Pediatric emergency medicine trisk 4215 4215
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Many children with psychiatric illness do not present to the ED with overt
psychiatric symptoms. It is also clear that many patients with psychiatric
disorders exhibit somatic symptoms, such as headache and abdominal pain;
some chronic medical illnesses, such as asthma and diabetes, can also be
exacerbated by stress and anxiety. Because the ED may be the only point of
contact for children with undiagnosed psychiatric illness, the American
Academy of Pediatrics (AAP) has acknowledged the role of the ED as a
safety net for children and adolescents with unmet mental health needs.
Several challenges are important to consider when screening for
behavioral disorders or psychiatric illness in acute care settings. Lack of an
ongoing therapeutic relationship and fear of stigma may prevent an
adolescent from reporting depression, substance use, or suicidal thoughts
and behaviors. The high stimulus setting of the ED may also discourage the
disclosure of sensitive mental health matters. Screening instruments need to
be valid when administered by clinicians who do not have specific training
in psychology or psychiatry. Oftentimes the behavioral health system,
particularly for low-income patients, leaves physicians with limited referral
options. Ethical and legal concerns are also of consideration, including the
need for standardized, confidential documentation for positive screens,
misperceptions about mandated reporting requirements, and legal limitations
of communication options with parents and other family members. It is very
helpful if ED and hospital leadership understand the legislative and local
policies around these issues and make their faculty and staff aware of the
standard of care in this regard.
While there are culturally sensitive and developmentally appropriate
screening tools that promote the accurate detection of suicide, depression,
and other psychiatric illnesses as well as substance use (e.g., the CRAFFT
tool, ), the need for efficiency in the acute care setting
creates an extra challenge. In the current medical and economic climate,
busy clinicians prefer clinical innovations to be “pushbutton” in nature,
creating added value while minimizing time and effort. Computer
technology and omnipresent mobile devices offer some solutions to these
barriers, and also offer the potential for skip-logic and “computerized
adaptive testing” that can maximize accuracy by adding follow-up questions
only when initial, more sensitive questions are answered positively.
