Crisis Interventions for Pediatric Mental Health Presentations in the Emergency Department

Scared_Child_at_Nighttime

Attribution: Wikimedia Commons

May 25, 2015 – This week’s blog post is also available from TREKK (Translating Emergency Knowledge for Kids).

Children’s Mental Health by the Numbers

Every year in Canada, 1.2 million children and youth experience mental health problems and illnesses (1). Fewer than 20% of them receive appropriate treatment (2). And from 2006-2007 to 2013-2014, the national rates of visits to the emergency department (ED) for mental disorders among children and youth between the ages of 5 and 24 increased by 45% (3).

Beyond the numbers, these statistics describe kids who are battling conditions like depression, harmful and hazardous substance use, and anxiety disorders. Kids who can present to the ED in acute crisis. Kids who often have nowhere else to go.

While ideally, children and youth with mental health needs would receive early intervention and community-based management, this doesn’t always align with service availability or the nature of the treatment need. Sometimes, a crisis can’t be avoided. In all these circumstances, the ED plays an important role in providing care.

 

Emergency Department-Based Management Interventions for Mental Health Presentations

A systematic review published in 2010 evaluated the effectiveness of different ED-based management strategies used when children and youth presented with mental health complaints (4). There were only three studies that focused on pediatric (≤18 years) populations, so nine additional studies in adult populations, or in populations where the age was unknown, were also included. In all cases, patients with a range of mental health conditions were represented.

The authors identified three main categories of interventions: specialized models of pediatric care, patient triage scales, and other ED mental health care.

Specialized Models of Pediatric Care: These interventions included referrals to a specialized psychiatric team, made up of at least a child psychiatrist, and possibly also other psychiatric professionals like a nurse specialist or social worker. In three studies, referrals to these teams were associated with reduced hospital admissions, length of stay in the ED, and a modest cost savings in the ED.

Patient Triage Scales: Five studies evaluated four different triage scales as they were applied to mental health presentations. The outcomes measured across studies were variable, limiting the conclusions that can be made.

Other ED Mental Health Care: While none were evaluated in pediatric populations, three other strategies were described in the systematic review. Changes in legislation allowing psychologists to recommend involuntary patient hospitalization did not lead to significant differences in disposition decisions made by psychologists, or between psychiatrists and psychologists. The use of crisis teams had no impact on patient distress in one study, but reduced hospitalization in another. A computerized reminder system for restraints reduced the time to renewal of restraint orders, as well as time spent in restraints.

Limited evidence on the best strategies to treat children and youth with mental health conditions was available, but this review did find some support for the use of specialized psychiatric teams, and identified gaps in the child health evidence where the adult literature may provide some direction, namely the use of triage scales and developing guidance for restraint.

Dr. Amanda Newton, the senior author of the review, commented “Recent statistics reinforce that addressing emergency mental health care is critical. What is clear from this review is that the pediatric evidence base requires development. Studies that evaluate the quality of care provided and patient reported outcomes are important. Evidence exists outside of this review for specialized care, such as care for intentional self-harm, but a focus on the quality of general emergency mental health care is also important as this is standard care provided in emergency departments.”

Please join the authors of the systematic review for a live discussion on Twitter this Wednesday May 17 @ 2 pm MT. Check out the journal club announcement here.

References:

  1. Mental Health Commission of Canada. School-based mental health and substance abuse project. 2013.
  2. Mental Health Commission of Canada. Topics: Child and Youth. 2015.
  3. Canadian Institute for Health Information. Care for Children and Youth with Mental Disorders. 2015.
  4. Hamm MP, Osmond M, Curran J, Scott S, Ali S, Hartling L, Gokiert R, Cappelli M, Hnatko G, Newton AS. A systematic review of crisis interventions used in the emergency department. Pediatric Emergency Care 2010;26:952-962.

Treating the #1 mental disorder in kids and teens

Fshutterstock_145347424eeling nervous or being worried about events such as school tests or soccer games is a natural response for many children and teenagers. For some children and teenagers, however, feeling nervous and worried is a day-to-day experience that causes distress and interferes with their quality of life. For these children and teenagers, the experience can reflect an anxiety disorder.

Anxiety disorders are the number one mental health problem identified in children and teenagers before the age of 18. They are also very treatable. Different approaches to treat anxiety disorders have been evaluated. Expert consensus guidelines recommend behavioural and cognitive-behavioural therapies as the first line treatment for children and teens with mild to moderate anxiety symptoms. These therapies teach children and teens how to replace anxious thoughts with more helpful ones, face feared situations, and self-reward to offset discomfort. For children and teens that are severely impaired by an anxiety disorder, one of these therapies is often used together with medication to treat the disorder.

In 2010, an overview of Cochrane systematic reviews was conducted to compile evidence from reviews that focused on treating childhood anxiety disorders. The reviewers identified three systematic reviews published from 2006 to 2008 that included 39 studies involving 3,550 children and teenagers with the following disorders:

  • Generalized Anxiety Disorder
  • Separation Anxiety Disorder
  • Social Phobia
  • Specific Phobia
  • Panic Disorder
  • Obsessive-Compulsive Disorder (OCD)

Findings from the overview included:

  • Cognitive-behavioural treatment delivered one-on-one with the child/teen, in a group setting with other children/teens, or as a family treatment (with parents) increased recovery.
  • Behavioural and cognitive-behavioural treatment delivered one-on-one or in a group setting for OCD reduced symptom severity and the child/teen’s risk of not completing treatment (treatment failure).
  • Use of selective serotonin reuptake inhibitors (SSRIs) and the selective norepinephrine reuptake inhibitor (SNRI) venlafaxine were superior to receipt of no medication for treating OCD and other anxiety disorders, but which medication was most efficacious or best tolerated by children and teens was unclear.
  • Cognitive-behavioural treatment combined with a SSRI or SNRI reduced anxiety and OCD symptom severity, and had a mixed impact on reducing the child/teen’s risk of treatment failure for OCD.

shutterstock_223920910The authors concluded that the treatments reviewed were shown to benefit children and teenagers with anxiety disorders, but cautioned that clinicians should explain to children, teenagers and families that treatment response is individual, and could range from reduced symptom severity to complete disorder remission.

They also recommended that clinicians encourage children, teenagers and families to persevere with treatment by focusing on treatment gains as they are realized. Because treatments in this area are continually being evaluated, the authors also noted that updating the evidence base is critical.

More information:

Read the full overview here.

For more information about the three systematic reviews included in the overview (note: the review on cognitive behavioural therapy was updated in 2013 following publication of the overview; the link below is for the updated review):

Find out more about anxiety disorders at: