The past 20 years have brought a dramatic constriction of inpatient, residential, and other acute-care services at the same time that demand for children’s mental health care, particularly for youth with severe mental illness, is steadily increasing.

Community mental health practitioners increasingly find themselves managing such high-risk, severely ill children and adolescents—including chronically suicidal, aggressive, or severely autistic youth—on an outpatient basis. Emergency department (ED) visits are also increasing for these youth, sometimes with the ED serving as the youth’s first entry into mental health treatment, and at other times with an outpatient clinician referring the child to the ED in hopes of obtaining greater services or a higher level of care. Unfortunately, ERs are poorly equipped to evaluate and safely and effectively manage youth with mental illness.

Across the country, young patients are often evaluated in medical ERs or in adult psychiatry settings, which are often neither safe nor therapeutic and lack access to specialist child and adolescent psychiatric clinicians. Less than half of youth who present to an ED in psychiatric crisis (such as after a suicide attempt) receive any type of mental health evaluation in the ED, and few are referred for outpatient treatment or follow-up.

The ED is also often frightening to children, particularly if they are housed with adult psychiatric patients or with children in acute medical crisis. Adolescents sent to the ED often feel as though they are being judged as “crazy,” and families may also experience the ED as stigmatizing, feel angry at having been pulled out of work if the child was sent from school or the clinic, and may worry about being stuck with ambulance or ED bills. If the ED evaluation does not lead to inpatient admission, many families—as well as many clinicians who referred a child to the ER—feel disappointed and upset that their time was wasted and their needs not met.

On the other side, ED clinicians (sometimes child psychiatrists, but often adult psychiatrists, pediatricians, or social workers) feel frustrated by the deluge of child psychiatric patients in the ED. ED clinicians often cannot access the collateral information (from school, outpatient providers, etc.) to assess fully the child in front of them, and insurance barriers, lack of inpatient beds, and waitlists for outpatient services mean there is little ED clinicians can offer for kids in crisis.

Given these challenges, it is helpful for community providers to work to deescalate and manage crises in the community. Take for example the case of a 15-year-old boy, Erik, who has an aggressive outburst in school in which he becomes verbally threatening and punches a wall when he cannot find his backpack. Erik could be sent to the ER, but by the time he gets there, he will likely be calm and composed, will promise not to hurt anyone, and will be sent home. An outpatient child psychiatrist or school-based clinician could look deeper, see why Erik had the outburst, and identify ways to prevent future aggression. The clinician could talk to Erik and discover the psychosocial stressors and untreated mental health needs that led to the outburst; in Erik’s case, longstanding untreated attention-deficit/hyperactivity disorder (ADHD), exposure to abuse and neglect by his biological parents, and recent placement with a new foster family where he feels looked down on by his new foster siblings. The clinician could start medication for ADHD and therapy to address his history of trauma and attachment disruption and coordinate with Erik’s school to provide greater academic and counseling support. None of these interventions is likely to happen in an ED.

When a crisis cannot be managed in the community, there is much that community providers can do to increase the likelihood that an ED referral will be productive—that it will include a full and effective risk assessment and connection to either additional outpatient services or an inpatient admission. Calling ahead to speak to the ED clinician and identify the safety concerns and need for a higher level of care, or providing after-hours contact information such that the ED clinician can call to get this information, will allow for a much more complete assessment and a better treatment plan. Explaining to children and families why they are being sent to the ED and what they should expect can reduce families’ experiences of stigmatization and frustration.

We have recently published a guidebook for community providers managing such high-risk, high-acuity cases, titled Helping Kids in Crisis: Managing Psychiatric Emergencies in Children and Adolescents. The volume includes symptom-based guidelines for managing different types of crises (for example, suicidality, aggression, odd behavior, risky sexual or runaway behavior, drug use), including guidelines for risk assessment, differential diagnosis, deescalation, and determination of when to go to the ER. It also includes tips for accessing community crisis services, school-based services, residential placements, and other important forms of treatment, and more extensive guidelines for community clinicians in working with ED providers to get the most out of a referral to the ED. Finally, for ED clinicians and hospital administrators, it provides models for higher-quality emergency services for youth in psychiatric crises.

Together, we can ensure that our youth in crisis receive the help they really need, both in the emergency of the moment and in the long term to get them back on track. ■