Case Presentation

A 15-year-old boy presents to the emergency department (ED) via EMS for evaluation after getting into a fight at school. He had reportedly threatened another student with a knife and was brought in by law enforcement. He has a history of oppositional defiant disorder. Upon arrival, he is refusing care. He says he is uninjured and does not feel suicidal. He does not wish to undergo any laboratory testing. The patient has been staying with a friend and does not want anyone to contact his grandmother, who is his legal guardian.

Overview of Adolescent Mental Health Emergencies

Pediatric mental health emergencies (MHE) constitute a large and growing segment of pediatric emergency medical care. Depression, anxiety, and behavioral disorders are the leading causes of illness and disability among adolescents. EDs, therefore, play a critical role in evaluating and managing child and adolescent patients with MHE. In 2020, compared to 2019, the proportion of MHE-related ED visits increased from 3.8 percent to 7.5 percent, primarily affecting older adolescents. This was also associated with an increase in the proportion of visits that required psychiatric admission or transfer.¹ According to the World Health Organization, globally, one in seven (14 percent) of 10 to 19-year-olds experience a mental disorder. Depression, substance use and suicide are foremost.² (See Table 1) Suicide is the fourth leading cause of death among 15-to-29 year-olds.³ Pediatric ED visits for suicidal ideation in the U.S. increased from 580,000 in 2007 to 1.12 million in 2015.⁴ On October 19, 2021, the American Academy of Pediatrics (AAP), American Academy of Child and Adolescent Psychiatry, and Children’s Hospital Association declared a national emergency in children’s mental health, noting the effect of the COVID-19 pandemic in addition to existing challenges.⁵

Mental-Health Determinants and Adolescent Triggers

Multiple factors affect mental health. In addition to biological and hormonal factors and changing brain chemistry of adolescents, mental health can be shaped by environmental factors, including life experiences. (See Table 2) Heavy episodic drinking among 15-to-19-year-olds was 13.6 percent in 2016, and cannabis was the most commonly used drug.³The pandemic exacerbated pre-existing challenges to America’s youth, including in-person schooling, in-person social opportunities with mentors and peers, access to health care and social services, food, housing, and health of parents or caregivers. More than 140,000 children in the U.S. experienced the death of a parent or grandparent caregiver.⁶ More heavily affected youth groups include those with disabilities, the LGBTQ+ population, racial and ethnic minorities, those from low-income families, rural areas, those in child-welfare and juvenile-justice systems, immigrants, and the unhoused.⁷ In recent years, black children are nearly twice as likely to die by suicide than white children,⁸ and in socioeconomically disadvantaged children and adolescents, those growing up in poverty are two to three times more likely to develop mental health conditions than peers with higher socioeconomic status.⁹ These factors are often referred to as social determinants of health.

Assessment

A critical part of mental health emergency evaluation is the determination that the patient is “medically cleared,” a phrase indicating that there is no acute medical or traumatic injury. The APA recommends that “universal requirements for routine testing…be abandoned” as part of the psychiatric evaluation, unless clinically indicated. Prompt recognition, treatment, and referral of adolescent mental-health problems can significantly affect emergency outcomes and contribute to these patients’ long-term prognosis.¹⁰ Targeting efforts to enhance MHE care includes expanding access to mental-health specialty consultation, dedicated mental-health policies, and establishing transfer agreements for children with MHE.

Adolescent Rights

Some aspects of the medical rights of minors can vary by state. However, there are some constant elements of which an emergency physician should be aware. EMTALA requires that a medical screening exam to assess for and stabilize life- or limb-threatening disease should be completed first, regardless of whether the patient is a minor or whether their parent or guardian is present. Once the patient is deemed medically stable, their autonomy with and without their guardian may be addressed.¹¹

First, the provider must assess whether the patient has decisional capacity.¹² Second, the patient must have the legal ability and capacity to consent or refuse. This element can vary by state for patients under the age of 18. In most cases, a minor may seek care for a protected health issue related to substance use or reproductive or mental health.  Emancipated minors are typically deemed so by the courts but typically include minors who are financially independent, married, on active military duty, or live independently with their own child(ren).¹¹ Some states have a “mature minor” doctrine. This common law definition allows minors to be seen independently if older than age of 14 and “emotionally mature” as judged by the provider. The physician, in this instance, must meticulously document their judgment of the patient’s capacity to make decisions.

For all other patients, the parent or guardian must be contacted and consent for the patient to be seen and treated in the emergency department.¹¹ Ideally, the minor patient would also assent to the testing and treatment. However, this is not necessary if the guardian has already given consent. If a patient is in the custody of the state or incarcerated, the courts can act as a guardian in certain states.¹²

In this scenario, the grandmother must be notified that the patient is in the ED and consent to treatment. Law enforcement should also have been called if a school administrator had brought in the adolescent. In this case, the prima facie right to confidentiality is superseded by other professional duties, including the protection of society. If a social worker is available, they should be consulted. A report to Child Protective Services is protective and may be helpful to guide the guardian, such as the grandmother in this case, who may be ill-prepared to deal with her grandson with oppositional defiant disorder.

The question also arises as to what should be done with the weapon if this patient or a similar one arrives with one. The weapon should be confiscated and locked up by security. In the case of a competent adult, the confiscated item is sometimes returned after a risk assessment. Some hospitals prefer to reimburse the patient for the cost of the item to avoid future liability. Illegal contraband should be cataloged and disposed of under supervision. If a risk manager is available, it is also a good idea to consult them.

Case Resolution

This case describes multiple complex issues in the emergency management of adolescent psychiatric patients. Because the patient exhibited violent behavior, he should be considered a risk to others. Due to this serious risk of violence, he should not be regarded as safe to refuse laboratory testing or psychiatric assessment. Although the teen may demonstrate decisional capacity, he has forfeited his right to privacy in this case. The patient’s grandmother is notified and reveals that the patient has not seen a counselor recently. The physician deems the patient a danger to himself and others, and he is admitted to an adolescent psychiatric unit.

References

1. Bolt J, Patel F, Stone L, et al. Impact of COVID-19 on Pediatric Mental and Behavioral Health Visits to the Emergency Department. Pediatr Emerg Care. 38(8:)409-415. DOI: 10.1097/PEC.0000000000002794.
2. Bitsko RH, Claussen AH, Lichstein J, et al. Mental Health Surveillance Among Children — United States, 2013–2019. MMWR Suppl 2022. 71(Suppl-2):1–42. DOI: 15585/mmwr.su7102a1external icon
3. World Health Organization.  Mental health of adolescents. https://www.who.int/news-room/fact-sheets/detail/adolescent-mental-health. Published November 17, 2021. Accessed March 8, 2023.
4. Burstein B, Agostino H, Greenfield B. Suicidal Attempts and Ideation Among Children and Adolescents in US Emergency Departments, 2007-2015. JAMA Pediatr.2019;173(6):598–600. DOI:10.1001/jamapediatrics.2019.0464.
5. AAP, AACAP, CHA declare national health emergency in children’s mental health. American Academy of Pediatrics News website. https://publications.aap.org/aapnews/news/17718/AAP-AACAP-CHA-declare-national-emergency-in. Published October 19, 2021. Accessed March 8, 2023.
6. Hillis, SD Blenkinsop A, Villaveces A, et al. COVID-19-Associated Orphanhood and Caregiver Death in the United States. Pediatrics. 2021;148(6): e2021053760 DOI:10.1542/peds.2021-053760.
7. Abrams AH, Badolato GM, Boyle MD, McCarter R, Goyal MK. Racial and Ethnic Disparities in Pediatric Mental Health-Related Emergency Department Visits. Pediatr Emerg Care. 2022;38(1):e214-e218. doi: 10.1097/PEC.0000000000002221.
8. Bridge JA, Horowitz LM, Fontanella CA, et al. Age-Related Racial Disparity in Suicide Rates Among US Youths From 2001 Through 2015. JAMA Pediatr.2018;172(7):697–699. doi:10.1001/jamapediatrics.2018.0399.
9. Reiss F. Socioeconomic inequalities and mental health problems in children and adolescents: a systematic review. Soc Sci Med. 2013;90:24-31. doi: 10.1016/j.socscimed.2013.04.026.
10. American Academy of Pediatrics Section on Emergency Medicine and the Canadian Association of Emergency Physicians Five Things Physicians and Patients Should Question. ABIM Foundation website. https://www.choosingwisely.org/wp-content/uploads/2022/11/AAP-SOEM-CAEP-5things-List_Draft-2.pdf. Released December 1, 2022. Accessed March 8, 2023.
11. Benjamin L, Ishimine P, Joseph M, Mehta S. Evaluation and Treatment of Minors. Ann Emerg Med. 2018;71(2): 225–232. doi:10.1016/j.annemergmed.2017
12. Morrison SN, Sigman L. Consent, refusal of care, and shared decision-making for pediatric patients in emergency settings. Pediatr Emerg Med Pract. 2021;18(5):1-20.