Pediatric Mental Health Emergencies in the Emergency Medical Services System
Reaffirmed by the ACEP Board of Directors April 2012
Originally approved by the ACEP Board of Directors and the American Academy of Pediatrics Board of Directors April 2006
Emergency Departments (ED’s) are vital in the management of pediatric patients with mental health emergencies (MHE). Pediatric MHE are an increasing part of emergency medical practice because ED’s have become the safety net for a fragmented mental health infrastructure which is experiencing critical shortages in services in all sectors. ED’s must safely, humanely, and in a culturally and developmentally appropriate manner, manage pediatric patients with undiagnosed and known mental illnesses including those with mental retardation, autistic spectrum disorders, attention deficit hyperactivity disorder (ADHD), and those experiencing a behavioral crisis. ED’s also manage patients with suicidal ideation, depression, escalating aggression, substance abuse, post traumatic stress disorder, maltreatment, and those exposed to violence and unexpected deaths. ED’s must address not only the physical but also the mental health needs of patients during and after mass casualty incidents and disasters.
The American Academy of Pediatrics and the American College of Emergency Physicians support the following actions: advocacy for increased mental health resources, including improved pediatric mental health tools for the ED, increased mental health insurance coverage, adequate reimbursement at all levels; acknowledgment of the importance of the child’s medical home, and promotion of education and research for mental health emergencies.
Key words: Emergency department, mental health emergencies, school and community mental health services, medical home
Pediatric mental health emergencies constitute a large and growing segment of pediatric emergency medical care. Emergency departments (EDs) play a critical role in the evaluation and management of child and adolescent patients with mental health emergencies. Community mental health resources have diminished and, in some regions, even disappeared through inpatient bed shortages, private and public health insurance changes, reorganization of state mental health programs, and shortages of pediatric-trained mental health specialists. These changes have resulted in critical shortages of inpatient and outpatient mental health services for children.1 The ED has increasingly become the safety net for a fragmented mental health infrastructure in which the needs of children and adolescents, among the most vulnerable populations, have been insufficiently addressed.
EDs must safely, humanely, and in a culturally sensitive manner manage patients with exacerbations of known diagnosed mental illnesses as well as those with mental retardation, autistic spectrum disorders, ADHD, or those who are having a behavioral crisis. EDs also must identify and manage patients with previously undiagnosed and/or undetected conditions, such as suicidal ideation, depression, escalating aggression, substance abuse, and post-traumatic stress disorder.2 EDs evaluate and treat trauma patients, physically and sexually maltreated children, and children exposed to community and domestic violence and also must deal with unexpected deaths of children in the ED. Violence-related situations may involve pediatric victims and/or pediatric-aged perpetrators of violence. In many states, adolescents can seek and receive care for mental health issues and drug/alcohol use without parental involvement, and EDs must maintain confidentiality unless the child is at risk of harming himself/herself or others. The ED must also recognize the primary support role of the family and caregivers in all phases of pediatric mental illness.
EDs play a critical role in mass casualty occurrences and disasters and must address the unique mental health needs of children during and after these events. A strong and growing body of evidence indicates that emotional and physical trauma to children can cause neurochemical and structural brain changes resulting in post-traumatic stress disorder, and can affect some children into their adult lives.1-12 Emotional trauma may be ameliorated by timely, culturally-appropriate, pediatric-specific stress intervention that may be implemented in the initial hours after the trauma.13,14
The epidemiologic and outcome data on pediatric mental health emergencies are insufficient, but there is evidence that pediatric mental health concerns are commonly unaddressed.15,16 Pediatric mental health emergencies are frequently not recognized as such, presenting initially as trauma or somatic complaints, and are, therefore, underrepresented in the existing data.17-20 The challenges to an already overburdened ED "safety net" are to provide safe, humane, and culturally and developmentally sensitive triage, diagnosis, stabilization, initial management, and treatment and referral for a broad spectrum of mental health emergencies, working within a mental health infrastructure in crisis.
Pediatric mental health emergencies are best managed by a skilled, multidisciplinary team approach, including specialized screening tools, pediatric-trained mental health consultants, the availability of pediatric psychiatric facilities when hospitalization is necessary, and an outpatient infrastructure that supports pediatric mental health care, including communication back to the primary care physician and timely and appropriate ED referrals to mental health professionals.21
The American Academy of Pediatrics and American College of Emergency Physicians support the following actions:
- Advocacy for adequate pediatric mental health resources in both inpatient and outpatient settings, including the availability of prompt psychiatric consultation for ED psychiatric patients and school and community mental health services, including adequate mental health screening.
- Development of mechanisms for the ED to deal with unique pediatric mental health issues, including violence in the community, physical trauma, domestic violence, child maltreatment, mass casualty incidents and disasters, suicides and suicide attempts, and the death of a child in the ED.
- Appropriate payment for both inpatient and outpatient pediatric mental health services.
- Acknowledgment of the importance of the child’s medical home• to his or her continued well–being, including prevention, screening, and treatment of mental health issues.22
- Advocacy for comprehensive pediatric mental health insurance coverage to include provision of mental health services for the uninsured and expansion of coverage to include mental health services for those who are insured.
- Advocacy for additional research funding dedicated to pediatric emergency mental health issues.
- Promotion of education and research for mental health emergencies, specifically:
- To expand the data on epidemiology, best practices, treatment outcomes, and cost-benefit issues for pediatric mental health emergencies in the ED.
- To evaluate the adequacy of patient access to pediatric mental health services.
- To evaluate children with behavioral crisis so as to understand gaps in primary care and community resources and to develop mental health support networks that minimize reliance on acute crisis management.
- To develop and validate accurate pediatric mental health screening tools for use in various settings and best practices for follow-up programs for pediatric mental health patients.
- To enhance the pediatric mental health curriculum for emergency medicine and pediatric residency training programs and pediatric emergency medicine fellowships.
- American Academy of Pediatrics, Committee on Child Health Financing. Scope of health care benefits from birth through age 21. Pediatrics. 2006;117:979-982
- American Academy of Pediatrics, Committee on Injury and Poison Prevention. Firearm-related injuries affecting the pediatric population. Pediatrics. 2000;105:888-895
- Terr LC. Childhood traumas: an outline and review. Am J Psychiatry. 1991;148:10-20
- Brick ND. The neurological basis for the theory of recovered memory [research paper]. AOL Hometown. 2003. Available at: http://members.aol.com/smartnews/Neurological_Memory.htm. Accessed August 7, 2005
- Meichenbaum D. A Clinical Handbook/Practical Therapist Manual for Assessing and Treating Adults with Post-Traumatic Stress Disorder (PTSD). Waterloo, Ontario: Institute Press; 1994
- Foy DW. Introduction and description of the disorder. In: Foy DW, ed. Treating PTSD: Cognitive-Behavioral Strategies. New York, NY: Guilford; 1992:1-12
- Knopp FH, Benson AR. A Primer on the Complexities of Traumatic Memory Childhood Sexual Abuse: A Psychobiological Approach. Brandon, VT: Safer Society Press; 1996
- van der Kolk BA. The Body Keeps the Score: Memory and the Evolving Psychobiology of Post Traumatic Stress. 1994. Available at: http://www.trauma-pages.com/vanderk4.htm. Accessed August 7, 2005
- Foy D. Scientific American. 1995;273(4):14
- Winston FK, Kassam-Adams N, Vivarelli-O’Neill C, et al. Acute stress disorder symptoms in children and their parents after pediatric traffic injury. Pediatrics. 2002;109(6):e90
- Children’s Hospital of Philadelphia. Post-traumatic stress disorder may follow traffic crashes according to doctors at the Children’s Hospital of Philadelphia [press release]. Available at: http://www.eurekalert.org/pub_releases/1999-12/CHoP-Psdm-061299.php. Accessed August 7, 2005
- American Academy of Pediatrics. Insurance coverage of mental health and substance abuse services for children and adolescents: a consensus statement. Pediatrics. 2000;106:860-862
- Davidhizar R, Shearer R. Helping children cope with public disasters. Am J Nurs. 2002;102:26-33
- Kalyjian A. Sri Lanka: post tsunami mental health outreach project—lessons learned. Psi Chi: The National Honor Society in Psychology. February 24, 2005.
- Popovic JR. 1999 National Hospital Discharge Survey: annual summary with detailed diagnosis and procedure data. Vital Health Stat 13. 2001;13(151):i-v, 1-206
- Olson L, Melese-d’Hospital I, Cook L, et al. Mental health problems of children presenting to emergency departments. Paper presented at: Third National Congress on Childhood Emergencies; April 15-17, 2002; Dallas, TX
- US Consumer Product Safety Commission, Division of Hazard and Injury Data Systems. Hospital-Based Pediatric Emergency Resource Survey. Bethesda, MD: US Consumer Product Safety Commission; 1997
- Seidel JS, Hornbein M, Yoshiyama K, Kuznets D, Finklestein JZ, St Geme JW Jr. Emergency medical services and the pediatric patient: are the needs being met? Pediatrics. 1984;73:769-772
- Seidel JS. Emergency medical services and the adolescent patient. J Adolesc Health. 1991;12:95-100
- Sapien RE, Fullerton L, Olson LM, Broxterman KJ, Sklar DP. Disturbing trends: the epidemiology of pediatric emergency medical services use. Acad Emerg Med. 1999;6:232-238
- American Academy of Pediatrics. Indications for management and referral of patients involved in substance abuse. Committee on Substance Abuse. Pediatrics. 2000;106:143-148
- American Academy of Pediatrics, Medical Home Initiatives for Children With Special Needs Project Advisory Committee. The medical home. Pediatrics. 2002;110:184-186