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Pediatric Mental Health Emergencies: Management Strategies
Strategies, resources, and recommendations for improving care of pediatric patients with mental and behavioral health emergencies.
Emergency department (ED) visits by children and youth with mental and behavioral health emergencies (MCS) in the United States have been increasing over the past decade.1 At the same time, there has been an increased prevalence of depression and suicide in pediatrics, which, for the purposes of this statement, refers to children, adolescents, and young adults.2,3
In response to this, the American Academy of Pediatrics and the American Foundation for Suicide Prevention created the following resource, “Suicide: Youth Suicide Prevention Plan,” for health care professionals caring for youth at risk for suicide. .4 Racial disparities exist in mental health, with higher suicide rates among black school-aged children.5–7
In a study looking at suicide rates in American youth from 2001 to 2015 among children ages 5 to 12, the suicide rate was approximately twice as high for black children compared to white children.8 Since 2010, there have been an increase in rates of black high school students with suicide attempts and injuries after a suicide attempt in the United States.7 Overall, American Indian/Alaska Native high school students have the highest rates of suicide and ideation suicide.
Recognizing these inequalities in SMC outcomes is an essential part of efforts toward equity in behavioral health. The Substance Abuse and Mental Health Services Administration defines behavioral health equity as “the right to access quality health care for all populations, regardless of race, ethnicity, gender, socioeconomic status, sexual orientation, or location.” geographic location of the individual. This includes access to prevention, treatment and recovery services for mental and substance use disorders.” 9
For children and youth with SMC conditions, there are often limited resources at the community10,11 and institutional level (from prehospital to the ED to inpatient) to provide them with optimal care.12 As a result, EDs have become become a critical access point and safety net for those requiring acute and subacute SMC care.13
Disparities also exist in access to care based on race, ethnicity, insurance status, gender identity, language preference, and geographic location of mental health specialists and inpatient psychiatric units.14–16 Additionally, there may be barriers for the patient and family to obtain care, including the potential stigma of a mental health disorder diagnosis and treatment.17 Community care models may be considered for the triage and management of acute SMC emergencies to expand the resources to care for these patients.18,19
In addition to these challenges, EDs have wide variation in their ability to care for pediatric patients with SMC conditions.20 Physicians, physician assistants (MAs), and nurse assistants (EAs) working in EDs may experience challenges in caring for SMC conditions of pediatric patients.21,22
Children and young people with intellectual disabilities, autism spectrum disorders and behavioral dysregulation23,24; immigrant children and people with specific cultural and linguistic preferences14; children in the child welfare system; youth in the juvenile justice system; and lesbian, gay, bisexual, queer, transgender (LGBQT+) youth may have additional challenges that need to be addressed.25
Due to the diversity of populations and the high prevalence of trauma and adversity among ED patients, ED organizations/leaders should provide resources for physicians, MAs, EAs, and nurses on trauma-informed relational care as a universal approach. of attention.26
There is often inconsistent evidence of risk for self-harm and substance use in patients presenting with mental health problems and other concerns.27 Additionally, pediatric patients with mental health problems may experience prolonged ED stays awaiting referral. appropriate for a higher level of psychiatric care (e.g., inpatient psychiatric unit, community-based acute treatment).28,29 There are also challenges in organizing outpatient mental health care after discharge from the ED. .
The ultimate goal in the ED is to provide optimal and equitable care for children and youth with SMC emergencies. This policy statement aims to provide evidence-based best practice guidance with resources and references for emergency physicians, AMs, and EAs for the management of SMC emergencies in children and youth.
Recommendations to optimize and improve the care of pediatric patients with mental health emergencies
Prehospital
Develop referral protocols from ED facilities involving emergency medical services (EMS) for children, such as appropriate referrals to psychiatric crisis units, within psychiatric facilities or community mental health centers when available. These centers could provide short-term stabilization and referrals.
Develop telehealth emergency psychiatric medical monitoring (via EMS and schools) to identify and divert low-acuity patients to facilities equipped to manage SMC conditions.
Activate existing mobile mental health crisis teams to be able to respond to schools, doctors’ offices, and homes.
Provide resources for prehospital staff in acute cases. SMC Pediatric Emergency Management.
Advocate for the implementation of crisis response teams as an alternative to law enforcement responding to an SMC emergency in the community. Unnecessary contact with authorities should be limited or avoided,35 if possible, during SMC emergencies, as the presence of trained individuals who can provide trauma-informed relational care is recommended, if available.26
emergency department
Provide resources for ED staff related to the recognition and provision of initial care to children and youth at potentially increased risk for SMC problems including LGBQT+ youth; victims of mistreatment, abuse or violence, including physical trauma, mass casualty incidents and disasters; and those with problems related to substance use (e.g., acute intoxication, overdose), pre-existing conditions (e.g., autism spectrum disorder, developmental delay, intellectual disability), post-traumatic stress disorder, depression, children in the welfare system, youth in the juvenile justice system, and suicidality.
Explore the development of expanding telehealth consultations (telepsychiatry), particularly in countries with limited resource areas, or during pandemics and disease outbreaks such as coronavirus disease 2019, including provision for documentation, compensation for such services and considering the best pricing practices (i.e., bundled payment for multiple visits for ED patients with extended stays). Broadband internet access should also be considered for telehealth services. Additionally, strategies should be developed to improve continuity of mental health specialist care for the same patient during the same encounter.
Advocate for 24-hour access to professional interpreter services, including American Sign Language, and/or trained crisis management interpreters for patients and families with limited English proficiency.
Develop standards and systems to establish acute consultation and referral networks within hospitals and communities.
Develop linkage and follow-up systems to help patients navigate the complex mental health system, including referral to outpatients and community behavioral health centers.
Leverage technology, including electronic applications and social media, for safety planning to improve follow-up/contact.
Ensure an appropriate and safe environment for patients with SMC disorders (e.g., quiet environment and schedule for children with developmental or autism spectrum disorder, safe shower facilities without hanging cords for patients presenting with suicidal ideation or attempts) .
Provide resources for ED staff to provide culturally appropriate care with a trauma-informed approach. This should include considerations to address systematic racism and implicit bias.
Community
Advocate for community-based behavioral services using a culturally sensitive, patient-centered approach to identify and manage behavioral health issues before an emergency condition develops.
Develop screening in schools and provide resources for staff to recognize special SMC issues related to children and youth who are victims of bullying, abuse, domestic violence, sexual violence, racism, and trauma. This should also include early identification and referral to appropriate, previously identified resources.
Address behavioral health equity in the community for SMC disorders, including prevention, treatment, and recovery programs for substance use disorders, particularly in vulnerable populations affected by poverty, racism, violence, and insecurity food and housing.9
Care systems
Advocate for adequate pediatric SMC resources in both inpatient and outpatient settings, including the availability of immediate psychiatric consultation and interpreter services for the ED, as well as school and community screening resources.
Establish standards for documentation, communication, and appropriate billing and payment for inpatient and outpatient psychiatric care by mental health specialists providing consultations to ED patients (including telemedicine consultations), as well as for emergency care and prolonged ED.
Create referral agreements between facilities, including streamlining the search for psychiatric beds for patients requiring additional inpatient care, to help limit ED targeting.
Advocate for referral networks with inclusive mental health coverage, even for those who may be uninsurable (e.g., undocumented immigrant children).
Recognize the medical home as a critical component of SMC in a comprehensive care approach for primary care physicians, MAs, and EAs. Advocate to improve residency education in pediatrics, and family medicine related to pediatric SMC conditions. Primary care physicians, MAs, and EAs should be provided resources to provide psychiatric care as part of the medical environment and receive appropriate payment for these services.
Optimize and expand insurance coverage for SMC coverage to overcome limitations in serving children with SMC conditions. Provider networks must include appropriate pediatric-trained mental health specialists to care for their patients. Insurance must cover access to pediatric mental health care and case management programs for people with chronic mental illnesses, high-risk conditions, developmental disabilities, and substance use disorders.
Advocate for increased funding for the training and compensation of a diverse population of pediatric mental health specialists to help address insufficient access secondary to the shortage of qualified mental health specialists in healthcare.
Include SMC topics in the educational curriculum of prehospital staff, emergency physicians, PAs, NPs, staff, nurses, and trainees, including emergency medicine residents and pediatric emergency medicine fellows to provide patient-centered, patient-informed care. trauma and culturally appropriate.
Identify current gaps, barriers, and opportunities to improve the current state of SMC care, including support programs to increase the diversity of SMC specialists caring for patients in the emergency setting.
Establish models to improve systems-level capacity for SMC care services across the spectrum of emergency care, including those awaiting transfer to higher levels of psychiatric care (e.g., beds in inpatient psychiatric hospital, community-based acute treatment setting).
Because there is a trend for increasing numbers of patients with SMC conditions to be admitted to both the ED28,42 and inpatient units, 43,44 the provision of SMC care is critical to some level of continuing care. This model may include initiating/titrating psychiatric medication for medication management, environmental modifications in the ED, individual and family therapy, and the development of coping skills.44,45
Investigation
Increased SMC research funding for EMS strategies for children to detect, identify, and connect to appropriate resources.
Support research and development of evidence-based guidelines and best practices for ED screening tools detection, assessment, consultation, acute management, and follow-up care related to children’s mental health crises.
Advanced research related to the acute management of pediatric SMC disorders and potential prevention strategies for SMC emergencies (e.g., models of care for acute psychiatric illnesses in the ED and inpatient units, psychiatric telehealth consultations for the ED, role of media in adolescent suicide and depression, and implementation of mobile community crisis teams that respond to multiple settings).
Expand research efforts focused on reducing risk factors for youth and examining health inequities related to presentations and management of SMC, with the goal of addressing and eliminating these disparities. These risk factors include those unique to certain populations, including, but not limited to: historically marginalized groups and racial and ethnic groups, LGBQT+ youth, immigrants and refugees, children in the welfare system, youth with substance use disorders, disability intellectual status, low socioeconomic status, history of exposure to trauma or violence, involvement in the child welfare system, involvement in the juvenile justice system, and limited English proficiency. These research efforts should include the epidemiology of children and youth SMC presentations to the ED and interventions focused on mental health-related disparities in care and outcomes.
Advance research to better understand the effects of racism and its effects on SMC. This research should include intervention studies to address disparities in access to and outcomes of mental health care, and care for children and youth from historically disadvantaged racial and ethnic groups.
Future directions
Develop and validate quality indicators and metrics to improve and standardize emergency care for children and young people who present with problems related to SMC. These quality indicators and metrics must also include a health equity perspective, examining disparities in care based on race or ethnicity, sexual orientation, gender identity, chronic illnesses, socioeconomic status, and limited English proficiency, as well as like other factors.
Assess the preparedness of EDs in the United States for care of children’s mental health emergencies to help identify gaps, needs, and innovations in care.
Develop models to incorporate assessment of SMC and treatment areas in the ED, when possible. This may include specifically designated spaces. These models have demonstrated an improvement in the patient and family experience in conducting confidential evaluations and treatments, and have allowed for more efficient use of the psychiatric consultant’s time.45–53
Support the development of up-to-date, easily accessible information and searchable online inventories of community mental health referral networks.
Develop national professional standards for children’s mental health consultations.
Develop mental health support networks that minimize dependence on the management of acute crises.
Advocate to optimize and expand insurance coverage, especially for states that have not expanded Medicaid, to improve mental health care screening and treatment for children and youth.
Conclusions
Mental and behavioral health emergencies are increasing in children and youth.
EDs have been hit hard by the surge as a safety net for a critically deficient system. The time has come to address this health crisis through the following methods: addressing SMC inequalities; increase detection of SMC diseases in ED patients; identify, treat and refer children and young people with SMC emergencies; improve access to resources for patients and staff; use standardized treatment protocols; and optimize the use of telehealth in the treatment of pediatric patients with SMC emergencies. A multidisciplinary and multifaceted approach will be necessary to provide patient-centered and trauma-informed services to improve the care of children and youth with SMC emergencies.
Comment
This work highlights that mental and behavioral health emergencies continue to increase in the pediatric population, which affects not only EDs, but the entire spectrum of medical services from the prehospital to the community level.
There are challenges in optimal care of these patients, mainly due to lack of staff, training, and infrastructure.
Strategies are proposed to improve comprehensive care that include coordination by levels of care, increasing the detection and prevention of mental health pathologies, improving access to resources and staff training, using standardized treatment protocols, and incorporating telehealth into the care. emergency.
