A 9-year-old is brought to her pediatrician because she drew a picture at school of a girl hanging herself, with a caption that read “Bye.” The school tells the parents that the child needs to be evaluated by a psychiatrist immediately. What should the pediatrician do next?
The prevalence of mental and behavioral health (MBH) emergencies among U.S. children and adolescents has risen sharply over the past decade. Suicide is one of the top three causes of mortality in children and young adults ages 11-24 and is a top 10 cause of death in 5- to 9-year-olds.
In 2021, the AAP, the American Academy of Child and Adolescent Psychiatry and Children’s Hospital Association declared a national emergency in pediatric mental health.
While mental and behavioral health concerns among youths continue to increase, the health care system’s capacity to provide adequate care continues to diminish. As a result of this, the emergency department (ED) frequently is the de facto referral center for children and youth with MBH emergencies.
A new joint policy statement and technical report from the AAP, American College of Emergency Physicians and Emergency Nurses Association provide updated information, resources and recommendations to improve emergency care for pediatric MBH. The statements outline evidence on the importance of providing a system of care — from the prehospital setting to the ED and back to the community. The primary care medical home serves a pivotal role in coordinating ongoing care for children with MBH conditions.
The documents, The Management of Children and Youth with Pediatric Mental and Behavioral Health Emergencies from the AAP Committee on Pediatric Emergency Medicine, are available at https://doi.org/10.1542/peds.2023-063255 and https://doi.org/10.1542/peds.2023-063256 and will be published in the September issue of Pediatrics.
Disparities in MBH emergencies
MBH emergencies do not affect all pediatric populations equally. Black youths and American Indian/Alaska Native high school students have higher rates of suicide attempts and death by suicide. Adolescents who identify as sexual and gender minorities (LGBTQ+) also are at higher risk for suicidal ideation and depression.
Youth who are at highest risk often have greater barriers to timely access to mental health services.
Given the complexity and increasing volume of pediatric patients presenting with mental and behavioral health emergencies, evidence-based best practices are essential to provide high-quality and equitable care to all youth. The following recommendations are outlined in the policy statement.
Prehospital care
- Refer to appropriate psychiatric crisis units, within psychiatric facilities or community mental health centers, when available.
- Use telehealth emergency psychiatric medical control (based in schools and emergency medical system dispatch) to identify and divert low-acuity patients to facilities equipped to manage MBH conditions.
- Activate mental health mobile crisis teams (where available) to respond to schools, primary care offices and homes.
- Minimize involvement of law enforcement agencies when possible and focus on community-based crisis response teams.
Management in the ED
- Establish a mental health clinical care pathway with electronic health record integration.
- Ensure culturally appropriate and trauma-informed interventions.
- Use telehealth or other arrangements to access mental health care professionals.
- Incorporate behavioral de-escalation strategies training (nonpharmacologic management of a child who is agitated and disruptive).
- Use discharge safety planning for the patient and family, including access to safe environment, lethal means counseling (e.g., firearms, medications, poisons) and connection to primary care medical home.
- Develop quality metrics to measure process and system-level improvements in mental health care.
Continuity in community
- Advocate for community-based behavioral services using a culturally sensitive, patient-centered approach to identify and manage behavioral health concerns.
- Develop school-based screening and provide resources for staff to recognize MBH issues in victims of bullying, abuse, domestic violence, sexual violence, racism and trauma.
- Address behavioral health equity in the community for MBH disorders, including prevention, treatment and recovery programs for substance use disorders, particularly in populations affected by poverty, racism, violence and food/housing insecurity.
- Improve mental health resources for primary care pediatricians and other medical professionals to connect youths with mental health disorders with their medical home.
The pediatrician screens the 9-year-old for suicide risk, and the results indicate further evaluation is required. The pediatrician has an established relationship with a local mental health clinic and refers the child for an immediate evaluation.
Dr. Saidinejad and Dr. Lee are lead authors of the policy statement and technical report. Dr. Saidinejad is a member of the AAP Committee on Pediatric Emergency Medicine. Dr. Lee is chair of the AAP Council on Injury, Violence and Poison Prevention.
Resources
- AAP Blueprint for Youth Suicide Prevention
- AAP information on child and adolescent healthy mental development
- Pediatric Education and Advocacy Kits for suicide, https://bit.ly/3KcRScs, and agitation, https://bit.ly/3Q8j2VJ, from the Emergency Medical Services for Children Innovation and Improvement Center
- Health Resources and Services Administration (HRSA) - Critical Crossroads: Pediatric Mental Health Care in the Emergency Department
- The 988 Suicide & Crisis Lifeline is available by texting or calling 988 or at https://988lifeline.org.
