The integration of mental health resources and treatments into primary pediatric care settings presents many opportunities and challenges (Pumariega & Winters, 2018). Most children in the United States have at least one visit with the primary care provider each year. The primary care provider may be required to interact with other systems, for example, school, child welfare, legal, as well as mental health. Although provision of medical care (including mental health care) has improved, mental health services remain lacking for many youth (Asarnow et al., 2005; Pumariega & Winters, 2018).

Typically, the primary care provider serves as a resource and potentially a gatekeeper in facilitating access to mental health services. The need for mental health providers is underscored by epidemiologic studies suggesting high rates of mental health problems in children, with probably one in five children having a significant problem (Pumariega & Winters, 2018). These problems take a significant toll on school success and may impact peer and family relationships. The public health significance of these problems is underscored by work suggesting that about half of all mental health disorders have their onset by age 14 years and 75% by age 24 years.

Unfortunately, the historic divisions between medical and psychiatric service systems have tended to fragment service delivery and complicate provision of effective, integrated care. This unfortunate dichotomy is now greatly compounded by issues of insurance reimbursement and the organization (or lack thereof) of health care. These issues become further complicated for some disorders specifically covered within the mandates of schools for providing services. There are a few model programs, for example, that of Massachusetts, that aim to integrate care (Sarvet et al., 2010).

Mental health conditions frequently present with physical problems, and patients with physical problems have associated psychiatric disabilities. Psychiatric conditions also have important associated medical risks, for example, for accidents and injuries, suicide, violence, substance abuse, and teen pregnancy, among others. Most chronic physical illnesses increase the risk for subsequent mental health problems. Conversely, the association of depression with a chronic condition like diabetes may be associated with significant risk for problems. It is important to be aware of medical conditions that increase the risk for mental health disturbances in the child (see Table 27.1).

Sadly, despite the awareness of the effective mental health interventions, most children and adolescents do not receive treatments they need and even those who do do not necessarily receive treatments considered best practice, evidence-based interventions. Primary care providers can offer clinical management for most psychosocial problems and account for the majority of prescriptions of psychoactive medications. This is true for various conditions ranging from depression, anxiety, and mood problems to attention-deficit disorder (see Havens et al., 2018). Fortunately, there have now been some attempts on the part of the American Academy of Pediatrics to produce guidelines for management of mental health care issues in primary pediatric care. The field of Developmental-Behavioral Pediatrics arose from concerns about the need for more sustained and effective training of pediatricians in behavioral health. This approach has focused on common behavioral and developmental problems, and the subspecialty has been officially recognized and now includes a period of fellowship training. The medical home model (Sheldrick & Perrin, 2010) has now been used with good results in a range of conditions, for example, autism, to provide better integrated care.

Primary care providers may feel more comfortable in the management of some disorders, like ADHD, but not others, for example, depression (Asarnow et al., 2005; Schonfeld & Campo, 2018). There are many obstacles to providing mental health services including lack of
access, social stigma, the shortage of child and adolescent psychiatrists, reimbursement, and administrative issues. Clearly, priorities in this area include better training, new models of care like the medical home, and new methods of service delivery, for example, school-based clinics. Communities in rural and impoverished areas may have the least access to good models of care, and telemedicine has some important potential advantages in these situations.

Although they can occur at any age, child mental health emergencies become more common as children enter school and high school. The urgency of the situation depends on the nature of the psychiatric symptoms, available supports, and issues of safety for the child and others. Unfortunately, as with other aspects of medical care, psychiatric emergency services are frequently, but inappropriately, used to deal with problems more appropriate to less urgent settings, but, given an absence of community resources, such problems may present on an emergent basis or directly in the emergency department. Sometimes, issues have been simmering for a long time and something finally tips the situation over the edge (Havens et al., 2018). At other times, there may be rapid emergence of difficulties. Referrals may come from many sources including parents and family, schools, juvenile justice, community agencies, and so forth. Referrals from junior high and high schools are frequent except in the summer. Heightened sensitivities to violence have often led schools to adopt a policy of zero tolerance; these policies may require some sort of psychiatric assessment before the child returns to the school.

Mental health emergency referral of all kinds has become more common in recent years. Kalb and colleagues (2019) reported a nearly 30% overall increase with a 2.5-fold increase in visits related to suicidal thoughts/actions. Sadly, only about 16% of youth were actually evaluated in the emergency department (ED) by a mental health professional. The reasons for the increased number of referrals remain unclear but include higher rates of suicidal thinking and increased rates of violent behavior. Dwindling options for community-based care force more children and adolescents to emergency settings when crises occur. Many mental health professionals in private practice are willing to see patients on an urgent basis but if issues of hospitalization or suicidality or violence arise, they typically will refer the patient and their family to the ED. Insurance coverage pressures have also forced shorter lengths of stay when mental health hospitalization is indicated. Finally, of course, the ED remains the place of last resort for the many uninsured children and adolescents who need acute mental health care.

Child psychiatric emergencies are characteristically times of great stress for all concerned. The sense of urgency is often complicated by anxiety about the outcome and/or the ongoing issues or conflicts. Typically, many different factors are involved in precipitating the trip to the ED and often a relevant place to begin is with the question “why now” (Havens et al., 2018).

Clarifying the relationships of the various individuals centrally involved is another important priority. Children function in several different contexts: home and family, school, and community. A crisis can occur with any number of changes to these overlapping systems—for example, school failure, parental discord, violence, bullying, and victimization. Sometimes a sudden upsurge in the level of severity of an ongoing problem can precipitate the crisis. Often clarifying the questions of why now and who is involved become the first steps in thinking about a resolution of the crisis.

In understanding the nature of the emergency, the evaluator typically has several important goals:

It is important to develop an emergency treatment plan and arrive at a disposition, with due consideration for the safety of the child (and others) with follow-up and collaboration with other clinicians involved in the child’s care, including the primary care provider.

Given the intense pressures on a busy hospital ED, it is not surprising that often the focus in an emergency is the question of dangerousness and potential needs for hospitalization. This approach misses the potential therapeutic value, that is, using a crisis to stimulate change, of the ED visit and the opportunity it presents for significant benefit. In contrast to the somewhat more leisurely pace of typical assessments, the urgency of the ED situation typically leads to rapid clinical decisions and treatment formulation. This process can be severely hampered, for example, by the absence of key adults who can provide information or by limited community resources for treatment after discharge from the ED. The latter can be even more of a problem when, as is often the case, the evaluation is conducted at night or on the weekend rather than during regular business hours. Given the pressures involved, the clinician must be efficient and well organized. With experience, clinicians rapidly develop a clear sense of the priority of problems and often begin to formulate their ideas about diagnosis and treatment planning as soon as the evaluation has begun.

The typical ED is a busy place with little privacy and many distractions. Depending on the situation, it can be very helpful if the clinician can locate a quieter and less stimulating area to use for interviewing the child and others. This area must, however, be safe and the clinician should feel that help is at hand should the need arise. Typically, an adult, rather than the child, will have been the source of the referral to the ED. Similar to other situations that require mental health evaluation (see Chapter 4), assessment often requires eliciting information from multiple sources, but in contrast to the usual outpatient situation, the adult bringing the child may not necessarily be the parent but a police officer, social service worker, or a teacher who might be involved in the crisis. A lack of relevant information and/or conflicting sources of information can complicate the task of assessment. Practically speaking, the examiner often ends up collecting information in a piecemeal fashion but with an overall understanding of the most critically important issues to address. Whoever is present becomes a legitimate source of information, that is, the child and whoever has transported them, for example, police or schoolteachers and resource officer or parents. It may be important to touch base with all concerned; in emergency situations, the clinician has considerable leeway in gathering information but parental contact is indicated as quickly as possible if parents do not come with the child. In many states, adolescents may be able to give consent when parents are not available and the clinician should be aware of applicable state laws and guidelines to mental health emergencies, consent issues, and involuntary hospitalization.

The chief complaint may vary, sometimes markedly, depending on who serves as the informant. These discrepant views (also termed informant variance) simultaneously complicate the task of the clinician but also provide helpful information about the factors that led to the emergency evaluation. They also can serve as a starting point for intervention because they reflect major areas of discrepancy between the views of the child and important adults. Other variations arise depending on the setting or context within which the child or adolescent is observed and levels of demands/expectations placed on them. The complaint, for example, that “Becky needs medication because of her behavior on the bus” suggests an important initial area of inquiry (“Only on the bus?”) that can tremendously streamline subsequent discussion! Benarous and colleagues (2019) examined data on ED use by children. Overall, there was a 3.85 times increase in the annual number of ED visits, with a sharp rise in primary complaints of anxiety or depression rising from 5% in 1981 to 34% in 2017.

A simple way to view mental health emergencies is to realize that children and adolescents can be disturbed or disturbing or both. It is the child who is disturbing or exhibiting “externalizing” problems who frequently is the focus of parental or school concern and complaint. On the other hand, the child who is disturbed (anxious, depressed, or quietly suicidal—that is, exhibiting “internalizing” problems) but does NOT exhibit high levels of behavior problems may be less likely to present for emergent evaluation. Parents may have a selective bias in their recognition of family or personal factors contributing to difficulties in the child, for example, marital conflict or violence in the home. The examiner should be alert
to the child who is vague or minimizes problems because often this results from an attempt on the child’s part to protect the parent(s) and/or to maintain some family secret within the family, for example, parental violence, illegal behavior, mental illness, substance abuse, or physical or sexual abuse. Evaluation in these cases is particularly difficult.