Children's Mental Health Emergency Department Visits: 2007-2016

Emergency Department Pediatric Mental and Behavioral Health Patients Transported by Emergency Medical Services and Police: Trends and Interventions

OBJECTIVE

We aimed to understand transport utilization trends, demographics, emergency department (ED) interventions, and outcomes of pediatric mental and behavioral health (MBH) patients transported by emergency medical services (EMS), police, or self-transported.

METHODS

This retrospective cohort study utilized electronic health record data from patients aged 5 to 18 years presenting with acute MBH conditions at 2 affiliated pediatric EDs from January 2012 to December 2020. Data included demographics, ED interventions for aggression/agitation, Brief Rating of Aggression by Children and Adolescents (BRACHA) scores, and ED dispositions. Descriptive statistics and comparative analyses were conducted using chi-square, Wilcoxon rank sum tests, and multivariable logistic regression. Linear regression analyzed trends.

RESULTS

Of 440,302 ED encounters, 70,557 (16%) were for acute MBH concerns, with 14.6% transported by EMS and 5.9% by police. The proportion of MBH visits increased from 9.9% in 2012 to 19.8% in 2020 (95% (confidence interval) CI [0.7, 1.7], P = 0.0009), with a concurrent 0.4% annual increase in those transported by EMS (95% CI [0.2, 0.6], P = 0.006). MBH patients transported by EMS and police had significantly higher odds of requiring restraint in the ED and were more likely to have higher BRACHA scores and to be admitted compared to self-transported patients (all comparisons, P < 0.001).

CONCLUSIONS

Pediatric MBH ED visits and EMS utilization are increasing. MBH patients transported by EMS and police may represent a more aggressive ED population. Given the rising encounters within this high-risk population, our EDs, EMS, and police need support and resources for safe pediatric MBH patient management.

Primary Care Quality Improvement Through Patient-Centered Medical Homes and the Impact on Emergency Department Utilization for Children With Autism and Mental Health Disorders

BACKGROUND AND OBJECTIVES

To address health care spending growth, coordinated care, and patient-centered primary care, most states in the United States have adopted value-based care coordination programs such as patient-centered medical homes (PCMHs). The objective of this study was to understand the relationship between having access to PCMHs and emergency department (ED) utilization for high cost/need children with autism and children with mental health disorders (MHDs).

METHODS

This cross-sectional study included 87 723 children between ages 3 and 17 years in the 2016-2018 National Survey for Children's Health. Multivariate-adjusted logistic regression analyses were used to assess the association between ED and PCMH utilization for children with autism, with MHDs without autism, and others without autism or MHDs. Marginal predictions were used to examine whether PCMH utilization was moderated by health conditions.

FINDINGS

The results showed that children with a PCMH had a 16% reduction in the odds to visit the ED (adjusted odds ratio [aOR] = 0.84; confidence interval [CI], 0.77-0.92; P < .001). When compared with the reference group of children without autism and without MHDs, children with MHDs but without autism had 93% higher odds to visit the ED (aOR = 1.93; CI, 1.75-2.13; P < .001) and children with autism had 35% higher odds to visit the ED (aOR = 1.35; CI, 1.04-1.75; P = .023). Marginal effects results suggested that PCMHs reduced the odds of ED visits the most for children with MHDs without autism and reduced the predicted ED visits from 30.1% to 23.7% (P < .001).

CONCLUSIONS

Primary care quality improvement through access to a PCMH reduced ED visits for children, but the effect varied by autism and MHD conditions. Future PCMH efforts should continue to support children with autism and address unmet needs for children with MHDs with a focus on needed care coordination, family-centered care, and referrals.

From Their Perspective: Pediatric Patients With Acute Mental Health Needs and Prolonged Emergency Department Stays

BACKGROUND

The pediatric emergency department (PED) is experiencing a rising volume of patients with mental health concerns, leading to prolonged boarding times and delays in initiating active therapeutic plans. A paucity of research exists for the self-reported pediatric patient experience during such boarding.

OBJECTIVES

To inform more individualized and patient-centered PED care for patients boarding for mental health admission, by learning the prior trauma experiences and patient perspective on prolonged PED mental health stays.

METHODS

A convenience sample was collected at an urban hospital's PED among those boarding for mental health emergency greater than 24 hours. Demographic information, exposures to past trauma, and perceptions on and understanding of their care experience, were discussed. Descriptive and thematic content analysis were used for data analysis.

RESULTS

A total of 99 youths were included in the study and the majority reported worsening mental health symptoms during PED boarding, notably increasing anxiety (72 [72.7%]). Patients were equivocal on efficacy of PED mental health intake on symptoms (41 [41.4%]). Personal suggestions were offered by these patients to guide the care of future children that would better mitigate their symptoms while boarding in the PED, such as group activities, electronics, and physical activity.

DISCUSSION

Patients in mental health crisis boarding in the PED have already experienced stressful life events. By listening to the personal stories of this vulnerable population, the PED can improve care delivery and design a more therapeutic environment, especially as the need for acute mental health management continues to increase.

Trends in Substance-Related Visits Among Youth to US Children's Hospitals, 2016-2021: An Analysis of the Pediatric Health Information System Database

PURPOSE

This study evaluates recent trends in substance-related visits among youth visiting children's hospitals.

METHODS

We conducted a cross-sectional study of substance-related visits to pediatric hospitals within the Pediatric Health Information System database of youth aged 12-21 years from 2016 through 2021. Substance-related visits were defined as acute visits for International Classification of Diseases, 10th Revision Clinical Modification codes related to substance 'use', dependence, or overdoses for alcohol, cannabis, nicotine, opioids, sedatives, stimulants, hallucinogens, or other substances. Cumulative growth rate and stratified substance-related trends were calculated using generalized estimating equations. Predicted number of visits during the COVID-19 pandemic was generated using an auto-regressive time series analysis.

RESULTS

There were 106,793 substance-related visits involving 84,632 youth. From 2016 to 2021, substance-related visits increased by 47.9% and increased across all ages, demographics, regions, and payors. Visits of Hispanic youth experienced the greatest percentage growth (63.3%, p < .05) when compared to Non-Hispanic (NH) White (46.2%) or NH Black (49.8%) youth. All substances except sedatives experienced an increase in growth in visits. Cannabis accounted for the largest percentage of visits (52.2%) and experienced the greatest percentage growth during the study period (82.4%, p < .001). During the pandemic, publicly insured, female, NH Black, and Hispanic youth experienced a greater-than-predicted number of substance-related visits.

DISCUSSION

Substance-related visits to children's hospitals are increasing for all demographics and nearly all substances. There were substantial increases in visits for most minoritized youth with a disproportionate rise among Hispanic youth. Visits over the pandemic were concentrated among publicly insured, female, NH Black, and Hispanic youth. Equitable large-scale investment is needed to address the rising morbidity of substance use among adolescents.

COVID-19 and Youth Mental Health Disparities: Intersectional Trends in Depression, Anxiety and Suicide Risk-Related Diagnoses

OBJECTIVES

Mental health disparities were prevalent among racially and ethnically minoritized youth prior to the COVID-19 pandemic. As complete datasets from 2022 become available, we can estimate the extent to which the pandemic further magnified existing inequities. Our objective was to quantify disparities in trajectories of depression, anxiety, and suicide risk-related diagnoses in youth before and after the start of the COVID-19 pandemic, using an intersectional lens of race, ethnicity and gender.

METHODS

Using electronic medical record data from one mid-Atlantic health care system (2015-2022), we evaluated changes in annual rates of depression, anxiety and suicide risk-related diagnoses in 29,117 youths, aged 8-20 years, using graphical analysis, comparison of adjusted mean differences (AMD) and adjusted mixed multilevel logistic regression.

RESULTS

Almost all racial and gender subgroups had significantly higher rates of depression and anxiety after the start of COVID-19 compared to the years prior, with the greatest changes observed in Hispanic and Asian females. Suicide risk-related diagnoses significantly increased among all female subgroups, with the largest increase among Asian females (AMD 4.8, 95% CI 0.2-9.3) and Black females (AMD 4.6, 95% CI 2.2-6.9).

CONCLUSIONS

Rates of depression, anxiety, and suicidal thoughts and/or behaviors in young people continued to increase in the post-pandemic period. Many pre-existing disparities between subgroups, especially females, significantly widened, highlighting the importance of using an intersectional lens. Urgent action is warranted, including universal screening of pediatric patients for suicide risk, broadening effective treatment and support options in minoritized patients, and increasing support services to patients and families.

Testing the Impact of a Law Enforcement-Operated Co-responder Program for Youths: A Quasi-Experimental Approach

OBJECTIVE

The authors examined whether use of a co-responder program reduced the likelihood of an involuntary commitment examination as the disposition of a police encounter with youths experiencing a mental health crisis and 1 year after the initial incident.

METHODS

Using a quasi-experimental design, the authors compared 206 incidents that involved the co-response program with 327 incidents that did not involve the program. Propensity score matching was used to balance groups on demographic and incident characteristics. The dependent variables included the disposition of the incident (deescalation or involuntary commitment examination), whether the youths experienced a later involuntary commitment examination within 1 year of the initial intervention, and time to the subsequent examination. Propensity score-weighted binary logistic regression and time-to-event analysis were used.

RESULTS

The co-responder program was associated with a significantly lower likelihood of police officer-initiated involuntary commitment examinations and a lower likelihood of an involuntary commitment examination within 1 year. Eighty percent of the incidents that resulted in a co-response involving a police officer and a mental health professional were deescalated, allowing the youth to remain in the community with a safety plan, whereas 17% of incidents with a police-only response ended with crisis deescalation.

CONCLUSIONS

These findings provide further support for the implementation of co-responder options that are available to police officers during encounters with children and adolescents experiencing a mental health crisis.

National Trends in Emergency Department Visits for Suicide Attempts and Intentional Self-Harm

OBJECTIVE

This study estimated national annual trends and characteristics of emergency department visits for suicide attempts and intentional self-harm in the United States from 2011 to 2020.

METHODS

Data were from the National Hospital Ambulatory Medical Care Survey, an annual cross-sectional national sample survey of emergency departments. Visits for suicide attempts and intentional self-harm were identified using discharge diagnosis codes (ICD-9-CM for 2011-2015; ICD-10-CM for 2016-2020) or reason-for-visit codes. The annual proportion of emergency department visits for suicide attempts and intentional self-harm was estimated.

RESULTS

The weighted number of emergency department visits for suicide attempts and intentional self-harm increased from 1.43 million, or 0.6% of total emergency department visits, in 2011-2012 to 5.37 million, or 2.1% of total emergency department visits in 2019-2020 (average annual percent change, 19.5%, 95% CI=16.9, 22.2). Visits per capita increased from 261 to 871 visits per 100,000 persons (average annual percent change, 18.8%, 95% CI=17.6, 20.0). The increase in visits was widely distributed across sociodemographic groups. While suicide attempt and intentional self-harm visits were most common among adolescents, adults age 65 or older demonstrated the largest increase (average annual percent change, 30.2%, 95% CI=28.5, 32.0). Drug-related diagnoses were the most common co-occurring diagnosis among suicide attempt and intentional self-harm visits. Despite the rise in emergency department visits for suicide attempts and intentional self-harm, less than 16% included an evaluation by a mental health professional.

CONCLUSIONS

A significant national increase in emergency department visits for suicide attempts and intentional self-harm occurred from 2011 to 2020, as a proportion of total emergency department visits and as visits per capita. These trends underscore an urgent need to improve the continuum of mental health care for individuals with suicidal symptoms.

Implementation Barriers Encountered During a Universal Suicide Screening Program in Pediatric Emergency Departments

OBJECTIVE

Because understanding barriers to universal suicide risk screening in pediatric emergency departments (PEDs) may improve both identification and management of suicidal behaviors and ideation, this study assessed barriers to a quality improvement initiative examining the use of a novel computerized adaptive test (CAT), the Kiddie-CAT, in 2 PEDs.

METHODS

Research assistants (RAs) trained in Rapid Assessment Procedures-Informed Clinical Ethnography methods documented barriers related to the environment, individuals, and workflow as encountered during screening shifts, categorizing the barriers' impacts as either general to a screening shift or related to screening an individual youth/caregiver dyad. Using thematic content analysis, investigators further categorized barriers based on type (eg, workflow, language/comprehension, clinician attitudes/behaviors) and relationship to the limited integration of this initiative into clinical protocols. Reasons for refusal and descriptive data on barriers are also reported.

RESULTS

Individual screen barriers were most often related to workflow (22.9%) and youth/caregiver language/comprehension challenges (28%). Similarly, workflow issues accounted for 48.2% of all general shift barriers. However, many of these barriers were related to the limited integration of the initiative, as RAs rather than clinical staff conducted the screening.

CONCLUSIONS

Although this study was limited by a lack of complete integration into clinical protocols and was complicated by the COVID-19 pandemic impacts on PEDs, the findings suggest that considerable attention needs to be directed both to physician education and to workflow issues that could impede universal screening efforts.

Adolescent Mental Health: A Focus on Psychiatric Counseling from the Emergency Room of an Italian University Hospital in the Five Years from 2019 to 2023

Recent studies have revealed increasingly worse and more complex mental health conditions in young people, which is reflected in a growing trend in emergency room (ER) visits for acute psychopathological symptoms (APSs). This phenomenon has become exacerbated in recent decades, with a peak in the post-pandemic period. To better characterize the phenomenon, we investigated the change in the rate and type of ER counseling requests provided at the Child Neuropsychiatry Unit of the University Hospital of Bari, Italy over the period between 2019 and 2023 for subjects younger than 18 years old. For this purpose, we retrospectively analyzed a total number of 1073 urgent consultation reports retrieved through the reporting computerized operating system of our hospital. The distribution of the counseling requests provided for APSs and, among these, the distribution of the numbers of APSs and of the male: female ratio were significantly different over the years, with an increasing linear trend identified for APSs (p = 3.095 × 10-7), the average number of APSs (p = 3.598 × 10-7), and female gender prevalence (p = 0.03908), as well as for the patients with a history of psychotropic drug assumption (p = 0.0006319). A significant change in the number of urgent counseling requests received for eating disorders (p = 0.0007408), depression (p = 7.92 × 10-8), somatization (p = 4.03 × 10-6), self-harm (SA) (p = 1.358 × 10-6), and non-suicidal self-injury (NSSI) (p = 8.965 × 10-6) was found, with a significant increasing trend for anxiety (p = 0.0444), depression (p = 8.06 × 10-6), somatization (p = 0.004616), SA (p = 3.998 × 10-8), and NSSI (p = 5.074 × 10-7). The findings of our study support the hypothesis of an alarming progressive worsening of the mental health of children and adolescents, with an overlapping effect of the pandemic exacerbating the process.

Urban Rural Differences on Accessing Patient- Centered Medical Home Among Children With Mental/Developmental Health Conditions/Disorders

INTRODUCTION

To address healthcare spending growth and coordinated primary care, most states in the United States have adopted patient-centered medical homes (PCMHs). To evaluate urban rural difference on accessing PCMH among US children, particularly for children with developmental disabilities (DDs) and mental health disorders (MHDs).

METHODS

This cross-sectional study used the 2016-2018 National Survey for Children's Health (NSCH). Multivariable adjusted logistic regression analyses were used to assess the association between accessing PCMHs and rurality and mental/developmental conditions/disorders.

RESULTS

Children with both DDs and MHDs were statistically significantly higher in rural areas (10.9% rural vs. 8.3% urban, p ≤ .001). Children in rural areas reported higher odds of accessing PCMHs (14%) among all U.S. children, but no differences by subgroups for children with MHDs and/or DDs. Compared with children without DDs/MHDs, the reduction in access to PCMHs varies by children's health status (41% reduction for children both DDs and MHDs, 25% reduction for children with MHDs without DDs) effects. Children with MHDs/DDs were less likely to receive family-centered care, care coordination, and referrals.

CONCLUSIONS

Quality improvements through PCMHs could focus on family-centered care, care coordination, and referrals. Patient-centered medical home performance measurement could be improved to better measure mental health integration and geographical differences.

Navigating Community-Based Psychiatry Care of Pediatric Patients in Low-Resource Settings: A Case Report

This case report examines the experience of a nine-year-old male with autism spectrum disorder (ASD) who was admitted to his rural community emergency department (ED) for the treatment of aggressive behaviors, agitation, and violence. Despite a high prevalence of such behaviors within the autistic pediatric population, multiple inpatient facilities that offer pediatric psychiatric services refused to transfer his care. Many other commonly used resources and treatment modalities were also not available, resulting in a nine-day ED boarding experience with minimal symptomatic improvement. Pharmacotherapy was utilized, but nationally recommended guidelines were not appropriately followed. Although this case is one of many pediatric patients who received inadequate psychiatric care from their local ED, it is significant in identifying specific areas of improvement within Northeast Louisiana psychiatric healthcare. This case report of a nine-year-old male with autism underlines the hardships faced by patients and their families due to the gaps in our current healthcare infrastructure and emphasizes the importance of protocols and resources for patient populations with higher-than-average wellness needs.

Improving Identification of Firearm Access in Children With Mental Health Complaints

OBJECTIVE

To determine if electronic medical record (EMR) changes and implementation of a study on firearm storage practices changed identification of firearm exposure in children presenting to a pediatric emergency department (PED) with mental health complaints. We also sought to determine the accuracy of information collected on firearm storage practices.

METHODS

Retrospective study of EMR documentation of firearm exposure in PED patients with mental health complaints from January 20, 2015 until November 20, 2017. EMR changes occurred on January 20, 2016 and the firearms study began on February 13, 2016. The primary outcome was documentation of firearm exposure. Secondary outcomes were documentation of unsafe firearm storage practices. We also examined differences between clinical and research documentation of unsafe firearm storage practices post-intervention. We compared groups using descriptive statistics and chi-squared tests. We used statistical process control to examine the relationship between interventions and changes in outcomes.

RESULTS

5582 encounters were examined. Identification of firearm exposure increased from 11 to 17% postintervention. Identification of unsafe storage practices increased from 1.9% to 4.4% across all encounters. Special cause variation in both metrics occurred concurrently with the interventions. Postintervention, unsafe firearms storage practices in firearm owning families were under-identified (39% identified as not triple-safe in clinical data vs 75% in research data).

CONCLUSIONS

EMR changes and implementation of a firearms study improved identification of firearm exposure and unsafe storage practices in families of PED patients being evaluated for mental health complaints. However, unsafe storage practices continued to be under-identified in firearm-owning families.

Implementation of a Suicide Risk Screening Clinical Pathway in a Children's Hospital: A Feasibility Study

OBJECTIVES

Youth suicide is a pressing global concern. Prior research has developed evidence-driven clinical pathways to screen and identify suicide risk among pediatric patients in outpatient clinics, emergency departments (ED) and inpatient hospital units. However, the feasibility of implementing these pathways remains to be established. Here, we share the results of a hospital-wide "youth suicide risk screening pathway" implementation trial at an urban academic pediatric hospital to address this gap.

METHODS

A 3-tier "youth suicide risk screening pathway" using The Ask Suicide-Screening Questions (ASQ) was implemented for patients aged 10 to 26 years who received care at an urban academic pediatric hospital's emergency department or inpatient units. We retrospectively reviewed implementation outcomes of this pathway from January 1 to August 31, 2019. The feasibility of this implementation was measured by assessing the pathway's degree of execution, fidelity, resource utilization, and acceptability.

RESULTS

Of 4108 eligible patient encounters, 3424 (83%) completed the screen. Forty-eight (1%) screened acute positive, 263 (8%) screened nonacute positive and 3113 (91%) screened negative. Patients reporting positive suicide risk were more likely to be older and female, although more males required specialty mental health evaluations. Pathway fidelity was 83% among all positive screens and 94% among acute positive screens. The clinical pathway implementation required 16 hours of provider training time and was associated with slightly longer length of stay for inpatients that screened positive (4 vs 3 days). Sixty-five percent of nurses and 78% of social work providers surveyed supported participation in this effort.

CONCLUSIONS

It is feasible to implement a youth suicide risk screening pathway without overburdening the system at an urban academic pediatric hospital.

Pediatric mental health emergency department visits from 2017 to 2022: A multicenter study

BACKGROUND

The COVID-19 pandemic adversely affected children's mental health (MH) and changed patterns of MH emergency department (ED) utilization. Our objective was to assess how pediatric MH ED visits during the COVID-19 pandemic differed from expected prepandemic trends.

METHODS

We retrospectively studied MH ED visits by children 5 to <18 years old at nine U.S. hospitals participating in the Pediatric Emergency Care Applied Research Network Registry from 2017 to 2022. We described visit length by time period: prepandemic (January 2017-February 2020), early pandemic (March 2020-December 2020), midpandemic (2021), and late pandemic (2022). We estimated expected visit rates from prepandemic data using multivariable Poisson regression models. We calculated rate ratios (RRs) of observed to expected visits per 30 days during each pandemic time period, overall and by sociodemographic and clinical characteristics.

RESULTS

We identified 175,979 pediatric MH ED visits. Visit length exceeded 12 h for 7.3% prepandemic, 8.4% early pandemic, 15.0% midpandemic, and 19.2% late pandemic visits. During the early pandemic, observed visits per 30 days decreased relative to expected rates (RR 0.80, 95% confidence interval [CI] 0.78-0.84), were similar to expected rates during the midpandemic (RR 1.01, 95% CI 0.96-1.07), and then decreased below expected rates during the late pandemic (RR 0.92, 95% CI 0.86-0.98). During the late pandemic, visit rates were higher than expected for females (RR 1.10, 95% CI 1.02-1.20) and for bipolar disorders (RR 1.83, 95% CI 1.38-2.75), schizophrenia spectrum disorders (RR 1.55, 95% CI 1.10-2.59), and substance-related and addictive disorders (RR 1.50, 95% CI 1.18-2.05).

CONCLUSIONS

During the late pandemic, pediatric MH ED visits decreased below expected rates; however, visits by females and for specific conditions remained elevated, indicating a need for increased attention to these groups. Prolonged ED visit lengths may reflect inadequate availability of MH services.

Driver's Licensure and Driving Outcomes Among Youths With Mood Disorders

Importance

Mood disorders are prevalent among adolescents and young adults, and their onset often coincides with driving eligibility. The understanding of how mood disorders are associated with youth driving outcomes is limited.

Objective

To examine the association between the presence of a mood disorder and rates of licensing, crashes, violations, and suspensions among adolescents and young adults.

Design, Setting, and Participants

This cohort study was conducted among New Jersey residents who were born 1987 to 2000, age eligible to acquire a driver's license from 2004 to 2017, and patients of the Children's Hospital of Philadelphia network within 2 years of licensure eligibility at age 17 years. The presence of a current (ie, ≤2 years of driving eligibility) mood disorder was identified using International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) or International Statistical Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes. Rates of licensure and driving outcomes among youths who were licensed were compared among 1879 youths with and 84 294 youths without a current mood disorder from 2004 to 2017. Data were analyzed from June 2022 to July 2023.

Main Outcomes and Measures

Acquisition of a driver's license and first involvement as a driver in a police-reported crash and rates of other adverse driving outcomes were assessed. Survival analysis was used to estimate adjusted hazard ratios (aHRs) for licensing and driving outcomes. Adjusted rate ratios (aRRs) were estimated for driving outcomes 12 and 48 months after licensure.

Results

Among 86 173 youths (median [IQR] age at the end of the study, 22.8 [19.7-26.5] years; 42 894 female [49.8%]), there were 1879 youths with and 84 294 youths without a mood disorder. A greater proportion of youths with mood disorders were female (1226 female [65.2%]) compared with those without mood disorders (41 668 female [49.4%]). At 48 months after licensure eligibility, 75.5% (95% CI, 73.3%-77.7%) and 83.8% (95% CI, 83.5%-84.1%) of youths with and without mood disorders, respectively, had acquired a license. Youths with mood disorders were 30% less likely to acquire a license than those without a mood disorder (aHR, 0.70 [95% CI, 0.66-0.74]). Licensed youths with mood disorders had higher overall crash rates than those without mood disorders over the first 48 months of driving (137.8 vs 104.8 crashes per 10 000 driver-months; aRR, 1.19 [95% CI, 1.08-1.31]); licensed youths with mood disorders also had higher rates of moving violations (aRR, 1.25 [95% CI, 1.13-1.38]) and license suspensions (aRR, 1.95 [95% CI, 1.53-2.49]).

Conclusions and Relevance

This study found that youths with mood disorders were less likely to be licensed and had higher rates of adverse driving outcomes than youths without mood disorders. These findings suggest that opportunities may exist to enhance driving mobility in this population and elucidate the mechanisms by which mood disorders are associated with crash risk.

Mental Health-Related Outpatient Visits Among Adolescents and Young Adults, 2006-2019

Importance

Concerns over the mental health of young people have been increasing over the past decade, especially with the rise in mental health burden seen during the COVID-19 pandemic. Examining trends in mental health-related outpatient visits provides critical information to elucidate contributing factors, identify vulnerable populations, and inform strategies to address the mental health crisis.

Objective

To examine characteristics and trends in mental health-related outpatient visits and psychotropic medication use among US adolescents and young adults.

Design, Setting, and Participants

A retrospective cross-sectional analysis of nationally representative data from the National Ambulatory Medical Care Survey, an annual probability sample survey, was conducted from January 2006 to December 2019. Participants included adolescents (age 12-17 years) and young adults (age 18-24 years) with office-based outpatient visits in the US. Data were analyzed from March 1, 2023, to September 15, 2023.

Main Outcomes and Measures

Mental health-related outpatient visits were identified based on established sets of diagnostic codes for psychiatric disorders. Temporal trends in the annual proportion of mental health-related outpatient visits were assessed, including visits associated with use of psychotropic medications. Analyses were stratified by age and sex.

Results

From 2006 to 2019, there were an estimated 1.1 billion outpatient visits by adolescents and young adults, of which 145.0 million (13.1%) were associated with a mental health condition (mean [SD] age, 18.4 [3.5] years; 74.0 million females [51.0%]). Mental health-related diagnoses were more prevalent among visits by male (16.8%) compared with female (10.9%) patients (P < .001). This difference was most pronounced among young adults, with 20.1% of visits associated with a psychiatric diagnosis among males vs 10.1% among females (P < .001). The proportion of mental health-related visits nearly doubled, from 8.9% in 2006 to 16.9% in 2019 (P < .001). Among all outpatient visits, 17.2% were associated with the prescription of at least 1 psychotropic medication, with significant increases from 12.8% to 22.4% by 2019 (P < .001).

Conclusions and Relevance

In this cross-sectional study, there were substantial increases in mental health-related outpatient visits and use of psychotropic medications, with greater overall burden among male patients. These findings provide a baseline for understanding post-pandemic shifts and suggest that current treatment and prevention strategies will need to address preexisting psychiatric needs in addition to the effects of the COVID-19 pandemic.

Reducing Physical Restraint Use in the Medical Behavioral Unit

OBJECTIVES

Children with behavioral health conditions often experience agitation when admitted to children's hospitals. Physical restraint should be used only as a last resort for patient agitation because it endangers the physical and psychological safety of patients and employees. At the medical behavioral unit (MBU) in our children's hospital, we aimed to decrease the weekly rate of physical restraint events per 100 MBU patient-days, independent of patient race, ethnicity, or language, from a baseline mean of 14.0 to <10 within 12 months.

METHODS

Using quality improvement methodology, a multidisciplinary team designed, tested, and implemented interventions including a series of daily deescalation huddles led by a charge behavioral health clinician that facilitated individualized planning for MBU patients with the highest behavioral acuity. We tracked the weekly number of physical restraint events per 100 MBU patient-days as a primary outcome measure, weekly physical restraint event duration as a secondary outcome measure, and MBU employee injuries as a balancing measure.

RESULTS

Our cohort included 527 consecutive patients hospitalized in the MBU between January 2021 and January 2023. Our 2021 baseline mean of 14.0 weekly physical restraint events per 100 MBU patient-days decreased to 10.0 during our 2022 intervention period from January through July and 4.1 in August, which was sustained through December. Weekly physical restraint event duration also decreased from 112 to 67 minutes without a change in employee injuries.

CONCLUSIONS

Multidisciplinary huddles that facilitated daily deescalation planning safely reduced the frequency and duration of physical restraint events in the MBU.

Differences in Healthcare Utilization in Children with Developmental Disabilities Following Value-Based Care Coordination Policies

GOAL

To address healthcare spending growth, coordinate care, and improve primary care utilization, a majority of states in the United States have adopted value-based care coordination programs. The objective of this study was to identify changes in national healthcare utilization for children with developmental disabilities (DDs), a high-cost and high-need population, following the broad adoption of value-based care coordination policies.

METHODS

This retrospective study included 9,109 children with DDs and used data from 2002-2018 Medical Expenditure Panel Survey. We applied an interrupted time series design approach to compare pre- and post-Affordable Care Act (ACA) care coordination policies concerning healthcare utilization outcomes, including outpatient visits, home provider days, emergency department (ED) visits, inpatient discharge, and inpatient nights of stay.

PRINCIPAL FINDINGS

We found statistically significant increases in low-cost care post-ACA, including outpatient visits (5% higher, p < .001) and home provider days (11% higher, p < .001). The study findings also showed a statistically significant increase in inpatient nights of stay post-ACA (4% higher, p = .001). There were no changes in the number of ED and inpatient visits. Overall, broad implementation of care coordination programs was associated with increased utilization of low-cost care without increases in the number of high-cost ED and inpatient visits for children with DDs. Our study also found changes in population composition among children with DDs post-ACA, including increases in Hispanic (16.9% post-ACA vs. 13.4% pre-ACA, p = .006) and non-Hispanic multiracial children (9.1% post-ACA vs. 5.5% pre-ACA, p = .001), a decrease in non-Hispanic Whites (60.2% post-ACA vs. 68.6% pre-ACA, p = .001), more public-only insurance (44.3% post-ACA vs. 35.7% pre-ACA, p = .001), fewer children with DDs from middle-income families (27.4% post-ACA vs. 32.8% pre-ACA, p < .001), and more children with DDs from poor families (28.2% post-ACA vs. 25.1% pre-ACA, p = .043).

PRACTICAL APPLICATIONS

These findings highlight the importance of continued support for broad care coordination programs for U.S. children with DDs and potentially others with complex chronic conditions. Policymakers and healthcare leaders might consider improving care transitions from inpatient to community or home settings by overcoming barriers such as payment models and the lack of home care nurses who can manage complex chronic conditions. Healthcare leaders also need to understand and consider the changing population composition when implementing care coordination-related policies. This study provides data regarding trends in hospital and home care utilization and evidence of the effectiveness of care coordination policies before the COVID-19 interruption. These findings apply to current healthcare management because COVID-19 has incentivized home care, which may have a strong potential to minimize high-cost care for people with complex chronic conditions. More research is warranted to continue monitoring care coordination changes over a longer period.

Child Health Needs and the Pediatric Emergency Medicine Workforce: 2020-2040

Approximately 30 million ill and injured children annually visit emergency departments (EDs) in the United States. Data suggest that patients seen in pediatric EDs by board-certified pediatric emergency medicine (PEM) physicians receive higher-quality care than those cared for by non-PEM physicians. These benefits, coupled with the continued growth in PEM since its inception in the early 1990s, have impacted child health broadly. This article is part of a Pediatrics supplement focused on predicting the future pediatric subspecialty workforce supply by drawing on the American Board of Pediatrics workforce data and a microsimulation model of the future pediatric subspecialty workforce. The article discusses the utilization of acute care services in EDs, reviews the current state of the PEM subspecialty workforce, and presents projected numbers of PEM subspecialists at the national, census region, and census division on the basis of this pediatric subspecialty workforce supply model through 2040. Implications of this model on education and training, clinical practice, policy, and future workforce research are discussed. Findings suggest that, if the current growth in the field of PEM continues on the basis of the increasing number and size of fellowship programs, even with a potential reduction in percentage of clinical time and attrition of senior physicians, the PEM workforce is anticipated to increase nationally. However, the maldistribution of PEM physicians is likely to be perpetuated with the highest concentration in New England and Mid-Atlantic regions and "PEM deserts" in less populated areas.

Pediatric Psychiatric Emergencies

Pediatric psychiatric emergencies account for 15% of emergency department visits and are on the rise. Psychiatric diagnoses in the pediatric population are difficult to make, due to their variable presentation, but early diagnosis and treatment improve clinical outcome. Medical reasons for the patient's presentation should be explored. Both physical and emotional safety must be ensured. A multidisciplinary approach, utilizing local primary care and psychiatric resources, is recommended.

Inpatient pediatric nursing staff experiences treating psychiatric patients: A mixed methods study

PROBLEM

A gap in the literature exists attempting to understand the impact that the influx of pediatric psychiatric patients has had on inpatient general medicine pediatric nursing staff.

METHODS

A mixed-method research study was conducted among full- and part-time pediatric nurses and nursing assistants working on general pediatric units. Quantitative data was collected via an anonymous survey using the Professional Quality of Life Scale version 5 and Support Appraisal for Work Stressors scale. Surveys were followed by semistructured interviews.

FINDINGS

Of the 158 staff eligible, 47 (29.7%) participated in the quantitative portion. [Correction added on 29 September 2023, after the first online publication: In the preceding sentence, the participation rate was revised from 23.5% to 29.7% in this version.] Significant differences were found between roles, with nurses experiencing lower levels of compassion satisfaction and higher levels of burnout. Role differences were seen in supervisor support and nonwork support, with nurses reporting less support from both. Supervisor support showed a significant correlational relationship with compassion satisfaction and burnout. Nonwork support showed similar correlations with compassion satisfaction and burnout. Themes that emerged from the interviews were Barriers to Care, Emotional Impact, and "Help Me Help You."

CONCLUSION

Nurses may be at greater risk for compassion fatigue due to perceived inadequate support from leadership, unclear role expectations, and lack of resources.

Characteristics, disposition, and outcomes of children hospitalized for mental health boarding at a children's hospital

Increasingly, youth experiencing mental health crises present to acute care medical hospitals and "board" on medical units due to inpatient psychiatric bed shortages. We conducted a retrospective cohort study of children experiencing mental health boarding at a US children's hospital from October 2020 to September 2022. We examined associations between patients' characteristics and their disposition and outcomes. Our cohort included 1891 boarding hospitalizations: 53.9% transferred to an inpatient psychiatric hospital and 46.1% discharged home. Characteristics associated with not being transferred to an inpatient psychiatric hospital included age <13 years (adjusted odds ratio [aOR] 0.6; 95% confidence interval [CI]: 0.4-0.7), disruptive or aggressive behavior (aOR 0.6; 95% CI: 0.4-0.8), psychosis (aOR 0.5; 95% CI: 0.3-0.8), COVID-19 infection (aOR 0.3; 95% CI: 0.2-0.6), or a complex chronic medical condition (aOR 0.8; 95% CI: 0.6-1.0). Our findings suggest that certain populations of children experiencing mental health boarding face disparate access to inpatient psychiatric care.

Reduction of Mental Health-Related Emergency Department Admissions for Youth and Young Adults Following a Remote Intensive Outpatient Program: Quality Improvement Analysis

BACKGROUND

Pediatric mental health emergency department (ED) visits are increasing at 6% to 10% per year, at substantial cost, while 13% of youth with psychiatric hospitalizations are readmitted in the following weeks. Hospitals do not have the resources to meet escalating youth's mental health needs. Intensive outpatient (IOP) programs, which provide multiple hours of care each week, have the power to reduce the number of patients in need of hospitalized care and provide a step-down option for patients discharging from ED's in order to prevent readmissions.

OBJECTIVE

The purpose of this program evaluation was to assess (1) whether youth and young adult ED admission rates decreased following participation in a remote IOP program and (2) whether there were differences in readmission rates between youth and young adults by gender identity, sexual orientation, race, or ethnicity.

METHODS

Data were collected from intake and 3-month postdischarge surveys for 735 clients who attended at least 6 sessions of a remote IOP program for youth and young adults. Patients reported if they had been admitted to an ED within the previous 30 days and the admission reason. Over half (407/707, 57.6%) of clients were adolescents and the rest were young adults (300/707, 42.4%; mean age 18.25, SD 4.94 years). The sample was diverse in gender identity (329/687, 47.9% female; 196/687, 28.5% male; and 65/669, 9.7% nonbinary) and sexual orientation (248/635, 39.1% heterosexual; 137/635, 21.6% bisexual; 80/635, 10.9% pansexual; and 170/635, 26.8% other sexual orientation) and represented several racial (9/481, 1.9% Asian; 48/481, 10% Black; 9/481, 1.9% Indigenous; 380/481, 79% White; and 35/481, 7.2% other) and ethnic identities (112/455, 24.6% Hispanic and 28/455, 6.2% other ethnic identity).

RESULTS

Mental health-related ED admissions significantly decreased between intake and 3 months after discharge, such that 94% (65/69) of clients with a recent history of mental health-related ED admissions at IOP intake reported no mental health-related ED admissions at 3 months after discharge from treatment (χ21=38.8, P<.001). There were no differences in ED admissions at intake or in improvement at 3 months after discharge by age, gender, sexuality, race, or ethnicity.

CONCLUSIONS

This study documents a decrease in ED admissions between intake and 3 months after discharge among both youth and young adults who engage in IOP care following ED visits. The similar outcomes across demographic groups indicate that youth and young adults experience similar decreases after the current tracks of programming. Future research could conduct a full return-on-investment analysis for intensive mental health services for youth and young adults.

Pediatric Mental Health Emergencies During 5 COVID-19 Waves in New York City

OBJECTIVES

To describe the proportion of pediatric mental health emergency department (MH-ED) visits across 5 COVID-19 waves in New York City (NYC) and to examine the relationship between MH-ED visits, COVID-19 prevalence, and societal restrictions.

METHODS

We conducted a time-series analysis of MH-ED visits among patients ages 5 to 17 years using the INSIGHT Clinical Research Network, a database from 5 medical centers in NYC from January 1, 2016, to June 12, 2022. We estimated seasonally adjusted changes in MH-ED visit rates during the COVID-19 pandemic, compared with predicted prepandemic levels, specific to each COVID-19 wave and stratified by mental health diagnoses and sociodemographic characteristics. We estimated associations between MH-ED visit rates, COVID-19 prevalence, and societal restrictions measured by the Stringency Index.

RESULTS

Of 686 500 ED visits in the cohort, 27 168 (4.0%) were MH-ED visits. The proportion of MH-ED visits was higher during each COVID-19 wave compared with predicted prepandemic trends. Increased MH-ED visits were seen for eating disorders across all waves; anxiety disorders in all except wave 3; depressive disorders and suicidality/self-harm in wave 2; and substance use disorders in waves 2, 4, and 5. MH-ED visits were increased from expected among female, adolescent, Asian race, high Child Opportunity Index patients. There was no association between MH-ED visits and NYC COVID-19 prevalence or NY State Stringency Index.

CONCLUSIONS

The proportion of pediatric MH-ED visits during the COVID-19 pandemic was higher during each wave compared with the predicted prepandemic period, with varied increases among diagnostic and sociodemographic subgroups. Enhanced pediatric mental health resources are essential to address these findings.

Addressing the Pediatric Mental Health Crisis in Emergency Departments in the US: Findings of a National Pediatric Boarding Consensus Panel

BACKGROUND

In 2021, several professional organizations declared a national state of emergency in child and adolescent mental health. Rising volume and acuity of pediatric mental health emergencies, coupled with reduced access to inpatient psychiatric care, has caused tremendous downstream pressures on EDs resulting in long lengths of stay, or "boarding", for youth awaiting psychiatric admission. Nationally, boarding times are highly heterogeneous, with medical / surgical patients experiencing much shorter boarding times compared to patients with primary mental health needs. There is little guidance on best practices in the care of the pediatric patient with significant mental health need "boarding" in the hospital setting.

OBJECTIVE

There is a significant increase in the practice of "boarding" pediatric patients within emergency departments and inpatient medical floors while awaiting psychiatric admission. This study aims to provide consensus guidelines for the clinical care of this population.

METHODS

Twenty-three panel participants of fifty-five initial participants (response rate 41.8%) committed to completing four successive rounds of questioning using Delphi consensus gathering methodology. Most (70%) were child psychiatrists and represented 17 health systems.

RESULTS

Thirteen participants (56%) recommended maintaining boarded patients in the emergency department, while 78% indicated a temporal limit on boarding in the emergency department should prompt transfer to an inpatient pediatric floor. Of this group, 65% recommended a 24-hour threshold. Most participants (87%) recommended not caring for pediatric patients in the same space as adults. There was unanimous agreement that emergency medicine or hospitalists maintain primary ownership of patient care, while 91% agreed that child psychiatry should maintain a consultative role. Access to social work was deemed most important for staffing, followed by behavioral health nursing, psychiatrists, child life, rehabilitative services, and lastly, learning specialists. There was unanimous consensus that daily evaluation is necessary with 79% indicating vitals should be obtained every 12 hours. All agreed that if a child psychiatric provider is not available on-site, a virtual consultation is sufficient to provide mental health assessment.

CONCLUSIONS

This study highlights findings of the first national consensus panel regarding the care of youth boarding in hospital-based settings and provides promising beginnings to standardizing clinical practice while informing future research efforts.

The Association between the Police, Ambulance, Clinician Early Response (PACER) Model and Involuntary Detentions of People Living with Mental Illness: A Protocol for a Retrospective Observational Study

Emergency services are frequently called to attend mental health incidents and are looking for innovative ways to improve their responses and reduce the burden on services. Involuntary detention of people living with mental illness is considered more frequent than necessary, leading to increased pressure on emergency departments, and is often a traumatic experience for patients. The Police, Ambulance, Clinician Early Response (PACER) model was developed in 2019 in Canberra, Australia, and seeks to reduce involuntary detentions by embedding a mental health clinician into emergency services as a mobile mental health crisis response intervention. This protocol details a retrospective cohort study that will examine the association between PACER and involuntary detentions using medical and police records and compare the results to standard ambulance and police responses. We will use relative risk and odds ratio calculations to determine the probability of being involuntarily detained or diverted from hospital; and we will describe the patient characteristics and outcomes in the PACER cohort. Results will be reported using the STROBE checklist for reporting cohort studies. This study was not registered on a publicly accessible registry.

Acceptability of Long Versus Short Firearm Safety Education Videos in the Emergency Department: A Pilot Randomized Controlled Trial

STUDY OBJECTIVE

Safe firearm storage is protective against pediatric firearm injuries. We sought to compare a 3-minute versus 30-second safe firearm storage video in terms of acceptability of video content and use in the pediatric emergency department (PED).

METHODS

We conducted a randomized controlled trial in a large PED (from March to September 2021). Participants were English-speaking caregivers of noncritically ill patients. Participants were surveyed about child safety behaviors (including firearm storage), then shown 1 of 2 videos. Both videos described safe storage principles; the 3-minute video included temporary firearm removal and a survivor testimonial. The primary outcome was acceptability, measured by responses on a 5-point Likert scale (strongly disagree to strongly agree). A survey at 3 months evaluated information recall. Baseline characteristics and outcomes were compared between groups using Pearson chi-squared, Fisher exact, and Wilcoxon Mann Whitney tests as appropriate. Absolute risk difference for categoric variables and mean difference for continuous variables are reported with 95% confidence interval (CI).

RESULTS

Research staff screened 728 caregivers; 705 were eligible and 254 consented to participate (36%); 4 withdrew. Of 250 participants, most indicated acceptability in terms of setting (77.4%) and content (86.6%), and doctors discussing firearm storage (78.6%), with no difference between groups. More caregivers viewing the longer video felt the length appropriate (99.2%) compared with the shorter video (81.1%, difference 18.1%, 95% CI 11.1 to 25.1).

CONCLUSIONS

We show that video-based firearm safety education is acceptable among study participants. This can provide consistent education to caregivers in PEDs and needs further study in other settings.

Treatment of pediatric behavioral health patients with intravenous and intramuscular chemical restraints: Results from a nationwide sample of emergency departments

BACKGROUND

Behavioral health crises in pediatric emergency department (ED) patients are increasingly common. Chemical restraints can be utilized for patients who present imminent danger to self or others. We sought to describe the use of intravenous (IV)/intramuscular (IM) chemical restraints for pediatric behavioral health ED patients across a nationwide sample of hospitals and describe factors associated with restraint use.

METHODS

This was a retrospective study of patients ages 8-17 treated at 822 EDs contributing data to the Premier Healthcare Database between January 1, 2018, and December 31, 2020, with a behavioral health discharge diagnosis. The primary outcome was the use of IV/IM chemical restraint medication. We developed a hierarchical model to examine patient and hospital-level factors associated with treatment with IV/IM chemical restraint medications.

RESULTS

Of 630,384 cases, 4.8% received IV/IM chemical restraint. Patient factors associated with higher odds of chemical restraint were older age (ages 13-17 years [adjusted odds ratio {AOR} 1.53, 95% confidence interval {CI} 1.48-1.58]), anxiety disorders (AOR 1.69, 95% CI 1.64-1.74), disruptive disorders (AOR 1.61, 95% CI 1.53-1.69), suicide/self-injury (AOR 1.3, 95% CI 1.26-1.34), substance use (AOR 1.24, 95% CI 1.20-1.28), and bipolar disorder (AOR 1.23, 95% CI 1.17-1.30). Participants with complex comorbidities were more likely to receive chemical restraint (AOR 1.32, 95% CI 1.26-1.39). After patient and hospital factors were adjusted for, the median OR indicating the influence of the individual hospital on the odds of chemical restraint was 1.43 (95% CI 1.40-1.47).

CONCLUSIONS

We found that age and certain behavioral health diagnoses were associated with receipt of IV/IM chemical restraint during pediatric behavioral health ED visits. Additionally, whether a patient was treated with chemical restraints was strongly influenced by the hospital to which they presented for treatment.

Trends in Acute Care Use for Mental Health Conditions Among Youth During the COVID-19 Pandemic

Importance

Understanding how children's utilization of acute mental health care changed during the COVID-19 pandemic is critical for directing resources.

Objective

To examine youth acute mental health care use (emergency department [ED], boarding, and subsequent inpatient care) during the second year of the COVID-19 pandemic.

Design, Setting, and Participants

This cross-sectional analysis of national, deidentified commercial health insurance claims of youth mental health ED and hospital care took place between March 2019 and February 2022. Among 4.1 million commercial insurance enrollees aged 5 to 17 years, 17 614 and 16 815 youth had at least 1 mental health ED visit in the baseline year (March 2019-February 2020) and pandemic year 2 (March 2021-February 2022), respectively.

Exposure

The COVID-19 pandemic.

Main outcomes and measures

The relative change from baseline to pandemic year 2 was determined in (1) fraction of youth with 1 or more mental health ED visits; (2) percentage of mental health ED visits resulting in inpatient psychiatry admission; (3) mean length of inpatient psychiatric stay following ED visit; and (4) frequency of prolonged boarding (≥2 midnights) in the ED or a medical unit before admission to an inpatient psychiatric unit.

Results

Of 4.1 million enrollees, 51% were males and 41% were aged 13 to 17 years (vs 5-12 years) with 88 665 mental health ED visits. Comparing baseline to pandemic year 2, there was a 6.7% increase in youth with any mental health ED visits (95% CI, 4.7%-8.8%). Among adolescent females, there was a larger increase (22.1%; 95% CI, 19.2%-24.9%). The fraction of ED visits that resulted in a psychiatric admission increased by 8.4% (95% CI, 5.5%-11.2%). Mean length of inpatient psychiatric stay increased 3.8% (95% CI, 1.8%-5.7%). The fraction of episodes with prolonged boarding increased 76.4% (95% CI, 71.0%-81.0%).

Conclusions and relevance

Into the second year of the pandemic, mental health ED visits increased notably among adolescent females, and there was an increase in prolonged boarding of youth awaiting inpatient psychiatric care. Interventions are needed to increase inpatient child psychiatry capacity and reduce strain on the acute mental health care system.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies

Mental and behavioral health (MBH) visits of children and youth to emergency departments are increasing in the United States. Reasons for these visits range from suicidal ideation, self-harm, and eating and substance use disorders to behavioral outbursts, aggression, and psychosis. Despite the increase in prevalence of these conditions, the capacity of the health care system to screen, diagnose, and manage these patients continues to decline. Several social determinants also contribute to great disparities in child and adolescent (youth) health, which affect MBH outcomes. In addition, resources and space for emergency physicians, physician assistants, nurse practitioners, and prehospital practitioners to manage these patients remain limited and inconsistent throughout the United States, as is financial compensation and payment for such services. This technical report discusses the role of physicians, physician assistants, and nurse practitioners, and provides guidance for the management of acute MBH emergencies in children and youth. Unintentional ingestions and substance use disorder are not within the scope of this report and are not specifically discussed.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure, challenges with timely access to a mental health professional, the nature of a busy ED environment, and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affects patient care and ED operations. Strategies to improve care for MBH emergencies, including systems level coordination of care, is therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure; challenges with timely access to a mental health professional; the nature of a busy ED environment; and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affect patient care and ED operations. Strategies to improve care for MBH emergencies, including systems-level coordination of care, are therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

College of education students' attitude towards the use of online information dissemination tools for counseling in Ghana

Online counseling is widely regarded as a cost-effective and convenient means to provide basic counseling services, and it is increasingly being used in university treatment. However, it is unclear what amount of information and attitude students have about online counseling in colleges of education. This study looked at students' views toward and likelihood of using online counseling towards help information seeking and dissemination to see if it has the potential to increase overall service consumption. A survey was conducted and responded to by 411 students from two Ghanaian colleges of education and based on the Theory of Planned Behaviour, students' attitudes and intentions to use online counseling were investigated. The paucity of online counseling systems in the colleges of education is shown in the study, yet 94% of participants said they would use online counseling services if given the opportunity. Based on these findings, it is recommended that providing online counseling in parallel to face-to-face counseling could be an effective strategy for counseling units in colleges of education to boost service delivery and so better serve their students.

Assessing Detection of Children With Suicide-Related Emergencies: Evaluation and Development of Computable Phenotyping Approaches

BACKGROUND

Although suicide is a leading cause of death among children, the optimal approach for using health care data sets to detect suicide-related emergencies among children is not known.

OBJECTIVE

This study aimed to assess the performance of suicide-related International Classification of Diseases, Tenth Revision, Clinical Modification (ICD-10-CM) codes and suicide-related chief complaint in detecting self-injurious thoughts and behaviors (SITB) among children compared with clinician chart review. The study also aimed to examine variations in performance by child sociodemographics and type of self-injury, as well as develop machine learning models trained on codified health record data (features) and clinician chart review (gold standard) and test model detection performance.

METHODS

A gold standard classification of suicide-related emergencies was determined through clinician manual review of clinical notes from 600 emergency department visits between 2015 and 2019 by children aged 10 to 17 years. Visits classified with nonfatal suicide attempt or intentional self-harm using the Centers for Disease Control and Prevention surveillance case definition list of ICD-10-CM codes and suicide-related chief complaint were compared with the gold standard classification. Machine learning classifiers (least absolute shrinkage and selection operator-penalized logistic regression and random forest) were then trained and tested using codified health record data (eg, child sociodemographics, medications, disposition, and laboratory testing) and the gold standard classification. The accuracy, sensitivity, and specificity of each detection approach and relative importance of features were examined.

RESULTS

SITB accounted for 47.3% (284/600) of the visits. Suicide-related diagnostic codes missed nearly one-third (82/284, 28.9%) and suicide-related chief complaints missed more than half (153/284, 53.9%) of the children presenting to emergency departments with SITB. Sensitivity was significantly lower for male children than for female children (0.69, 95% CI 0.61-0.77 vs 0.84, 95% CI 0.78-0.90, respectively) and for preteens compared with adolescents (0.66, 95% CI 0.54-0.78 vs 0.86, 95% CI 0.80-0.92, respectively). Specificity was significantly lower for detecting preparatory acts (0.68, 95% CI 0.64-0.72) and attempts (0.67, 95% CI 0.63-0.71) than for detecting ideation (0.79, 95% CI 0.75-0.82). Machine learning-based models significantly improved the sensitivity of detection compared with suicide-related codes and chief complaint alone. Models considering all 84 features performed similarly to models considering only mental health-related ICD-10-CM codes and chief complaints (34 features) and models considering non-ICD-10-CM code indicators and mental health-related chief complaints (53 features).

CONCLUSIONS

The capacity to detect children with SITB may be strengthened by applying a machine learning-based approach to codified health record data. To improve integration between clinical research informatics and child mental health care, future research is needed to evaluate the potential benefits of implementing detection approaches at the point of care and identifying precise targets for suicide prevention interventions in children.

Standardizing and Improving Care for Pediatric Agitation Management in the Emergency Department

BACKGROUND AND OBJECTIVES

Pediatric mental health emergency department (ED) visits are rising in the United States, with more visits involving medication for acute agitation. Timely, standardized implementation of behavioral strategies and medications may reduce the need for physical restraint. Our objective was to standardize agitation management in a pediatric ED and reduce time in physical restraints.

METHODS

A multidisciplinary team conducted a quality improvement initiative from September 2020 to August 2021, followed by a 6-month maintenance period. A barrier assessment revealed that agitation triggers were inadequately recognized, few activities were offered during long ED visits, staff lacked confidence in verbal deescalation techniques, medication choices were inconsistent, and medications were slow to take effect. Sequential interventions included development of an agitation care pathway and order set, optimization of child life and psychiatry workflows, implementation of personalized deescalation plans, and adding droperidol to the formulary. Measures include standardization of medication choice for severe agitation and time in physical restraints.

RESULTS

During the intervention and maintenance periods, there were 129 ED visits with medication given for severe agitation and 10 ED visits with physical restraint use. Among ED visits with medication given for severe agitation, standardized medication choice (olanzapine or droperidol) increased from 8% to 88%. Mean minutes in physical restraints decreased from 173 to 71.

CONCLUSIONS

Implementing an agitation care pathway standardized and improved care for a vulnerable and high-priority population. Future studies are needed to translate interventions to community ED settings and to evaluate optimal management strategies for pediatric acute agitation.

Psychotropic Medication Use in United States Pediatric Emergency Department Visits

OBJECTIVE AND BACKGROUND

Little is known about pediatric psychotropic medication use in the emergency department (ED), despite a rise in mental and behavioral health visits. This study describes psychotropic medication use in a nationally representative sample of pediatric mental and behavioral health ED visits over a 14-year period.

METHODS

We conducted a cross-sectional analysis of pediatric (6-17 years) mental and behavioral health ED visits using the National Hospital Ambulatory Medical Care Survey, 2006-2019. We describe administration of psychotropic medications by medication type, diagnosis, and over time. Using multivariable survey-weighted logistic regression, we examine associations between medication administration and sociodemographics.

RESULTS

A psychotropic medication was administered in 11.4% of the estimated 11,792,860 pediatric mental and behavioral health ED visits in our sample. Benzodiazepines were administered most frequently (4.9% of visits). Visits with anxiety disorders had the highest frequency of psychotropic medication use (26.7%). Visits by Black non-Hispanic patients had a 60% decreased odds of medication administration compared to visits for White non-Hispanic patients. Visits with public compared to private insurance had a 3.5 times increased odds of psychotropic polypharmacy. The proportion of visits in which a psychotropic medication was administered did not change statistically over time.

CONCLUSIONS

A psychotropic medication was administered in 1 in 10 pediatric mental and behavioral health ED visits. Use differed by sociodemographics but did not change over time. As more youth seek mental and behavioral health care in the ED, we must better understand appropriate medication use to ensure quality and equitable care.

Pediatric Agitation in the Emergency Department: A Survey of Pediatric Emergency Care Coordinators

OBJECTIVE

Acute agitation episodes in the emergency department (ED) can be distressing for patients, families, and staff and may lead to injuries. We aim to understand availability of ED resources to care for children with acute agitation, perceived staff confidence with agitation management, barriers to use of de-escalation techniques, and desired resources to enhance care.

METHODS

We conducted a survey of pediatric emergency care coordinators (PECCs) in EDs in Massachusetts, Rhode Island, and Los Angeles County, California.

RESULTS

PECCs from 63 of 102 (61.8%) EDs responded. PECCs reported that ED staff feel least confident managing agitation due to developmental delay (DD) or autism spectrum disorder (ASD) (52.4%). Few EDs had a separate space to care for children with mental health conditions (22.5%), a standardized agitation scale (9.6%), an agitation management guideline (12.9%), or agitation management training (24.2%). Modification of the environment was not perceived possible for 42% of EDs. Participants reported that a barrier to the use of the de-escalation techniques distraction and verbal de-escalation was perceived lack of effectiveness (22.6% and 22.6%, respectively). Desired resources to manage agitation included guidelines for medications (82.5%) and sample care pathways (57.1%).

CONCLUSIONS

ED PECCs report low confidence in managing agitation due to DD or ASD and limited pediatric resources to address acute agitation. Additional pediatric-specific resources and training, especially for children with DD or ASD, are needed to increase clinician confidence in agitation management and to promote high-quality, patient-centered care. Training programs can focus on the early identification of agitation and the effective use of non-invasive de-escalation strategies.

Minding the gap: Evidence, implementation and funding gaps in mental health services delivery for school-aged children

State and local educational agencies are grappling with growing mental health needs among school-aged children that intensified during the COVID-19 pandemic. We undertake a case study of the experiences of one state, Tennessee, to examine the landscape of mental health interventions that are being deployed and to illuminate contextual factors that can support their implementation or exacerbate state and local challenges in addressing children's fast-rising mental health needs. We begin with an examination of the knowledge base on interventions and approaches that are commonly employed in K-12 schools to address children's mental health needs, including in Tennessee, with the aim to identify notable gaps in what we understand about their implementation and impacts on student outcomes. We find a lack of rigorous research that can inform efforts to improve the implementation and effectiveness of school-based mental health interventions. We bring this insight to our case-study analysis, which shows that this lack of guidance from research is compounded by inadequate, time-limited and fluctuating public funding that hinders local efforts to establish strong, ongoing programs that provide or connect K-12 students to essential mental health services. We call for more federal funding to support state and local implementation of proven and promising interventions for addressing children's mental health needs and more rigorous evaluations to strengthen the evidence base on their implementation and impacts.

Evaluating the pediatric mental health care continuum at an American health system

Objective

To describe trends in the pediatric mental health care continuum and identify potential gaps in care coordination.

Methods

We used electronic medical record data from October 2016 to September 2019 to characterize the prevalence of mental health issues in the pediatric population at a large American health system. This was a single institution case study. From the electronic medical record data, primary mental health discharge and readmission diagnoses were identified using International Classification of Diseases (ICD-9-CM, ICD-10-CM) codes. The electronic medical record was queried for mental health-specific diagnoses as defined by International Classification of Diseases classification, analysis of which was facilitated by the fact that only 176 mental health codes were billed for. Additionally, prevalence of care navigation encounters was assessed through electronic medical record query, as care navigation encounters are specifically coded. These encounter data was then segmented by care delivery setting.

Results

Major depressive disorder and other mood disorders comprised 49.6% and 89.4% of diagnoses in the emergency department and inpatient settings respectively compared to 9.0% of ambulatory care diagnoses and were among top reasons for readmission. Additionally, only 1% of all ambulatory care encounters had a care navigation component, whereas 86% of care navigation encounters were for mental health-associated reasons.

Conclusions

Major depressive disorder and other mood disorders were more common diagnoses in the emergency department and inpatient settings, which could signal gaps in care coordination. Bridging potential gaps in care coordination could reduce emergency department and inpatient utilization through increasing ambulatory care navigation resources, improving training, and restructuring financial incentives to facilitate ambulatory care diagnosis and management of major depressive disorder and mood disorders. Furthermore, health systems can use our descriptive analytic approach to serve as a reasonable measure of the current state of pediatric mental health care in their own patient population.

The aftermath of the COVID-19 pandemic on pediatric mental health: A pediatric emergency department's perspective

BACKGROUND

Pediatric mental health visits in the United States has become a public health crisis. Pediatric emergency departments (PED) encounter these patients during mental health emergencies. The COVID-19 pandemic disrupted the social environment of pediatric patients which potentially lead to new and worsening mental health issues. This study examined the proportion of mental health visits to PED around the first wave of the COVID-19 pandemic.

METHODS

This retrospective cohort study assessed the proportion of mental health visits at a urban, PED between September 2019 to February 2022. Inclusion criteria were subjects aged 6 to 18 years with a holding order assigned, and one of identified mental health International Classification of Disease, Tenth Division (ICD-10) codes: F01-F99, T14.19, R45, R46.89. Proportion of mental health visits were compared in 6-month periods with the first 6-months representing the pre-COVID-19 period. Secondary analysis compared demographic information and ICD-10 codes.

RESULTS

A total of 1036 charts were studied: 126 charts from 2019 to 2020, 512 from 2020 to 2021, and 398 from 2021 to 2022. The proportion of mental health visits from September 2019 to February 2020 was 1.4%, and for the following 6-month periods, the proportion of mental health visits was 1.2%, 7.5%, 4.9%, and 5.7%. There was a statistically significant difference (p < 0.001) demonstrating a higher proportion of mental health visits after the start of the COVID-19 pandemic. Secondary analysis demonstrated statistically significant difference in both median age (p < 0.001) and median length of hospitalization (p < 0.001).

CONCLUSION

This study demonstrated a significant increase in pediatric mental health visits following the start of the COVID-19 pandemic. We believe further investigation into the needs and management during acute surges will improve the care we provide to this vulnerable population.

National Trends in Mental Health-Related Emergency Department Visits Among Youth, 2011-2020

Importance

There has been increasing concern about the burden of mental health problems among youth, especially since the COVID-19 pandemic. Trends in mental health-related emergency department (ED) visits are an important indicator of unmet outpatient mental health needs.

Objective

To estimate annual trends in mental health-related ED visits among US children, adolescents, and young adults between 2011 and 2020.

Design, Setting, and Participants

Data from 2011 to 2020 in the National Hospital Ambulatory Medical Care Survey, an annual cross-sectional national probability sample survey of EDs, was used to examine mental health-related visits for youths aged 6 to 24 years (unweighted = 49 515).

Main Outcomes and Measures

Mental health-related ED visits included visits associated with psychiatric or substance use disorders and were identified by International Classification of Diseases-Ninth Revision, Clinical Modification (ICD-9-CM; 2011-2015) and ICD-10-CM (2016-2020) discharge diagnosis codes or by reason-for-visit (RFV) codes. We estimated the annual proportion of mental health-related pediatric ED visits from 2011 to 2020. Subgroup analyses were performed by demographics and broad psychiatric diagnoses. Multivariable-adjusted logistic regression analyses estimated factors independently associated with mental health-related ED visits controlling for period effects.

Results

From 2011 to 2020, the weighted number of pediatric mental health-related visits increased from 4.8 million (7.7% of all pediatric ED visits) to 7.5 million (13.1% of all ED visits) with an average annual percent change of 8.0% (95% CI, 6.1%-10.1%; P < .001). Significant linearly increasing trends were seen among children, adolescents, and young adults, with the greatest increase among adolescents and across sex and race and ethnicity. While all types of mental health-related visits significantly increased, suicide-related visits demonstrated the greatest increase from 0.9% to 4.2% of all pediatric ED visits (average annual percent change, 23.1% [95% CI, 19.0%-27.5%]; P < .001).

Conclusions and Relevance

Over the last 10 years, the proportion of pediatric ED visits for mental health reasons has approximately doubled, including a 5-fold increase in suicide-related visits. These findings underscore an urgent need to improve crisis and emergency mental health service capacity for young people, especially for children experiencing suicidal symptoms.

Prehospital Management of Pediatric Behavioral Health Emergencies: A Scoping Review

Pediatric behavioral health emergencies (BHE) are increasing in prevalence, yet there are no evidence-based guidelines or protocols for prehospital management. The primary objective of this scoping review is to identify prehospital-specific pediatric BHE research and publicly available emergency medical services (EMS) protocols for pediatric BHE. Secondary objectives include identifying the next priorities for research and EMS protocol considerations for children with neurodevelopmental conditions. This is a scoping review comprised of a research literature search for publications from 2012-2022 and an internet search for publicly available EMS protocols from the United States. Included publications contain data on the epidemiology of pediatric BHE or describe prehospital management of pediatric BHE. EMS protocols were included if they had advisements specific to pediatric BHE. A total of 50 research publications and EMS protocols from 43 states were screened. Seven publications and four protocols were included in this study. Research studies indicated an increase in pediatric BHE over the last decade, but few papers discuss current prehospital management (n=4). Two EMS protocols were specific to pediatric BHE or pediatric agitation, and the other two EMS protocols focused on adult populations with integrated pediatric recommendations. All four EMS protocols encouraged nonpharmaceutical interventions prior to the use of pharmacologic restraints. Although there is a substantial rise in pediatric BHE, there is sparse research data and clinical EMS protocols to support best practices for prehospital pediatric BHE management. This scoping review identifies important future research aims to inform best practices for the prehospital management of pediatric BHE.

Experiences of Child and Adolescent Psychiatric Patients Boarding in the Emergency Department from Staff Perspectives: Patient Journey Mapping

Over the past decade, healthcare providers nationwide have contended with a growing boarding crisis as pediatric patients await psychiatric treatment in emergency departments (EDs). COVID-19 has exacerbated this urgent youth mental health crisis, driving EDs to act as crisis units. Journey mapping is a robust methodology with which to examine strengths and challenges in patient care workflows such as boarding and emergency psychiatric care. Psychiatric, emergency medicine, and hospitalist providers serving patients boarding at a northeastern children's hospital participated in semi-structured qualitative interviews. Investigators conducted directed content analysis with an inductive approach to identify facilitators, barriers, and persistent needs of boarding patients, which were summarized in a patient journey map. Findings were presented to participants for feedback and further refinement. Quantitative data showed a three-fold increase in the number of patients who boarded over the past three years and a 60% increase in the average time spent boarding in the ED. Emergent qualitative data indicated three stages in the boarding process: Initial Evaluation, Admitted to Board, and Discharge. Data highlighted positive and negative factors affecting patient safety, availability of beds in pediatric hospital and psychiatric inpatient settings, high patient-provider ratios that limited staffing support, and roadblocks in care coordination and disposition planning. Patient journey mapping provided insight into providers' experiences serving patients boarding for psychiatric reasons. Findings described bright points and pain points at each stage of the boarding process with implications for psychiatric care and systemic changes to reduce boarding volume and length of stay.

Suicide in young people: screening, risk assessment, and intervention

Suicide is the fourth leading cause of death among young people worldwide and the third leading cause of death among those in the US. This review outlines the epidemiology of suicide and suicidal behavior in young people. It discusses intersectionality as an emerging framework to guide research on prevention of suicide in young people and highlights several clinical and community settings that are prime targets for implementation of effective treatment programs and interventions aimed at rapidly reducing the suicide rate in young people. It provides an overview of current approaches to screening and assessment of suicide risk in young people and the commonly used screening tools and assessment measures. It discusses universal, selective, and indicated evidence based suicide focused interventions and highlights components of psychosocial interventions with the strongest evidence for reducing risk. Finally, the review discusses suicide prevention strategies in community settings and considers future research directions and questions challenging the field.

Pediatric Mental Health Hospitalizations at Acute Care Hospitals in the US, 2009-2019

Importance

Approximately 1 in 6 youth in the US have a mental health condition, and suicide is a leading cause of death among this population. Recent national statistics describing acute care hospitalizations for mental health conditions are lacking.

Objectives

To describe national trends in pediatric mental health hospitalizations between 2009 and 2019, to compare utilization among mental health and non-mental health hospitalizations, and to characterize variation in utilization across hospitals.

Design, Setting, and Participants

Retrospective analysis of the 2009, 2012, 2016, and 2019 Kids' Inpatient Database, a nationally representative database of US acute care hospital discharges. Analysis included 4 767 840 weighted hospitalizations among children 3 to 17 years of age.

Exposures

Hospitalizations with primary mental health diagnoses were identified using the Child and Adolescent Mental Health Disorders Classification System, which classified mental health diagnoses into 30 mutually exclusive disorder types.

Main Outcomes and Measures

Measures included number and proportion of hospitalizations with a primary mental health diagnosis and with attempted suicide, suicidal ideation, or self-injury; number and proportion of hospital days and interfacility transfers attributable to mental health hospitalizations; mean lengths of stay (days) and transfer rates among mental health and non-mental health hospitalizations; and variation in these measures across hospitals.

Results

Of 201 932 pediatric mental health hospitalizations in 2019, 123 342 (61.1% [95% CI, 60.3%-61.9%]) were in females, 100 038 (49.5% [95% CI, 48.3%-50.7%]) were in adolescents aged 15 to 17 years, and 103 456 (51.3% [95% CI, 48.6%-53.9%]) were covered by Medicaid. Between 2009 and 2019, the number of pediatric mental health hospitalizations increased by 25.8%, and these hospitalizations accounted for a significantly higher proportion of pediatric hospitalizations (11.5% [95% CI, 10.2%-12.8%] vs 19.8% [95% CI, 17.7%-21.9%]), hospital days (22.2% [95% CI, 19.1%-25.3%] vs 28.7% [95% CI, 24.4%-33.0%]), and interfacility transfers (36.9% [95% CI, 33.2%-40.5%] vs 49.3% [95% CI, 45.9%-52.7%]). The percentage of mental health hospitalizations with attempted suicide, suicidal ideation, or self-injury diagnoses increased significantly from 30.7% (95% CI, 28.6%-32.8%) in 2009 to 64.2% (95% CI, 62.3%-66.2%) in 2019. Length of stay and interfacility transfer rates varied significantly across hospitals. Across all years, mental health hospitalizations had significantly longer mean lengths of stay and higher transfer rates compared with non-mental health hospitalizations.

Conclusions and Relevance

Between 2009 and 2019, the number and proportion of pediatric acute care hospitalizations due to mental health diagnoses increased significantly. The majority of mental health hospitalizations in 2019 included a diagnosis of attempted suicide, suicidal ideation, or self-injury, underscoring the increasing importance of this concern.