A new research project could be a major step toward expanding and improving care in hospital emergency departments for children and adolescents who go there for psychological emergencies including suicide attempts, delusional behavior and schizophrenia, or for treatment of physical trauma with psychological components such as child abuse, sexual assault or violent behavior.

Members of the Emergency Medical Services for Children's (EMSC) Partnership for Children initiative--a group of 14 professional organizations including APA--provided suggestions and guidance to the federal EMSC program for a large-scale study to identify gaps in service delivery and resources in the handling of child and adolescent mental health problems by hospital emergency departments.

The study will examine how psychological emergencies are handled, as well as whether children receive the follow-up mental health care they need.

"All we really have right now is anecdotal information, and it's hard to make policy without hard data," says Jean Athey, PhD, former head of the EMSC program, part of the U.S. Department of Health and Human Services, which awarded APA's Public Interest Directorate a contract in 1998 to investigate the mental health needs of children who require emergency medical care. "If we collect such data, it will help us understand deficiencies in emergency medical care and provide impetus for solving the problems."

With the Surgeon General's recent Mental Health Report and Call to Action to Prevent Suicide, now is the perfect time to move forward with a study on this topic, says Merritt Schreiber, PhD, APA's former representative to the Partnership for Children initiative.

"It is shocking that suicide is the third leading cause of death in adolescents and frequently presents in the emergency department and, often, there are no mental health services available," he says.

The new research project was discussed at the Second National Congress on Childhood Emergencies, held March 27­29 in Baltimore. The event, co-sponsored by APA, was attended by more than 1,000 people, including emergency physicians, trauma surgeons, emergency medical technicians, nurses, social workers, mental health professionals and policy-makers.

Identifying service gaps

Also spurring the work of the Partnership for Children are emergency medical service providers who frequently express concerns over the lack of appropriate mental health services for children and adolescents. They have called for increased support from mental health professionals to help them handle such emergencies--they want more places to turn to and more training on what to do.

What's more, many emergency medical service providers relate stories about children with mental disorders including schizophrenia, attention-deficit/hyperactivity disorder and major depressive disorder who were kept in the emergency room for several days without care or were placed in adult psychiatric wards.

"Emergency medical professionals feel abandoned by mental health services," says Schreiber. "They are the ones who have really pushed for more attention to this issue."

In a move to fill in such gaps, in 1998, the EMSC awarded a contract to APA to explore the mental health needs of children who receive emergency medical care. Since then, APA's EMSC proj-ect developed a bibliography of research on psychological and behavioral aspects of emergency medical care for children, along with a literature review by Schreiber and Lisa Horowitz, PhD.

In 1998, the Partnership initiative formed a subcommittee on mental health to research the extent of pediatric psychological emergencies.

"There has never been a study to see what happens with pediatric psychological emergencies in the emergency department--who saw them, how long it took, who the payer is," says Schreiber. "We suspect there is very limited specialized assessment--a shortage of people who really know how to evaluate the unique aspects of children with mental health emergencies."

For the study, the EMSC program is teaming with the Consumer Product Safety Commission (CPSC). In the commission's system of 104 hospitals, representing a stratified random sample of all hospital emergency departments in the nation, data collectors will look at:

  • The types of pediatric psychological emergencies seen in the emergency department.

  • How long children with psychological emergencies stay in the emergency department.

  • Who evaluates pediatric psychological emergencies.

  • What types of follow-up services are suggested for children who experience psychological trauma in the emergency room.

  • Whether recommended follow-up visits take place.

As a starting point, the CPSC will conduct a pilot study in six hospitals through the fall. If the pilot study goes smoothly, the large-scale study will likely move forward in 2001, and final results could be available as early as 2002, says Athey, EMSC's former head.

Challenges ahead

In the meantime, mental health professionals and emergency medical professionals are calling for more collaboration between hospital emergency departments and community mental health services.

At the Baltimore conference, physician John Santamaria, MD, encouraged emergency medical professionals to learn about mental health resources in the community and to persuade parents to follow through with referrals to mental health professionals.

"I don't expect myself to be able to do the same evaluation a psychologist or psychiatrist can do," says Santamaria, who represents the American College of Emergency Physicians to the Partnership initiative and co-chairs the subcommittee on mental health. "My role is to identify the problem and make sure the right thing gets done."

And Schreiber urged psychologists to respond to emergency departments' call for resources and information. "Psychologists need to reach out to the emergency departments in their area and to pediatric emergency specialists--to establish a dialogue about what each is seeing in terms of psychological emergencies and how to work together to improve care."

Psychologists interested in joining the effort to improve emergency medical services for children can provide feedback on the EMSC five-year plan, which is posted on the EMSC Web site at www.ems-c.org for comment. Another way to influence improvements is through outcome studies on the success of suicide intervention and treatment programs, Schreiber says. He also sees a need for an APA interdivisional task force focusing on pediatric psychological emergencies.

"This is a wake-up call for clinical child psychologists--we need to take a stronger advocacy stance."

Further Reading

Representatives from the Partnership for Children initiative will provide an overview of the EMSC/CPSC research proj-ect at APA's 2000 Annual Convention in Washington, D.C. The session "The joint APA federal Emergency Medical Services for Children project symposium" will be held Aug. 7 from 2 to 2:50 p.m.

Through its contract with EMSC, APA produced a bibliography of research on psychological and behavioral aspects of emergency medical care for children, "Psychological Factors in Emergency Medical Services for Children: Abstracts of the psychological, behavioral, and medical literature, 1991­1998," published in September 1999. Copies are available from APA's Order Department at (800) 374-2721 [in Washington D.C., call (202) 336-5510] and ask for item number 4319220; the cost is $19.95.