- Email: [email protected]
Utility of MyHEARTSMAP for Universal Psychosocial Screening in the Emergency Department
ORIGINAL ARTICLES Utility of MyHEARTSMAP for Universal Psychosocial Screening in the Emergency Department Quynh Doan, MDCM, PhD1, Bruce Wright, MD2, Amanbir Atwal, BSc3, Elizabeth Hankinson, MD1, Punit Virk, MSc4, Hawmid Azizi, BSc, MSc3, Rob Stenstrom, MD, PhD5, Tyler Black, MD6, Rebecca Gokiert, R.Psych, PhD7, and Amanda S. Newton, PhD2 Objectives To evaluate the utility of universal psychosocial screening in the emergency department (ED) using MyHEARTSMAP, a digital self-assessment and management guiding tool.
Study design We conducted a cohort study of youth 10-17 years of age with nonmental health related presentations at 2 pediatric EDs. On randomly selected shifts (December 2017-February 2019), participants completed their psychosocial self-assessments using MyHEARTSMAP on a mobile device, then underwent a standardized clinical mental health assessment (criterion standard). We reported the sensitivity and specificity of respondents’ self-assessment, against a clinician’s standard emergency psychosocial assessment, and the frequency of psychosocial issues and recommended mental health resources identified by screening. Results We approached 1432 eligible youth, among which 795 youth consented to participate (55.5%). Youth and guardians’ sensitivity at self-identifying psychiatric concerns was 92.7% (95% CI 89.1, 95.4%) and 93.1% (95% CI 89.5, 95.8%), respectively. In cases where clinicians had determined to be no psychiatric issues, 98.5% (95% CI 96.7, 99.4%) of youth and 98.9% (95% CI 97.3, 99.7%) of guardians identified the youth as having no or only mild issues. Screening identified 36.4% of youth as having issues in at least 1 psychosocial domain which warranted further follow-up. Conclusions Psychosocial screening in EDs using MyHEARTSMAP can reliably be conducted using the MyHEARTSMAP self-assessment tool and over one-third of screened youth identified issues which can be directed to further care. (J Pediatr 2020;-:1-8).
M
ental health concerns, including suicidal ideation, in childhood and adolescence are prevalent and undertreated.1 They rank among the most disabling diseases in high-income countries and are associated with comorbidities such as smoking and poor social functioning.2,3 Suicide is the second leading cause of death in youth, accounting for 23% of deaths among youth age 15-19 years.4 Visits for mental health concerns in the emergency department (ED) have steadily increased,5-7 and in Canada, rates of pediatric ED visits for mental health concerns increased up to 8.5% per year.8,9 However, these numbers underestimate the full burden of mental illness in the ED, as youth presenting with nonpsychiatric concerns often have significant underlying psychosocial morbidity.10-12 In the absence of routine screening, up to 98% of mental illnesses can go unrecognized by ED clinicians.12 Studies have shown that screening for mood disorders in the ED increases early identification and access to services.13,14 Screening has been found acceptable and feasible for ED clinicians and their patients.15-17 However, barriers to routine screening have been cited and include limited time, and challenges with disposition planning.18 Using an electronic selfadministered screening tool, which provides tailored management recommendations, could overcome these barriers and minimize impact on ED flow. Computer-based ED interventions have already been well received for other indications but have rarely been implemented for mental health screening in youth.19-21 Adapted from HEARTSMAP (acronym for home, education and activities, alcohol and drugs, relationships and bullying, thoughts and anxiety, safety, sexual health, mood, abuse, and professional resources), a previously validated From the Department of Pediatrics, University of British computerized tool currently used by ED clinicians for assessment and manageColumbia, Vancouver, British Columbia; Department of Pediatrics, University of Alberta, Edmonton, Alberta; 22-25 ment of patients with mental health concerns, our team developed MyFaculty of Medicine, University of British Columbia, Vancouver, British Columbia; School of Population and HEARTSMAP through youth and parent focus groups, among whom it Public Health, University of British Columbia, Vancouver, British Columbia; Department of Emergency Medicine, displayed high inter-rater reliability.26 Youth (10-17 years of age) self-screen, 1
2
3
4
5
ED HEARTSMAP
PERC
Emergency department Home, education and activities, alcohol and drugs, relationships and bullying, thoughts and anxiety, safety, sexual health, mood, abuse, and professional resources Pediatric Emergency Research Canada
University of British Columbia, Vancouver, British Columbia; 6Department of Psychiatry, University of British Columbia, Vancouver, British Columbia and 7 Faculty of Extension, University of Alberta, Edmonton, Alberta, Canada Funded by an operating grant from the Canadian Institutes of Health Research (PJT-152997). The authors declare no conflicts of interest.
0022-3476/$ - see front matter. ª 2019 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jpeds.2019.12.046
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or parent/guardians act as a proxy-screen, using a mobile electronic device, which takes them between 10 and 15 minutes to complete. The tool covers 10 areas of functioning: home, education and activities, alcohol and drugs, relationships and bullying, thoughts and anxiety, safety, sexual health, mood, abuse, and professional resources. These areas map to 1 of 4 domains: psychiatry, social, functional status, and youth health. Users are guided with prompting questions to score the severity of the youth’s concern in each of the 10 sections, rated from 0 for “no concern” to 3 for “severe.” Users also indicate whether resources to address each area have been accessed, allowing the tool to assess the urgency of their needs. An algorithm, based on electronically computed individual areas and domain composite scores, generates targeted recommendations for mental health services. Recommendations are specific to the domain, the acuity of the concern, and whether resources are already in place.27 For example, for concerns in the psychiatric domain, the tool can recommend ED psychiatry consultation or urgent follow-up with a crisis response team for severe and acute concerns, or referral to community counseling or follow-up with an established care team for less acute concerns. This prospective cohort study reports on the utility of MyHEARTSMAP self-assessment when used by youth or their parents for universal psychosocial screening for early identification and access to mental health resources compared with the clinicians’ HEARTSMAP assessment, which is currently used for the assessment of children and youth with an emergency mental health presentation.
Methods A prospective cohort study of youth was conducted at 2 tertiary care pediatric EDs, BC Children’s Hospital in Vancouver, British Columbia and Stollery Children’s Hospital in Edmonton, Alberta. Both hospitals provide care for a diverse population of patients from wide referral geographic areas and have access to tertiary level psychosocial resources. Our population included all youth age 1017 years and their guardians presenting with nonmental health related reason for ED visit during study shifts. These were scheduled over a random selection of day (10 a.m-4 p.m) and evening shifts (4 p.m-10 p.m), including weekends, from December 2017 to February 2019. Patients presenting specifically for mental health related concerns (triage complaints consistent with those in the mental health and psychological issues section of the Canadian ED Information System Presenting Complaint28) were analyzed in another parallel study but excluded from the analyses reported in this manuscript. Patients were excluded if they presented with severe overall disability (eg, dependent on others for activities of daily living support), were unable to communicate in English and assent to research, needed sustained level of critical care, were previously enrolled in the study, presented without a legal 2
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guardian to provide consent, or were unavailable for a 30-day follow-up telephone interview. Ethics approval was granted by the University of British Columbia Children’s and Women’s Health Center of British Columbia Research Ethics Board. Written informed consent from a parent/legal guardian and assent from the participating youth was obtained prior to study enrollment. Objectives and Outcome Measures We defined utility of the MyHEARTSMAP psychosocial selfassessments tool for screening, primarily as the sensitivity and specificity of youth and guardian’s identification of concerns in each domain of the tool, compared with a clinician’s assessment. The clinicians (research emergency mental health nurse) used HEARTSMAP, the currently implemented emergency psychosocial assessment tool for youth presenting with a mental health complaint in the ED. Secondary objectives included estimating the prevalence of psychosocial disorders in youth presenting to the ED with nonmental health-related concerns identified by a clinician assessment, and the impact of screening on the proportion of youth with identified psychosocial concerns accessing mental health resources at 30day follow-up. Barriers to accessing resources were explored through thematic content analysis of open-ended questions at the 30-day follow-up. Study Procedure Upon enrollment, youth or their guardian (or both) completed a psychosocial self-assessment using MyHEARTSMAP, delivered on a tablet. A 5-minute instructional video was included on the tablet, to facilitate families’ use of the tool independently. After self-assessment completion, a research nurse (hired from our hospital pool of clinical nurses who are trained to conduct emergency mental health assessments at our institution) blinded to the participants’ MyHEARTSMAP results interviewed the youth and/or their accompanying parent to complete their assessment using the HEARTSMAP clinician tool (criterion standard). If the nurse’s assessment triggered recommendations requiring acute psychiatric care, the research clinician notified the participant’s ED physician to ensure that concerns were addressed and managed. In these cases, the research clinician’s report was added to the patient’s medical record as documentation. If the research nurse’s assessment was reassuring or generated only nonacute recommendations, such as referral to community mental health services without a prescribed timeline, the nurse provided participants with a resource pamphlet and counseled participants on how to access these services. Thirty days (5 days) following the ED encounter, parents of youth who screened positive for a psychosocial concern were contacted for a semistructured telephone interview. The focus of the interview was on families’ interactions (access, barriers) with the mental health resources recommended as a result of the screening. This follow-up could also optionally be performed via email questionnaire, per participants’ preferences. Doan et al
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ORIGINAL ARTICLES
Figure 1. Patient flow through study enrollment and participation processes. BCCH, BC Children’s Hospital Research Institute; MH, mental health; RA, research assistant.
Statistical Analyses We used descriptive statistics to summarize our study population demographic distributions and outcome measures. Average annual individual income quartile was derived using data from the Canada Revenue Agency Individual Tax Statistics, using participants’ residential postal codes.29 Frequencies and categorical variables are presented as proportion with 95%
CIs and continuous variables are presented as means and SDs. When appropriate, proportions were compared using the Z test and means were compared using ANOVA. Based on a 95% CI around the conservatively estimated sensitivity 50% for psychosocial self-assessments using MyHEARTSMAP compared with a standardized clinician’s assessment, with a total interval width of 7% (3.5%), complete data were
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needed for 784 participants. Although we estimated the baseline sensitivity to be higher than 50%, a 50% estimate renders the largest possible sample size required.
Results Between December 2017 and February 2019, 4448 youth age 10-17 years presented to the ED during study shifts, of whom 2639 (59.3%) were screened by research assistants for eligibility. Research assistants did not screen 1809 potential participants (40.7%) mainly because these youth were discharged from the ED prior to being approached, while the research assistant was occupied with other enrollments, or arrived in the ED near the end of study shifts with insufficient time to reasonably complete study enrollment and assessment. A total of 1432 youth met study eligibility criteria and were given an opportunity to participate in the mental health self-assessment. Among these, 795 youth and/or their guardians agreed to participate (55.5%) with 64.4% being enrolled from the site in Vancouver. Detailed breakdown of subjects approached and excluded from the study are presented in Figure 1. Study participants median age was 13 years old (IQR 11-15 and range 10-17 years) and 51.6% were female. The distribution in patient characteristics of the enrolled cohort was comparable with a sample of eligible youth (193) who declined to participate but provided some demographic data, as detailed in Table I. Although 795 youth and their families were enrolled in the study, only 760 completed the study intervention which consisted of completing the MyHEARTSMAP self-assessment (youth [694] or guardian [680]) paired with a clinician assessment. Detailed reasons for study drop out are reported in Figure 1. The sensitivity of MyHEARTSMAP when used by youth to identify presence of issues ranged from 73.1 (95% CI 67.5, 78.2%) in the functional domain to 92.7% (89.1, 95.4%) in the psychiatric domain. Specificity of youth assessment at identifying absence of issues ranged from 42.2% (95% CI 37.3, 47.3%) in the psychiatric domain to 84.1% (95% CI 80.5, 87.3%) in the youth health domain. However, among youth deemed to have no concerns by the clinician, youth identified themselves as having no or only mild concerns across domains ranged from 98.4 (95% CI 96.6, 99.3%) in the social domain to 100% (95% CI 99.2, 100%) in the youth health domain. Detailed utility measures for youth and guardian assessment at identifying issues in all domains of the MyHEARTSMAP by level of severity are reported in Table II. Overall, screening by a nurse identified 36.3% (95% CI 32.9, 39.9%) of participating youth as having issues in at least 1 psychosocial domain with recommendations to follow-up with specific resources. In 22.5% (95% CI 19.6, 25.6%) of all screened youth, the recommended resources had not yet been accessed, thus, the issues were still unaddressed. Identified issues in individual psychosocial domains and frequency of recommendations by type are reported in Table III (available at www.jpeds.com). 4
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Table I. Patient and visit characteristics of enrolled and declining participants Characteristics Total Complaint category Medical Injury/Trauma Age (y) 10-13 14-17 Sex Female Male Gender Female Male Other Did not specify Data unavailable‡ Ethnicity European origins Aboriginal East/Southeast Asian South Asian West Central Asian/ Middle Eastern Latin American Sub-Saharan African/ Afro-Caribbean origins Other Data unavailable Acuity of presentation (CTAS) 1 2 3 4 5 Data unavailable Average annual income§ Quartile 1 Quartile 2 Quartile 3 Quartile 4 Data unavailable
Study participants N (%)
Declined* n (%)
P value†
795
193
524 (65.9) 271 (34.1)
136 (70.5) 57 (29.5)
.23
456 (57.4) 339 (42.6)
118 (61.1) 75 (38.9)
.33
410 (51.6) 385 (48.4)
95 (49.2) 98 (50.8)
.56
411 (51.8) 379 (47.7) 3 (0.4) 2
85 (48.0) 92 (52.0) 16
.5
469 (59.1) 21 (2.7) 92 (11.6) 65 (8.2) 17 (2.1)
102 (57.6) 11 (6.2) 20 (11.3) 21 (11.9) 4 (2.3)
.27
14 (1.8) 9 (1.1)
4 (2.3) 2 (1.1)
106 (13.4) 2
13 (7.4) 16
2 (0.3) 98 (12.4) 385 (48.6) 290 (36.6) 18 (2.3) 2
0 (0.0) 19 (22.4) 32 (37.6) 33 (38.8) 1 (1.2) 108
.12
225 (28.4) 147 (18.5) 215 (27.1) 206 (26.0) 2
50 (26.8) 33 (17.7) 60 (32.3) 43 (23.1) 7
.63
CTAS, Canadian Triage and Acuity Score. For Stollery, Q1: <$51 860.25; Q2: $51 860.26-$63 820.50; Q3: $63 820.51-$75 055.25; Q4: >$75 055.25. *Declining participation but consented to an optional health record review and demographic data collection. †Z test for 2-proportion or c2 test as appropriate. ‡Withdrew or not collected; excluded to allow complete-case analyses. §Annual Individual Income based on the participant’s postal code categorized by quartiles. For BC Children’s Hospital, Q1: <$41 186.83; Q2: $41 186.84-$47 298.85; Q3: $47 298.86$54 898.88; Q4: >$54 898.88.
We were able to complete a 30-day follow-up for 72.5% (124 of 171) of families with newly recommended mental health services resulting from the screening. Although 74.2% (92/124) of families agreed with these recommendations, only 33.1% (41 of 124) of contacted families had attempted to access any of the recommended mental health services. The main reason for not following through with the recommendations was the families’ perception that the recommendation was not yet necessary or that it was not yet a priority. Other reasons (Figure 2) included lack of time, inconvenience, inability to recall what the recommendations were, misplacing the written information Doan et al
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Table II. Utility of psychosocial self-screening by youth and their guardians, using MyHEARTSMAP, reported with 95% CIs Psychometric properties by sub-categories Sensitivity Youth cases (total N = 694) Any degree* Severe† Moderate§ Sensitivity by youth self-assessments Any degree Severe Moderate Guardian cases (total N = 680) Any degree Severe Moderate Sensitivity by guardians’ assessments Any degree Severe Moderate Specificity Youth cases (total N = 694) Clinician assessment: no issues Specificity by youth self-assessments No issues No worse than mild issues Guardian cases (total N = 680) Clinician assessment: no issues Specificity by guardians’ assessments No issues No or mild issues
Psychiatric
Social
Youth health
Functional
301 7‡ 56
210 5 8
222 5 7
286 13 21
92.7 (89.1, 95.4) 85.7 (42.1, 99.6) 78.6 (65.6, 88.4)
91.9 (87.4, 95.2) 0 (0, 52.2) 100 (63.1, 100)
80.7 (74.9, 85.7) 20 (0.5, 71.6) 42.9 (9.9, 81.6)
73.1 (67.5, 78.2) 61.5 (31.6, 86.1) 47.1 (31.6, 86.1)
302 8 54
222 5 9
225 6 8
292 13 21
93.1 (89.5, 95.8) 75.0 (34.9, 96.8) 68.5 (54.5, 80.5)
86.9 (81.8, 91.1) 20 (0.5, 71.6) 66.7 (29.9, 92.5)
75.6 (69.4, 81.0) 16.7 (0.4, 64.1) 50 (15.7, 84.3)
79.9 (74.8, 84.4) 30.8 (9.1, 61.4) 57.1 (34.0, 78.2)
393
423
471
408
42.2 (37.3, 47.3) 98.5 (96.7, 99.4)
43.3 (38.5, 48.1) 98.4 (96.6, 99.3)
84.1 (80.5, 87.3) 100 (99.2, 100)
76.5 (72.1, 80.5) 100 (99.1, 100)
378
458
455
396
37.0 (32.2, 42.1) 98.9 (97.3, 99.7)
37.8 (33.3, 42.4) 98.5 (96.9, 99.4)
77.1 (73.0, 80.9) 99.8 (98.8, 100)
77.7 (72.5, 82.4) 100 (99.1, 100)
*Any degree: any and at least mild psychosocial concerns (cumulative domain 1-3). †Severe: concerns with a cumulative domain score of 7-9. ‡A single section score of 3 mapping to the psychiatry domain also qualifies as severe. §Moderate: concerns with a cumulative domain score of 4-6.
on services, and youth’s reluctance to access help. Among those who attempted to access resources, 22 of 41 (53.7%) were successful. Access delay (eg, on a wait list) was the most common cited barrier (11 of 18 or 61.1%).
Discussion Our study found that both patients and their families displayed similar degrees of sensitivity and specificity in identifying psychosocial support needs across all tool domains. One-third (33.1%) of youth were recommended mental health supports, however, only 33.9% among these attempted to access recommended care within 30 days of their ED visit. Although presenting to the ED for a nonmental health-related complaint, participants self-identified psychosocial issues above national estimates.9,30 The advantages of psychosocial self-assessment tools like MyHEARTSMAP, compared with clinician administered assessments for universal screening in the ED have been established. In addition to empowering families, screening can be implemented without adding to ED clinician workload.31 In addition, evidence suggests youth prefer to disclose personal and sensitive information within an electronic, interactive interface compared with in-person interviews.19 Computerized screening may offer a sense of privacy for users and may be culturally and linguistically aligned with youth
needs.20 However, few self-administered psychosocial instruments have been psychometrically evaluated in the pediatric ED setting. In 1 such study, Winston et al observed high youth and parent sensitivity, 88% and 96%, respectively, of a brief post-traumatic stress disorder ED screening tool.32 In the primary care setting, youth self-reporting with the Public Health Questionnaire-9 tool have shown 89.5% sensitivity and 77.5% specificity in detecting depressive disorder using the Diagnostic and Statistical Manual IV criteria.33 Similarly, our participating youth showed comparable accuracy in identifying any (92.7%), moderate (78.6%), and severe (85.7%) psychiatric concerns, which capture concerning mood-related issues. Although MyHEARTSMAP showed modest specificity in identifying lack of concerns, false positives almost entirely identified only mild concerns. Tools such as the Pediatric Symptom Checklist-17 offer more comprehensive psychosocial evaluation than MyHEARTSMAP, however, the sensitivity of parental scoring using this tool and others is variable, ranging from 31% in identifying any mental health diagnosis (Child Behavior Checklist) to 73% in identifying depression (Pediatric Symptom Checklist).34 In comparison, MyHEARTSMAP displays consistently higher sensitivity for identifying concerns associated with any psychiatric, social, youth health, and functional support need, with a lower response burden (fewer items). MyHEARTSMAP’s utility in predicting mental health needs may permit early identification and intervention in other
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Figure 2. Youth connection with psychosocial resources following screening.
environments if confirmed, such as primary care (eg, family doctor or pediatrician’s office) and schools, where there is growing interest in prevention-oriented screening and intervention to support students’ academic success.35 Many existing validated measures display sufficient sensitivity, however, the lack of precision of existing tools 36 may challenge untrained staff or place further burden on counselors with heavy caseloads to both administer and review screening. Emerging practices and guidelines support self-reporting assessments that may reduce demands on staff and provide crucial information on how students appraise their own experiences and needs.37 In our study, approximately one-third of youth receiving care recommendations upon screening attempted to access resources for support, but approximately one-half of them were either unsuccessful or delayed in receiving services. This is similar to results reported by Hacker et al, who found only 18% of adolescents who screened positive for a mental health concern at a routine primary care visit and were referred for treatment completed necessary follow-up within 6 months.38 Our follow-up interviews found that the primary contributor to low access was parental beliefs that recommendations were not yet necessary or currently not a family 6
priority. Families may perceive their child’s mental health issues as transient that their child will “grow out of” and do not warrant services.39 Lower help-seeking may also reflect lower parental mental health literacy, compared with physical concerns, although the former has potentially higher impact on families.40 Despite large-scale awareness campaigns and growing dialog, stigma surrounding mental health persists, and parents may fear embarrassment seeking support and choose to self-manage in fear of their child being labelled with a mental health disorder.41 Applying behavioral change frameworks to address barriers to help-seeking may shift parental attitudes toward service engagement42-44 and support the development of sensitive and engaging psychoeducation initiatives. Sustained and more frequent follow-up may also support families’ connectivity with care and may present opportunities for multidisciplinary collaboration between the ED and primary care or school-based settings. In addition to families’ decision to access mental health services, availability and accessibility of such services have to be secured, to mitigate the burden of mental health conditions through screening and early detection. Comparable with previous studies,45 approximately one-half our participants who attempted to access care were delayed (eg, waitlisted), Doan et al
- 2020 suggesting that additional service demands uncovered through screening may be greater than current health system preparedness.46,47 Our study supports the need for improved community-based and primary care capacities to provide mental healthcare. It is crucial to ensure that resources are available to appropriately deal with uncovered psychosocial needs, when applying universal screening interventions. Integrating the option to connect with telemedicine or the digital mental health counterparts of in-person care (eg, online psychotherapy, counseling) may help address structural challenges such as saturated and potentially inaccessible services (eg, for rural/remote communities).48 This study was strengthened by the 2-site study design, allowing for time efficient sampling of a regionally diverse sample of youth and families across Western Canada. However, this study was not without limitations. First, despite using dedicated research staff to approach patient families in the ED, only 55.5% of eligible potential participants consented to participate. Although this potentially introduced selfselection bias, when we compared demographic characteristics between participants and those who declined, we did not observe any meaningful or significant differences. Recruiting research participants in the pediatric ED is challenging because of the high level of acuity of patient needs and busy setting. Adding the sensitive nature of reporting psychosocial concerns, which may be perceived as invasive when accessing the ED for nonmental health related complaints, likely affected our participation rate. Our experience is consistent with published participation consent rates (50.7%) in the ED setting.49 In addition, follow-up interviews were only conducted at 1 month; given families may have prioritized managing their acute complaints following their ED visit and that a number of mental health referrals can take longer durations to access, a higher access rate may have been seen with 3- or 6-month follow-up. In addition, 47 out of 171 youth whose screening triggered mental health service recommendations and required follow-up, could not be reached. However, upon reviewing their demographic (eg, age, socioeconomic status) information and severity/acuity scoring, we found them to be comparable (no statistically significant differences on any variables) with those completing 30-day follow-up. In conclusion, using MyHEARTSMAP in the ED identified a sizable proportion of youth with previously unaddressed psychosocial service needs. Moreover, HEARTSMAP has high sensitivity and false positive screens consisted mostly of self-identification of no worse than mild concerns. n This study was conducted at 2 Pediatric Emergency Research Canada (PERC) sites, and we are grateful for the contribution from the respective PERC research coordinators: Karly Stillwell, Mithra Sivakumar, and Manasi Rajagopal. We also acknowledge the support of the PERC executives and peer reviewers. Lastly, we are thankful to Mr Max LeBlanc for his contribution to MyHEARTSMAP through the creation of the MyHEARTSMAP instructional video. Submitted for publication Oct 29, 2019; last revision received Dec 20, 2019; accepted Dec 20, 2019.
ORIGINAL ARTICLES Reprint requests: Quynh Doan, MDCM, PhD, BC Children’s Hospital, 4480 Oak St, Office B428-B, Vancouver, BC, V6H 3N1, Canada. E-mail: qdoan@ bcchr.ca
References 1. Pearson C, Janz T, Ali J. Health at a glance: mental and substance use disorders in Canada. Stat Canada [Internet] 2013; Catalog. http://www. statcan.gc.ca/pub/82-624-x/2013001/article/11855-eng.pdf. Accessed December 6, 2019. 2. World Health Organization. The global burden of disease: 2004 update. Geneva, Switzerland; 2008. https://www.who.int/healthinfo/global_ burden_disease/2004_report_update/en/. Accessed December 27, 2019. 3. Glied S, Pine DS. Consequences and correlates of adolescent depression. Arch Pediatr Adolesc Med 2002;156:1009-14. 4. Navaneelan T. Health at a glance. Suicide rates: an overview. Stat Canada [Internet] 2012;(82-624-X). https://www150.statcan.gc.ca/n1/pub/82624-x/2012001/article/11696-eng.htm#archived. Accessed December 6, 2019. 5. Dolan MA, Fein JJA, The Committee on pediatric emergency medicine. Technical report: pediatric and adolescent mental health emergencies in the emergency medical services system. Pediatrics 2011;127:e1356-66. 6. Mahajan P, Alpern ER, Grupp-Phelan J, Chamberlain J, Dong L, Holubkov R, et al. Epidemiology of psychiatric-related visits to emergency departments in a multicenter collaborative research pediatric network. Pediatr Emerg Care 2009;25:715-20. 7. Simon AE, Schoendorf KC. Emergency department visits for mental health conditions among US children, 2001-2011. Clin Pediatr (Phila) 2014;53:1359-66. 8. Mapelli E, Black T, Doan Q. Trends in pediatric emergency department utilization for mental health-related visits. J Pediatr 2015;167:905-10. 9. Canadian Institute for Health Information. Care for children and youth with mental disorders [Internet] 2015. https://secure.cihi.ca/free_ products/CIHI CYMH Final for pubs_EN_web.pdf. Accessed December 6, 2019. 10. Grupp-phelan J, Wade TJ, Pickup T, Ho ML, Lucas CP, Brewer DE, et al. Mental health problems in children and caregivers in the emergency department setting. J Dev Behav Pediatr 2007;28:16-21. 11. Kelly TM, Donovan JE, Cornelius JR, Bukstein OG, Delbridge TR, Clark DB. Psychiatric Disorders amond older adolescents treated in emergency departments on weekends: a comparison with a matched community sample. J Stud Alcohol 2003;64:616-22. 12. Downey LVA, Zun LS, Burke T. Undiagnosed mental illness in the emergency department. J Emerg Med 2012;43:876-82. 13. Biros MH, Hick K, Cen YY, Mann J, Gaetz A, Hansen R, et al. Occult depressive symptoms in adolescent emergency department patients. Arch Pediatr Adolesc Med 2008;162:769-73. 14. Scott EG, Luxmore B, Alexander H, Fenn RL, Christopher NC. Screening for adolescent depression in a pediatric emergency department. Acad Emerg Med 2006;13:537-42. 15. Pailler ME, Cronholm PF, Barg FK, Wintersteen MB, Diamond GS, Fein JA. Patients’ and caregivers’ beliefs about depression screening and referral in the emergency department. Pediatr Emerg Care 2009;25:721-7. 16. Horowitz L, Ballard E, Teach SJ, Bosk A, Rosenstein DL, Joshi P, et al. Feasibility of screening patients with nonpsychiatric complaints for suicide risk in a pediatric emergency department: a good time to talk? Pediatr Emerg Care 2010;26:787-92. 17. Williams JR, Ho ML, Grupp-Phelan J. The acceptability of mental health screening in a pediatric emergency department. Pediatr Emerg Care 2011;27:611-5. 18. Cronholm PF, Barg FK, Pailler ME, Wintersteen MB, Diamond GS, Fein JA. Adolescent depression: views of Health care providers in a pediatric emergency department. Pediatr Emerg Care 2010;26:111-7. 19. Ranney ML, Choo EK, Spirito A, Mello MJ. Adolescents’ preference for technology-based emergency department behavioral interventions: does it depend on risky behaviors? Pediatr Emerg Care 2013;29:475-81.
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20. Choo EK, Ranney ML, Aggarwal N, Boudreaux ED. A Systematic review of emergency department technology-based behavioral health interventions. Acad Emerg Med 2012;19:318-28. 21. Fein JA, Pailler ME, Barg FK, Wintersteen MB, Hayes K, Tien AY, et al. Feasibility and effects of a Web-based adolescent psychiatric assessment administered by clinical staff in the pediatric emergency department. Arch Pediatr Adolesc Med 2010;164:1112-7. 22. Lee A, Deevska M, Stillwell K, Black T, Meckler G, Park D, et al. A psychosocial assessment and management tool for children and youth in crisis. Can J Emerg Med 2018;0:1-10. 23. Virk P, Stenstrom R, Doan Q. Reliability testing of the HEARTSMAP psychosocial assessment tool for multidisciplinary use and in diverse emergency settings. Paediatr Child Health 2018;23:503-8. 24. Doan Q, Black T. Behavioural disorders in Children. In: Tintinalli J, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM, eds. Tintinalli’s emergency medicine: a comprehensive study guide. 9th ed. New York: McGraw Hill; 2020. p. 982-8. 25. Koopmans E, Black T, Newton A, Dhugga G, Karduri N, Doan Q. Provincial dissemination of HEARTSMAP, an emergency department psychosocial assessment and disposition decision tool for children and youth. Paediatr Child Health 2019;24:359-65. 26. Virk P, Laskin S, Gokiert R, Richardson C, Newton M, Stenstrom R, et al. MyHEARTSMAP: development and evaluation of a psychosocial self-assessment tool, for and by youth. BMJ Open Paediatr 2019;3: e000493. 27. Doan Q, Black T. Heartsmap psychosocial assessment and mental health resource navigation tools. 2018. www.openheartsmap.ca. Accessed January 24, 2020. 28. Grafstein E, Bullard MJ, Warren D, Unger B. Revision of the Canadian Emergency Department Information System (CEDIS) presenting complaint list Version 1.1. CJEM 2008;10:151-61. 29. Canada Revenue Agency. Individual tax statistics by forward sortation area. Table 1b: FSA for all returns, by total income-2015 tax year. 2017. https://www.canada.ca/content/dam/cra-arc/prog-policy/stats/individualtax-stats-fsa/2015-tax-year/tbl1b-en.pdf. Accessed September 20, 2019. 30. Perou R, Bitsko RH, Blumberg SJ, Pastor P, Ghandour RM, Gfroerer JC, et al. Mental health surveillance among children—United States, 20052011. MMWR Suppl 2013;62:1-35. 31. Chun TH, Duffy SJ, Linakis JG. Emergency department screening for adolescent mental health disorders: the who, what, when, where, why, and how it could and should be done. Clin Pediatr Emerg Med 2013;14:3-11. 32. Winston FK, Kassam-Adams N, Garcia-Espa~ na F, Ittenbach R, Cnaan A. Screening for Risk of persistent post-traumatic stress in injured children and their parents. JAMA 2003;290:643-9. 33. Richardson LP, McCauley E, Grossman DC, McCarty CA, Richards J, Russo JE, et al. Evaluation of the Patient Health Questionnaire-9 Item for detecting major depression among adolescents. Pediatrics 2010;126:1117-23. 34. Gardner W, Lucas A, Kolko DJ, Campo JV. Comparison of the PSC-17 and alternative mental health screens in an at-risk primary care sample. J Am Acad Child Adolesc Psychiatry 2007;46:611-8.
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35. Eklund K, Renshaw TL, Dowdy E, Jimerson SR, Hart SR, Jones CN, et al. Early Identification of behavioral and emotional problems in youth: universal screening versus teacher-referral identification. Calif Sch Psychol 2009;14:89-95. 36. Albers CA, Glover TA, Kratochwill TR. Where are we, and where do we go now? Universal screening for enhanced educational and mental health outcomes. J School Psychol 2007;45:257-63. 37. Moore SA, Widales-Benitez O, Carnazzo KW, Kim EK, Moffa K, Dowdy E. Conducting universal complete mental health screening via student self-report. Contemp Sch Psychol 2015;19:253-67. 38. Hacker K, Arsenault L, Franco I, Shaligram D, Sidor M, Olfson M, et al. Referral and follow-up after mental health screening in commercially insured adolescents. J Adolesc Heal 2014;55:17-23. 39. Godoy L, Mian ND, Eisenhower AS, Carter AS. Pathways to service receipt: modeling parent help-seeking for childhood mental health problems. Adm Policy Ment Health 2014;41:469-79. 40. Dey M, Wang J, Jorm AF, Mohler-Kuo M. Children with mental versus physical health problems: differences in perceived disease severity, health care service utilization and parental health literacy. Soc Psychiatry Psychiatr Epidemiol 2015;50:407-18. 41. Owens PL, Hoagwood K, Horowitz S, Leaf P, Poduska JM, Kellam SG, et al. Barriers to children’s mental health services. J Am Acad Child Adolesc Psychiatry 2002;41:731-8. 42. Michie S, Yardley L, West R, Patrick K, Greaves F. Developing and evaluating digital interventions to promote behavior change in health and health care: recommendations resulting from an international workshop. J Med Internet Res 2017;19:e232. 43. Morrison LG. Theory-based strategies for enhancing the impact and usage of digital health behaviour change interventions: a review. Digit Heal 2015;1:2055207615595335. https://www.ncbi.nlm.nih.gov/pubmed/299 42544. Accessed December 6, 2019. 44. Olin SS, Hoagwood KE, Rodriguez J, Ramos B, Burton G, Penn M, et al. The application of behavior change theory to family-based services: improving parent empowerment in children’s mental health. J Child Fam Stud 2010;19:462-70. 45. Chisolm DJ, Klima J, Gardner W, Kelleher KJ. Adolescent behavioral risk screening and use of health services. Adm Policy Ment Health 2009;36:374-80. 46. O’Brien D, Harvey K, Howse J, Reardon T, Creswell C. Barriers to managing child and adolescent mental health problems: a systematic review of primary care practitioners’ perceptions. Br J Gen Pract 2016;66:e693-707. 47. Kim WJ, American Academy of Child and Adolescent Psychiatry Task Force on Workforce Needs. Child and Adolescent psychiatry workforce: a critical shortage and national challenge. Acad Psychiatry 2003;27:277-82. 48. E-Mental Health in Canada: transforming the mental health system using technology [Internet]. 2014. https://www.mentalhealthcommission.ca/ sites/default/files/MHCC_E-Mental_Health-Briefing_Document_ENG_ 0.pdf. Accessed December 6, 2019. 49. Taylor RG, Hounchell M, Ho M, Grupp-Phelan J. Factors associated with participation in research conducted in a pediatric emergency department. Pediatr Emerg Care 2015;31:348-52.
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Table III. Prevalence of concerns by domain and severity and recommendations triggered by clinician HEARTSMAP assessment N total: 760 No concerns n (%; 95% CI) Mild concerns n (%; 95% CI) Moderate concerns n (%; 95% CI) Severe concerns n (%; 95% CI)
Psychiatry
Youth health
Social
Functional
433 (57.0; 53.4, 60.5) 262 (34.5; 31.1, 38.0) 60 (7.9; 6.1, 10.1) 5 (0.7; 0.2, 1.5)
516 (67.0; 64.5, 71.2) 233 (30.7; 27.4, 34.1) 9 (1.2; 0.5, 2.2) 2 (0.3; 0.03, 1.0)
521 (68.6; 65.1, 71.8) 229 (30.1; 26.9, 33.5) 10 (1.3; 0.6, 2.4) 0
449 (59.1; 55.5, 62.6) 286 (37.6; 34.2, 41.2) 18 (2.4; 1.4, 3.7) 7 (0.9; 0.4, 1.9)
Psychiatric follow- up Recommendations triggered n (%; 95% CI)
254 (33.4; 30.1, 36.9) Psychiatry consultation in ED 6 (0.8; 0.3, 1.7)
Youth health and addiction services
Social worker support
Child protective services
49 (6.4; 4.8, 8.4)
10 (1.3; 0.6, 2.4)
5 (0.7; 0.2, 1.5)
Utility of MyHEARTSMAP for Universal Psychosocial Screening in the Emergency Department
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Study design We conducted a cohort study of youth 10-17 years of age with nonmental health related presentations at 2 pediatric EDs. On randomly selected shifts (December 2017-February 2019), participants completed their psychosocial self-assessments using MyHEARTSMAP on a mobile device, then underwent a standardized clinical mental health assessment (criterion standard). We reported the sensitivity and specificity of respondents’ self-assessment, against a clinician’s standard emergency psychosocial assessment, and the frequency of psychosocial issues and recommended mental health resources identified by screening. Results We approached 1432 eligible youth, among which 795 youth consented to participate (55.5%). Youth and guardians’ sensitivity at self-identifying psychiatric concerns was 92.7% (95% CI 89.1, 95.4%) and 93.1% (95% CI 89.5, 95.8%), respectively. In cases where clinicians had determined to be no psychiatric issues, 98.5% (95% CI 96.7, 99.4%) of youth and 98.9% (95% CI 97.3, 99.7%) of guardians identified the youth as having no or only mild issues. Screening identified 36.4% of youth as having issues in at least 1 psychosocial domain which warranted further follow-up. Conclusions Psychosocial screening in EDs using MyHEARTSMAP can reliably be conducted using the MyHEARTSMAP self-assessment tool and over one-third of screened youth identified issues which can be directed to further care. (J Pediatr 2020;-:1-8).
M
ental health concerns, including suicidal ideation, in childhood and adolescence are prevalent and undertreated.1 They rank among the most disabling diseases in high-income countries and are associated with comorbidities such as smoking and poor social functioning.2,3 Suicide is the second leading cause of death in youth, accounting for 23% of deaths among youth age 15-19 years.4 Visits for mental health concerns in the emergency department (ED) have steadily increased,5-7 and in Canada, rates of pediatric ED visits for mental health concerns increased up to 8.5% per year.8,9 However, these numbers underestimate the full burden of mental illness in the ED, as youth presenting with nonpsychiatric concerns often have significant underlying psychosocial morbidity.10-12 In the absence of routine screening, up to 98% of mental illnesses can go unrecognized by ED clinicians.12 Studies have shown that screening for mood disorders in the ED increases early identification and access to services.13,14 Screening has been found acceptable and feasible for ED clinicians and their patients.15-17 However, barriers to routine screening have been cited and include limited time, and challenges with disposition planning.18 Using an electronic selfadministered screening tool, which provides tailored management recommendations, could overcome these barriers and minimize impact on ED flow. Computer-based ED interventions have already been well received for other indications but have rarely been implemented for mental health screening in youth.19-21 Adapted from HEARTSMAP (acronym for home, education and activities, alcohol and drugs, relationships and bullying, thoughts and anxiety, safety, sexual health, mood, abuse, and professional resources), a previously validated From the Department of Pediatrics, University of British computerized tool currently used by ED clinicians for assessment and manageColumbia, Vancouver, British Columbia; Department of Pediatrics, University of Alberta, Edmonton, Alberta; 22-25 ment of patients with mental health concerns, our team developed MyFaculty of Medicine, University of British Columbia, Vancouver, British Columbia; School of Population and HEARTSMAP through youth and parent focus groups, among whom it Public Health, University of British Columbia, Vancouver, British Columbia; Department of Emergency Medicine, displayed high inter-rater reliability.26 Youth (10-17 years of age) self-screen, 1
2
3
4
5
ED HEARTSMAP
PERC
Emergency department Home, education and activities, alcohol and drugs, relationships and bullying, thoughts and anxiety, safety, sexual health, mood, abuse, and professional resources Pediatric Emergency Research Canada
University of British Columbia, Vancouver, British Columbia; 6Department of Psychiatry, University of British Columbia, Vancouver, British Columbia and 7 Faculty of Extension, University of Alberta, Edmonton, Alberta, Canada Funded by an operating grant from the Canadian Institutes of Health Research (PJT-152997). The authors declare no conflicts of interest.
0022-3476/$ - see front matter. ª 2019 Elsevier Inc. All rights reserved. https://doi.org/10.1016/j.jpeds.2019.12.046
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or parent/guardians act as a proxy-screen, using a mobile electronic device, which takes them between 10 and 15 minutes to complete. The tool covers 10 areas of functioning: home, education and activities, alcohol and drugs, relationships and bullying, thoughts and anxiety, safety, sexual health, mood, abuse, and professional resources. These areas map to 1 of 4 domains: psychiatry, social, functional status, and youth health. Users are guided with prompting questions to score the severity of the youth’s concern in each of the 10 sections, rated from 0 for “no concern” to 3 for “severe.” Users also indicate whether resources to address each area have been accessed, allowing the tool to assess the urgency of their needs. An algorithm, based on electronically computed individual areas and domain composite scores, generates targeted recommendations for mental health services. Recommendations are specific to the domain, the acuity of the concern, and whether resources are already in place.27 For example, for concerns in the psychiatric domain, the tool can recommend ED psychiatry consultation or urgent follow-up with a crisis response team for severe and acute concerns, or referral to community counseling or follow-up with an established care team for less acute concerns. This prospective cohort study reports on the utility of MyHEARTSMAP self-assessment when used by youth or their parents for universal psychosocial screening for early identification and access to mental health resources compared with the clinicians’ HEARTSMAP assessment, which is currently used for the assessment of children and youth with an emergency mental health presentation.
Methods A prospective cohort study of youth was conducted at 2 tertiary care pediatric EDs, BC Children’s Hospital in Vancouver, British Columbia and Stollery Children’s Hospital in Edmonton, Alberta. Both hospitals provide care for a diverse population of patients from wide referral geographic areas and have access to tertiary level psychosocial resources. Our population included all youth age 1017 years and their guardians presenting with nonmental health related reason for ED visit during study shifts. These were scheduled over a random selection of day (10 a.m-4 p.m) and evening shifts (4 p.m-10 p.m), including weekends, from December 2017 to February 2019. Patients presenting specifically for mental health related concerns (triage complaints consistent with those in the mental health and psychological issues section of the Canadian ED Information System Presenting Complaint28) were analyzed in another parallel study but excluded from the analyses reported in this manuscript. Patients were excluded if they presented with severe overall disability (eg, dependent on others for activities of daily living support), were unable to communicate in English and assent to research, needed sustained level of critical care, were previously enrolled in the study, presented without a legal 2
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guardian to provide consent, or were unavailable for a 30-day follow-up telephone interview. Ethics approval was granted by the University of British Columbia Children’s and Women’s Health Center of British Columbia Research Ethics Board. Written informed consent from a parent/legal guardian and assent from the participating youth was obtained prior to study enrollment. Objectives and Outcome Measures We defined utility of the MyHEARTSMAP psychosocial selfassessments tool for screening, primarily as the sensitivity and specificity of youth and guardian’s identification of concerns in each domain of the tool, compared with a clinician’s assessment. The clinicians (research emergency mental health nurse) used HEARTSMAP, the currently implemented emergency psychosocial assessment tool for youth presenting with a mental health complaint in the ED. Secondary objectives included estimating the prevalence of psychosocial disorders in youth presenting to the ED with nonmental health-related concerns identified by a clinician assessment, and the impact of screening on the proportion of youth with identified psychosocial concerns accessing mental health resources at 30day follow-up. Barriers to accessing resources were explored through thematic content analysis of open-ended questions at the 30-day follow-up. Study Procedure Upon enrollment, youth or their guardian (or both) completed a psychosocial self-assessment using MyHEARTSMAP, delivered on a tablet. A 5-minute instructional video was included on the tablet, to facilitate families’ use of the tool independently. After self-assessment completion, a research nurse (hired from our hospital pool of clinical nurses who are trained to conduct emergency mental health assessments at our institution) blinded to the participants’ MyHEARTSMAP results interviewed the youth and/or their accompanying parent to complete their assessment using the HEARTSMAP clinician tool (criterion standard). If the nurse’s assessment triggered recommendations requiring acute psychiatric care, the research clinician notified the participant’s ED physician to ensure that concerns were addressed and managed. In these cases, the research clinician’s report was added to the patient’s medical record as documentation. If the research nurse’s assessment was reassuring or generated only nonacute recommendations, such as referral to community mental health services without a prescribed timeline, the nurse provided participants with a resource pamphlet and counseled participants on how to access these services. Thirty days (5 days) following the ED encounter, parents of youth who screened positive for a psychosocial concern were contacted for a semistructured telephone interview. The focus of the interview was on families’ interactions (access, barriers) with the mental health resources recommended as a result of the screening. This follow-up could also optionally be performed via email questionnaire, per participants’ preferences. Doan et al
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Figure 1. Patient flow through study enrollment and participation processes. BCCH, BC Children’s Hospital Research Institute; MH, mental health; RA, research assistant.
Statistical Analyses We used descriptive statistics to summarize our study population demographic distributions and outcome measures. Average annual individual income quartile was derived using data from the Canada Revenue Agency Individual Tax Statistics, using participants’ residential postal codes.29 Frequencies and categorical variables are presented as proportion with 95%
CIs and continuous variables are presented as means and SDs. When appropriate, proportions were compared using the Z test and means were compared using ANOVA. Based on a 95% CI around the conservatively estimated sensitivity 50% for psychosocial self-assessments using MyHEARTSMAP compared with a standardized clinician’s assessment, with a total interval width of 7% (3.5%), complete data were
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needed for 784 participants. Although we estimated the baseline sensitivity to be higher than 50%, a 50% estimate renders the largest possible sample size required.
Results Between December 2017 and February 2019, 4448 youth age 10-17 years presented to the ED during study shifts, of whom 2639 (59.3%) were screened by research assistants for eligibility. Research assistants did not screen 1809 potential participants (40.7%) mainly because these youth were discharged from the ED prior to being approached, while the research assistant was occupied with other enrollments, or arrived in the ED near the end of study shifts with insufficient time to reasonably complete study enrollment and assessment. A total of 1432 youth met study eligibility criteria and were given an opportunity to participate in the mental health self-assessment. Among these, 795 youth and/or their guardians agreed to participate (55.5%) with 64.4% being enrolled from the site in Vancouver. Detailed breakdown of subjects approached and excluded from the study are presented in Figure 1. Study participants median age was 13 years old (IQR 11-15 and range 10-17 years) and 51.6% were female. The distribution in patient characteristics of the enrolled cohort was comparable with a sample of eligible youth (193) who declined to participate but provided some demographic data, as detailed in Table I. Although 795 youth and their families were enrolled in the study, only 760 completed the study intervention which consisted of completing the MyHEARTSMAP self-assessment (youth [694] or guardian [680]) paired with a clinician assessment. Detailed reasons for study drop out are reported in Figure 1. The sensitivity of MyHEARTSMAP when used by youth to identify presence of issues ranged from 73.1 (95% CI 67.5, 78.2%) in the functional domain to 92.7% (89.1, 95.4%) in the psychiatric domain. Specificity of youth assessment at identifying absence of issues ranged from 42.2% (95% CI 37.3, 47.3%) in the psychiatric domain to 84.1% (95% CI 80.5, 87.3%) in the youth health domain. However, among youth deemed to have no concerns by the clinician, youth identified themselves as having no or only mild concerns across domains ranged from 98.4 (95% CI 96.6, 99.3%) in the social domain to 100% (95% CI 99.2, 100%) in the youth health domain. Detailed utility measures for youth and guardian assessment at identifying issues in all domains of the MyHEARTSMAP by level of severity are reported in Table II. Overall, screening by a nurse identified 36.3% (95% CI 32.9, 39.9%) of participating youth as having issues in at least 1 psychosocial domain with recommendations to follow-up with specific resources. In 22.5% (95% CI 19.6, 25.6%) of all screened youth, the recommended resources had not yet been accessed, thus, the issues were still unaddressed. Identified issues in individual psychosocial domains and frequency of recommendations by type are reported in Table III (available at www.jpeds.com). 4
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Table I. Patient and visit characteristics of enrolled and declining participants Characteristics Total Complaint category Medical Injury/Trauma Age (y) 10-13 14-17 Sex Female Male Gender Female Male Other Did not specify Data unavailable‡ Ethnicity European origins Aboriginal East/Southeast Asian South Asian West Central Asian/ Middle Eastern Latin American Sub-Saharan African/ Afro-Caribbean origins Other Data unavailable Acuity of presentation (CTAS) 1 2 3 4 5 Data unavailable Average annual income§ Quartile 1 Quartile 2 Quartile 3 Quartile 4 Data unavailable
Study participants N (%)
Declined* n (%)
P value†
795
193
524 (65.9) 271 (34.1)
136 (70.5) 57 (29.5)
.23
456 (57.4) 339 (42.6)
118 (61.1) 75 (38.9)
.33
410 (51.6) 385 (48.4)
95 (49.2) 98 (50.8)
.56
411 (51.8) 379 (47.7) 3 (0.4) 2
85 (48.0) 92 (52.0) 16
.5
469 (59.1) 21 (2.7) 92 (11.6) 65 (8.2) 17 (2.1)
102 (57.6) 11 (6.2) 20 (11.3) 21 (11.9) 4 (2.3)
.27
14 (1.8) 9 (1.1)
4 (2.3) 2 (1.1)
106 (13.4) 2
13 (7.4) 16
2 (0.3) 98 (12.4) 385 (48.6) 290 (36.6) 18 (2.3) 2
0 (0.0) 19 (22.4) 32 (37.6) 33 (38.8) 1 (1.2) 108
.12
225 (28.4) 147 (18.5) 215 (27.1) 206 (26.0) 2
50 (26.8) 33 (17.7) 60 (32.3) 43 (23.1) 7
.63
CTAS, Canadian Triage and Acuity Score. For Stollery, Q1: <$51 860.25; Q2: $51 860.26-$63 820.50; Q3: $63 820.51-$75 055.25; Q4: >$75 055.25. *Declining participation but consented to an optional health record review and demographic data collection. †Z test for 2-proportion or c2 test as appropriate. ‡Withdrew or not collected; excluded to allow complete-case analyses. §Annual Individual Income based on the participant’s postal code categorized by quartiles. For BC Children’s Hospital, Q1: <$41 186.83; Q2: $41 186.84-$47 298.85; Q3: $47 298.86$54 898.88; Q4: >$54 898.88.
We were able to complete a 30-day follow-up for 72.5% (124 of 171) of families with newly recommended mental health services resulting from the screening. Although 74.2% (92/124) of families agreed with these recommendations, only 33.1% (41 of 124) of contacted families had attempted to access any of the recommended mental health services. The main reason for not following through with the recommendations was the families’ perception that the recommendation was not yet necessary or that it was not yet a priority. Other reasons (Figure 2) included lack of time, inconvenience, inability to recall what the recommendations were, misplacing the written information Doan et al
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Table II. Utility of psychosocial self-screening by youth and their guardians, using MyHEARTSMAP, reported with 95% CIs Psychometric properties by sub-categories Sensitivity Youth cases (total N = 694) Any degree* Severe† Moderate§ Sensitivity by youth self-assessments Any degree Severe Moderate Guardian cases (total N = 680) Any degree Severe Moderate Sensitivity by guardians’ assessments Any degree Severe Moderate Specificity Youth cases (total N = 694) Clinician assessment: no issues Specificity by youth self-assessments No issues No worse than mild issues Guardian cases (total N = 680) Clinician assessment: no issues Specificity by guardians’ assessments No issues No or mild issues
Psychiatric
Social
Youth health
Functional
301 7‡ 56
210 5 8
222 5 7
286 13 21
92.7 (89.1, 95.4) 85.7 (42.1, 99.6) 78.6 (65.6, 88.4)
91.9 (87.4, 95.2) 0 (0, 52.2) 100 (63.1, 100)
80.7 (74.9, 85.7) 20 (0.5, 71.6) 42.9 (9.9, 81.6)
73.1 (67.5, 78.2) 61.5 (31.6, 86.1) 47.1 (31.6, 86.1)
302 8 54
222 5 9
225 6 8
292 13 21
93.1 (89.5, 95.8) 75.0 (34.9, 96.8) 68.5 (54.5, 80.5)
86.9 (81.8, 91.1) 20 (0.5, 71.6) 66.7 (29.9, 92.5)
75.6 (69.4, 81.0) 16.7 (0.4, 64.1) 50 (15.7, 84.3)
79.9 (74.8, 84.4) 30.8 (9.1, 61.4) 57.1 (34.0, 78.2)
393
423
471
408
42.2 (37.3, 47.3) 98.5 (96.7, 99.4)
43.3 (38.5, 48.1) 98.4 (96.6, 99.3)
84.1 (80.5, 87.3) 100 (99.2, 100)
76.5 (72.1, 80.5) 100 (99.1, 100)
378
458
455
396
37.0 (32.2, 42.1) 98.9 (97.3, 99.7)
37.8 (33.3, 42.4) 98.5 (96.9, 99.4)
77.1 (73.0, 80.9) 99.8 (98.8, 100)
77.7 (72.5, 82.4) 100 (99.1, 100)
*Any degree: any and at least mild psychosocial concerns (cumulative domain 1-3). †Severe: concerns with a cumulative domain score of 7-9. ‡A single section score of 3 mapping to the psychiatry domain also qualifies as severe. §Moderate: concerns with a cumulative domain score of 4-6.
on services, and youth’s reluctance to access help. Among those who attempted to access resources, 22 of 41 (53.7%) were successful. Access delay (eg, on a wait list) was the most common cited barrier (11 of 18 or 61.1%).
Discussion Our study found that both patients and their families displayed similar degrees of sensitivity and specificity in identifying psychosocial support needs across all tool domains. One-third (33.1%) of youth were recommended mental health supports, however, only 33.9% among these attempted to access recommended care within 30 days of their ED visit. Although presenting to the ED for a nonmental health-related complaint, participants self-identified psychosocial issues above national estimates.9,30 The advantages of psychosocial self-assessment tools like MyHEARTSMAP, compared with clinician administered assessments for universal screening in the ED have been established. In addition to empowering families, screening can be implemented without adding to ED clinician workload.31 In addition, evidence suggests youth prefer to disclose personal and sensitive information within an electronic, interactive interface compared with in-person interviews.19 Computerized screening may offer a sense of privacy for users and may be culturally and linguistically aligned with youth
needs.20 However, few self-administered psychosocial instruments have been psychometrically evaluated in the pediatric ED setting. In 1 such study, Winston et al observed high youth and parent sensitivity, 88% and 96%, respectively, of a brief post-traumatic stress disorder ED screening tool.32 In the primary care setting, youth self-reporting with the Public Health Questionnaire-9 tool have shown 89.5% sensitivity and 77.5% specificity in detecting depressive disorder using the Diagnostic and Statistical Manual IV criteria.33 Similarly, our participating youth showed comparable accuracy in identifying any (92.7%), moderate (78.6%), and severe (85.7%) psychiatric concerns, which capture concerning mood-related issues. Although MyHEARTSMAP showed modest specificity in identifying lack of concerns, false positives almost entirely identified only mild concerns. Tools such as the Pediatric Symptom Checklist-17 offer more comprehensive psychosocial evaluation than MyHEARTSMAP, however, the sensitivity of parental scoring using this tool and others is variable, ranging from 31% in identifying any mental health diagnosis (Child Behavior Checklist) to 73% in identifying depression (Pediatric Symptom Checklist).34 In comparison, MyHEARTSMAP displays consistently higher sensitivity for identifying concerns associated with any psychiatric, social, youth health, and functional support need, with a lower response burden (fewer items). MyHEARTSMAP’s utility in predicting mental health needs may permit early identification and intervention in other
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Figure 2. Youth connection with psychosocial resources following screening.
environments if confirmed, such as primary care (eg, family doctor or pediatrician’s office) and schools, where there is growing interest in prevention-oriented screening and intervention to support students’ academic success.35 Many existing validated measures display sufficient sensitivity, however, the lack of precision of existing tools 36 may challenge untrained staff or place further burden on counselors with heavy caseloads to both administer and review screening. Emerging practices and guidelines support self-reporting assessments that may reduce demands on staff and provide crucial information on how students appraise their own experiences and needs.37 In our study, approximately one-third of youth receiving care recommendations upon screening attempted to access resources for support, but approximately one-half of them were either unsuccessful or delayed in receiving services. This is similar to results reported by Hacker et al, who found only 18% of adolescents who screened positive for a mental health concern at a routine primary care visit and were referred for treatment completed necessary follow-up within 6 months.38 Our follow-up interviews found that the primary contributor to low access was parental beliefs that recommendations were not yet necessary or currently not a family 6
priority. Families may perceive their child’s mental health issues as transient that their child will “grow out of” and do not warrant services.39 Lower help-seeking may also reflect lower parental mental health literacy, compared with physical concerns, although the former has potentially higher impact on families.40 Despite large-scale awareness campaigns and growing dialog, stigma surrounding mental health persists, and parents may fear embarrassment seeking support and choose to self-manage in fear of their child being labelled with a mental health disorder.41 Applying behavioral change frameworks to address barriers to help-seeking may shift parental attitudes toward service engagement42-44 and support the development of sensitive and engaging psychoeducation initiatives. Sustained and more frequent follow-up may also support families’ connectivity with care and may present opportunities for multidisciplinary collaboration between the ED and primary care or school-based settings. In addition to families’ decision to access mental health services, availability and accessibility of such services have to be secured, to mitigate the burden of mental health conditions through screening and early detection. Comparable with previous studies,45 approximately one-half our participants who attempted to access care were delayed (eg, waitlisted), Doan et al
- 2020 suggesting that additional service demands uncovered through screening may be greater than current health system preparedness.46,47 Our study supports the need for improved community-based and primary care capacities to provide mental healthcare. It is crucial to ensure that resources are available to appropriately deal with uncovered psychosocial needs, when applying universal screening interventions. Integrating the option to connect with telemedicine or the digital mental health counterparts of in-person care (eg, online psychotherapy, counseling) may help address structural challenges such as saturated and potentially inaccessible services (eg, for rural/remote communities).48 This study was strengthened by the 2-site study design, allowing for time efficient sampling of a regionally diverse sample of youth and families across Western Canada. However, this study was not without limitations. First, despite using dedicated research staff to approach patient families in the ED, only 55.5% of eligible potential participants consented to participate. Although this potentially introduced selfselection bias, when we compared demographic characteristics between participants and those who declined, we did not observe any meaningful or significant differences. Recruiting research participants in the pediatric ED is challenging because of the high level of acuity of patient needs and busy setting. Adding the sensitive nature of reporting psychosocial concerns, which may be perceived as invasive when accessing the ED for nonmental health related complaints, likely affected our participation rate. Our experience is consistent with published participation consent rates (50.7%) in the ED setting.49 In addition, follow-up interviews were only conducted at 1 month; given families may have prioritized managing their acute complaints following their ED visit and that a number of mental health referrals can take longer durations to access, a higher access rate may have been seen with 3- or 6-month follow-up. In addition, 47 out of 171 youth whose screening triggered mental health service recommendations and required follow-up, could not be reached. However, upon reviewing their demographic (eg, age, socioeconomic status) information and severity/acuity scoring, we found them to be comparable (no statistically significant differences on any variables) with those completing 30-day follow-up. In conclusion, using MyHEARTSMAP in the ED identified a sizable proportion of youth with previously unaddressed psychosocial service needs. Moreover, HEARTSMAP has high sensitivity and false positive screens consisted mostly of self-identification of no worse than mild concerns. n This study was conducted at 2 Pediatric Emergency Research Canada (PERC) sites, and we are grateful for the contribution from the respective PERC research coordinators: Karly Stillwell, Mithra Sivakumar, and Manasi Rajagopal. We also acknowledge the support of the PERC executives and peer reviewers. Lastly, we are thankful to Mr Max LeBlanc for his contribution to MyHEARTSMAP through the creation of the MyHEARTSMAP instructional video. Submitted for publication Oct 29, 2019; last revision received Dec 20, 2019; accepted Dec 20, 2019.
ORIGINAL ARTICLES Reprint requests: Quynh Doan, MDCM, PhD, BC Children’s Hospital, 4480 Oak St, Office B428-B, Vancouver, BC, V6H 3N1, Canada. E-mail: qdoan@ bcchr.ca
References 1. Pearson C, Janz T, Ali J. Health at a glance: mental and substance use disorders in Canada. Stat Canada [Internet] 2013; Catalog. http://www. statcan.gc.ca/pub/82-624-x/2013001/article/11855-eng.pdf. Accessed December 6, 2019. 2. World Health Organization. The global burden of disease: 2004 update. Geneva, Switzerland; 2008. https://www.who.int/healthinfo/global_ burden_disease/2004_report_update/en/. Accessed December 27, 2019. 3. Glied S, Pine DS. Consequences and correlates of adolescent depression. Arch Pediatr Adolesc Med 2002;156:1009-14. 4. Navaneelan T. Health at a glance. Suicide rates: an overview. Stat Canada [Internet] 2012;(82-624-X). https://www150.statcan.gc.ca/n1/pub/82624-x/2012001/article/11696-eng.htm#archived. Accessed December 6, 2019. 5. Dolan MA, Fein JJA, The Committee on pediatric emergency medicine. Technical report: pediatric and adolescent mental health emergencies in the emergency medical services system. Pediatrics 2011;127:e1356-66. 6. Mahajan P, Alpern ER, Grupp-Phelan J, Chamberlain J, Dong L, Holubkov R, et al. Epidemiology of psychiatric-related visits to emergency departments in a multicenter collaborative research pediatric network. Pediatr Emerg Care 2009;25:715-20. 7. Simon AE, Schoendorf KC. Emergency department visits for mental health conditions among US children, 2001-2011. Clin Pediatr (Phila) 2014;53:1359-66. 8. Mapelli E, Black T, Doan Q. Trends in pediatric emergency department utilization for mental health-related visits. J Pediatr 2015;167:905-10. 9. Canadian Institute for Health Information. Care for children and youth with mental disorders [Internet] 2015. https://secure.cihi.ca/free_ products/CIHI CYMH Final for pubs_EN_web.pdf. Accessed December 6, 2019. 10. Grupp-phelan J, Wade TJ, Pickup T, Ho ML, Lucas CP, Brewer DE, et al. Mental health problems in children and caregivers in the emergency department setting. J Dev Behav Pediatr 2007;28:16-21. 11. Kelly TM, Donovan JE, Cornelius JR, Bukstein OG, Delbridge TR, Clark DB. Psychiatric Disorders amond older adolescents treated in emergency departments on weekends: a comparison with a matched community sample. J Stud Alcohol 2003;64:616-22. 12. Downey LVA, Zun LS, Burke T. Undiagnosed mental illness in the emergency department. J Emerg Med 2012;43:876-82. 13. Biros MH, Hick K, Cen YY, Mann J, Gaetz A, Hansen R, et al. Occult depressive symptoms in adolescent emergency department patients. Arch Pediatr Adolesc Med 2008;162:769-73. 14. Scott EG, Luxmore B, Alexander H, Fenn RL, Christopher NC. Screening for adolescent depression in a pediatric emergency department. Acad Emerg Med 2006;13:537-42. 15. Pailler ME, Cronholm PF, Barg FK, Wintersteen MB, Diamond GS, Fein JA. Patients’ and caregivers’ beliefs about depression screening and referral in the emergency department. Pediatr Emerg Care 2009;25:721-7. 16. Horowitz L, Ballard E, Teach SJ, Bosk A, Rosenstein DL, Joshi P, et al. Feasibility of screening patients with nonpsychiatric complaints for suicide risk in a pediatric emergency department: a good time to talk? Pediatr Emerg Care 2010;26:787-92. 17. Williams JR, Ho ML, Grupp-Phelan J. The acceptability of mental health screening in a pediatric emergency department. Pediatr Emerg Care 2011;27:611-5. 18. Cronholm PF, Barg FK, Pailler ME, Wintersteen MB, Diamond GS, Fein JA. Adolescent depression: views of Health care providers in a pediatric emergency department. Pediatr Emerg Care 2010;26:111-7. 19. Ranney ML, Choo EK, Spirito A, Mello MJ. Adolescents’ preference for technology-based emergency department behavioral interventions: does it depend on risky behaviors? Pediatr Emerg Care 2013;29:475-81.
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20. Choo EK, Ranney ML, Aggarwal N, Boudreaux ED. A Systematic review of emergency department technology-based behavioral health interventions. Acad Emerg Med 2012;19:318-28. 21. Fein JA, Pailler ME, Barg FK, Wintersteen MB, Hayes K, Tien AY, et al. Feasibility and effects of a Web-based adolescent psychiatric assessment administered by clinical staff in the pediatric emergency department. Arch Pediatr Adolesc Med 2010;164:1112-7. 22. Lee A, Deevska M, Stillwell K, Black T, Meckler G, Park D, et al. A psychosocial assessment and management tool for children and youth in crisis. Can J Emerg Med 2018;0:1-10. 23. Virk P, Stenstrom R, Doan Q. Reliability testing of the HEARTSMAP psychosocial assessment tool for multidisciplinary use and in diverse emergency settings. Paediatr Child Health 2018;23:503-8. 24. Doan Q, Black T. Behavioural disorders in Children. In: Tintinalli J, Stapczynski JS, Ma OJ, Yealy DM, Meckler GD, Cline DM, eds. Tintinalli’s emergency medicine: a comprehensive study guide. 9th ed. New York: McGraw Hill; 2020. p. 982-8. 25. Koopmans E, Black T, Newton A, Dhugga G, Karduri N, Doan Q. Provincial dissemination of HEARTSMAP, an emergency department psychosocial assessment and disposition decision tool for children and youth. Paediatr Child Health 2019;24:359-65. 26. Virk P, Laskin S, Gokiert R, Richardson C, Newton M, Stenstrom R, et al. MyHEARTSMAP: development and evaluation of a psychosocial self-assessment tool, for and by youth. BMJ Open Paediatr 2019;3: e000493. 27. Doan Q, Black T. Heartsmap psychosocial assessment and mental health resource navigation tools. 2018. www.openheartsmap.ca. Accessed January 24, 2020. 28. Grafstein E, Bullard MJ, Warren D, Unger B. Revision of the Canadian Emergency Department Information System (CEDIS) presenting complaint list Version 1.1. CJEM 2008;10:151-61. 29. Canada Revenue Agency. Individual tax statistics by forward sortation area. Table 1b: FSA for all returns, by total income-2015 tax year. 2017. https://www.canada.ca/content/dam/cra-arc/prog-policy/stats/individualtax-stats-fsa/2015-tax-year/tbl1b-en.pdf. Accessed September 20, 2019. 30. Perou R, Bitsko RH, Blumberg SJ, Pastor P, Ghandour RM, Gfroerer JC, et al. Mental health surveillance among children—United States, 20052011. MMWR Suppl 2013;62:1-35. 31. Chun TH, Duffy SJ, Linakis JG. Emergency department screening for adolescent mental health disorders: the who, what, when, where, why, and how it could and should be done. Clin Pediatr Emerg Med 2013;14:3-11. 32. Winston FK, Kassam-Adams N, Garcia-Espa~ na F, Ittenbach R, Cnaan A. Screening for Risk of persistent post-traumatic stress in injured children and their parents. JAMA 2003;290:643-9. 33. Richardson LP, McCauley E, Grossman DC, McCarty CA, Richards J, Russo JE, et al. Evaluation of the Patient Health Questionnaire-9 Item for detecting major depression among adolescents. Pediatrics 2010;126:1117-23. 34. Gardner W, Lucas A, Kolko DJ, Campo JV. Comparison of the PSC-17 and alternative mental health screens in an at-risk primary care sample. J Am Acad Child Adolesc Psychiatry 2007;46:611-8.
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35. Eklund K, Renshaw TL, Dowdy E, Jimerson SR, Hart SR, Jones CN, et al. Early Identification of behavioral and emotional problems in youth: universal screening versus teacher-referral identification. Calif Sch Psychol 2009;14:89-95. 36. Albers CA, Glover TA, Kratochwill TR. Where are we, and where do we go now? Universal screening for enhanced educational and mental health outcomes. J School Psychol 2007;45:257-63. 37. Moore SA, Widales-Benitez O, Carnazzo KW, Kim EK, Moffa K, Dowdy E. Conducting universal complete mental health screening via student self-report. Contemp Sch Psychol 2015;19:253-67. 38. Hacker K, Arsenault L, Franco I, Shaligram D, Sidor M, Olfson M, et al. Referral and follow-up after mental health screening in commercially insured adolescents. J Adolesc Heal 2014;55:17-23. 39. Godoy L, Mian ND, Eisenhower AS, Carter AS. Pathways to service receipt: modeling parent help-seeking for childhood mental health problems. Adm Policy Ment Health 2014;41:469-79. 40. Dey M, Wang J, Jorm AF, Mohler-Kuo M. Children with mental versus physical health problems: differences in perceived disease severity, health care service utilization and parental health literacy. Soc Psychiatry Psychiatr Epidemiol 2015;50:407-18. 41. Owens PL, Hoagwood K, Horowitz S, Leaf P, Poduska JM, Kellam SG, et al. Barriers to children’s mental health services. J Am Acad Child Adolesc Psychiatry 2002;41:731-8. 42. Michie S, Yardley L, West R, Patrick K, Greaves F. Developing and evaluating digital interventions to promote behavior change in health and health care: recommendations resulting from an international workshop. J Med Internet Res 2017;19:e232. 43. Morrison LG. Theory-based strategies for enhancing the impact and usage of digital health behaviour change interventions: a review. Digit Heal 2015;1:2055207615595335. https://www.ncbi.nlm.nih.gov/pubmed/299 42544. Accessed December 6, 2019. 44. Olin SS, Hoagwood KE, Rodriguez J, Ramos B, Burton G, Penn M, et al. The application of behavior change theory to family-based services: improving parent empowerment in children’s mental health. J Child Fam Stud 2010;19:462-70. 45. Chisolm DJ, Klima J, Gardner W, Kelleher KJ. Adolescent behavioral risk screening and use of health services. Adm Policy Ment Health 2009;36:374-80. 46. O’Brien D, Harvey K, Howse J, Reardon T, Creswell C. Barriers to managing child and adolescent mental health problems: a systematic review of primary care practitioners’ perceptions. Br J Gen Pract 2016;66:e693-707. 47. Kim WJ, American Academy of Child and Adolescent Psychiatry Task Force on Workforce Needs. Child and Adolescent psychiatry workforce: a critical shortage and national challenge. Acad Psychiatry 2003;27:277-82. 48. E-Mental Health in Canada: transforming the mental health system using technology [Internet]. 2014. https://www.mentalhealthcommission.ca/ sites/default/files/MHCC_E-Mental_Health-Briefing_Document_ENG_ 0.pdf. Accessed December 6, 2019. 49. Taylor RG, Hounchell M, Ho M, Grupp-Phelan J. Factors associated with participation in research conducted in a pediatric emergency department. Pediatr Emerg Care 2015;31:348-52.
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ORIGINAL ARTICLES
Table III. Prevalence of concerns by domain and severity and recommendations triggered by clinician HEARTSMAP assessment N total: 760 No concerns n (%; 95% CI) Mild concerns n (%; 95% CI) Moderate concerns n (%; 95% CI) Severe concerns n (%; 95% CI)
Psychiatry
Youth health
Social
Functional
433 (57.0; 53.4, 60.5) 262 (34.5; 31.1, 38.0) 60 (7.9; 6.1, 10.1) 5 (0.7; 0.2, 1.5)
516 (67.0; 64.5, 71.2) 233 (30.7; 27.4, 34.1) 9 (1.2; 0.5, 2.2) 2 (0.3; 0.03, 1.0)
521 (68.6; 65.1, 71.8) 229 (30.1; 26.9, 33.5) 10 (1.3; 0.6, 2.4) 0
449 (59.1; 55.5, 62.6) 286 (37.6; 34.2, 41.2) 18 (2.4; 1.4, 3.7) 7 (0.9; 0.4, 1.9)
Psychiatric follow- up Recommendations triggered n (%; 95% CI)
254 (33.4; 30.1, 36.9) Psychiatry consultation in ED 6 (0.8; 0.3, 1.7)
Youth health and addiction services
Social worker support
Child protective services
49 (6.4; 4.8, 8.4)
10 (1.3; 0.6, 2.4)
5 (0.7; 0.2, 1.5)
Utility of MyHEARTSMAP for Universal Psychosocial Screening in the Emergency Department
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