The Rise of Child and Adolescent Psychiatric Emergency Visits

Mental health problems and self-harm are leading causes of morbidity and mortality of children. The Centers for Disease Control and Prevention (CDC) lists the leading causes of death in 10-14-year-olds as accidents, accounting for 30% of total deaths, malignant neoplasms at 16.2%, intentional self-harm at 9.1%, followed by assault at 5.1%. For adolescents ages 15—19 years old, accidents are the leading cause of death at 41.7%, followed by assault at 16.8%, and intentional self-harm at 15.2% (Heron 2013). One-fourth of youth experiences a mental disorder during the past year and about one-third across their lifetimes (Merikangas et al. 2009).

Child psychiatric department visits have been on the rise. From 1993 to 1999 ED pediatric mental health visits accounted for 1.6% of all ED visits (Sills and Bland 2002). During that time, the visits for suicidal attempts, self-injury, and psychosis was stable, suggesting that the overall rise in ED pediatric mental health visits may have been attributable to nonurgent complaints more appropriately managed by a primary mental health provider. The pediatric ED at Yale University noted an increase of 59% in psychiatric illness-related visits between 1995 and 1999 (Santucci et al. 2000). National percentages of total visits, visit counts, and population rates were calculated, overall and by race, age, and sex. ED visits for mental health issues increased from 4.4% of all visits in 2001 to 7.2% in 2011 (Simon and Schoendorf 2014).

The rise of ED visits is connected to the decrease of inpatient hospital beds, without a concomitant increase in outpatient services, and a zero-tolerance policy for agitation or threat of violence by school systems. In the 2011—2012 school year, there were 3435 calls to the emergency medical services (EMS) by New York City schools, costing at least 4.4 million dollars (Brill 2013). Of these, 947 calls were to handle disruptive or dangerous kids, costing 1.2 million dollars (Rosen 2013). These referrals have gained the name “psychiatric suspensions” with schools illegally mandating a psychiatric assessment before returning to the classroom. According to a study, only 3% of the kids brought to an emergency department from school were admitted to the hospital (Rosen 2013). Many of these referrals stem from zero tolerance and the citywide standards on discipline and intervention of the board of education. The practice of removing misbehaving students by EMS is traumatic to the students, and a costly waste of EMS and hospital resources.

The national youth risk behavior survey (YRBS) monitors health-risk behaviors that contribute to the leading causes of death, disability, and social problems among youth and adults in the United States. The national YRBS is conducted every 2 years during the spring semester and provides data representative of ninth- through twelfth-grade students in public and private schools throughout the United States. In 2013, 39.1% of women and 20.8% of males reported feeling sad 2 weeks in a row, reducing some usual activities. Overall, 17% seriously considered attempting suicide, 13.6% made a plan, 8% attempted suicide, and 2.7% received medical treatment for their attempt (Centers for Disease Control and Prevention 2016b). Rotheram-Borus (2000) reported that fewer than 50% of adolescents seen for suicidal behavior in the ED were ever referred for treatment, and, even when they were referred, compliance with treatment was low. Another study revealed that only one-fifth of these children receive necessary treatment.

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