Q&A: AAP issues guidance on emergency care for pediatric mental, behavioral health
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Key takeaways:
- New guidance aims to help emergency physicians dealing with pediatric mental and behavioral health emergencies.
- Experts called for systemic changes, more resources and a focus on inequities within the system.
The AAP published guidance for emergency physicians that addresses best practices for managing pediatric mental and behavioral health emergencies, its first since 2018.
The American College of Emergency Physicians (ACEP) and Emergency Nurses Association (ENA) collaborated with the AAP on the guidance, which calls for systemic changes, more resources and a focus on inequities.
We spoke with Mohsen Saidinejad, MD, MS, MBA, FAAP, FACEP, a professor of clinical emergency medicine and pediatrics at the David Geffen School of Medicine at UCLA and member of the AAP and ACEP committees on pediatric emergency medicine, on the changing landscape of pediatric mental health, updates to the guidance and takeaways for providers. Saidinejad’s responses have been lightly edited for clarity.
Healio: How has the landscape of pediatric mental health changed from the most recent policy statement on the subject?
Saidinejad: The last policy statement that we had was in 2018. The AAP, the ACEP and the ENA each had their own policy statement with their own variations. So, one of the things that we decided to do is to have the three organizations be invited at the table together and make a joint statement. We really felt strongly that a lot has changed [in pediatric mental health].
Clearly, the scope of the problem has become much greater. A lot more children and youth are coming to the ED with these complaints related to mental and behavioral health issues. The complexity has also increased. They are not just simple one-time visits, but these are kids who seem to have a history of having mental health issues. The other thing that has changed is that we're starting to see kids younger and younger. We never used to see a 5-year-old child come to the ED with a mental or behavioral health problem, and that's another thing that's completely new to us.
The urgency has really increased quite a bit, and in 2021, the AAP, the American Academy of Child and Adolescent Psychiatry and the Children's Hospital Association, published a joint statement calling this pediatric mental health problem a crisis and a public health emergency. This is definitely getting a lot of attention nationally; it's a moving target. We continue to get increased burden [in] the ED, and we're just not well equipped to handle this because prolonged wait times for children to be assessed. There's also boarding in the ED, and all of those have increased to a point where we felt that we need to provide some kind of resource guide for what EDs can do to manage this increase in the number of children.
Healio: Can you outline some of the more prominent updates?
Saidinejad: The general theme was that we wanted to address the entire spectrum of emergency care. We do have sections in our policy statement that specifically address a screening and assessment part. Then there's the ED-based interventions, and then there's the safe discharge planning.
[In] each one of those sections, we go into some details and provide some recommendations about things that the ED can do. For example, we know that the entire country [has a shortage of pediatric mental health clinicians]. We know that 55% of counties in the country do not have a single, licensed psychiatric professional on staff, and we know that there is one psychiatrist in the U.S. for every 124,000 children. Because of that, we need to try to optimize our resources.
We've mentioned things like use of telehealth, use of preagreed arrangements with psychiatrists to come and cover your hospital. In other words, know who you're going to consult, and how you're going to do that, and invest in the infrastructure to get that psychiatric referral.
The other thing is screening, so you can identify which child really needs to be expedited when it comes to mental health. We also know that the majority of children who come to the ED with mental and behavioral health problems can be safely discharged. So, it's really important to add more resources for those children who are acutely addressed for harming themselves or others.
The problem is overwhelming, but if you were able to safely discharge 80% to 90% of the children, then you have 10% to 20% scope of the overall problems. So, we talk a little bit about screening, and we talk about things to do with telehealth.
We also talk about having standing protocols about how you manage to talk about potentially having a space that children with mental or behavioral health (issues) can be taken care of that might be further away from the rest of the ED. It's safer for them and safer for the rest of the ED, especially those general EDs that don't have even a pediatric space.
We also talk a lot about things to do with safe discharge planning. For example, if you feel that a child has access to lethal means, being able to provide ... counseling and trying to figure a way that maybe access to that lethal means can be either eliminated or decreased by you know, engaging the family. And one last view is in the schools. We wanted the schools to also [be involved] in recognizing identifying and referring children for care.
Healio: What would you most like providers to take away from this?
Saidinejad: The most important thing is that this problem [has] a great scope. It is a problem that continues to escalate. We are unfortunately seeing a lot of these children coming in with mental behavioral health issues. We don't really completely understand the underlying cause of it, although we can make some guesses.
It is important to realize that, first of all, it is important to screen and identify those who are at lower risk, and then be able to connect them with mental health follow ups. The other thing we want them to take away is that a primary care doctor or a medical home really should be more engaged in identifying and being able to find opportunities for mental health follow-ups for these children before the problem becomes an emergency. Early recognition should be part of the initial annual visits for a child to their primary care doctor.
Finally, we want to recognize the role that schools play in being able to help children get access to resources. The take-home message is that the problem is great, but there are some strategies that can make things a little bit easier.
References:
- Saidinejad M, et al. Pediatrics. 2023;doi:10.1542/peds.2023-063255.
- Saidinejad M, et al. Pediatrics. 2023;doi:10.1542/peds.2023-063256.
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