Pediatric mental health emergencies encompass a range of conditions, including psychiatric conditions such as mood and anxiety disorders (depression, bipolar disorder, suicidal ideation, obsessive compulsive disorders, posttraumatic stress syndrome), exacerbations of behavioral disorders (attention-deficit/hyperactivity disorder, aggressive outbursts, conduct disorders), deteriorating neurodevelopmental disorders (autistic spectrum disorders, tic disorders, intellectual disabilities), addictive disorders, and eating disorders. The psychological and sometimes physical aftermath of child maltreatment, mass casualty incidents and disasters, and exposure to violence and unexpected deaths are also likely causes of mental health emergencies.1-4
Traditionally, the role of the emergency provider includes medically stabilizing children presenting with a mental health complaint, differentiating physical from mental health causes of symptoms, performing a psychosocial assessment, and directing patients and families toward appropriate resources for acute and long-term needs. Initial management may include pharmacologic therapy, physical restraint, and referral for inpatient admission.2,5 More recently, increased recognition of the burden of unidentified mental health concerns among vulnerable youth has led to calls for universal screening of psychosocial status for youth seeking medical care in the ED. Barriers to universal screening for mental health conditions in the ED include time restrictions, lack of familiarity with screening instruments, often fragmented or limited local community resources, and reluctance to broach the subject of mental health on the part of families seeking urgent medical care.6
Despite these barriers, a number of brief screening tools targeting specific conditions such as suicidal risk (Ask Suicide-Screening Questions and Risk of Suicide Questionnaire; see later section, “Suicidal Ideation and Attempts”), depression (Beck Depression Inventory-II), anxiety (revised parental and child versions of the Screen for Child Anxiety-Related Disorders), and alcohol use disorder (Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, 2-Item Scale), have been validated in the ED population to identify youth requiring further assessment.7 Although concerns about privacy and confidentiality are sometimes raised by families, a study of mental health screening in the ED suggests that most parents and youth find the process acceptable, and clinicians report that screening does not interfere with medical care.8
The mental health crisis involves all socioeconomic and ethnic groups and is not unique to any one geographic area, state, or region. A meta-analysis of worldwide prevalence of mental health disorders suggests that North America has the highest prevalence of mental health disorders in children and adolescents (19.9%) with lower rates in Europe (12%) and Africa (8.3%); there is a peak prevalence among youth age 12 to 18 years.9 National surveillance data from the United States and Canada report a prevalence of pediatric mental health disorders of 10% to 20% and suicide as the second most common cause of mortality among youth.10,11
Although the prevalence of youth mental health disorders remains stable, acute care visits for mental health–related issues are on the rise. In the United States, ...