M. Douglas Baker, MD
Professor of Pediatrics
Johns Hopkins University, School of Medicine
Director, Emergency Services
Charlotte R. Bloomberg Children’s Center
During the past 20 years, visits to pediatric emergency departments by children with psychiatric needs have increased in number and acuity. National media coverage of tragedies in schools and other public settings has contributed to the increased general awareness of psychiatric illnesses.
Somewhat understandably, a seemingly universal ‘zero tolerance’ approach to behavioral outbursts in schools has emerged, augmenting the number of children presenting to emergency departments for assessment of aggression, depression, self-harmful behavior, or other psychiatric illness. Recidivism is common. The need for inpatient management of these disorders often outstrips the supply of inpatient beds and providers. Outpatient services are equally saturated, and often used as surrogates for more intensive, but less available inpatient services.
Emergency departments remain the single universally-available resource for children with psychiatric needs. However, even there, services by psychiatrists are very limited. In most pediatric emergency departments, psychiatric services consist of medical screening examinations by medical physicians and psychiatric screening assessments by non-physician staff, who are trained to recognize types and acuities of psychiatric illness and refer children to either in-patient or out-patient services.
Children in need of in-patient admission often wait for days in emergency departments until in-patient resources are available. Indeed, the average length of stay for children with psychiatric illness is many times that for children with other medical or surgical needs. Those extended stays in the emergency departments often add little value to the management of the child’s psychiatric illness, but further complicate the overcrowding that has also become commonplace in emergency departments in the United States.
The emergency medicine provider’s perspective is naturally slanted toward the characteristics of the population that we serve; our experience is not representative of pediatric psychiatry as a whole. There are many successes within the realm of pediatric psychiatry, some associated with the smaller contributions provided in emergency departments. However, from our vantage point, it seems clear that there is substantial need for additional resources to be targeted toward prevention of psychiatric illness and personalized management of disease. Investment in family support services, parenting skills and early intervention for behavioral abnormalities would likely yield greater downstream rewards. As is true of many others, access to psychiatric services at all levels needs to be substantially improved.