Dr. ChunMental health problems are among the greatest contributors to the global burden of disease, and the number of U.S. children and adolescents diagnosed and treated for these issues have burgeoned in the last two decades.
A set of new clinical reports can assist clinicians in caring for children and adolescents with acute mental health and behavioral problems (see Resources), including in the emergency department (ED).
The two reports, Evaluation and Management of Children and Adolescents With Acute Mental Health or Behavioral Problems. Part 1: Common Clinical Challenges of Patients With Mental Health and/or Behavioral Emergencies and Part II: Recognition of Clinically Challenging Mental Health Related Conditions Presenting With Medical or Uncertain Symptoms, along with their executive summaries, will be published in the September issue of Pediatrics. They were developed by the pediatric emergency medicine committees of the Academy and the American College of Emergency Physicians (ACEP). The documents, which support the 2006 joint AAP-ACEP policy on pediatric mental health emergencies reaffirmed in 2013, address common knowledge gaps in these areas and provide comprehensive yet practical, hands-on clinical guidance.
Increase in ED visits for mental health
Epidemiologic studies of pediatric ED patients have found skyrocketing rates of children and adolescents presenting for mental health and behavioral emergencies. Up to 70% of ED patients screen positive for at least one mental health disorder, and 45% may have a mental health problem resulting in impaired psychosocial functioning.
An especially concerning trend is the rise in “boarding” of psychiatric patients in the ED and inpatient pediatric units (i.e., extended stays of days or even weeks). Although not well-studied, this practice is problematic because it significantly taxes the functioning and efficiency of the ED and hospital, and because mental health services may not be available in these care areas.
At present, few resources are available to guide pediatricians in caring for these patients during acute crises. Both pediatricians and ED clinicians cite lack of training and confidence in their abilities as barriers to caring for patients with mental health emergencies.
While the new reports are written from the perspective of ED clinicians, they are intended for all who care for children.
Breakdown of reports
Part I focuses on patients presenting to the ED with a mental health chief complaint and includes medical clearance of pediatric psychiatric patients, suicidal ideation and suicide attempts, involuntary hospitalization, restraint of agitated patients (verbal, chemical and physical restraint are discussed), as well as coordination of care with the medical home.
Part II discusses challenging patients with primarily medical or indeterminate presentations in whom an underlying mental health condition may be an unclear or a complicating factor. Covered in this report are somatic symptom and related disorders, adverse effects to psychiatric medications (including antipsychotics, neuroleptic malignant syndrome and serotonin syndrome) and children with special needs in the ED (including autism spectrum and developmental disorders).
Because mental health conditions frequently go unrecognized by pediatricians, patients and their caregivers, part II also discusses rapid mental health screening tools, including screens for depression, anxiety, post-traumatic stress and substance abuse.
A similar phenomenon has been described with suicidal patients. Individuals who commit suicide frequently visited a health care provider in the months preceding their death. While some suicidal patients present with overt self-harm, many have vague somatic complaints (e.g., headache, gastrointestinal tract distress, back pain, concern for a sexually transmitted infection, etc.) masking their underlying mental health condition.
Dr. Chun is lead author of the clinical reports and a member of the AAP Committee on Pediatric Emergency Medicine.
See related Parent Plus article, "Mind-body therapies can be helpful for children."
