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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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I have to say that like most things I read these days there is a lot of talk of what the problem is and no discussion of how to fix it (both in the article and the comments). It's very easy to sit back and criticize teachers, parents and other doctors but nowhere in this article is a mention of what to do instead of the ER. To state that parents need to be better disciplinarians is blatant evidence that you are uninformed and have never had to deal with a child in need.
I have a son with issues. Do you think I just sit back and watch him struggle and do nothing? We have set rigid rules and consequences for behavior at school and at home. I am in constant contact with his school. He sees a psychologist every other week. I am constantly reading every piece of material I can pick up that will give me some insight into how he thinks and what will help him get better or at least survive in a world he can't understand. He is also on medication based on recommendations from his school, pediatrician and counselor. To suggest that everything can be cured by "spare the rod and spoil the child" is asinine. You think that if that worked I would be spending all my time and effort on more expensive, time consuming avenues? It doesn't work. He is violent enough without me teaching him how to do it better!
I keep waiting for the right article, the right study, the right advice, anything that will help my family and most especially my son. Why? Because I love him more than anything and refuse to give up. I refuse to believe he can't be helped. I will keep trying! He is worth it and so is my family. It's not easy and every day is a struggle. What is the alternative? Give up on my son...it'll be a cold day in hell.
So please don't sit back in your easy chair and say if his parents can't handle him they're lazy or don't care. I'll try anything and everything to help him. Which means if the day comes when I can't calm him down or his anger takes over and safety becomes an issue I'll go to the emergency room, his pediatrician's office, his counselor's office, or anywhere else I can thing of to help him because the last thing I'll do is nothing.
No useful advice other than don't give up - and don't let these internet "experts" get you down. You sound like a great parent - keep fighting for your son, and keep your head high.
Have you had your child checked for food allergies and chemical sensitivities?
It's absolutely amazing how those things can affect your child's mental, emotional, and physical health. It sounds like you are doing everything you can, but it's hard to find a doctor who is trained in environmental medicine. The Valley Clinic in Paradise Valley, AZ, is such a place. Check it out. I've met people from all over the country there who come to finally get an accurate diagnosis - the kind that doesn't show up in a blood test!
Good luck with your son! I agree with Intelligent and Independent about the environmental testing. If you have already tried everything else, that sounds like a good option.
The only other option is hope and pray to whatever deity you believe in that he grows out of it. That is not a very good option though.
What a sad situation we are in. Children, adults, veterans, the elderly...ALL require some sort of mental health care. Now, I agree this is a huge issue. The sad part is, there are not many resources available in mental health. Either the patients are un-insured or under insured, meaning that they do not have mental health benefits in their plan. Medicaid or other gov.t medical benefits do not cover patients to be treated in this manner. Unfortunately, patients are being told the only way they can get care is to present to the ER. I am in the healthcare field and this is so disturbing. You have no idea how many people would be in better health if they only had some sort of benefits covering counseling. IT WORKS!!! We are a very backwards society that we don't do a damn thing to prevent these issues but when the problem grows out of control, it's out fault. It's horrible to hear someone talk about how they need help and in many cases for children, they only get help when law enforcement gets involved. They don't get help until they are already in the system. Why? Why do we have to work it this way. It is sooooo frustrating. I think we need to stop cutting funding for Mental Health. This area of medicine is vastly under-rated. I'm sorry, but if we had adequate mental health benefits and coverage and resources, you would have less ER visits, less alcohol and drug dependancy issues, less violence and less unnecessary uses of time and resources. I am not sure which big gov't company is trying to fatten their wallets by thinking mental health services are unwanted or not needed are sadly mistaken. Quit trying to inflate your wallet and lets care about the citizens of our own country and give them the best resources we have available. Everyone is entitled to live the best way they can and to have the oppurtunities there if they need. We are circling the drain as a society. I am so sick of other people, other companies telling me what is good for me and what I need. Most the time they have no medical knowledge at all. How on earth would anyone want to be told that they can't have services because someone else thinks it's not needed. I know what I need, and most the time so does everyone esle. So how about we give people what they REALLY need. Most the time, people just want to be heard and helped.
remember class clowns? kids who made jokes to relieve stress= now called classroom "disruptions"
pent up tension or add= pat your kid on the bottom and make him/her run around the yard five or six times or the block.
kids being lonely, social issues, etc.= have them join a group, for fun, like crafts, girl/boy scouts, youth groups, church, etc.
Lets see...
No public mental health programs, Check.
National gun culture, Check.
Violence glorified in popular media, Check
I think we're on track ! Vote Mitt !
Tell you what, it's having guns that have kept you and me free, and I'd much rather deal with the problems that guns present rather than not have any choice at all..in anything..and it can happen.!!
Old Dud - Guns do not shoot freedom out the barrel.
Guns are used for suicide over 50% of the time in the USA (2007), about 50 people per day, mostly white males over 45. Then next largest group of gun related deaths, is black males 16 to 30, usually while committing a crime... see http://www.nytimes.com/imagepages/2007/04/21/weekinreview/20070422_MARSH_GRAPHIC.html
Japan which has almost ZERO guns, has the highest suicide rate in the world almost 100 per day. This is over twice the suicide rate of the USA & UK. In 2009, the number of suicides among men rose 641 to 23,472 (with those age 40–69 accounting for 40.8% of the total). Suicide was the leading cause of death among men age 20–44.[4][5]
The UK is now the most VIOLENT society in the World (2007), surpassing the USA & South Africa. But they banned guns for almost everyone, two decades ago... see http://www.telegraph.co.uk/news/uknews/law-and-order/5712573/UK-is-violent-crime-capital-of-Europe.html
While Kennesaw, GA has required every household to own & maintain a gun for almost 30+years. Has almost ZERO gun deaths, during this period, and their crime rates are well below the US averages... see http://www.freerepublic.com/focus/news/1818862/posts
Yep, there are just those kids that you just have to get their attention first, what ever it takes sometimes...repeatedly if necessary.
I raised two boys, if they wanted something, they had to work for it. You set boundrys, and you stick to them. And never..ever ..back down. They will always test you...that's when it's fun, cuz I tried all that with my Dad. Been there done that.
No wonder some ERs have 4 hour waiting times. Back in the day we sent these brats off to Juvenile Detention Centers.
Let me see, first you take god out of the equation, then you deflowered the teachers by unionization and allowing threats of law suits, main streaming the insane and troubled, refusing to recognize boys don't learn like girls (shock we are different), then you emasculated us by watching Murphy Brown and minimizing the importance of Males in the family, and weakened the police by allowing them to die at an amazing rate with only politically correct responses, tolerate a horrendous body politic who get paid whether they perform or not, I.e., balancing our budget, totally ignore our horrifyingly large budget, and then you dare to complain??? What of the above isn't clear?
Watching Murphy Brown hurt men???? Are you kidding me? That's the funniest, and saddest, thing I've heard all day - ha!
It is no longer a matter of what is and isn't appropriate to be seen in ERs. Its simply that emergency rooms have become the primary source of medical care. The uninsured often have simple problems that would be easily treated, but without access to health care they wait until their conditions are dire, and far more costly.
Parents paying the price for lack of discipline. and bring back spanking...it works. I am old enough to remember the strap in school....it worked. Kids simply are out of control because they have not learned to get custody of their emotions. They do what they wish to do or ELSE. There are no consequences. Their wills dominate. It is very hard to live in a world with other people when your will rules.
Funny thing, no one in my family uses violence and pain on our children. We do however pay them a lot of attention, keep them active and talk/LISTEN alot. With very few exceptions our children are utterly non-violent, very well behaved, and highly succesful.
BTW, what happens when the child is bigger than you? Is he automatically always correct and allowed to do whatever he wants--- because he can now kick your azz? Yeah, more violence and teaching that might equals right. Thats really going to help (?)!
I've known too many adults who had never in their lives been around a child until they had one of their own. Only a couple generations ago, children were a normal part of extended families - not just younger siblings, but younger cousins & such. Now, people can reach their 30s having never spent any significant time around children. There is some idea that rearing children is instinctive. It isn't. It's learned behavior. We have reached such a bizarre state of development that the most basic function of the species, rearing the next generation, is something a great many people know nothing about. That the children have mental problems or that the parents think the children have mental problems does not surprise, since the parents never in their lives had any opportunity to learn what is normal.
The children today know how to work the system
, they been taught this by the liberal school system. If a parent tries to discipline their children they run to school and tell the teachers they are being abused. Next thing that the parents know is that they are under investigation.
There is a national epidemic of SPOILED BRATITIS & HORRIBLE PARENTITIS!
There's no unruly behavior OR mental disorder that a couple of stiff backhands across the mouth won't cure in a heartbeat.
I certainly agree with Doubledoc....As a medical provider also.....I have people coming in my office all the time wanting a pych dx so they can get meds when what the child needs is some consistent discipline with consequences that are held to if the child does not behave....It is hard for me to look at a child who was brought into the Er by a Mom because the child got mad...the child was 5...and threw her toys out the window....after throwing the first one through the window....She wanted the child on meds....She left my practice and found someone who gave her what she wants....she now has a handicap sticker because she stated (along with the new provider) that it wasn't safe for her child to park at the back of a parking lot....because the child has threatened to run away from her.....She has a pych dx that will stick with her throughout her life....She is on Abilify.....and her Mom has quit her job and now stays at home...Of course the child is in school now.....and gets SSI....This is not unusual........this is a story that happens frequently......Very sad....
People are going to the ER because they don't have health insurance. And if they do have insurance they may not have mental health coverage. If psychiatrists wouldn't charge over $125 an hour for treatment, perhaps these children could be helped.
I feel this article is quite accurate when describing the current state of emergency child mental health care. As a psych ER nurse, I have worked with a number of children and their parents. Luckily, I come across legitamately mentally ill children who are requiring treatment. Being able to care for these kids and helping their parents solidifies why I work in my field. Unfortunately, I have encountered a number of children who say they are suicidal in order to manipulate their parents into getting what they want. I have also encountered parents who want their child admitted to the psych unit to punish their child for bad behavior. Educating this set of patients is a unnerving task as they are often still in crisis mode and not receptive to suggestions.
Kids need discipline---Not necessarily of the woodshed variety but often even natural consequences are ok.
If a kid does not study for a test a lower grade is the natural consequence---We should not be passing kids so they will "feel good about themselves". Failure is a learning experience.
If a kiddo is told no HOT! and still touches the hot iron one burnt finger will teach volumes---Parents should comfort but say "You were told NOT to touch it next time perhaps you will listen." This does not mean you leave a 2yo alone with a hot iron that is silly and hopefully no one here will think that is the plan.
Yes, people are stupid and that is why kids drink bleach and eat soap pods.
Sadly we no longer teach kids HOW to think in favor of telling them WHAT to think. Due to this we will see more stupid parents who lack the ability of forethought and will of course leave soap pods and worse within a child's reach.
Worse still it is not only cool but it is EXPECTED to have a kiddo with a diagnosis much the same way as it was cool to have the kid who walked earliest or potty trained earliest.
many will protest but deep down inside you all know it is true for the masses.
We see so many behavioural problems now in our classrooms here in Canada. Too many kids now are just DUMPED into daycare or dayhomes 5 days a week while mom and dad are gone. Many of these kids even come to school on the bus from the daycares and are lucky if they see their mothers or fathers by 5:30 or 6:00 p.m. Its RIDICULOUS what has happened to society. It used to take a "VILLAGE" to raise a child and now we are lucky if there is a "SINGLE" parent. These kids feel rejected, ignored, frustrated, unloved and the list goes on and on. Not to mention the "BROKEN" homes and these kids seldom have any time with their parents and many are NOT eating properly either. Then not to mention spending hours in front of technology which some is very VIOLENT in nature. Wake up mom and dad as we are paying a HUGE price for the sake of two incomes.
I was in mental health for 30 years. I saw kids often in an ER. With the exception of a serious suicide attempt such as ingesting an entire bottle of acetaminophen or a history of schizophrenia, major depression or bipolar disorder, most of them were nothing but manipulative game players. If they managed to weasel their way into a psychiatric unit they would come back time and time again because they never received the discipline they should have been getting at home to corral their behaviors. Pediatric units are mostly places for parents to take a vacation away from their kids or a place for kids to take a vacation away from their parents. Social Workers and Psychologists need frequenting retesting instead of the continuing education non-sense they get away with now. Yeah, I'm still angry with these fools even though I'm now retired. I let my license lapse so I would never never never be tempted to go into the field again.