Chapter 147: Behavioral Disorders in Children

INTRODUCTION

Pediatric mental health emergencies encompass a range of conditions, including psychological disorders 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.^1,2,3,4

The role of the emergency physician includes medical stabilization, differentiating physical from mental health issues, 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

EPIDEMIOLOGY

The mental health crisis involves all socioeconomic and ethnic groups and is not unique to any one geographic area, state, or region. The cause of the dramatic rise in pediatric mental health emergencies is multifactorial and complex. A Centers for Disease Control and Prevention report of a 5-year (2005 to 2011) mental health surveillance among children in the United States cited a prevalence of mental health disorders of 13% to 20% and suicide as the second most common cause of mortality among children 12 to 17 years old in 2010.⁶ The National Comorbidity Survey–Adolescent Supplement data found the lifetime a prevalence of any one Diagnostic and Statistical Manual of Mental Disorders class disorder among adolescents of 51%.⁷ In Canada, 14% to 25% of children and youth are affected by at least one diagnosable mental disorder.^8,9 Factors contributing to high prevalence of mental illnesses among children and youths include family instability or dysfunction, economic crisis or financial hardship, inadequate numbers of mental health professionals (especially those with pediatric expertise), lack of access to care, shortage of funding for mental health services, and failure to seek care due to cultural stigma.¹ In addition, social networking exposes youths to cyberbullying, online harassment, social isolation, and "Facebook depression," adding further risks for developing mental health illnesses.¹⁰

Multiple economic forces negatively impact the availability and delivery of mental health services^1,4,5,11,12 and have transformed EDs into the safety net for a fragmented mental health infrastructure.⁵ Mental health follow-up or aftercare is also a problem. Of patients discharged from psychiatric emergency facilities, 40% to 60% do not receive aftercare, which increases the risk of repeat ED visits.¹¹

It is therefore not surprising that ED use for mental health care by children and youth is increasing. In the United States, both the absolute number (from 565,000 to 823,000) and proportion of all ED visits (from 2.0% to 2.8%) by children and youth for a mental health problem ...