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Pediatric mental health emergencies are frequently encountered
in emergency medical practice and comprise a substantial and growing component
of pediatric emergency medical care.1–10
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Pediatric mental health emergencies encompass a range of conditions, including
psychological disorders such as depression, suicidal ideation, aggressive
behavior, conduct disorders, bipolar disease, and post-traumatic
stress syndrome, as well as substance abuse, attention-deficit/hyperactivity
disorder, autistic spectrum disorders, and mental retardation. 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
in children presenting to the ED.9–11
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The role of the emergency physician in the care of children with
mental health emergencies includes achieving medical stabilization,
differentiating organic from psychiatric disease, performing a psychosocial
interview, and initiating therapy. Initial management may include pharmacologic
therapy, implementation of physical restraint, and referral for
inpatient admission or outpatient counseling.9,10
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About one in five children between the ages 9 and 17 years in
the U.S. have a diagnosable mental or addictive disorder according
to the Surgeon General’s Report on Mental Health.12 Over
13 million children in the U.S. are thought to need mental health
or substance abuse services.13
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According to a study conducted at Boston Children’s
Hospital, there has been a sixfold increase in the number of patients
with mental health disorders presenting to the ED over 15 years.2 At
Cincinnati Children’s Hospital, mental health disorders
were the tenth most common reason for coming to the ED and accounted
for 3.7% of all pediatric ED visits, which was comparable
to the rate for other common diagnoses such as vomiting and diarrhea
(4.8%) and asthma (4.7%).8 A
similar rise in the number of visits related to psychosocial problems
has been observed in the outpatient setting, with an increase from
7% to 18% between 1979 and 1996 among children
4 to 15 years of age.1 The percentage of mental health
hospitalizations has also been rising: over a 10-year period in Washington
State, the number one cause for hospitalization of 5- to 19-year-olds
was mental health disorders, accounting for one third of all hospital
days.6 In addition to these general trends, pediatric
psychiatric emergencies show seasonal variation and are more common
during the school year.5
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Prehospital providers also encounter children with mental health
disorders frequently. A study of almost 60,000 EMS pediatric transports
(age ≤14 years) in four states reported that almost 1 out of 10
transports (9.2%) were for mental health disorders, including
behavioral/psychiatric disorders (2.4%) and poisoning
or overdose (6.8%).14 These data may underestimate
the EMS burden, because older adolescents were not included.14 Although
some of the overdoses included accidental ingestions in toddlers
and young children, the majority were likely intentional.14 Another
study of EMS transports in Albuquerque, New Mexico over a 3-year
period also found a 9% incidence of transport for mental ...