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Troubled kids in ER: Psych illness or just unruly?

By Dr. Tyeese Gaines

American children visit the emergency room as often as 825,000 times a year -- not for broken bones or bellyaches -- but to urgently see a psychiatrist. Yet, aside from the select few who are suicidal, a threat to others or severely debilitated, most are discharged and sent home.

It turns out that a surprising number of ER patients are being seen for behavioral issues or a minor psychiatric crisis. A review of 2,900 records of ER patients ages 17 and younger showed the majority were brought to the hospital because of issues such as disruptive classroom behavior, verbal altercations and running away, according to a 2011 John Hopkins study.

Experts question whether these children need to visit the ER at all and whether they are unnecessarily taxing an already overstretched emergency care system.

“If somebody comes in with pneumonia, we give antibiotics and they’re fine,” said Dr. Muhammad Waseem, pediatric emergency physician at Lincoln Medical and Mental Health Center in Bronx, NY. “But, with mental health, they require significant resources, time, and services.”

Several reports confirm that pediatric ER visits for psychiatric complaints have risen over the last decade and continue to increase. National data presented last fall found that visits over an eight-year period -- from 1999 to 2007 -- had increased by 20 percent.

“[Parents] don’t know what to do,” says Dr. Gary M. Blau, clinical psychologist and chief of the Child, Adolescent and Family Branch of the U.S. Center for Mental Health Services. “They’re not sure what mental health conditions are and whether to be concerned about them or not.”

Dr. Tyeese Gaines

“Often the parents themselves feel unsafe, or the home situation is unsafe, such as for a younger sibling,” says emergency medicine doctor Dr. Audrey Paul. “They are in a state of crisis.”

The ER, however, is not the best location for pediatric mental health concerns, according to child and adolescent psychiatrist Dr. Jacqueline Smith at University of North Carolina Hospitals.

“The emergency department can be traumatizing for a child,” she says. “Also, appropriate staff may not be readily available for assessments or recommendations, leading to very long waits for these children.”

Paul agrees. “It’s loud. It’s overcrowded. And, privacy is an issue.”

Given the limited amount of available mental health beds for admitted children, Paul -- who is a pediatric ER physician and an associate professor of emergency medicine at Mount Sinai School of Medicine -- shares that these children can sometimes stay in the emergency department for over 24 hours.

Similarly, nationwide, children with mental health complaints are twice as likely to wait four hours or more than those with other ER complaints, subsequently contributing to ER overcrowding and limiting care to the other children waiting to be seen.

Some studies suggest that the increase in visits do not actually correlate to an increase in psychiatric illnesses among children.

 “Unruly behavior can be the result of a psychiatric or medical illness, but it can also be the result of parents having difficulty setting limits,” Smith says. “If behavior is simply unruly, it should be addressed, but perhaps not in an emergency room.”

Tanya Haney-Miller, a school counselor in New Jersey, says that it sometimes comes down to discipline.

“A lot of parents are fearful of [child protective services], and parents don’t want anyone in their business,” she says. “They’d rather avoid disciplining their child because they think that the main way of disciplining is hitting. Some don’t know another way.”

Waseem acknowledges that parents have it rough, making it hard to give troubled children the type of attention and support needed to defuse such issues.

“Parents are living in a high-stress situation,” he says. “They don’t have adequate time. With economic issues, both parents are forced to work in order to sustain, and there is no one to adequately supervise the child.”

Children are exposed to these same high-stress environments which can lead to psychological outbursts after just a minor exposure to emotional trauma, Waseem adds.

He also points out that just because many of these children are discharged doesn’t mean the visit wasn’t warranted. At times, the complaints are issues that can be solved in the emergency department during a long ER stay.

Blau, too, says not to discount the demand for ER psychiatric care. The rates of mental health among children are significant: the U.S. Department of Health and Human Services reports that one in five adolescents has a diagnosable mental health disorder.

All of those interviewed felt that the lack of outpatient resources was a key factor in the increase in ER mental health visits. The most at-risk and economically disadvantaged patients make up a large amount of the visits.

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“There are simply not enough child and adolescent mental health providers, particularly psychiatrists,” Smith says. “As more parents lose insurance coverage, so do their children. This increases the number of children requiring community mental health services, straining that system. Out of frustration, parents turn to the emergency department.”

In some cases, even the outpatient resources that do exist, such as counselors and schools, still refer patients to the ER for behavioral issues rather than solely psychiatric ones.

“If the schools had programs in place to deal with these things, many of these visits could be avoided,” Paul says. “But, a lot of after school and community based programs have been cut.”

Haney-Miller says that despite her opinion that ER psychiatric evaluations often fall short of expectations, there are protocols to follow.

“Sometimes, it’s not even a thorough evaluation,” she says. “But, we still have to send them. It’s policy.” Haney-Miller adds that with certain mental health crises, the children can’t attend school until a psychiatrist evaluates them.

“They can opt to go to their private physician,” she says. “But, if they don’t have insurance or they have Medicaid, there may be a huge wait for the clinic, and they’re not allowed to return to school.”

Several schools near Lincoln Medical and Mental Health Center have mental health services embedded into their programs, according to Waseem. He says in six months, his ER only received three children from those schools.

“They are not referring their psychiatric children to the ER,” he says. “They are managing themselves.”

However, Blau cautions against broadly discouraging parents from bringing their children to the ER for evaluation.

“While there is truth to the overuse of the ER,” he says, “that one time a parent doesn’t go, there’s a tragedy.”

Dr. Tyeese Gaines is a physician-journalist with over 10 years of print and broadcast experience, now serving as health editor for theGrio.com (NBC News). Dr. Ty is also a practicing emergency medicine physician in New Jersey. Follow her on twitter at @doctorty or on Facebook.

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