatment in Primary Care#141194
• Challenges, Coping, and Meaning-Making of Registered Guidance Counselors Toward a Proposed Support Program#452067
• Linking COVID‐19 Stressors to Early Communication Skills in Pandemic‐Born Children.#615695
• Stepping outside the clinic walls: health professionals' encounters with place during the COVID-19 pandemic.#157195