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Trends and shifting ecologies: part I
Child Adolesc Psychiatric Clin N Am 12 (2003) 599 – 611
Trends and shifting ecologies: part I Lynelle E. Thomas, MD Yale University School of Medicine, Child Study Center, 230 South Frontage Road, Post Office Box 207900, New Haven, CT 06520-7900, USA
Childhood psychiatric emergencies, in the sense that one defines them for adults, were once considered uncommon [1,2]. For example, between October 1, 1963 and July 31, 1964, the number of consultations in the Yale-New Haven Hospital emergency department for children under the age of 15 years represented only 0.61% of the pediatric emergency room population [3]. In contrast, between 1995 and 1999, emergency visits for trauma, abdominal pain, and other routine hazards of childhood increased by 2%, whereas admissions for psychoemotional and behavior-related concerns increased by 59% [4]. By 2001, the child psychiatric visits had increased to 4% of all visits to the pediatric emergency department. The national usage of pediatric psychiatric emergency services has increased substantially over the past three decades [5– 9], most notably in the Northeast and Midwest (Sills MR, Bland SD, unpublished data). The magnitude of this clinical burden is even more apparent if this information is extrapolated to the more than 31 million annual child and adolescent emergency department visits that occur nationally [10]. This number does not include children in crisis who present to emergency mobile crisis services, pediatric outpatient clinics, and general medical settings and children who never present for services. Speculation as to the cause of this increase in child and adolescent patients’ presentations for psychiatric emergency services are many. Alterations in use patterns are likely multidetermined and occur at many levels of the system.
Population-based causes A broad range of studies and authors suggest that behavioral and emotional problems have increased among children in the United States [11], particularly urban youth [12]. Studies have estimated that between 5% and 20% of children in the United States aged 9 to 17 have a ‘‘diagnosable mental or addictive disorder associated with at least minimum impairment significant enough to require
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mental health services’’ (Sills MR, Bland SD, unpublished data) [8,13]. This hypothesized surge in children and adolescents with serious emotional disturbances has coincided with a marked increase in the number of children living in poverty, both in numbers and in their share of the population. Although we do not fully understand the mechanisms by which poverty (and other social conditions) affect the development of psychopathology, poverty is a known risk factor for the development of emotional and behavioral disorders in childhood [11], even after controlling for ethnicity and urban residence [14,40]. Changes in the pattern of psychiatric emergency service use also have been explained by what is called the ‘‘wood work effect.’’ In short, increases in the acknowledgment of and the attention to the mental and emotional states of children within a population have the effect of increasing the demand for behavioral health services and increasing the identification of children whose problems were formerly neglected [6]. One illustration of this is evident within school administration policy. Schools have become a major referral source for psychiatric emergency service (Sills MR, Bland SD, unpublished data). Recent and wellpublicized violence within school settings has resulted in fearful communities. Schools, in turn, are increasingly sensitized to problematic behavior and have adopted a ‘‘zero tolerance policy,’’ whereby any student behavior or utterance that can loosely be interpreted as threatening to self or others mandates an emergency psychiatric assessment before the youth is permitted to return to school. The ‘‘kindling properties’’ of certain psychiatric conditions lend potential explanation to noted escalations in youth behavioral and emotional problems. Kindling disorders (a term borrowed from a model for depressive disorders) are those that have a spreading, contagious action that is self-propagating and self-perpetuating. This phenomenon is traditionally described as occurring within an individual. It may also occur between individuals. Behaviors such as drug abuse and suicide are examples of such disturbances that may ‘‘spread’’ from one person to another. Kindling disorders also occur when the recipient of one trauma, such as sexual abuse or physical abuse, becomes more likely to initiate similar traumata upon others in their own generation as well as offspring in subsequent generations [15].
Fiscal considerations There is considerable documentation of the trend toward privatization of mental health services that resulted from efforts at cost containment and changing incentive structures. Managed health care –driven efforts at cost containment have presumably led to denied and reduced access to inpatient care and shorter courses of inpatient hospital stay [8,16]. The privatization of mental health services has created multiple disincentives for the integration of psychiatric and medical services at the primary care level, thus lessening behavioral health care to those who have no access to subspecialty services [17]. As children and families have become increasingly dependent on federal sources of care and funding and these sources of care are scaled back and they have become more vulnerable [8].
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The care service system The recent psychiatric emergency service use boom has arisen in the context of a well-recognized child and adolescent mental health services system crisis. A litany of lay-created vocabulary poignantly describes child patients and the climate of the care system: ‘‘wait-list kids.’’ That is, ‘‘stuck kids’’ or ‘‘boarder kids’’ are those patients who cannot be discharged from psychiatric hospitals for lack of outside treatment programs, or patients who are admitted to emergency departments or pediatric wards because there are no available beds in residential treatment facilities or psychiatric hospitals. Analogous service system descriptors—‘‘logjamming,’’ ‘‘bottlenecking,’’ ‘‘gridlocking’’—refer to the accumulation of untreated and undertreated children at each level of treatment resource along the entire length of mental health care provider system: out-of-community placements (eg, residential treatment facilities and inpatient beds) and in-community-level treatments (eg, partial hospitals, outpatient community-based clinics, and child and adolescent clinician offices). System distress is so widespread that it has prompted a series of lawsuits demanding more outpatient treatment in states from New York to Idaho to California. It has been suggested that increased psychiatric emergency service usage is only one of the more visible indicators of broader, deeper problems, yawning gaps in the treatment of mental illness among the nation’s children (Sills MR, Bland SD, unpublished data) [18 – 20]. Shifts in the field’s theoretical evolution have begun to focus on diverting patients in crisis from inpatient hospital settings to a collage of well-integrated ‘‘wrap around’’ community-based and family-centered settings, with a focus on existing strengths and resources. (See the article by Pumariega elsewhere in this issue) [17,21]. But broad implementation of the National Institutes of Mental Health goals in statewide mental health programs has been limited by financial and political realities [22]. Because the pediatric psychiatric emergency service operates at the interface of the fractured community mental health system and the community and must—by default—continue to absorb the weighty burden of containing, defining, and reconciling the emotional turmoil of the patient population while access to other levels of the care system remain delayed, discontinuous or unavailable [6]. The author believes that even in the midst of this service access crisis, potential for pediatric emergency service intervention can begin during the first contact with a child and family. Hospital emergency department based psychiatric emergency services have the potential not only to intervene in critical ways that address the crisis needs of the child and the caretaking system but also provide them with information and support that would increase the likelihood of their reconnection to community-based treatment. Psychiatric emergency services often have brief windows of time in which the child or adolescent and the family are, for the first time, ready to receive help and engage in change [5]. To address the specific needs of the pediatric psychiatric patient, child psychiatric emergency services must be conceived as organizationally unique treatment facilities at each level of their operation.
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Underlying structure of psychiatric emergency service provision Gerson and Bassuk’s [6] critical review of the literature and practice of psychiatric emergency service provision highlighted ubiquitous, subtle, and notso-subtle elements of the general hospital emergency room atmosphere, organization and treatment of psychiatric patients that likely affect patient care, from the hospital systems level and the level of inter- and intradisciplinary treatment teams to a conscious and unconscious manner at the level of the treating clinicians, individual patient, and caretaker system [6]. Process Space specifically set aside for the evaluation of children and adolescents and their families is rare [19]. Beginning with the impersonal and transient nature of the process, the standard child psychiatric-related visit in most facilities consists of multiple interviews by multiple parties, which represents multiple disciplines and inordinate amounts of waiting time in varied areas. These process features leave little attention for or opportunity to establish rapport [6], the sine quo non of a psychiatric treatment. Staffing The pressure for rapid assessment and disposition planning is often a powerful determinant in the decision-making process. The existing ‘‘on-call’’ nature of emergency coverage reinforces the premium on brevity in assessment and a tunneled search for pathognomonic indicators and overt, presenting symptoms [6] rather than attention to the precipitants of the presentation, the ‘‘why now,’’ and the dynamics of the interpersonal issues that are often pivotal to most child and adolescent psychiatric crises. Staffing for child and adolescent services varies and ranges from non-child non-MD, to child and adolescent non-MD, to MD fellow presence, to MD attending level available for phone consultation, depending on the time of day and day of the week. A questionnaire circulated to members of the American Association for Emergency Psychiatry found that nearly all hospitalbased psychiatric emergency services evaluate children and adolescents; however, given the acuity of presenting complaints and the intricacy in dealing with the multiple systems involved, it was striking that only 3 of the 17 facilities surveyed had a designated child and adolescent emergency program. Staffing with child- and adolescent-trained staff was also limited [7,19]. Atmosphere A negative, hostile attitude frequently exists toward psychiatric patients of the emergency department setting. In the hierarchically arranged political structure of the medical emergency department, the primary medicolegal responsibility and power rest with the general medical staff. The priority is treatment of primary medical and surgical emergencies. Psychiatric patients often are seen as a drain of
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resources and intrusions into the essential business. They are at best tolerated. The same stigmatization of psychiatrically compromised persons that pervades the larger community finds its way into the minds of non-psychiatrically trained and, occasionally, psychiatrically trained providers. The problems of these children and families are perceived as self-inflicted, deserved outcomes that are evidence of weak, disorganized, undisciplined life choices [6]. Remodeling An optimized child-dedicated psychiatric emergency service begins with the availability of quiet and comfortable interview rooms that ensure confidentiality and insulate the patient and therapist from the hectic atmosphere of the medical emergency room. Extended evaluation time leads to decreased rate of hospitalization and increased acceptance of treatment referrals. Most hospital-based settings have a 23-hour observation bed, although it is not clear how often they are used exclusively for evaluation of children and adolescents. Provisions for child- and adolescent-dedicated extended holding units would make unhurried assessments and referrals possible. Such units can be especially useful in containing acute conditions or resolving transitory reactions to the crisis-precipitating events. In this way the assessment process is enhanced and can often reduce the incidence of hospitalization. The skills required for child and adolescent psychiatric emergency intervention are unique, varied, and far-reaching [24]. Researchers have argued that agespecific training and accreditation are necessary to ensure that the service needs of this particular population are met most efficaciously [7,25]. The benefits of a dedicated, age- specific – trained staff are many; the cost-benefit advantages should become clear. Their regular presence would mitigate negative attitudes toward psychiatric emergency work, enhance service efficiency, and optimize care for psychiatric and non-psychiatric patients. It also would function to integrate psychiatric emergency service concepts with those of the general medical services and enhance teaching and supervision of rotating child and adolescent psychiatry fellows, general psychiatry residents, pediatric housestaff, and emergency staffing at all levels. Finally, the dedicated focus would allow for the development of expertise that could guide and support needed research in child psychiatric emergency services delivery.
Examination and expansion of its knowledge base and practice of crisis assessment and crisis intervention Crisis assessment General Alteration in physical structure, atmosphere, and staffing alone will not address other key gaps within child and adolescent psychiatric emergency service
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provision. As a field, psychiatric emergency service must overcome the intellectual neglect from which it has suffered. The literature on psychiatric emergency treatment of children and adolescents is meager [19], especially when compared with that of adult practice. It continues to lack empiric research on the efficacy and effectiveness of decision making. In the same ways in which one evaluates the risk-benefits of any medical, surgical, or pharmacologic intervention, so must one dutifully weigh and consider the potential risks and benefits of any chosen disposition. Rates and lengths of stay for adolescents’ psychiatric hospitalization and lengths of stay for adolescents have been a focus of recent controversy. Given their use of hospitals’ already dwindling resources and the notoriously low reimbursement rates for psychiatric inpatient care, the appropriateness of psychiatric hospitalization for adolescents is an increasingly important concern for psychiatrists, health care planners, and third party payers [26]. Most state funds continue to be appropriated for inpatient treatment (particularly private psychiatric hospitals) or other out-of-home residential placements. Out-of-home placement is increasing for children and adolescents despite the growing consensus about the appropriateness of alternative services [22]. Studies that attempted to decipher the complexity of clinical judgment and their comparison to more straightforward linear models of decision making have a long and controversial history [27]. Various professional and accrediting organizations (most notably managed care review administrators) have begun to develop standards for hospital admission. Virtually all standards lack specificity required to assist a clinician (or reviewer) to decide whether admission is appropriate, however. Hospitalization in and of itself is not curative; it serves the purpose of stabilizing or protecting the patient (and others) to preserve the possibility of treatment or cure. Inappropriate psychiatric emergency services release may lead to violence against another community member, increase an individual’s risk of self-injury or suicide, burden his or her support system (resulting in loss of foster or residential placement), and result in further psychological or behavioral deterioration. Hospitalizing a child (appropriately or not) also may have adverse effects [26]. A needless psychiatric admission may prove to be a disruptive, regressive, and stigmatizing experience for the child and family (with associated drastic effects for self-esteem and social appraisals) [27], have negative fiscal implications, and affect a family’s decision about subsequent treatment interventions [28]. Assessments conducted in a psychiatric emergency service and the resulting disposition have major physical, psychological, and fiscal implications. Yet, we know little about the decision-making process that leads to psychiatric hospitalization, the effectiveness of inpatient services, and the outcomes of children who are diverted from hospitalization and who receive alternative forms of care. Given the paucity of guidelines from rigorous empirical tests and the inherently broad sweep of most new clinical guidelines, the decisions might appear to be chosen from each psychiatrist’s idiosyncratic clinical experience. The real world practice of child and adolescent psychiatric emergency service assessment is founded and conducted based on longstanding and well-recognized
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principles. General agreement exists about the validity of hospitalizing certain patients. The crucial dispositive question that faces the emergency clinician, however, is whether the child can return to the current living situation with additional interventions and supports or whether some other more intensive, secure, or restrictive disposition must be found. Some cases are clear cut. The child with a medically serious ingestion or other suicide attempt, active delirium or acute intoxication, or florid psychosis requires medical or psychiatric hospitalization. Similarly, a child who remains acutely aggressive or agitated despite crisis assessment and interventions in the emergency department also requires a secure placement. In other cases, however, the assessment of risk and its implications is more complex [29]. Evaluators and parents vary considerably in their perception and tolerance of a range of behavioral presentations. Legal statutes in many states give the evaluating physician broad justification for hospitalizing a minor. For example, ‘‘danger to self or others’’ aside, Connecticut physicians may hospitalize any child in need of ‘‘hospitalization for evaluation or treatment of a mental disorder’’ [30]. The crucial decision hinges largely on an estimation of the child’s probable risk to self or others. The assessment of risk is a difficult and often anxiety-provoking task for the clinician. The history, interview of child and adult informants, and patient’s mental status usually provide the emergency clinician with the data for a tentative formulation of diagnostic possibilities. Empirical results to date are equivocal on the role of diagnosis in facilitating clinical evaluations in emergency department care. In essence, the position against the importance of rendering a Diagnostic and Statistical Manual axial diagnosis in an emergency assessment offers that being a ‘‘danger to self or others’’ is a more compelling indicator of need for hospitalization. It also suggests that the influence of a diagnosis in the setting of a child crisis is further minimized by the confound of developmental factors, environmental and caretakers considerations, and comorbidity [31]. Assessing the context-specific aspects of the crisis—the factors that have led to the current crisis and emergency referral—is particularly important in weighing risk in these more relative cases. Children and adolescents may become violent or destructive in one setting, such as home or school, and show little or no dangerous propensities in other settings (hospital or outpatient clinic). Making a prediction based solely on the child’s behavior in the emergency department may have little predictive value as to behavior after discharge. For example, most child and adolescent emergency visits for aggressive or suicidal threats or behaviors occur in the context of conflict with immediate caretakers. Effective crisis family intervention, psychoeducation, and short-term problem solving in the emergency department may result in temporary amelioration and resolution of the family crisis [29]. In currently arranged psychiatric emergency service, the time and expertise necessary for this type of intervention may not exist. Evaluator factors Research conducted by Strauss et al [26] helps to dispel some part of the notion that the data for clinical decision making in psychiatry and mental health
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are somehow fuzzier or more difficult to agree on than in the rest of medicine. Authors used an appropriateness methodology developed at the Rand Corporation. It uses the opinions of expert clinicians to determine the appropriateness of highly specific indications for medical or surgical procedures. They discovered that the consensus achieved by a cohort of experts from adolescent psychiatry, adolescent substance abuse, and pediatric medicine compared favorably with that achieved by any previous panel on which the method was used. The level of clinician agreement regarding hospitalization as an appropriate treatment substantially exceeded the levels of agreement achieved for coronary artery bypass surgery or hysterectomy. The low level of disagreement also was even more striking [26]. Dicker et al [41] found that hospitalization preference was inversely proportional to professional preference. Their findings confirmed the idea that experienced clinicians use known risk factors for adolescent suicide in making recommendations for hospitalization [27,41]. System factors Because they are less disruptive to inpatient milieu, patients with internalizing disorders are seen by many institutions as more easily accepted for admission more readily than children who present with aggressive and violent behaviors. In their retrospective review, Potick et al [22] found that the strongest influence on the sorting process that leads to inpatient or outpatient psychiatric services is insurance coverage, especially private insurance coverage. Although managed care has disingenuously perpetrated the myth that ‘‘medical necessity’’ is an unambiguously determined criteria and synonymous with imminent risk to self or others, the judgment of risk and clinical indications for hospitalization are not easily decided in many cases. Disposition is often ‘‘the art of the possible.’’ Obtaining insurance authorization when needed is often difficult and time consuming. It is important, however, for the clinician not to accept self-serving corporate guidelines as more important than his or her own clinical judgment of what is clinically appropriate for a given child [29]. Patient factors In one of the few systematic investigations of the clinical predictors of inpatient and outpatient care, Pheffer et al [32] studied children treated in inpatient and outpatient settings and children from nonclinical populations. They found that the ‘‘illness factors’’ that best predicted psychiatric hospitalization were suicidal behavior, recent depression, recent aggression, poor reality testing, and the use of the ego defenses of regression and projection. Other researchers have found that behaviors that indicate danger to self or others influence the decision to hospitalize; children and adolescents with internalizing disorders are more likely to be hospitalized than patients with externalizing disorders. Children and adolescents with histories of hospitalization or other mental health care are more likely to be hospitalized than children without such histories [22]. Because these results are correlational, one can make no causal inferences about the decision-making process. It is certain, however, that psychiatric
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emergency service assessments require standardization and improvement. It is critical to understand how different financing strategies and clinician and patient characteristics affect decision making and service use. Crisis intervention Two of the highest needs expressed by patients at psychiatric emergency room exit interviews were those for information and advice [33]. Because current ecology and systems realities persist, it is important for psychiatric emergency services to create, study, and increase their allegiance to standardized, evidencebased psychiatric emergency service intervention models that not only address a patient’s crisis state but also engage patients and caretakers in a therapeutic process. For many children and adolescents, the visit to the emergency department in the psychiatric emergency service represents a first formal contact with the behavioral health care system. A targeted, education-based intervention process would serve to build some preliminary alliance between the mental health care system and family system and would likely maximize the possibility of a completed referral. Some programs have evaluated innovative and apparently effective interventions that accomplish these aims. A handful of recent reports demonstrated the benefit of structured, psychotherapeutic interventions for adolescent depression [34]. Parental perceptions of the symptoms and behavior of their children are inextricably associated with follow-up adherence and, ultimately, outcome. Entrenched caretaker-child patterns of response are sometimes more malleable for positive change during a crisis than at other times. (See the article by Spirito and Overholser elsewhere in this issue.) Rotheram-Borus et al [34] hypothesized that the high emotions and crisis atmosphere generated by an emergency department visit present a window of opportunity for altering preexisting expectations of a suicide attempters and their mothers. Rather than the emergency department encounter exacerbating and solidifying negative interaction patterns (eg, child suicide attempter or the family defensively reporting that it was a big mistake and that nothing is wrong), they developed and examined a creative intervention condition in which families were provided with an alternative style of understanding the suicide event. The specialized care included a brief intervention that included a soap opera – type video regarding suicidality, a family therapy session, and staff training. The study prospectively assigned female suicide attempters (aged 12 –18 years) and their mothers to receive either the specialized or standard emergency department care during their emergency department visit. They found that the specialized condition was associated with significantly lower depression scores by the suicide attempters and enhanced adherence to outpatient therapy follow-up. These are impressive results given the relatively low cost of delivering the specialized emergency department care condition. The mechanisms of these changes remain to be understood, but authors speculate that findings result from parents shifting their perceptions of the cause, meaning, and consequence of (the symptom) the suicide attempt [34].
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Standardizing interventions, particularly those aimed at ‘‘structural change’’ or shifts in perception, may accrue modest benefits to the youth, parents, and providers of care and might enhance therapeutic adherence. Any end behavior, such as suicide, has various complex causes. Parent-child conflicts and general family dysfunction are common precipitants for referring youth into care. The ability of the family to provide support can be paramount to either continued decompensation or stabilization of the crisis in a child presentation [35 –37]. There also is a significant body of literature on differences in youth-parent reporting of symptomatology. Parents, relative to their children, report a larger number of externalizing symptoms (ie, conduct problems). In interviewing teenagers who have made serious suicide attempt and their parents, Velting et al [38] found that for those who acknowledged their depression, a large proportion of their parents did not perceive the offspring’s level of distress. Parents also were apparently less aware of symptoms that are salient features of alcohol abuse and conduct disorder – nonaggressive. Another study of treatment follow-through after psychiatric hospitalization noted that the mother’s selfreported hostility was associated with less adolescent follow-through, which highlighted the importance of parental characteristics and concerns in efforts to maximize outcome by way of medication follow-through [39]. The findings underscore the importance of parents—a primary target for crisis intervention. The Rotheram-Borus intervention highlighted one other vital consideration in the construction of targeted, standardized crisis interventions: the existence of cultural variance in family communication styles and conceptualization of psychiatric symptomatology and illness. Their patient sample consisted primarily of first-generation Puerto Rican and Dominican families, in which the ‘‘suicide attempts were often precipitated by a family fight regarding restricted interdependence for the adolescent’’ [34]. Beyond the practical constraints of physical proximity and actual availability, ‘‘cultural proximity and accessibility’’ or lack thereof is an often ignored determinant of barriers to behavioral health help-seeking for many family systems that might benefit from behavioral health care intervention. This is particularly true within cultural minority groups and other disenfranchised communities.
Improvement of ‘‘bridging function’’ with the community behavioral health care network Follow-up Despite their great need for mental health intervention, a large proportion of patients and families who seek psychiatric emergency service during a crisis fail to attend their initial outpatient referral session. Family systems seek out crisisbased services specifically to avoid the commitment of longer term follow-up. Many families make clinic appointments, but by the time of the scheduled
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appointment, the crisis is over and the appointments are not kept. Of those who do attend, many do not complete treatment. Other groups of patients do not seek treatment between crises. Absence from follow-up treatment by suicidal adolescents is especially disturbing, considering that psychiatric intervention, particularly medication follow-through, can reduce subsequent attempts and is a predictor positive social adjustment [39]. Researchers have argued that the success of interagency referral is affected much less by patient characteristics than by the technique used by the referring professional and on the needs and intake policies of the receiving agency. Several studies have demonstrated that when a clinician directly contacts the agency rather than suggesting that the patient do it, the rate of completed treatment increased significantly; it often doubled. The length of the wait list only has an additive effect [21,23].
Liaison Ellison and Wharff [21] described how, by building closer relationships with community agencies, one psychiatric emergency service in an inner-city general hospital ultimately improved continuity of care and strengthened ties to the community. Given that their service already served a triage and back-up, consultative function to various psychiatric and social service agencies, they found it beneficial and worthwhile to extend one of their primary goals to that of educating community agencies that they already served in the appropriate process and use of hospital and emergency services. This consisted of various sets of meetings between staff members of the emergency department and representatives of community and state agencies, public and private. The goal was to streamline the referral and admissions process, review and problem solve around specific admissions, and helping to dissipate tensions that might arise among the various sectors. This ‘‘bridging’’ also consisted of regular liaisons between local shelters, day hospitals, outpatient clinics, and other inpatient services. They found that this expansion of roles not only improved communication and working relationships but also increased the frequency of successful referrals [21].
Summary Ultimately, decreased hospital lengths of stay, endemic shortages of psychiatric hospital beds, lengthy waits for indicated outpatient services, and closing of residential treatment facilities, safe homes, and detention centers have led to what could be viewed as a children’s mental health service ‘‘de-institutionalization.’’ Only critical shifts in the underlying philosophy, practice, financing, and perceived role of hospital-based child and adolescent psychiatric emergency service will put the pediatric emergency department in a position to keep up with the accelerating service demands.
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[26] Strauss G, Chassin M, Lock J. Can experts agree when to hospitalize adolescents? J Am Acad Child Adoles Psychiatry 1995;34:418 – 24. [27] Morrisey RF, Dicker R, Abikoff H, et al. Hospitalizing the suicidal adolescent: an empirical investigation of decision making criteria. J Am Acad Child Adolesc Psychiatry 1995;34:902 – 11. [28] Way BB, Allen MH, Mumpower JL, et al. Interrater agreement among psychiatrists in psychiatric emergency assessment. Am J Psychiatry 1999;155:1423 – 8. [29] Thomas LE, King RA. Child and adolescent psychiatric emergencies. In: Lewis M, editor. Child and adolescent psychiatry: a comprehensive textbook. 3rd edition. Philadelphia: Lippincott Williams and Wilkins; 2002. p. 1104 – 10. [30] Connecticut General Statutes. Section 17a-78 statute. [31] Gutterman EM. Is diagnosis relevant in the hospitalization of potentially dangerous children and adolescents? J Am Acad Child Adolesc Psychiatry 1998;37:1030 – 7. [32] Pfeffer CR, Plutchik R, Mizruchi MS, et al. A comparison of psychopathology in child psychiatric inpatients, outpatients, and nonpatients: implications for treatment planning. J Nerv Ment Dis 1986;174:529 – 35. [33] Solomon P, Beck S. Patients’ perceived service needs when seen in a psychiatric emergency room. Psychiatr Q 1989;60:215 – 26. [34] Rotheram-Borus MJ, Piacentini J, Cantwell C, et al. The 18-month impact of an emergency room intervention for adolescent female suicide attempters. J Consult Clin Psychol 2000;68:1081 – 93. [35] Claassen CA, Hughes CW, Gilfillan S, et al. Toward a redefinition of psychiatric emergency. Health Serv Res 2000;35:735 – 54. [36] Kilbert R. Mobile crisis for youth: an alternative option for emergency psychiatric care. Journal of the American Association for Emergency Psychiatry Emergency Psychiatry 2002;8:12 – 6. [37] Miller. A psychiatric emergency service and dome treatment concepts. Am J Psychiatry 1968; 124:924 – 33. [38] Velting DM, Schaffer D, et al. Parent-victim agreement in adolescent suicide research. J Am Acad Child Adolesc Psychiatry 1998;37:1161 – 6. [39] King CA, Hovey JD, Brand E, et al. Prediction of positive outcomes for adolescent psychiatric inpatients. J Am Acad Child Adolesc Psychiatry 1997;36:1434 – 42. [40] Costello EJ, Angold A, Burs BJ, et al. The Great Smoky Mountains study of youth: functional impairment and serious emotional disturbance. Arch Gen Psychiatry 1996;53:1137 – 43. [41] Dicker R, Morrisey RF, Abikoff H, et al. Hospitalizing the suicidal adolescent: decision making criteria of psychiatric residents. J Am Acad Child Adolesc Psychiatry 1997;36:769 – 76.
Trends and shifting ecologies: part I Lynelle E. Thomas, MD Yale University School of Medicine, Child Study Center, 230 South Frontage Road, Post Office Box 207900, New Haven, CT 06520-7900, USA
Childhood psychiatric emergencies, in the sense that one defines them for adults, were once considered uncommon [1,2]. For example, between October 1, 1963 and July 31, 1964, the number of consultations in the Yale-New Haven Hospital emergency department for children under the age of 15 years represented only 0.61% of the pediatric emergency room population [3]. In contrast, between 1995 and 1999, emergency visits for trauma, abdominal pain, and other routine hazards of childhood increased by 2%, whereas admissions for psychoemotional and behavior-related concerns increased by 59% [4]. By 2001, the child psychiatric visits had increased to 4% of all visits to the pediatric emergency department. The national usage of pediatric psychiatric emergency services has increased substantially over the past three decades [5– 9], most notably in the Northeast and Midwest (Sills MR, Bland SD, unpublished data). The magnitude of this clinical burden is even more apparent if this information is extrapolated to the more than 31 million annual child and adolescent emergency department visits that occur nationally [10]. This number does not include children in crisis who present to emergency mobile crisis services, pediatric outpatient clinics, and general medical settings and children who never present for services. Speculation as to the cause of this increase in child and adolescent patients’ presentations for psychiatric emergency services are many. Alterations in use patterns are likely multidetermined and occur at many levels of the system.
Population-based causes A broad range of studies and authors suggest that behavioral and emotional problems have increased among children in the United States [11], particularly urban youth [12]. Studies have estimated that between 5% and 20% of children in the United States aged 9 to 17 have a ‘‘diagnosable mental or addictive disorder associated with at least minimum impairment significant enough to require
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mental health services’’ (Sills MR, Bland SD, unpublished data) [8,13]. This hypothesized surge in children and adolescents with serious emotional disturbances has coincided with a marked increase in the number of children living in poverty, both in numbers and in their share of the population. Although we do not fully understand the mechanisms by which poverty (and other social conditions) affect the development of psychopathology, poverty is a known risk factor for the development of emotional and behavioral disorders in childhood [11], even after controlling for ethnicity and urban residence [14,40]. Changes in the pattern of psychiatric emergency service use also have been explained by what is called the ‘‘wood work effect.’’ In short, increases in the acknowledgment of and the attention to the mental and emotional states of children within a population have the effect of increasing the demand for behavioral health services and increasing the identification of children whose problems were formerly neglected [6]. One illustration of this is evident within school administration policy. Schools have become a major referral source for psychiatric emergency service (Sills MR, Bland SD, unpublished data). Recent and wellpublicized violence within school settings has resulted in fearful communities. Schools, in turn, are increasingly sensitized to problematic behavior and have adopted a ‘‘zero tolerance policy,’’ whereby any student behavior or utterance that can loosely be interpreted as threatening to self or others mandates an emergency psychiatric assessment before the youth is permitted to return to school. The ‘‘kindling properties’’ of certain psychiatric conditions lend potential explanation to noted escalations in youth behavioral and emotional problems. Kindling disorders (a term borrowed from a model for depressive disorders) are those that have a spreading, contagious action that is self-propagating and self-perpetuating. This phenomenon is traditionally described as occurring within an individual. It may also occur between individuals. Behaviors such as drug abuse and suicide are examples of such disturbances that may ‘‘spread’’ from one person to another. Kindling disorders also occur when the recipient of one trauma, such as sexual abuse or physical abuse, becomes more likely to initiate similar traumata upon others in their own generation as well as offspring in subsequent generations [15].
Fiscal considerations There is considerable documentation of the trend toward privatization of mental health services that resulted from efforts at cost containment and changing incentive structures. Managed health care –driven efforts at cost containment have presumably led to denied and reduced access to inpatient care and shorter courses of inpatient hospital stay [8,16]. The privatization of mental health services has created multiple disincentives for the integration of psychiatric and medical services at the primary care level, thus lessening behavioral health care to those who have no access to subspecialty services [17]. As children and families have become increasingly dependent on federal sources of care and funding and these sources of care are scaled back and they have become more vulnerable [8].
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The care service system The recent psychiatric emergency service use boom has arisen in the context of a well-recognized child and adolescent mental health services system crisis. A litany of lay-created vocabulary poignantly describes child patients and the climate of the care system: ‘‘wait-list kids.’’ That is, ‘‘stuck kids’’ or ‘‘boarder kids’’ are those patients who cannot be discharged from psychiatric hospitals for lack of outside treatment programs, or patients who are admitted to emergency departments or pediatric wards because there are no available beds in residential treatment facilities or psychiatric hospitals. Analogous service system descriptors—‘‘logjamming,’’ ‘‘bottlenecking,’’ ‘‘gridlocking’’—refer to the accumulation of untreated and undertreated children at each level of treatment resource along the entire length of mental health care provider system: out-of-community placements (eg, residential treatment facilities and inpatient beds) and in-community-level treatments (eg, partial hospitals, outpatient community-based clinics, and child and adolescent clinician offices). System distress is so widespread that it has prompted a series of lawsuits demanding more outpatient treatment in states from New York to Idaho to California. It has been suggested that increased psychiatric emergency service usage is only one of the more visible indicators of broader, deeper problems, yawning gaps in the treatment of mental illness among the nation’s children (Sills MR, Bland SD, unpublished data) [18 – 20]. Shifts in the field’s theoretical evolution have begun to focus on diverting patients in crisis from inpatient hospital settings to a collage of well-integrated ‘‘wrap around’’ community-based and family-centered settings, with a focus on existing strengths and resources. (See the article by Pumariega elsewhere in this issue) [17,21]. But broad implementation of the National Institutes of Mental Health goals in statewide mental health programs has been limited by financial and political realities [22]. Because the pediatric psychiatric emergency service operates at the interface of the fractured community mental health system and the community and must—by default—continue to absorb the weighty burden of containing, defining, and reconciling the emotional turmoil of the patient population while access to other levels of the care system remain delayed, discontinuous or unavailable [6]. The author believes that even in the midst of this service access crisis, potential for pediatric emergency service intervention can begin during the first contact with a child and family. Hospital emergency department based psychiatric emergency services have the potential not only to intervene in critical ways that address the crisis needs of the child and the caretaking system but also provide them with information and support that would increase the likelihood of their reconnection to community-based treatment. Psychiatric emergency services often have brief windows of time in which the child or adolescent and the family are, for the first time, ready to receive help and engage in change [5]. To address the specific needs of the pediatric psychiatric patient, child psychiatric emergency services must be conceived as organizationally unique treatment facilities at each level of their operation.
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Underlying structure of psychiatric emergency service provision Gerson and Bassuk’s [6] critical review of the literature and practice of psychiatric emergency service provision highlighted ubiquitous, subtle, and notso-subtle elements of the general hospital emergency room atmosphere, organization and treatment of psychiatric patients that likely affect patient care, from the hospital systems level and the level of inter- and intradisciplinary treatment teams to a conscious and unconscious manner at the level of the treating clinicians, individual patient, and caretaker system [6]. Process Space specifically set aside for the evaluation of children and adolescents and their families is rare [19]. Beginning with the impersonal and transient nature of the process, the standard child psychiatric-related visit in most facilities consists of multiple interviews by multiple parties, which represents multiple disciplines and inordinate amounts of waiting time in varied areas. These process features leave little attention for or opportunity to establish rapport [6], the sine quo non of a psychiatric treatment. Staffing The pressure for rapid assessment and disposition planning is often a powerful determinant in the decision-making process. The existing ‘‘on-call’’ nature of emergency coverage reinforces the premium on brevity in assessment and a tunneled search for pathognomonic indicators and overt, presenting symptoms [6] rather than attention to the precipitants of the presentation, the ‘‘why now,’’ and the dynamics of the interpersonal issues that are often pivotal to most child and adolescent psychiatric crises. Staffing for child and adolescent services varies and ranges from non-child non-MD, to child and adolescent non-MD, to MD fellow presence, to MD attending level available for phone consultation, depending on the time of day and day of the week. A questionnaire circulated to members of the American Association for Emergency Psychiatry found that nearly all hospitalbased psychiatric emergency services evaluate children and adolescents; however, given the acuity of presenting complaints and the intricacy in dealing with the multiple systems involved, it was striking that only 3 of the 17 facilities surveyed had a designated child and adolescent emergency program. Staffing with child- and adolescent-trained staff was also limited [7,19]. Atmosphere A negative, hostile attitude frequently exists toward psychiatric patients of the emergency department setting. In the hierarchically arranged political structure of the medical emergency department, the primary medicolegal responsibility and power rest with the general medical staff. The priority is treatment of primary medical and surgical emergencies. Psychiatric patients often are seen as a drain of
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resources and intrusions into the essential business. They are at best tolerated. The same stigmatization of psychiatrically compromised persons that pervades the larger community finds its way into the minds of non-psychiatrically trained and, occasionally, psychiatrically trained providers. The problems of these children and families are perceived as self-inflicted, deserved outcomes that are evidence of weak, disorganized, undisciplined life choices [6]. Remodeling An optimized child-dedicated psychiatric emergency service begins with the availability of quiet and comfortable interview rooms that ensure confidentiality and insulate the patient and therapist from the hectic atmosphere of the medical emergency room. Extended evaluation time leads to decreased rate of hospitalization and increased acceptance of treatment referrals. Most hospital-based settings have a 23-hour observation bed, although it is not clear how often they are used exclusively for evaluation of children and adolescents. Provisions for child- and adolescent-dedicated extended holding units would make unhurried assessments and referrals possible. Such units can be especially useful in containing acute conditions or resolving transitory reactions to the crisis-precipitating events. In this way the assessment process is enhanced and can often reduce the incidence of hospitalization. The skills required for child and adolescent psychiatric emergency intervention are unique, varied, and far-reaching [24]. Researchers have argued that agespecific training and accreditation are necessary to ensure that the service needs of this particular population are met most efficaciously [7,25]. The benefits of a dedicated, age- specific – trained staff are many; the cost-benefit advantages should become clear. Their regular presence would mitigate negative attitudes toward psychiatric emergency work, enhance service efficiency, and optimize care for psychiatric and non-psychiatric patients. It also would function to integrate psychiatric emergency service concepts with those of the general medical services and enhance teaching and supervision of rotating child and adolescent psychiatry fellows, general psychiatry residents, pediatric housestaff, and emergency staffing at all levels. Finally, the dedicated focus would allow for the development of expertise that could guide and support needed research in child psychiatric emergency services delivery.
Examination and expansion of its knowledge base and practice of crisis assessment and crisis intervention Crisis assessment General Alteration in physical structure, atmosphere, and staffing alone will not address other key gaps within child and adolescent psychiatric emergency service
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provision. As a field, psychiatric emergency service must overcome the intellectual neglect from which it has suffered. The literature on psychiatric emergency treatment of children and adolescents is meager [19], especially when compared with that of adult practice. It continues to lack empiric research on the efficacy and effectiveness of decision making. In the same ways in which one evaluates the risk-benefits of any medical, surgical, or pharmacologic intervention, so must one dutifully weigh and consider the potential risks and benefits of any chosen disposition. Rates and lengths of stay for adolescents’ psychiatric hospitalization and lengths of stay for adolescents have been a focus of recent controversy. Given their use of hospitals’ already dwindling resources and the notoriously low reimbursement rates for psychiatric inpatient care, the appropriateness of psychiatric hospitalization for adolescents is an increasingly important concern for psychiatrists, health care planners, and third party payers [26]. Most state funds continue to be appropriated for inpatient treatment (particularly private psychiatric hospitals) or other out-of-home residential placements. Out-of-home placement is increasing for children and adolescents despite the growing consensus about the appropriateness of alternative services [22]. Studies that attempted to decipher the complexity of clinical judgment and their comparison to more straightforward linear models of decision making have a long and controversial history [27]. Various professional and accrediting organizations (most notably managed care review administrators) have begun to develop standards for hospital admission. Virtually all standards lack specificity required to assist a clinician (or reviewer) to decide whether admission is appropriate, however. Hospitalization in and of itself is not curative; it serves the purpose of stabilizing or protecting the patient (and others) to preserve the possibility of treatment or cure. Inappropriate psychiatric emergency services release may lead to violence against another community member, increase an individual’s risk of self-injury or suicide, burden his or her support system (resulting in loss of foster or residential placement), and result in further psychological or behavioral deterioration. Hospitalizing a child (appropriately or not) also may have adverse effects [26]. A needless psychiatric admission may prove to be a disruptive, regressive, and stigmatizing experience for the child and family (with associated drastic effects for self-esteem and social appraisals) [27], have negative fiscal implications, and affect a family’s decision about subsequent treatment interventions [28]. Assessments conducted in a psychiatric emergency service and the resulting disposition have major physical, psychological, and fiscal implications. Yet, we know little about the decision-making process that leads to psychiatric hospitalization, the effectiveness of inpatient services, and the outcomes of children who are diverted from hospitalization and who receive alternative forms of care. Given the paucity of guidelines from rigorous empirical tests and the inherently broad sweep of most new clinical guidelines, the decisions might appear to be chosen from each psychiatrist’s idiosyncratic clinical experience. The real world practice of child and adolescent psychiatric emergency service assessment is founded and conducted based on longstanding and well-recognized
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principles. General agreement exists about the validity of hospitalizing certain patients. The crucial dispositive question that faces the emergency clinician, however, is whether the child can return to the current living situation with additional interventions and supports or whether some other more intensive, secure, or restrictive disposition must be found. Some cases are clear cut. The child with a medically serious ingestion or other suicide attempt, active delirium or acute intoxication, or florid psychosis requires medical or psychiatric hospitalization. Similarly, a child who remains acutely aggressive or agitated despite crisis assessment and interventions in the emergency department also requires a secure placement. In other cases, however, the assessment of risk and its implications is more complex [29]. Evaluators and parents vary considerably in their perception and tolerance of a range of behavioral presentations. Legal statutes in many states give the evaluating physician broad justification for hospitalizing a minor. For example, ‘‘danger to self or others’’ aside, Connecticut physicians may hospitalize any child in need of ‘‘hospitalization for evaluation or treatment of a mental disorder’’ [30]. The crucial decision hinges largely on an estimation of the child’s probable risk to self or others. The assessment of risk is a difficult and often anxiety-provoking task for the clinician. The history, interview of child and adult informants, and patient’s mental status usually provide the emergency clinician with the data for a tentative formulation of diagnostic possibilities. Empirical results to date are equivocal on the role of diagnosis in facilitating clinical evaluations in emergency department care. In essence, the position against the importance of rendering a Diagnostic and Statistical Manual axial diagnosis in an emergency assessment offers that being a ‘‘danger to self or others’’ is a more compelling indicator of need for hospitalization. It also suggests that the influence of a diagnosis in the setting of a child crisis is further minimized by the confound of developmental factors, environmental and caretakers considerations, and comorbidity [31]. Assessing the context-specific aspects of the crisis—the factors that have led to the current crisis and emergency referral—is particularly important in weighing risk in these more relative cases. Children and adolescents may become violent or destructive in one setting, such as home or school, and show little or no dangerous propensities in other settings (hospital or outpatient clinic). Making a prediction based solely on the child’s behavior in the emergency department may have little predictive value as to behavior after discharge. For example, most child and adolescent emergency visits for aggressive or suicidal threats or behaviors occur in the context of conflict with immediate caretakers. Effective crisis family intervention, psychoeducation, and short-term problem solving in the emergency department may result in temporary amelioration and resolution of the family crisis [29]. In currently arranged psychiatric emergency service, the time and expertise necessary for this type of intervention may not exist. Evaluator factors Research conducted by Strauss et al [26] helps to dispel some part of the notion that the data for clinical decision making in psychiatry and mental health
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are somehow fuzzier or more difficult to agree on than in the rest of medicine. Authors used an appropriateness methodology developed at the Rand Corporation. It uses the opinions of expert clinicians to determine the appropriateness of highly specific indications for medical or surgical procedures. They discovered that the consensus achieved by a cohort of experts from adolescent psychiatry, adolescent substance abuse, and pediatric medicine compared favorably with that achieved by any previous panel on which the method was used. The level of clinician agreement regarding hospitalization as an appropriate treatment substantially exceeded the levels of agreement achieved for coronary artery bypass surgery or hysterectomy. The low level of disagreement also was even more striking [26]. Dicker et al [41] found that hospitalization preference was inversely proportional to professional preference. Their findings confirmed the idea that experienced clinicians use known risk factors for adolescent suicide in making recommendations for hospitalization [27,41]. System factors Because they are less disruptive to inpatient milieu, patients with internalizing disorders are seen by many institutions as more easily accepted for admission more readily than children who present with aggressive and violent behaviors. In their retrospective review, Potick et al [22] found that the strongest influence on the sorting process that leads to inpatient or outpatient psychiatric services is insurance coverage, especially private insurance coverage. Although managed care has disingenuously perpetrated the myth that ‘‘medical necessity’’ is an unambiguously determined criteria and synonymous with imminent risk to self or others, the judgment of risk and clinical indications for hospitalization are not easily decided in many cases. Disposition is often ‘‘the art of the possible.’’ Obtaining insurance authorization when needed is often difficult and time consuming. It is important, however, for the clinician not to accept self-serving corporate guidelines as more important than his or her own clinical judgment of what is clinically appropriate for a given child [29]. Patient factors In one of the few systematic investigations of the clinical predictors of inpatient and outpatient care, Pheffer et al [32] studied children treated in inpatient and outpatient settings and children from nonclinical populations. They found that the ‘‘illness factors’’ that best predicted psychiatric hospitalization were suicidal behavior, recent depression, recent aggression, poor reality testing, and the use of the ego defenses of regression and projection. Other researchers have found that behaviors that indicate danger to self or others influence the decision to hospitalize; children and adolescents with internalizing disorders are more likely to be hospitalized than patients with externalizing disorders. Children and adolescents with histories of hospitalization or other mental health care are more likely to be hospitalized than children without such histories [22]. Because these results are correlational, one can make no causal inferences about the decision-making process. It is certain, however, that psychiatric
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emergency service assessments require standardization and improvement. It is critical to understand how different financing strategies and clinician and patient characteristics affect decision making and service use. Crisis intervention Two of the highest needs expressed by patients at psychiatric emergency room exit interviews were those for information and advice [33]. Because current ecology and systems realities persist, it is important for psychiatric emergency services to create, study, and increase their allegiance to standardized, evidencebased psychiatric emergency service intervention models that not only address a patient’s crisis state but also engage patients and caretakers in a therapeutic process. For many children and adolescents, the visit to the emergency department in the psychiatric emergency service represents a first formal contact with the behavioral health care system. A targeted, education-based intervention process would serve to build some preliminary alliance between the mental health care system and family system and would likely maximize the possibility of a completed referral. Some programs have evaluated innovative and apparently effective interventions that accomplish these aims. A handful of recent reports demonstrated the benefit of structured, psychotherapeutic interventions for adolescent depression [34]. Parental perceptions of the symptoms and behavior of their children are inextricably associated with follow-up adherence and, ultimately, outcome. Entrenched caretaker-child patterns of response are sometimes more malleable for positive change during a crisis than at other times. (See the article by Spirito and Overholser elsewhere in this issue.) Rotheram-Borus et al [34] hypothesized that the high emotions and crisis atmosphere generated by an emergency department visit present a window of opportunity for altering preexisting expectations of a suicide attempters and their mothers. Rather than the emergency department encounter exacerbating and solidifying negative interaction patterns (eg, child suicide attempter or the family defensively reporting that it was a big mistake and that nothing is wrong), they developed and examined a creative intervention condition in which families were provided with an alternative style of understanding the suicide event. The specialized care included a brief intervention that included a soap opera – type video regarding suicidality, a family therapy session, and staff training. The study prospectively assigned female suicide attempters (aged 12 –18 years) and their mothers to receive either the specialized or standard emergency department care during their emergency department visit. They found that the specialized condition was associated with significantly lower depression scores by the suicide attempters and enhanced adherence to outpatient therapy follow-up. These are impressive results given the relatively low cost of delivering the specialized emergency department care condition. The mechanisms of these changes remain to be understood, but authors speculate that findings result from parents shifting their perceptions of the cause, meaning, and consequence of (the symptom) the suicide attempt [34].
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Standardizing interventions, particularly those aimed at ‘‘structural change’’ or shifts in perception, may accrue modest benefits to the youth, parents, and providers of care and might enhance therapeutic adherence. Any end behavior, such as suicide, has various complex causes. Parent-child conflicts and general family dysfunction are common precipitants for referring youth into care. The ability of the family to provide support can be paramount to either continued decompensation or stabilization of the crisis in a child presentation [35 –37]. There also is a significant body of literature on differences in youth-parent reporting of symptomatology. Parents, relative to their children, report a larger number of externalizing symptoms (ie, conduct problems). In interviewing teenagers who have made serious suicide attempt and their parents, Velting et al [38] found that for those who acknowledged their depression, a large proportion of their parents did not perceive the offspring’s level of distress. Parents also were apparently less aware of symptoms that are salient features of alcohol abuse and conduct disorder – nonaggressive. Another study of treatment follow-through after psychiatric hospitalization noted that the mother’s selfreported hostility was associated with less adolescent follow-through, which highlighted the importance of parental characteristics and concerns in efforts to maximize outcome by way of medication follow-through [39]. The findings underscore the importance of parents—a primary target for crisis intervention. The Rotheram-Borus intervention highlighted one other vital consideration in the construction of targeted, standardized crisis interventions: the existence of cultural variance in family communication styles and conceptualization of psychiatric symptomatology and illness. Their patient sample consisted primarily of first-generation Puerto Rican and Dominican families, in which the ‘‘suicide attempts were often precipitated by a family fight regarding restricted interdependence for the adolescent’’ [34]. Beyond the practical constraints of physical proximity and actual availability, ‘‘cultural proximity and accessibility’’ or lack thereof is an often ignored determinant of barriers to behavioral health help-seeking for many family systems that might benefit from behavioral health care intervention. This is particularly true within cultural minority groups and other disenfranchised communities.
Improvement of ‘‘bridging function’’ with the community behavioral health care network Follow-up Despite their great need for mental health intervention, a large proportion of patients and families who seek psychiatric emergency service during a crisis fail to attend their initial outpatient referral session. Family systems seek out crisisbased services specifically to avoid the commitment of longer term follow-up. Many families make clinic appointments, but by the time of the scheduled
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appointment, the crisis is over and the appointments are not kept. Of those who do attend, many do not complete treatment. Other groups of patients do not seek treatment between crises. Absence from follow-up treatment by suicidal adolescents is especially disturbing, considering that psychiatric intervention, particularly medication follow-through, can reduce subsequent attempts and is a predictor positive social adjustment [39]. Researchers have argued that the success of interagency referral is affected much less by patient characteristics than by the technique used by the referring professional and on the needs and intake policies of the receiving agency. Several studies have demonstrated that when a clinician directly contacts the agency rather than suggesting that the patient do it, the rate of completed treatment increased significantly; it often doubled. The length of the wait list only has an additive effect [21,23].
Liaison Ellison and Wharff [21] described how, by building closer relationships with community agencies, one psychiatric emergency service in an inner-city general hospital ultimately improved continuity of care and strengthened ties to the community. Given that their service already served a triage and back-up, consultative function to various psychiatric and social service agencies, they found it beneficial and worthwhile to extend one of their primary goals to that of educating community agencies that they already served in the appropriate process and use of hospital and emergency services. This consisted of various sets of meetings between staff members of the emergency department and representatives of community and state agencies, public and private. The goal was to streamline the referral and admissions process, review and problem solve around specific admissions, and helping to dissipate tensions that might arise among the various sectors. This ‘‘bridging’’ also consisted of regular liaisons between local shelters, day hospitals, outpatient clinics, and other inpatient services. They found that this expansion of roles not only improved communication and working relationships but also increased the frequency of successful referrals [21].
Summary Ultimately, decreased hospital lengths of stay, endemic shortages of psychiatric hospital beds, lengthy waits for indicated outpatient services, and closing of residential treatment facilities, safe homes, and detention centers have led to what could be viewed as a children’s mental health service ‘‘de-institutionalization.’’ Only critical shifts in the underlying philosophy, practice, financing, and perceived role of hospital-based child and adolescent psychiatric emergency service will put the pediatric emergency department in a position to keep up with the accelerating service demands.
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