For emergency physicians, they’re a daunting and familiar sight: children in the grip of mental health crises returning again and again, brought in by caregivers who are frightened or overwhelmed.
Much has been written about the rise in psychiatric emergency visits to children in recent years, as rates of depression and suicidal behavior in teenagers have soared. Patients often spend days or weeks in examination rooms waiting for a rare psychiatric bed to become available, greatly reducing hospital capacity.
But a large study published on Tuesday found a surprising trend in adolescents who returned to the hospital repeatedly. The patients most likely to reappear in emergency rooms were not patients who had harmed themselves, but rather those whose agitation and aggressive behavior proved too much for their caregivers.
In many cases, repeat visitors had previously been given sedatives or other medications to restrain them when their behavior became disruptive.
“Families come in with their kids who have severe behavior problems, and the families just get at their wits end, you know,” said Dr. Anna M. Cushing, a pediatric emergency room physician at Children’s Hospital Los Angeles and one of the study’s authors. “Their child’s behavior can pose a danger to themselves, but also to the parents and the other children in the home.”
The findings, published in the journal JAMA Pediatrics, analyzed more than 308,000 visits to mental health facilities at 38 hospitals between 2015 and 2020.
Compared to patients with suicidal or self-injurious behavior, patients with psychotic disorders were 42 percent more likely to return to the emergency room within six months, according to the study; Patients with impulse control disorders were 36 percent more likely; and those with disorders like autism and ADHD were 22 percent more likely. Patients who needed medication to suppress them were 22 percent more likely to come back than patients who didn’t.
Tips for parents to help their struggling teens
Worried about your teenager? If you’re concerned that your teen is experiencing depression or suicidal thoughts, there are a few things you can do to help. Dr. Christine Moutier, Chief Medical Officer of the American Foundation for Suicide Prevention, suggests the following steps:
The results suggest researchers should pay more attention to families whose children have cognitive and behavioral problems who may be visiting the emergency room to recover, said Dr. said Cushing.
“I’m not sure we’ve spent that much time talking about these agitated and misbehaving patients, at least nationally,” she said.
The frequency of revisits suggests the care they’re receiving in emergency rooms “is really not appropriate,” she said.
Guidelines recommend that so-called chemical restraints — benzodiazepines, or antipsychotics given by injection or via an IV drip — be used as a last resort because they can be traumatizing or physically injuring the patient, medical staff, or caregivers, said Dr. Ashley A. Foster, Assistant Professor of Emergency Medicine at the University of California San Francisco.
The use of these drugs in pediatric emergency departments has increased in recent years. According to a study that Dr. Foster and her colleagues published last year.
The drugs were more commonly used in black patients, as well as in male patients between the ages of 18 and 21, the study found. DR Foster described these differences as “worrying and motivating to think about how to improve equitable care”.
Dr. Christine M. Crawford, a child and adolescent psychiatrist at Boston Medical Center, said caregivers of children with behavioral disorders often turn to emergency rooms when “it gets to the point where someone could get hurt.”
“They come in sixth, seventh, eighth grade — that’s when we see these families that have been struggling for a long time,” said Dr. Crawford, who is also an assistant professor at Boston University School of Medicine.
Families in this situation, she said, “are quite isolated” and often hide their struggles from friends and family. Emergency room treatment is reassuring for caregivers but offers little long-term benefit, she said.
“It just puts a band-aid on the problem,” she said. “They go home and are still waiting for that appointment to meet with a therapist.”
Dr. Andrea E. Spencer, a psychiatrist and researcher at Lurie Children’s Hospital of Chicago, said behavioral disorders can be dismissed as less urgent than suicidal thoughts or self-harm, when in fact they are “very high-risk behaviors and dangerous behaviors. “
“There’s a tendency to watch these kids and wait and see and deprioritize them as to who’s the worst, and then they tend to just get worse,” she said, adding that public hospitals may be reluctant to consider them as too accept stationary because they are disruptive.
“In many ways, these kids are actually more difficult to treat,” she said.
The JAMA study found that the total number of visits to pediatric emergency departments for mental health crises increased by 43 percent from 2015 to 2020, an average increase of 8 percent per year, with an increase in emergency department visits for each category of mental illness. In comparison, emergency room visits for all medical reasons increased 1.5 percent annually.
Almost a third of the visits were related to suicidal thoughts or self-harm, and about a quarter of the patients presented with mood disorders, followed by anxiety disorders and impulse control disorders. About 13 percent of patients returned within six months.
“It causes a lot of moral suffering for a lot of us just because it doesn’t feel like the ER is always the right or best place to take care of a lot of our patients,” said Dr. said Cushing.
“But,” she added, “they really have nowhere else to go.”