The Child and Adolescent Psychiatric Emergency: A Public Health Challenge

[[{"type":"media","view_mode":"media_crop","fid":"43588","attributes":{"alt":"","class":"media-image media-image-right","id":"media_crop_6015003306047","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"4775","media_crop_rotate":"0","media_crop_scale_h":"150","media_crop_scale_w":"84","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"float: right;","title":" ","typeof":"foaf:Image"}}]]Psychiatric emergencies and mental health concerns account for between 2% and 5% of all pediatric hospital emergency department (ED) visits.^1-4 Most young people who present for emergency psychiatric care are seen in general medical or adult psychiatric EDs. The experience of being in an ED is frequently difficult for children and families; the environment is noisy, crowded, and often frightening. Adolescents seen in adult psychiatric EDs often feel they are being labeled as “crazy.” Moreover, the presence of indigent or intoxicated adult patients around them may reinforce negative stereotypes and stigma about the mentally ill and mental health treatment. Parents feel angry at having to wait in the ED to see a clinician, frustrated at having been pulled out of work if the child was sent from school, and worried about the cost of the ambulance and ED visit.

Limitations of an ED

Despite the increasing volume of child psychiatric patients, few EDs have staff trained in working with children with mental illness, and many lack access to child psychiatry or social work for consultation. As a result, almost half of children and adolescents who come to the ED after a suicide attempt are discharged without receiving a mental health evaluation.⁵ Of the patients who receive a mental health assessment, most are discharged without any follow-up, leaving families feeling angry and lost. For children for whom it is clearly unsafe to go home and who need inpatient psychiatric care, the “bed crunch” often leads to long stays boarding in the ED without treatment; this feels like punishment to the children and often alienates them and their families from the mental health care system.

CASE VIGNETTE

Fourteen-year-old Raquel is brought to her local ED. Raquel had been in a routine meeting with the guidance counselor when the counselor noticed several superficial cuts on Raquel’s left wrist. The guidance counselor had been hearing worrisome things about Raquel for a few months-she had been cutting classes, seemed not to be paying attention when she was there, and had been dropped from the track team-but this seemed like something more serious, so the counselor called emergency medical services.

When Raquel got to the ED, she was placed in the “psychiatric” area to wait for her mother, who was coming from work. Raquel waited alone, next to 2 malodorous older men snoring loudly and a younger woman who seemed to be talking to herself. When Raquel’s mother arrived, they had to wait several hours to be seen, and by the time they met with the psychiatrist both Raquel and her mother were tired, frustrated, and just wanted to go home. Raquel said little to the psychiatrist, and her mother did not have much of a sense of what was going on with her increasingly shut-down and isolative daughter. They left the ED with the phone number for a therapist, but when Raquel’s mother tried to call, there was a 2-month wait for an appointment, so she let it go. Raquel went back to school the next day and, embarrassed and angry, avoided the guidance counselor for the rest of the year.

Treating children and adolescents in this context is a difficult task, made more so by the complexity of the child’s symptoms, cognitive and emotional development, family complexity, and school and peer dynamics. In cases such as Raquel’s, there are several issues that need to be addressed:

• Determine safety for discharge versus need for admission

• Understand why Raquel is harming herself

• Understand which resources are available and how to access them

• Connect Raquel to treatment providers

Almost half of children and adolescents who come to the ED after a suicide attempt are discharged without receiving a mental health evaluation.

Gathering information

To determine safety requires more than just asking Raquel if she is suicidal (although, of course, that is a crucial step); a more in-depth assessment of suicide risk is needed, perhaps using a structured screening tool such as the Columbia Suicide Severity Risk Screen, the Ask Suicide Questions screen, or the Suicide Assessment Five-Step Evaluation and Triage tool.^6-9 The 3 tools (all free and available online) were developed to be used by non-psychiatric and nonclinical staff; they can easily be administered in the waiting area while patients wait to see a clinician. These tools do not determine admission but can help screen patients and determine who should see the patient: a psychiatrist or a social worker. Screening tools are also helpful because adolescents are often embarrassed to divulge psychiatric symptoms and may be more forthcoming using a checklist or screener, with the clinician asking follow-up questions.

Understanding Raquel’s level of risk requires ascertaining why she is engaging in self-harm, by approaching her with a curious, nonjudgmental attitude and learning in detail the thoughts, feelings, and events that led to her self-harm. Getting collateral information from the guidance counselor, which can be done by non-clinical staff, is crucial for an effective risk assessment. Speaking to the guidance counselor will not only elucidate the details leading up to Raquel being sent to the ED, but it will clarify Raquel’s overall functioning and illustrate whether Raquel has supports at school (eg, how well the guidance counselor and other staff know her, if she has any friends, whether she is being bullied at school) and at home (eg, are there any concerns about the family; how engaged are Raquel’s parents with her education-do they attend parent-teacher conferences?).

One of the challenges of psychiatric emergency assessment of youth is that collateral data are often essential to clarify the clinical picture, which can be burdensome to overworked ED staff. To truly assess Raquel’s safety, the context for her behaviors needs to be known. This includes knowing how the family is doing. Are a recent divorce, financial stress, domestic violence, or abuse contributing to her self-injury or making it harder for her mother to help her? What kind of support is she receiving in school-are bullying or undiagnosed learning disabilities triggering her self-harm?

Understanding Raquel’s home and academic life will make it easier to identify what resources Raquel and her family have and what additional supports (internal, such as coping skills or psychoeducation, and external, such as extended family, community resources, or treatment) they need to keep Raquel safe. This will in turn inform what referrals are necessary.

The majority of child psychiatric emergencies are managed by pediatricians, emergency medicine physicians, and adult psychiatrists-yet all of these clinicians receive little training in child psychiatry.

If Raquel is cutting herself to cope with the stress of domestic violence at home, she will need more than a phone number for a clinic intake-she and her mother will need support from social services (and possibly child protective services), as well as individual and family therapy. If Raquel is cutting herself to cope with flashbacks from a sexual assault that occurred a few months ago after school, she will need trauma-focused therapy and legal support. With this approach, Raquel’s ED visit goes from a frightening and stigmatizing experience for her and a frustrating waste of time for ED staff, to an important diagnostic and therapeutic intervention that ensures her connection to treatment and decreases her likelihood of engaging in self-harm or suicide in the future.

Fixing the system

Ensuring that more effective emergency psychiatric care is provided always requires more than individual clinicians asking the right questions. Improving care across EDs will require systemic changes in training, development of standards, and innovation in the delivery of care in EDs and in the community.

The majority of child psychiatric emergencies are managed by pediatricians, emergency medicine physicians, and adult psychiatrists-yet all of these clinicians receive little training in child psychiatry and generally no specific training in assessing and managing child psychiatric emergencies. This has implications not only for the risk assessments done on children in the ED, but also on the management of agitation.

Currently, 1 in 15 youths undergoing psychiatric evaluation in the ED is restrained, and in this vulnerable time he or she may be given medications for agitation at doses that are too low (by pediatricians giving weight-based dosing), too high (by adult psychiatrists used to adult dosing), or frankly contraindicated (such as benzodiazepines, which can be disinhibiting and cause greater agitation in young children or those with autism spectrum disorders). To avoid this, pediatric, emergency medicine, and general psychiatry training programs should include specific training in assessment and management of child psychiatric emergencies. Consultation models, such as those developed for primary care, should be developed to allow pediatricians and general psychiatrists real-time access to phone consultation by child psychiatrists, for ongoing education and support.

Standards specific to emergency psychiatric care for children must be developed and disseminated. It is unacceptable that nearly half of children who present to EDs with self-harm receive no mental health assessment; such absence of treatment for cardiac emergencies or stroke would cause outrage-the frequency of suicide and serious violence among youth show that child psychiatric emergencies are no less life-threatening. The American Psychiatric Association, the American Academy of Child and Adolescent Psychiatry, and regulatory agencies must work together to develop standards for staffing, access to care, screening for suicide and violence risk, and practice guidelines for evaluation and management of agitation.

Innovative care models are being used around the country to improve the psychiatric care provided to children in EDs and to enhance access to crisis services outside the ED to divert unnecessary ED referrals. These models need to be studied, standardized, and disseminated, just as stroke teams and cardiac arrest protocols have become standards of care.

A range of care models are needed that are appropriate for hospitals with different levels of staffing and demand. For hospitals without sufficient demand to warrant child psychiatric staffing in the ED, crisis services outside the ED, such as mobile crisis teams or crisis clinics for same-day assessment and consultation, may be able to divert most cases so that only those requiring hospitalization will come to the ED. Telepsychiatry can also provide access to child psychiatric consultation. It is being used successfully in health care networks to address the shortage of child and adolescent psychiatrists.

For EDs that have a more moderate volume of child psychiatric patients, the children’s crisis specialist model may be appropriate. This model provides 24/7 staffing by a psychiatric social worker trained in evaluation, brief family therapy, brief cognitive-behavioral therapy, and skills training. This clinician also provides referrals, crisis support by phone and, if needed, interim visits to the home or on an outpatient basis until the child is connected to services. This model has been shown to decrease ED duration of stay and cost, and to enhance connection to long-term treatment.^10,11

For hospitals and areas with a high demand for child psychiatric emergency services, centralizing acute specialty care can create a hub for high-quality care and ongoing multidisciplinary training. In New York City, Bellevue Hospital’s Children’s Comprehensive Psychiatric Emergency Program is a specialized ED staffed with child psychiatrists, child psychologists, experienced psychiatric nurses, and social workers. The program also includes a crisis observation unit for brief hospitalization, an outpatient crisis clinic, mobile crisis services, and a home-based stabilization team, to allow family-friendly treatment at a range of intensity to best meet the child’s needs.

By centralizing services, this program provides a range of services in a cost-effective way, serving all of New York City as well as children from neighboring counties and states. The program also provides training for child psychiatry fellows, general psychiatry residents, pediatrics residents and fellows, psychology interns, social work students, nurse practitioner students, and other trainees.

Conclusion

Helping children in psychiatric crisis to access thorough, effective emergency evaluation and connection to care can put them on a path to recovery. Maintaining the status quo means leaving them vulnerable at the time of highest risk and potentially alienating them and their families from seeking further mental health treatment. With suicide as the third leading cause of death among teenagers, improving the capacity of our psychiatric emergency response system represents a public health imperative.

Disclosures:

Dr Gerson is Director of the Children’s Comprehensive Psychiatric Emergency Program; Dr Havens is Vice Chair for Public Psychiatry in the department of child and adolescent psychiatry at the New York University School of Medicine, Bellevue Hospital Center in New York. The authors report no conflicts of interest concerning the subject matter of this article.

References:

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6. Columbia Suicide Severity Risk Screen (CSSRS). http://www.cssrs.columbia.edu/. Accessed September 30, 2015.

7. Horowitz LM, Bridge JA, Teach SJ, et al. Ask Suicide-Screening Questions (ASQ) a brief instrument for the pediatric emergency department. Arch Pediatr Adolesc Med. 2012;166:1170-1176.

8. Ask Suicide-Screening Questions (ASQ). http://www.nimh.nih.gov/news/science-news/ask-suicide-screening-questions-asq.shtml. Accessed September 30, 2015.

9. Suicide Assessment Five-Step Evaluation and Triage (SAFE-T) tool. http://store.samhsa.gov/product/Suicide-Assessment-Five-Step-Evaluation-and-Triage-SAFE-T-Pocket-Card-for-Clinicians/SMA09-4432. Accessed September 30, 2015.

10. Rotheram-Borus MJ, Piacentini J, Cantwell C, et al. The 18-month impact of an emergency room intervention for adolescent female suicide attempters. J Consult Clin Psychol. 2000;68:1081-1093.

11. Wharff EA, Ginnis KM, Ross AM. Family-based crisis intervention with suicidal adolescents in the emergency room. Soc Work. 2012;57:133-143.