- ED —
- emergency department
A 15-year-old boy with a previous traumatic brain injury arrives in the emergency department (ED) with aggressive behavior. During his ED visit and admission to the inpatient unit, the boy initially requires physical restraints and medications to treat his aggression. A thorough medical evaluation reveals that his behavior is a symptom of constipation. After medical treatment, along with mental health counseling and adjustment of his psychiatric medications, he is discharged from the hospital with outpatient rehabilitation, regular pediatrician visits, and community mental health services. The health care team was able to identify effective physical and mental health treatments using a collaborative multidisciplinary approach.
At least 1 in 5 children experiences a mental health condition during childhood or adolescence,1 and more children with mental health concerns than ever before require ED and acute hospital care.2 Improvements in preventing and treating children’s mental health conditions have not kept pace with the remarkable progress in preventing and treating other pediatric illnesses. To illustrate, over the past 2 decades, childhood cancer deaths have declined by 20%,3 and infant mortality rates have reached historic lows.3 During the same time period, adolescent suicide deaths have increased by 1% to 2% each year, and deaths from opioid overdose in young adults have quadrupled.3 Improving these and other outcomes requires integrating mental health care into all levels of the continuum of care, from prevention to crisis management.
Currently, EDs and acute care hospitals are safety nets focused on crisis stabilization for patients with severe mental health concerns. Even within this limited mission, hospitals have inadequate capacity to provide mental health care, as evidenced by the practice of “psychiatric boarding” and the shortage of clinicians to deliver acute mental health treatments.4 In some cases, ED and hospital visits focused on physical health can exacerbate mental health problems. For example, intensive medical evaluation might reinforce symptoms of conversion disorder, and a stimulating ED environment can exacerbate agitation. Although hospitals are not equipped to replace community-based ambulatory mental health services or inpatient psychiatric treatment, opportunities exist to better address mental health concerns during ED and hospital encounters.
Primary care pediatricians and medical homes can provide patients and families guidance about when to seek emergency evaluation and what to expect in the ED and hospital. Hospitals, in turn, can be a partner to primary care medical homes by being well-prepared to address mental health concerns. We propose 3 priority areas to improve integration of mental health care into EDs and hospitals: reliable screening for and identification of mental health concerns, initial management (beyond stabilization) of mental health problems, and effective referrals to ongoing mental health treatment. Fully implementing processes to address these priorities will establish a continuum of care focused on supporting both physical and emotional health.
ED and hospital teams need reliable tools for identifying patients’ mental health needs. Currently, no guidelines specifically address best practices for mental health screening in pediatric acute care settings, and screening practices vary. Although some patients present with a stated mental health complaint, other patients present with complaints that have a less-apparent mental health component. For example, diabetic ketoacidosis or asthma exacerbation might be triggered by medication nonadherence due to substance abuse. Children and adolescents with depression or anxiety may present with somatic symptoms like headache or chest pain. Screening for mental health problems affecting a patient’s acute presentation can help clinicians offer targeted diagnostic evaluation and treatments, potentially avoiding unnecessary evaluation or overtreatment while ensuring a patient’s safety. Barriers to screening include lack of resources, confidentiality, timely communication of results to clinicians, and ensuring that screening does not interfere with competing demands like acute stabilization. The authors are aware of 2 instruments in use at children’s hospitals. The Behavioral Health Screen5 is a comprehensive Web-based self-report instrument used to assess adolescents for depression, suicide ideation, posttraumatic stress, and substance use. In settings with resources to address screening results, the Behavioral Health Screen can be used to identify a range of psychiatric problems and risk factors. For hospitals with fewer resources, focused screening for high-risk problems like suicide ideation remains important. The Ask Suicide-Screening Questions6 can be used to identify patients at risk for suicide in acute medical settings. Successful screening programs require clinicians competent in explaining the rationale for screening to patients and caregivers and that the screening be embedded in a system of care that can address concerns.
Effective management of mental health concerns relies on a health care team equipped to offer mental health support. Generalist clinicians report having inadequate skills to address mental health complaints.7 Programs to help clinicians develop these skills include Positive Behavioral Intervention and Support,8 Trauma Informed Care,9 and Crisis Prevention Institute10 trainings. Leveraging such training programs requires a commitment from health system leaders to incorporate mental health care into the health system’s mission. To help clinicians obtain mental health training, institutions could provide continuing education credits, offer protected time or adjustments in productivity targets to accommodate attendance, host mental health training events, or require training in mental health skills for clinical leaders. In addition, strategic investment in mental health and behavior specialists, including social workers, child life specialists, psychologists, psychiatrists, and behavior analysts, can increase clinical teams’ effectiveness in evaluating and initiating treatment of complex mental health problems. Where specialists are not available at the point of care, telephonic support, similar to poison control centers or primary care telephonic child psychiatry consultations, could improve patients’ timely receipt of treatments. Technology-based solutions such as psychological therapies delivered via video interface or smart phone applications might also offer innovative and lower-cost opportunities to initiate treatment. With appropriate staff training and investment in specialty expertise, clinicians can provide initial management of mental health problems in acute care settings.
Although we posit that EDs and hospitals can substantially improve mental health care for children and adolescents in acute settings, connection to ongoing mental health services in primary care and specialty settings remains a critical component of effective treatment. Both stigma and logistical challenges (appointment availability, insurance, transportation) prevent patients from accessing mental health care. A system of follow-up from the acute care team after discharge can address these barriers and improve a patient’s probability of enrolling in outpatient care.11 Follow-up might involve a nurse or community health worker home visit, a phone call, or a planned return to the ED or hospital for ongoing treatment or safety monitoring. Direct communication between acute care clinicians and the outpatient team can help prevent loss of continuity in the patient’s mental health treatment. To facilitate direct communication, clinicians must be familiar with community primary care practices, schools, mental health service agencies, and child protective services. In some cases, hospitals might build partnerships with community groups to exchange expertise and develop integrated systems for efficient mental health care. In other settings, an individual staff member or professional group, like a social work team, can be a liaison to community clinicians.
Patients who present to EDs and hospitals with overt or underlying mental health concerns deserve a systematic approach to effective and sustained care. We propose that EDs and acute care hospitals can improve patients’ mental health if health care teams are equipped to identify mental health concerns, manage acute mental health problems, and provide referrals to ongoing mental health care. To implement these strategies, EDs and hospital systems must view mental health care as an integral part of their mission and work toward building teams that can meet all patients’ mental health needs.
- Accepted December 18, 2017.
- Address correspondence to Stephanie K. Doupnik, MD, MSHP, #10194 Roberts Center for Pediatric Research, Children’s Hospital of Philadelphia, 2716 South St, Philadelphia, PA 19146. Email:
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Dr Doupnik was supported by a National Research Service Award (HP-010026).
POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.
- Zima BT,
- Rodean J,
- Hall M,
- Bardach NS,
- Coker TR,
- Berry JG
- Centers for Disease Control and Prevention
- Freed GL,
- Dunham KM,
- Switalski KE,
- Jones MD Jr,
- McGuinness GA; Research Advisory Committee of the American Board of Pediatrics
- US Department of Education Office of Special Education Programs.
- The Trauma Informed Care Project.
- Crisis Prevention Institute
- Copyright © 2018 by the American Academy of Pediatrics