The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies

Emergency department (ED) visits by children and youth with mental and behavioral health (MBH) emergencies in the United States have been increasing over the last 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 “Suicide: Blueprint for Youth Suicide Prevention” to be a resource for health professionals caring for youth at risk for suicide.⁴  Racial disparities exist in mental health, with increased rates of suicide in Black school-aged children.^5–7  In a study analyzing suicide rates in US youth from 2001 to 2015 among children 5 to 12 years old, the suicide rate was approximately two times higher for Black children compared with white children.⁸  Since 2010, there have been increased rates of Black high school students with suicide attempts and injury after suicide attempt in the United States.⁷  Overall, American Indian/Alaska Native high school students have the highest rates of suicide and suicidal ideation.

Acknowledging these inequities in MBH outcomes is an essential part of efforts toward behavioral health equity. 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 the individual’s race, ethnicity, gender, socioeconomic status, sexual orientation, or geographical location. This includes access to prevention, treatment, and recovery services for mental and substance use disorders.”⁹ 

For children and youth with MBH conditions, there are often limited resources in the community^10,11  and on the institutional level (prehospital to ED to inpatient) to provide optimal care.¹²  As a result, EDs have become a critical access point and safety net for those requiring acute and subacute MBH care.¹³  There are also disparities in access to care based on race, ethnicity, insurance status, gender identity, language preference, and the geographic location of mental health specialists and inpatient psychiatric units.^14–16  In addition, there may be patient and family barriers to obtaining care, including the potential stigma of a mental health disorder diagnosis and treatment.¹⁷  Models of community-based care to triage and manage acute MBH emergencies can be considered to broaden resources to care for these patients.^18,19 

In addition to these challenges, EDs have a wide variation in their capability to care for pediatric patients with MBH conditions.²⁰  Physicians, physician assistants (PAs), and nurse practitioners (NPs) working in EDs may experience challenges caring for pediatric patients’ MBH conditions.^21,22  Children and youth with intellectual disabilities, autism spectrum disorders, and behavioral dysregulation^23,24 ; immigrant children and those with specific cultural and language preferences¹⁴ ; children in the child welfare system; youth in the juvenile justice system; and lesbian, gay, bisexual, queer, transgender, or questioning (LGBQT+) youth may have additional challenges, which need to be addressed.²⁵  Because of the diversity of the populations and the high prevalence of trauma and adversity among ED patients, organizations/ED leadership should provide resources for physicians, PAs, NPs, and nurses about trauma-informed relational care as a universal approach to care.²⁶ 

There is often inconsistent screening for self-harm risks and substance use in patients presenting for both mental health concerns and other complaints.²⁷  Furthermore, pediatric patients with mental health conditions may experience prolonged ED lengths of stay while awaiting appropriate placement for a higher level of psychiatric care (eg, inpatient psychiatric unit, community-based acute treatment).^28,29  There are also challenges in organizing outpatient mental health care after ED discharge. The ultimate goal in the ED is to provide optimal and equitable care for children and youth with MBH emergencies. This policy statement aims to provide guidance on evidence-based best practices with resources and references (Table 1) to emergency physicians, PAs, and NPs for the management of MBH emergencies in children and youth.

• Develop ED facility transfer protocols involving emergency medical services (EMS) for children, such as appropriate referrals to psychiatric crisis units, within psychiatric facilities or community mental health centers where available (eg, Pittsburgh,³⁰  San Francisco³¹ ). These centers could provide short-term stabilization and referrals (eg, Northwell System³² ).

• Develop telehealth emergency psychiatric medical control (via EMS and schools) to identify and divert low-acuity patients to facilities equipped to manage MBH conditions.

• Activate existing mental health mobile crisis teams to be able respond to schools, physicians’ offices, and homes (eg, South Carolina,³³  Georgia³⁴ ).

• Provide resources for prehospital personnel in acute management of pediatric MBH emergencies.

• Advocate for the implementation of crisis response teams as an alternative to having law enforcement respond to an MBH emergency in the community. Unnecessary contact with law enforcement should be limited or avoided,³⁵  if possible, during MBH emergencies, because the presence of trained individuals who can provide trauma-informed relational care is recommended, if available.²⁶ 

• Provide resources for ED staff related to recognition and provision of initial care to children and youth with potentially increased risks of MBH concerns including LGBQT+ youth; victims of maltreatment, abuse, or violence, including physical trauma, mass casualty incidents, and disasters; and those with substance use-related problems (eg, acute intoxication, overdose), preexisting conditions (eg, autism spectrum disorder, developmental delay, intellectual disability), posttraumatic stress, depression, children in the child welfare system, youth in the juvenile justice system, and suicidality.

• Explore development of expanding telehealth consultations (telepsychiatry), particularly in resource-limited areas, or during pandemics and disease outbreaks such as coronavirus disease 2019, including provision for documentation, compensation for such services, and considering best practices for pricing (ie, payment bundled for multiple consults for ED patient with prolonged length of stay). Access to broadband internet for telehealth services must also be considered. In addition, strategies to improve mental health specialist continuity of care for the same patient during the same encounter should be developed.

• Advocate for 24-hour access to professional interpreter services, including for American Sign Language, and/or interpreters trained in crisis management for patients and families with limited English proficiency.

• Develop standards and systems to establish consultation and acute referral networks within hospitals and communities.

• Develop systems for care linkages and follow-up to help patients navigate the complex mental health system, including referral to outpatient and community behavioral health centers.

• Leverage technology, including electronic apps and social media, for safety planning to improve follow-up/contact (eg, ED SAFE, Tennessee program for treatment/supplement treatment interventions, for accessioning help; Colorado suicide app for teens^36–41 ).

• Ensure an appropriate and safe environment for patients with MBH disorders (eg, quiet environment and schedule for children with autism spectrum or developmental disorders, safe shower facilities with no hanging cords for patient presenting with suicidal ideation or attempt).

• Provide resources for ED staff to deliver culturally appropriate care with a trauma-informed approach. This should include considerations for addressing systemic racism and implicit bias.

• Advocate for community-based behavioral services using a culturally sensitive, patient-centered approach to identify and manage behavioral health concerns before development of an emergency condition.

• Develop school-based screening and provide resources for staff to recognize special MBH 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 resources, previously identified.

• Address behavioral health equity in the community for MBH disorders, including prevention, treatment, and recovery programs for substance use disorders, particularly in vulnerable populations affected by poverty, racism, violence, and food/housing insecurity.⁹ 

• Advocate for adequate pediatric MBH resources in both inpatient and outpatient settings, including the availability of prompt 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 consulting on ED patients (including telemedicine consults), as well as for emergency and prolonged ED care for psychiatric borders.

• Create interfacility transfer agreements, including simplification of psychiatric bed search for patients requiring further care as inpatient, to help limit ED boarding.

• Advocate for referral networks with inclusive mental health coverage, including for those who may be uninsurable (eg, undocumented immigrant children).

• Recognize the medical home as a critical component of MBH in a whole-person care approach for the primary care physicians, PAs, and NPs. Advocate for enhancing residency education in pediatrics, medicine-pediatrics, and family medicine related to pediatric MBH conditions. Primary care physicians, PAs, and NPs should be provided with resources to provide psychiatric care as part of the medical home and to receive appropriate payment for these services.

• Optimize and expand insurance coverage for MBH coverage to overcome limitations of service to children with MBH conditions. Provider networks should include adequate pediatric-trained mental health specialists to serve their patients. Insurance should cover access to pediatric mental health care and case management programs for those with chronic mental illness, 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 inadequate access secondary to the shortage of qualified mental health care specialists.

• Include MBH topics in the educational curriculum of prehospital personnel, emergency physicians, PAs, NPs, staff, nurses, and trainees, including emergency medicine residents and pediatric emergency medicine fellows to provide patient-centered, trauma-informed, and culturally appropriate care.

• Identify current gaps, barriers, and opportunities to improve the current state of MBH care, including supporting programs to increase the diversity of MBH specialists caring for patients in the emergency setting.

• Establish models for improving capacity at the systems level for MBH care services in the entire emergency care spectrum, including those awaiting transfer to higher levels of psychiatric care (eg, inpatient psychiatric hospital beds, community-based acute treatment placement).

• Because there are trends of increasing numbers of patients with MBH conditions boarding in both the ED^28,42  and inpatient units,^43,44  provision of MBH care is critical for some level of ongoing care. This model may include initiating/titrating psychiatric medication for medication management, ED environmental modifications, individual and family therapy, and development of coping skills.^44,45 

• Increase in MBH research funding for EMS for children strategies to screen, identify, and connect to appropriate resources.

• Support the research and development of evidence-based guidelines and best practices for ED screening tools, assessment, consultation, acute management, and follow-up care related to children’s mental health crises.

• Advance research related to the acute management of pediatric MBH disorders and potential prevention strategies for MBH emergencies (eg, acute psychiatric care models in the ED and inpatient units, psychiatric telehealth consultations for the ED, role of mass media in teen suicidality and depression, and implementation of community mobile crisis teams responding to multiple settings).

• Expand research efforts focused on reducing risk factors for youth and examine health inequities related to MBH presentations and management, 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 and racial and ethnic groups, LGBQT+ youth, immigrants and refugees, children in the welfare system, youth with substance use disorders, intellectual disability, 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 MBH presentations of children and youth to the ED and interventions focused on mental health-related inequities in care and outcomes.

• Advance research to better understand the effects of racism and its effects on MBH. This research should include interventional studies to address inequities in mental health care access and outcomes, and care of children and youth of historically disadvantaged racial and ethnic groups.

• Develop and validate quality indicators and metrics to improve and standardize ED care of children and youth presenting with MBH concerns. These quality indicators and metrics must also include a health equity lens, examining disparities in care based on race or ethnicity, sexual orientation, gender identity, chronic conditions, socioeconomic status, and limited English proficiency, as well as other factors.

• Assess the readiness of EDs in the United States to care for children’s mental health emergencies to help identify gaps, needs, and innovations in care.

• Develop models to incorporate MBH evaluation and treatment areas in the ED, where feasible (Table 1). This can include specifically designated spaces. These models have demonstrated improvement in patient and family experience for conducting confidential evaluation and treatment, and have allowed more efficient use of psychiatric consultant time.^45–53 

• Support development of up-to-date, easily accessible, 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 reliance on acute crisis management.

• Advocate for optimizing and expanding insurance coverage, especially for states that have not expanded Medicaid, to improve mental health care screening and treatment of children and youth.

Mental and behavior health emergencies are increasing in children and youth. EDs have been seriously affected by the increases as the safety net for a system with critical shortcomings. The time has come to address this health care crisis through the following methods: addressing MBH inequities; increasing screening of ED patients for MBH conditions; identifying, treating, and referring children and youth with MBH emergencies; improving access to resources for patients and staff; utilizing standardized treatment protocols; and optimizing the use of telehealth in the treatment of pediatric patients with MBH emergencies. A dedicated multipronged, multidisciplinary approach will be necessary to provide patient-centered, trauma-informed services to improve the care of children and youth with MBH emergencies.

Mohsen Saidinejad, MD, MS, MBA, FAAP, FACEP

Susan Duffy, MD, MPH, FAAP

Dina Wallin, MD

Jennifer A. Hoffmann, MD, FAAP

Madeline Joseph, MD, FAAP, FACEP

Jennifer Schieferle Uhlenbrock, DNP, MBA, RN, TCRN

Kathleen Brown, MD, FAAP

Muhammad Waseem, MD, MS, FAAP, FACEP, CHSE-A

Sally Snow, BSN, RN, CPEN, FAEN

Madeline Andrew, MD

Alice A. Kuo, MD, PhD, MBA, FAAP

Carmen Sulton, MD, FAAP

Thomas Chun, MD, MPH, FAAP

Lois K. Lee, MD, MPH, FAAP, FACEP

Gregory P. Conners, MD, MPH, MBA, FAAP, FACEP, Chairperson

James Callahan, MD, FAAP

Toni Gross, MD, MPH, FAAP

Madeline M. Joseph, MD, FAAP, FACEP

Lois K. Lee, MD, MPH, FAAP, FACEP

Elizabeth Mack, MD, MS, FAAP

Jennifer Marin, MD, MSc, FAAP

Suzan Mazor, MD, FAAP

Ronald Paul, MD, FAAP

Nathan Timm, MD, FAAP

Mark Cicero, MD, FAAP – National Association of EMS Physicians

Ann Dietrich, MD, FACEP – American College of Emergency Physicians

Andrew Eisenberg, MD, MHA – American Academy of Family Physicians

Mary Fallat, MD, FAAP – AAP Section on Surgery/American College of Surgeons

Sue Tellez

Ann M. Dietrich, MD, Chairperson

Kiyetta H. Alade, MD

Christopher S. Amato, MD

Zaza Atanelov, MD

Marc Auerbach, MD

Isabel A. Barata, MD, FACEP

Lee S. Benjamin, MD, FACEP

Kathleen T. Berg, MD

Kathleen Brown, MD, FACEP

Cindy Chang, MD

Jessica Chow, MD

Corrie E. Chumpitazi, MD, MS, FACEP

Ilene A. Claudius, MD, FACEP

Joshua Easter, MD

Ashley Foster, MD

Sean M. Fox, MD, FACEP

Marianne Gausche-Hill, MD, FACEP

Michael J. Gerardi, MD, FACEP

Jeffrey M. Goodloe, MD, FACEP (board liaison)

Melanie Heniff, MD, JD, FAAP, FACEP

James (Jim) L. Homme, MD, FACEP

Paul T. Ishimine, MD, FACEP

Susan D. John, MD

Madeline M. Joseph, MD, FACEP

Samuel Hiu-Fung Lam, MD, MPH, RDMS, FACEP

Simone L. Lawson, MD

Moon O. Lee, MD, FACEP

Joyce Li, MD

Sophia D. Lin, MD

Dyllon Ivy Martini, MD

Larry Bruce Mellick, MD, FACEP

Donna Mendez, MD

Emory M. Petrack, MD, FACEP

Lauren Rice, MD

Emily A. Rose, MD, FACEP

Timothy Ruttan, MD, FACEP

Mohsen Saidinejad, MD, MBA, FACEP

Genevieve Santillanes, MD, FACEP

Joelle N. Simpson, MD, MPH, FACEP

Shyam M. Sivasankar, MD

Daniel Slubowski, MD

Annalise Sorrentino, MD, FACEP

Michael J. Stoner, MD, FACEP

Carmen D. Sulton, MD, FACEP

Jonathan H. Valente, MD, FACEP

Samreen Vora, MD, FACEP

Jessica J. Wall, MD

Dina Wallin, MD, FACEP

Theresa A. Walls, MD, MPH

Muhammad Waseem, MD, MS

Dale P. Woolridge, MD, PhD, FACEP

Sam Shahid, MBBS, MPH

Roberta Miller, RN, CPEN, TCRN, Chairperson

Elyssa Wood, PhD, MPH, RN, FAEN

Tasha Lowery, RN, APRN, CEN, CPEN, ENP-C, FNP-C

Julie Cohen, MSN, RN, CPEN, CEN

Rebecca VanStanton, MSN, RN, CEN, CPEN, TCRN

Lisa Hill, DNP, RN, TCRN

Elizabeth Stone, PhD, RN, CPEN, CHSE, FAEN

Domenique Johnson, MSN, RN

We thank Lorah Ludwig, Health Resources and Services Administration, Emergency Medical Services for Children, for her advice and feedback on this paper. We also thank Sam Shahid of American College of Emergency Physicians for all her assistance in the organization of this manuscript.

ED

emergency department

EMS

emergency medical services

LGBQT+

lesbian, gay, bisexual, queer, or questioning

MBH

mental and behavioral health

NP

nurse practitioner

PA

physician assistant