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Emergency departments across the United States have become the primary point of mental health crisis response for children and adolescents, a role they were not designed for and for which they are often poorly equipped. The surge in pediatric mental health emergency visits, which accelerated dramatically during the COVID-19 pandemic and has not returned to pre-pandemic levels, has created crisis conditions in many emergency departments and highlighted the inadequacy of the broader child mental health system. The data on pediatric mental health emergency department visits are striking. Emergency departments saw substantial increases in mental health-related visits by children and adolescents beginning in 2020, with particular spikes in eating disorders, suicidal ideation, and self-harm. The American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Children's Hospital Association jointly declared a national emergency in child and adolescent mental health in 2021, citing data showing these trends and the inadequacy of the existing system to respond. Several factors drive the pattern. Community mental health resources for children are severely limited, with long wait times for outpatient therapy and psychiatric evaluation and a shortage of child psychiatrists that is particularly acute in rural and underserved areas. When children are in acute crisis, families often have no option other than the emergency department. The ED becomes the default crisis response because the appropriate community resources do not exist. Emergency departments are ill-suited to address pediatric mental health crises. Most emergency physicians and nurses have limited training in pediatric mental health assessment and treatment. Emergency department environments, with bright lights, loud noise, frequent interruptions, and the presence of many other patients in crisis, are not therapeutic environments for children experiencing mental health crises. Long waits for psychiatric consultation or inpatient psychiatric placement can last hours or even days, with children placed in ED holds that are distressing for children and families and expensive for hospitals. Boarding, the practice of keeping patients who have been admitted or who need specialized care in the emergency department while awaiting placement, has become particularly acute for pediatric mental health patients. Psychiatric inpatient beds for children are scarce, and the process of arranging inpatient placement can extend waits significantly. Children who board in emergency departments have worse experiences and outcomes than those who receive appropriate care in appropriate settings. Telepsychiatry has expanded the ability of emergency departments to access psychiatric consultation without requiring a psychiatrist to be physically present. Many hospital systems have developed tele-mental health consultation programs that provide real-time video consultation for emergency providers evaluating mental health patients. These programs reduce the need for on-site psychiatric coverage while providing clinical support for emergency providers who may be uncomfortable with mental health assessment. Mobile crisis teams, which dispatch mental health professionals to respond to mental health crises in the community before they reach the emergency department, represent a strategy for diverting some crisis situations from emergency settings. Evidence on mobile crisis team effectiveness shows reductions in emergency department utilization and law enforcement involvement for populations served. Expanding mobile crisis capacity requires workforce investment and operational infrastructure that many communities lack. Crisis stabilization units, which provide short-term crisis care in settings less intensive than inpatient hospitalization and less acute than emergency departments, represent another system-level solution to the capacity problem. Evidence on crisis stabilization outcomes shows effective crisis resolution with high rates of avoiding inpatient admission. These units require community investment in facilities, staffing, and referral infrastructure. The pediatric mental health crisis in emergency departments is ultimately a symptom of the broader child mental health system's inadequacy. Addressing it requires expanding community mental health resources, building the child psychiatry workforce, developing crisis response alternatives, and investing in school-based mental health services that might intervene before crises reach emergency intensity. The emergency department is the visible point of failure, but the solutions lie upstream in the mental health system that has not been built to adequately meet children's needs.

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''Originally published August 16, 2022 on [https://docmoates.com/blog/pediatric-mental-health-crisis-the-emergency-department-as-front-line/ docmoates.com].''