A 15-year-old male is brought to the emergency department (ED) after he jumped from the second floor of a building in a suicide attempt and sustained a complex ankle fracture.

His fracture was placed in a splint in the ED, but he requires outpatient surgery for definitive fracture repair. He was evaluated by psychiatry and deemed to need inpatient psychiatric care, but due to concern that he may use his splint to harm himself, he was deemed not eligible for the inpatient psychiatry floor and has been boarding in the ED.

Background

Over the past decade, the number and complexity of pediatric mental-health emergencies have increased at an alarming rate.¹ The COVID-19 pandemic significantly exacerbated this already existing problem.²

By 2021, mental-health visits to the emergency departments (EDs) by children five to 11 years old increased by 24 percent, while visits by adolescents aged 12 to 17 years increased by 31 percent, compared to 2019.³ In addition to this, children of diverse groups have been disparately affected.⁴

This combination of historic increases in pediatric mental-health visits, lack of adequate mental-health-care infrastructure, and shortage of mental-health professionals prompted several organizations to declare a national crisis in pediatric mental health.⁵ As a result of the continuing increase in demand for immediate psychiatric assessment and limited community psychiatric resources, the nation’s EDs have become de facto referral centers.⁶

With limited ED staffing and resources to care for these conditions, children spend several hours to days boarding in the ED as they await definitive psychiatric care.⁷ For these children and their families, as well as the ED staff, boarding in the ED causes significant stress and anxiety, further exacerbating the situation.

Although the problem of psychiatric boarding also affects adult patients, as was highlighted in a recent ACEP Now article, the unique challenge with pediatric mental health is the even greater shortage of services and the complexity of caring for this population and their families.⁸

A critical role of the ED is to provide initial screening and assessment of youth with mental-health concerns to determine which patients are at low risk and can be discharged from the ED with outpatient resources. Studies have shown that most children who present to the ED with a mental and behavioral health emergency can be safely discharged with an appropriate mental-health follow up.⁹ To this end, use of reliable and proven screening tools, such as the Ask Suicide Screening Questions and Columbia Suicide Severity Rating Scale, can help ED and primary care clinicians with suicide risk assessment.^10-12

Several factors contribute to the decision to discharge a child with a mental or behavioral complaint from the ED versus admission for inpatient psychiatric care. Key factors associated with difficulty in safe ED discharge as well as predictors of ED revisit include: impulse control issues; neuro-developmental disorders; acute suicidality or psychomotor agitation; anxiety; mood disruption; and drug or alcohol intoxication.^13,14

In addition to this, patients are more likely to make a return visit to the ED if they did not have a mental-health follow-up within 30 days of the initial ED visit, although less than 50 percent of children with mental-health concerns do not receive proper mental-health follow-up within 30 days.¹⁵

Discharge planning for low-risk children during the ED visit is critically important, as evidence suggests that children who were not given a specific follow-up appointment with a mental-health professional were more likely to have an ED revisit within three months.¹⁶

In addition to providing timely followup, access to therapeutic interventions such as the Stanley Brown Safety Plan, lethal-means counseling education, and interventions help patients and families learn to identify triggers and coping skills so they can feel more knowledgeable, safe, and empowered to seek help when needed.^17,18 The Emergency Medical Services for Children Innovation and Improvement Center, funded by the Health Resources and Services Administration in collaboration with several professional societies including ACEP, has developed a series of resources for care of children with suicidality and agitation through its Pediatric Education and Advocacy Kits.^19,20

For children who are not deemed to be at low risk and who require inpatient care, the ED often serves as the boarding site, as the number of available inpatient pediatric psychiatric beds are far fewer than the number of children needing them. This results in ED beds and staff being allocated to mental-health boarding, which affects ED staffing and throughput. These children sometimes spend days and weeks in the ED, and their treatment needs (medications and therapeutic engagement) and daily activity needs such as food, hygiene, and entertainment must be met.²¹

However, there are resources, including free online toolkits such as the New England Behavioral Health toolkit developed by the New England Emergency Services for Children collaborative, that include a daily schedule template, free activities patients can do in the ED, and a safe-toy purchasing guide for pediatric ED patients who are boarding for a mental and behavioral health crisis.^22,23

As EDs continue to struggle to keep up with the great surge of pediatric mental-health emergencies, especially prolonged boarding, a new, joint, policy statement by ACEP, American Academy of Pediatrics, and Emergency Nurses Association on management of pediatric mental health in the ED was recently published online and appears in the September 2023 issues of the Annals of Emergency Medicine, the Journal of Emergency Nursing, and Pediatrics.^24-26

Dr. Li is an assistant professor in pediatrics and emergency medicine at Harvard Medical School and a pediatric emergency medicine physician at Boston Children’s Hospital, both in Boston.

Dr. Feuer is associate vice president of school mental health and director of pediatric emergency psychiatry at Northwell Health, Cohen Children’s Medical Center. She is also an associate professor of psychiatry, pediatrics and emergency medicine at the Zucker School of Medicine at Hofstra/Northwell Health, NY.

Dr. Saidinejad is a professor of emergency medicine and pediatrics at the David Geffen School of Medicine, and director of pediatric emergency medicine at the University of California, Los Angeles.

References

1. Piao J, Huang Y, Han C, et al. Alarming changes in the global burden of mental disorders in children and adolescents from 1990 to 2019: a systematic analysis for the Global Burden of Disease study. Eur Child Adolesc Psychiatry. 2022;31(11):1827-1845.
2. Shankar LG, Habich M, Rosenman M, et al. Mental health emergency department visits by children before and during the COVID-19 pandemic. Acad Pediatr. 2022;22(7):1127-1132.
3. Radhakrishnan L, Leeb RT, Bitsko RH, et al. Pediatric emergency department visits associated with mental health conditions before and during the COVID-19 pandemic – United States, January 2019-January 2022. MMWR Morb Mortal Wkly Rep. 2022;71(8):319-324.
4. Hoffmann JA, Alegría M, Alvarez K, et al. Disparities in pediatric mental and behavioral health conditions. Pediatrics. 2022;150(4):e2022058227.
5. American Academy of Pediatrics. AAP-AACAPCHA Declaration of a National Emergency in Child and Adolescent Mental Health. AAP website. Updated October 19, 2021. Accessed October 11, 2023.
6. Manuel MM, Yen K, Feng SY, et al. The burden of mental and behavioral health visits to the pediatric ED: A 3-year tertiary care center experience. Child Adolesc Ment Health. 2023;28(4):488-496.
7. Wolff JC, Maron M, Chou T, et al. Experiences of child and adolescent psychiatric patients boarding in the emergency department from staff perspectives: Patient journey mapping. Adm Policy Ment Health. 2023;50(3):417-426.
8. Miller, G, Enguidanos, E. Emergency departments and the growing mental health crisis. ACEP Now website. Published May 2, 2023. Accessed October 11, 2023.
9. Randall MM, Parlette K, Reibling E, et al. Young children with psychiatric complaints in the pediatric emergency department. Am J Emerg Med. 2021;46:344-348.
10. National Institute of Mental Health. Ask suicide screening questions (ASQ). NIMH website (OMB approval #0925-0648). Expiration date June 30, 2024. Accessed October 11, 2023.
11. Columbia Lighthouse Project. Columbia suicide severity rating scale (C-SSRS). Columbia Lighthouse website. Published 2016. Accessed October 11, 2023.
12. Columbia Lighthouse Project. Columbia Suicide Screening Rating Scale (C-SSRS) – screen for triage points for primary care. University of Washington Psychiatry & Behavioral Health Sciences Division of Population Health website. Accessed October 11, 2023.
13. Marzola E, Duranti E, De-Bacco C, et al. Psychiatric patients at the emergency department: factors associated with length of stay and likelihood of hospitalization. Intern Emerg Med. 2022;17(3):845-855.
14. Cushing AM, Liberman DB, Pham PK, et al. Mental health revisits at us pediatric emergency departments. JAMA Pediatr. 2023;177(2):168-176.
15. Hoffmann JA, Krass P, Rodean J, et al. Follow-up after pediatric mental health emergency visits. Pediatrics. 2023;151(3):e2022057383.
16. Bardach NS, Doupnik SK, Rodean J, et al. ED visits and readmissions after follow-up for mental health hospitalization. Pediatrics. 2020;145(6):e20192872.
17. Stanley B, Brown G. Stanley-Brown safety planning intervention. Stanley-Brown website. Accessed October 11, 2023.
18. Harvard University TH Chan School of Public Health. Means Matter. Harvard University website. Copyright 2023. Accessed October 11, 2023.
19. Emergency Medical Services for Children Innovation and Improvement Center. Pediatric education and advocacy kits (PEAK): Suicide. EIIC website. https://emscimprovement.center/education-and-resources/peak/pediatric-suicide-screening-mental-health/. Accessed October 11, 2023.
20. Emergency Medical Services for Children Innovation and Improvement Center. Pediatric education and advocacy kits (PEAK): Agitation. EIIC website. https://emscimprovement.center/education-and-resources/peak/pediatric-agitation/. Accessed October 11, 2023.
21. Feuer V, Mooneyham GC, Malas NM. Addressing the pediatric mental health crisis in emergency departments in US: Findings of a national pediatric boarding consensus panel. J Acad Consult Liaison Psychiatry. 2023:S2667-2960(23)00089-7.
22. Emergency Medical Services for Children Innovation and Improvement Center. New England Regional Behavioral Toolkit. EIIC website. https://emscimprovement.center/state-organizations/new-england/new-england-behavioral-health-toolkit/. Published June 2021. Accessed October 11, 2023.
23. Pulcini CD, Schneider S, Wolfley H, Collins B, Li J. Assessment of statewide initiative for children boarding in rural emergency departments with mental health concerns. Acad Emerg Med. 2023. doi: 10.1111/acem.14772. Epub ahead of print.
24. Saidinejad M, Duffy S, Wallin D, et al. The management of children and youth with pediatric mental and behavioral health emergencies. Pediatrics. 2023:1;152(3):e2023063256.
25. Saidinejad M, Duffy S, Wallin D, et al. The management of children and youth with pediatric mental and behavioral health emergencies. J Emerg Nurs. 49(5):703-713.
26. Saidinejad M, Duffy S, Wallin D, et al. The management of children and youth with pediatric mental and behavioral health emergencies. Ann Emerg Med. 2023;82(3):e97-105.