Visits to the emergency department (ED) by children for mental health conditions have risen over the last decade, but not all EDs may be equally prepared to serve this vulnerable population. In “Children’s Mental Health Emergency Department Visits: 2007–2016” featured in this issue of Pediatrics, Lo et al1  analyzed a nationally representative sample of EDs and found that pediatric mental health visits rose by 60%, with visits for deliberate self-harm rising by a staggering 329%. This study fills a gap in the literature by describing the sites where children are increasingly seeking mental health care in terms of rural-urban location, pediatric volume, and children’s versus general ED setting. Although mental health visits increased across all ED visit types, of particular concern are rising visits at low-pediatric-volume and rural hospitals, which may be less well equipped to care for children with mental health needs.

The National Pediatric Readiness Project, a multiphase quality-improvement initiative sponsored by the federal Emergency Medical Services for Children program and health care professional organizations, demonstrated that EDs with lower pediatric volume are less likely to have pediatric-specific equipment, policies, and procedures in place that are recommended for emergency care of children.2,3  In the most recent national assessment, less than half of all EDs had recommended policies in place for children with mental health conditions, and among low-pediatric-volume EDs, the number was less than one-third.4,5  The survey did not assess the content or number of policies related to mental health, which may be developed by EDs to standardize patient search procedures, ensure an appropriate level of observation, enhance environment and room safety, and provide guidance for appropriate use of chemical and physical restraints, among other purposes. The adoption of policies for mental health care may be an important starting point, but policies alone are not sufficient to guarantee delivery of high-quality care. Few rigorously tested quality-improvement metrics currently exist for emergency pediatric mental health care; these must be developed, validated, and disseminated to ensure consistent care delivered across all ED settings.6 

Although Lo et al1  found the greatest rise in pediatric mental health ED visits in metropolitan areas, rural areas also experienced notable increases. Disparities in access to mental health care exist in rural areas, with shortages of mental health providers leading to unmet mental health needs.7  Youth living in rural areas are nearly twice as likely to die by suicide, and the rural-urban disparity in youth suicide rates has been widening over time.8  For youth discharged from the ED in rural areas, connection to outpatient mental health services may be challenging in the face of limited resources. For children who require a higher level of care, only 38% of rural and remote EDs have guidelines in place for the transfer of children with mental health conditions.4  Children awaiting psychiatric placement may experience ED boarding, with lengths of stay exceeding 24 hours.9  While boarding, the high-stimulation ED environment may be detrimental to some mental health conditions, and the occupied beds may reduce provider capacity to care for other children.10  Increasing the number of rural hospitals with transfer agreements will be an important first step, but it will not solve the access issues that are prevalent in many rural areas.

Clearly, innovative solutions are needed at a systems level to better meet the needs of children with mental health emergencies, who are among the most vulnerable we serve. In response to rising numbers of emergency mental health visits, the Health Resources and Services Administration developed a toolkit, “Critical Crossroads: Pediatric Mental Health Care in the Emergency Department,” that offers an adaptable framework with recommendations for triage, screening, assessment, and disposition for pediatric mental health patients in the ED.4  Other opportunities for further development include the use of telehealth for remote evaluation, expansion of models that provide on-site mental health evaluation in the home or school, and diversion programs that direct children to dedicated mental health crisis centers rather than to EDs.11  Integration of mental health services into the pediatric medical home will be critical to improve access to care and reduce ED visits.12  Meanwhile, to serve the rising demand for emergency mental health services, every ED across the country must do the hard work required to be ready to provide high-quality mental health care for each child who walks through its doors.

Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2019-1536.

     
  • ED

    emergency department

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: No external funding.