For emergency room doctors, they are a daunting and familiar sight: children who return again and again in the onslaught of mental health crises, carried by frightened or overwhelmed caregivers.
Much has been written about the rise in pediatric mental health emergency visits in recent years, as rates of depression and suicidal behavior among teens have risen. Patients often spend days or weeks in exam rooms waiting for a rare psychiatric bed to open up, dramatically reducing hospital capacity.
But a large study published Tuesday found a surprising trend among teens who repeatedly visited the hospital. The patients most likely to reappear in emergency rooms were not patients who hurt themselves, but those whose agitation and aggressive behavior became too much for their caregivers.
In many cases, repeat visitors had previously been given sedatives or other drugs to slow them down when their behavior became disruptive.
“Families come in with their kids who have severe behavioral problems, and families are really 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 be a danger to themselves, but also to the parents, to the other children in the home.”
The results, published in the journal JAMA Pediatrics, analyzed more than 308,000 mental health visits at 38 hospitals between 2015 and 2020.
Compared with patients who exhibited suicidal or self-harming behaviors, those with psychotic disorders were 42 percent more likely to return to the emergency department within six months, the study found; patients with impulse control disorders were 36 percent more likely; and patients with disorders such as autism and ADHD were 22 percent more likely. Patients who required medication to undergo them were 22 percent more likely to return for a visit than patients who did not.
Tips for parents to help their struggling teens
Worried about your teenager? If you are concerned that your teen may be suffering from depression or suicidal thoughts, there are some things you can do to help. Dr. Christine Moutier, the medical director of the American Foundation for Suicide Prevention, suggests these steps:
The findings suggest that researchers should focus more attention on families whose children have cognitive and behavioral problems and may turn to emergency rooms for respite, said Dr. Cushing said.
“I’m not sure we’ve spent that much time talking about these agitated, behaviorally dysregulated patients, at least on a national scale,” he said.
The frequency of visits suggests that the care they’re getting in emergency rooms is “really not adequate,” he said.
The guidelines recommend that so-called chemical restraints — benzodiazepines or antipsychotics given by injection or through an intravenous drip — be used as a last resort because they can be traumatizing or cause physical injury to 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 emergencies has increased in recent years. According to a study by Dr. Foster and colleagues published last year.
The study found that the drugs were used more often in black patients, as well as in male patients between the ages of 18 and 21. Dr. Foster described these disparities as “concerning 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 get into sixth, seventh, eighth grade, that’s when we see those 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, he said, “are quite isolated,” often hiding their struggles from friends and family. Emergency treatment is comforting to caregivers, but offers little long-term benefit, he said.
“It’s just putting a Band-Aid on the problem,” he said. “They come home and they’re still waiting for that appointment to meet with a therapist.”
Dr. Andrea E. Spencer, a psychiatrist and researcher at Lurie Children’s Hospital in Chicago, said that conduct disorders might be dismissed as less urgent than suicidal thoughts or self-harm, when in reality “these are very high-risk behaviors and are dangerous conduct”. “
“There is a tendency to watch and wait and deprioritize these children in terms of who are the most serious, and then they tend to get worse,” he said, adding that public hospitals might be reluctant to accept them as to hospitalized patients because they are disruptive.
“In many ways, these kids are really harder to deal with,” he said.
The JAMA study found that overall visits to pediatric emergency rooms for mental health crises increased 43% from 2015 to 2020, increasing by an average of 8% annually, with an increase in visits to emergency for each category of mental illness. In comparison, emergency room visits for all medical causes increased by 1.5 percent annually.
Almost a third of visits were related to suicidal ideation or self-harm, and about a quarter of patients had mood disorders, followed by anxiety disorders and impulse control disorders. About 13 percent of patients had a repeat visit within six months.
“It causes a lot of moral distress for a lot of us, just because the emergency department doesn’t always seem like the right place or the best place to take care of many of our patients,” said Dr. Cushing said.
“But,” he added, “they don’t really have anywhere else to go.”