Parents often bring their children to psychiatric ERs to get them under control, study finds

For emergency physicians, it’s a daunting and familiar sight: children returning again and again plagued by mental health crises, brought in by frightened or overwhelmed caregivers.

Much has been written about the increase in visits to pediatric mental health emergency rooms in recent years, as rates of depression and suicidal behavior among adolescents have increased. Patients often spend days or weeks in exam rooms waiting for a scarce psychiatric bed to become available, dramatically reducing hospital capacity.

But a large study published on Tuesday found a surprising trend among teenagers who visited the hospital multiple times. The patients most likely to reappear in the ER were not patients who self-harmed, but rather those whose agitation and aggressive behavior proved too much for their caregivers to handle.

In many cases, regular visitors had already been given sedatives or other drugs to control them when their behavior became disruptive.

“Families come in with their kids who have severe behavioral issues, and families are really at their wits’ end, you know,” said Dr. Anna M. Cushing, pediatric emergency physician at Children’s Hospital Los Angeles. and one of the study’s authors. “The behavior of their child can be a danger for themselves, but also for the parents, for the other children in the house.”

The findings, published in the journal JAMA Pediatrics, analyzed more than 308,000 mental health visits to 38 hospitals between 2015 and 2020.

Compared to patients with suicidal or self-harming behavior, those with psychotic disorders were 42% more likely to return to the emergency department within six months, according to the study; patients with impulse control disorders were 36% more likely; and patients with conditions like autism and ADHD were 22% more likely. Patients who needed medication to control them were 22% more likely to return than patients who did not.

The findings suggest that researchers should pay more attention to families whose children have cognitive and behavioral problems, and who may turn to emergency rooms for respite, Dr. Cushing said.

“I’m not sure we’ve spent that much time talking about these agitated, behaviorally dysregulated patients, at least on a national scale,” she said.

The frequency of revisits suggests that the care they receive in emergency rooms “is really not adequate”, she said.

The guidelines recommend that so-called chemical restraints – benzodiazepines or antipsychotics given by injection or intravenous drip – should be used as a last resort as they can be traumatic or cause physical injury to the patient, medical staff or caregivers. caregivers, said Dr. Ashley A. Foster, assistant professor of emergency medicine at the University of California, San Francisco.

The use of these drugs in pediatric emergency rooms has increased in recent years. Between 2009 and 2019, the use of chemical restraints increased by 370%, while visits to mental health emergency rooms increased by 268%, according to a study that Dr. Foster and his colleagues published last year.

The drugs were used more often on black patients, as well as on male patients between the ages of 18 and 21, according to the study. Dr Foster described these disparities as ‘worrying and motivating to think about how to improve equitable care’.

Dr. Christine M. Crawford, a child and adolescent psychiatrist at Boston Medical Center, said caregivers of children with behavioral disorders often turn to the ER when “it gets to the point where someone could get hurt” .

“They go into sixth, seventh, eighth grade – that’s when we see these families who have been struggling for a long time,” said Dr. Crawford, who is also an assistant professor at Boston University School of Medicine.

Families in this situation, she said, “are quite isolated”, often hiding their struggles from friends and loved ones. Emergency room treatment is comforting for caregivers but offers little long-term benefit, she said.

“It’s just putting a band-aid on the problem,” she said. “They go home and they’re still waiting for that appointment to meet with a therapist.”

Dr Andrea E. Spencer, a psychiatrist and researcher at Lurie Children’s Hospital in Chicago, said behavioral disorders might be considered less urgent than suicidal thoughts or self-harm, when in fact “these are behaviors to very high risk and they are dangerous”. behaviours.”

“There is a tendency to watch and wait and deprioritize these children in terms of who is the most serious and then they tend to get worse,” she said, adding that public hospitals might be reluctant to take them. accept as hospital patients because they are disruptive.

“In many ways, these kids are actually harder to treat,” she said.

The JAMA study found that overall pediatric ER visits for mental health crises increased by 43% from 2015 to 2020, increasing by 8% per year on average, with an increase in ER visits for every disease category mental. In comparison, emergency room visits for all medical causes have increased by 1.5% per year.

Almost a third of visits were related to suicidal thoughts or self-harm, and about a quarter of patients had mood disorders, followed by anxiety disorders and impulse control disorders. About 13% of patients returned within six months.

“It causes a lot of moral distress for a lot of us, just because we don’t feel like the emergency department is always the right place or the best place to care for many of our patients,” said Dr. Cushing.

“But,” she added, “they really have nowhere to go.”