Emergency psychiatric care for children and adolescents: a literature review.

REVIEW ARTICLE

Emergency Psychiatric Care for Children and Adolescents A Literature Review Astrid Janssens, PhD,* Sarah Hayen, MD,* Vera Walraven, PhD,* Mark Leys, PhD,Þ and Dirk Deboutte, PhD, MD*

Objectives: Over the years, increasing numbers of children and adolescents have sought help for acute psychiatric problems. The responses to this treatment-seeking behavior are heterogeneous in different settings and nations. This review aimed to provide an answer to the questions ‘‘which care should be offered to children and adolescents presenting with a psychiatric emergency or crisis and how should it be organized.’’ Methods: We committed a literature review to find out if any recommendations can be made regarding the organization of emergency care for children and adolescents with acute mental health problems. Results: The lack of a clear definition of emergencies or urgencies hampered this review; we note the differences between adult and child or adolescent psychiatry. The theoretical models of care found in the literature are built up from several process and structural components, which we describe in greater detail. Furthermore, we review the main service delivery models that exist for children and adolescents. Conclusions: Currently, emergency psychiatric care for children and adolescents is practiced within a wide range of care models. There is no consensus on recommended care or recommended setting for this population. More research is needed to make exact recommendations on the standardization of psychiatric care for young people in emergency settings. Key Words: adolescent, psychiatry, psychiatric care, crisis intervention services, models (Pediatr Emer Care 2013;29: 1041Y1050)

O

ver the years, increasing numbers of children and adolescents have sought help for acute psychiatric problems. Newton et al1 observed a 15% increase in pediatric mental health presentations from 2002 to 2006, and a further increase is expected in the future. The responses to this treatment-seeking behavior are heterogeneous in different settings and nations. In many European countries, as well as Australia, Canada, and the United States, policy questions are being raised2 regarding the content and organization of child and adolescent psychiatric emergency care services. We undertook a review of all available literature to determine whether conclusions could be made concerning the optimal organizational structure of child and adolescent psychiatric emergency care. This review aimed to address questions of what types of care should be offered to children and adolescents who present with a psychiatric emergency or crisis and how this care should be organized. We devote a separate From the *Collaborative Antwerp Psychiatric Research Institute (CAPRI), University of Antwerp, Antwerp; and †Belgian Health Care Knowledge Centre (KCE), Brussels, Belgium. Disclosure: The authors declare no conflict of interest. Reprints: Sarah Hayen, MD, Van Schoonbekestraat 20 B8, 2018 Antwerpen, Belgium (e-mail: [email protected], [email protected]). This study was funded by the Belgian Health Care Knowledge Centre. Copyright * 2013 by Lippincott Williams & Wilkins ISSN: 0749-5161

Pediatric Emergency Care

&

Volume 29, Number 9, September 2013

section to a description of the definitions related to psychiatric care that are used in the literature.

METHODS Conceptual Approach The concept of ‘‘psychiatric emergency’’ lacks a clear definition in the literature.3Y7 The concepts of ‘‘psychiatric emergency’’ and ‘‘psychological or mental health crisis’’ are frequently confused or erroneously used interchangeably.6Y9 Because the definitions of emergency and crisis are often used interchangeably and because few authors have addressed the issue of their definition, we used both terms in this literature analysis. The terms emergency psychiatric services (EPS) and crisis intervention services (CIS) are used in this report to encompass all services dealing with psychiatric emergencies or crises. For adults, the distinction between an emergency and a crisis is important for deciding where and how the patient can best be treated. The American Psychiatric Association (APA) Task Force on EPS distinguishes between emergency services (which are able to address the full range of behavioral and psychiatric emergencies immediately, including involuntary treatment) and urgent services (which provide care in a short time frame to avoid a potential emergency).6 For children and adolescents, the distinction is less relevant. The involvement of parents or other caregivers, which is inherent to the situations of children and adolescents, means that a decision about the seriousness of the acute situation is made within the context of a young person’s environment. The impact of the situation on the child or adolescent and his/her environment is more important to the decision to seek help than are his/her symptoms in isolation. We emphasize that the behavior of minors is determined and reviewed within a specific context; therefore, the context is essential when handling emergencies involving children and adolescents. A child’s or adolescent’s behavior or thoughts are brought to psychiatric attention when an adult figure interprets them as inappropriate or unmanageable in the environmental context.10 A multitude of potential referees might consider a child’s behavior to be inappropriate and might request or initiate an emergency consult.4,10Y15

Selection Procedure We conducted a systematic literature search for reports that address the operationalization of emergency psychiatric care (EPC) for children and adolescents. We searched the journal articles that are available through electronic peerreviewed bibliographic databases, including PubMed at the National Library of Medicine, all EBM Reviews in OvidSP, Francis, PsychINFO, Ovid MEDLINE(R), CSA, EonLit, EMBASE, and CRD (http://www.york.ac.uk/inst/crd/). All databases were searched starting from 1993, which was the year that the Institute of Medicine published a report on ‘‘Emergency Medical Services for Children,’’ demonstrating the need for and www.pec-online.com

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.

1041


Janssens et al

discussing the efficacy of pediatric emergency services in the United States.16 The research question was operationalized according to a SPICE (Setting, Perspective, Intervention, Comparison, Evaluation) format to identify the appropriate keywords. The following keywords were selected: & Setting: psychiatry, child or adolescent psychiatry, psychiatric hospitals, mental health, community mental health services or centers; & Perspective: child, adolescent, youth, p(a)ediatrics; & Intervention: emergency services, crisis intervention; & Comparison: voluntary versus compulsory, adult versus pediatric, community versus hospital based; & Evaluation: organizational system, financial system, efficiency. The study selection process was initiated by running the search algorithms in all databases. The search results were downloaded in a separate Endnote file (Thomson Reuters, New York, NY) for each database. Subsequently, the search results from all databases were merged into an Endnote file, thereby automatically removing the majority of duplicate results. A first selection of studies was performed by one of the researchers based on a review of the study titles and abstracts. The selection criteria for the title and abstract evaluation were as follows: & Inclusion: emergency psychiatry (child, adolescent, pediatric psychiatry, or unspecified population) and mental health; inside or outside of a hospital setting; crisis intervention in the context of mental health problems; organizational, structural, and financial aspects of emergency psychiatry; populations using (psychiatric) emergency services; theoretical articles focusing on definitions, history of emergency psychiatry; and English, French, and Dutch languages; & Exclusion: crisis intervention in the context of disasters caused by either man or nature (eg, hurricanes, earthquakes, attacks on 9/11 in the United States, school shootings) and schoolbased crisis intervention systems; prevention (eg, projects on suicide prevention); treatment strategies for specific disorders within emergency departments (EDs); epidemiological aspects of psychiatric disorders; languages other than English, French, and Dutch. After the initial title and abstract selection, a full-text evaluation of the remaining articles was performed, during which a manual search was also conducted. Articles that the first researcher could not clearly include or exclude were reviewed by a second reviewer for selection. Some adultbased studies were included and evaluated for their potential ability to be translated to pediatrics. We identified a total of 1234 potentially relevant articles from all electronic databases, of which 284 full articles were reviewed for inclusion. After the selection process, 221 articles remained relevant and were analyzed.

RESULTS Definition of Emergency The definition of psychiatric emergency has received little attention in the literature. Although several authors express the need for a clear definition of ‘‘emergency,’’ ‘‘urgency,’’ and/or ‘‘crisis’’ in the mental health field, only a few studies on the topic of psychiatric emergencies have explicitly defined the concept of psychiatric emergency.3Y7 Psychiatric emergencies in children and adolescents differ from those of adults in several important ways. In a pediatric

1042

www.pec-online.com

&


population, psychiatric emergencies often occur in the context of a crisis, and the connection between psychiatric emergencies and crises may warrant further attention. In addition, psychiatric emergencies in children and adolescents are different from adult psychiatric emergencies because minors are embedded in the context of their families, schools, neighborhoods, and other social systems. There are additional age-related challenges given that the emergencies are most often defined by someone other than the affected child or adolescent and given that a multitude of potential referees are possible. In the majority of studies on (pediatric) psychiatric emergencies, the concepts of emergency and crisis are approached from a functional perspective: each presentation at an emergency service is initially viewed as an emergency.17 Few studies have discussed these concepts on a content level. A clear distinction of the terms emergency and crisis will benefit patients and their families by allowing more appropriate referrals and settings for intervention. Overall, authors seem to agree on 2 aspects of an emergency: (1) it involves a danger of harm to the patient or to others, as primarily determined by the patient’s context, or it involves a context in which there exists a threat to the child’s life or development and (2) immediate intervention is required. The goal of EPC is to provide immediate care and to assist in the provision of long-term care within the mental health system.18 The primary aim of EPC is to ensure a patient’s safety: immediate danger must be controlled. Furthermore, emergency psychiatric interventions aim to improve the situation and to allow the children to gain control and to maintain themselves within their appropriate context.

Classification of Findings The previous discussion illustrated that the terms emergency and crisis are used interchangeably (Fig. 1). Therefore, both terms (emergency psychiatric services [EPS] and crisis intervention services [CIS]) are used in this report to encompass all services dealing with psychiatric emergencies or crises. The organization of emergency mental health services differs between countries and regions and is very diverse. We discuss the following 2 elements regarding the organization of EPC: process and structural elements (Fig. 1, items 5 and 6), including the theoretical models and service delivery models that are found in the literature.

Process Components First, we discuss the process components that are found in the literature on EPS/CIS, followed by an overview of the associated theoretical models (containing some or all of the process components) (Fig. 1, item 5). The process flow and components refer to the core functions involved in psychiatric emergency and crisis response care: ‘‘the set of activities that go on within and between practitioners and patients,’’ response times and duration of service use. These process components form the building blocks of different theoretical models. The process components (Fig. 1, item 5) are not included by all authors in their descriptions, but the following components were found in the literature: registration, stabilization, evaluation and assessment, disposition, treatment, referral, and follow-up. When a patient enters an emergency setting, he/she is first registered. Registration can be limited to the personal information that is needed for enrollment, or it can be used to log additional data.11,19 * 2013 Lippincott Williams & Wilkins



&


Emergency Psychiatric Care

FIGURE 1. Schematic overview of the classification of literature findings.

After registration, medical stabilization is often a priority for children and adolescents who report to the ED with mental health emergencies, particularly for patients who have attempted suicide.18,20Y23 After treating any acute medical needs, the process focuses on ensuring the child’s safety and wellbeing.21 Crisis stabilization services are initiated upon admission or presentation and typically span the first 24 to 72 hours.24,25 An evaluation process is next.12,13,18Y20,22,26Y30 The first stage, triage, consists of an assessment of the degree of risk through direct, empathic questioning of the child regarding the actual or potential threat of harm to the child or others.19,20,22,26,27,31Y33 Triage involves making a crucial determination, within several minutes, about an individual’s course of treatment, and it determines the initial level of treatment needed to ensure safety.20,34Y37 Triage can be performed with specific screening tools, and it requires specific staff skills. A somatic and psychiatric assessment is focused on risk. A physical examination is required to exclude a medical cause (‘‘organic disease’’) for the patient’s psychobehavioral symptoms or to stabilize the patient.20,21,38 The cornerstone of medical clearance is a thorough history and physical examination, but assessment and evaluation may also include a mental status examination, laboratory evaluation (toxicology screen), or other assessments depending on the clinical scenario.21 The psychiatric assessment consists of a review of psychiatric symptoms, an assessment of risk factors for suicide and/or violence toward others, and social factors that influence functioning.28 In most reports, the authors conclude that the focus needs to lie on the assessment of risk rather than on the diagnosis. Goldstein and Findling19,20,23,28,39,40 describe the disposition as the most difficult aspect of the evaluation process. The decision is made via 2 primary questions: whether the patient is a clear danger to himself or others and what is the most appropriate level of care for the patient. Although the emphasis in the clinical literature is on treating young people in the least restrictive and most clinically appropriate setting, the * 2013 Lippincott Williams & Wilkins

constraints of the mental health service delivery system need to be considered. Despite the need, there may not be sufficient numbers of community-based mental health programs available. The pediatric EPS/CIS can make dispositions for discharge, admission to an inpatient psychiatric facility, extended observation units, hospitalization, detoxification programs, partial hospital programs, and outpatient services.12,18,19,23,40,41 The treatment process follows.12,18,22,26Y28 Crisis intervention is expected to provide active treatment intervention rather than serving as a holding station on the way to beginning ‘‘real’’ treatment in some other venue.42Y44 After a period of crisis stabilization and/or assessment, transitional care services may be provided that are linked to explicitly identified treatment goals. These services are generally delivered within a 2- to 6-week period.24,44 Referral and follow-up end the process. This stage varies greatly, and the decision for referral or follow-up may be based on the availability of the resources to which the patient is referred.12,18,22,26,35,39 Within the process flow (Fig. 1, item 4), we include the response time, which refers to the speed at which services are delivered once requested.45 We note a difference between an emergency, which requires an immediate response, and a crisis, which needs to be addressed when all participants in the crisis and personal supports can be included.9 Generally, emergency services respond within 24 hours of receiving a request.46 Few authors discuss the theoretical basis underlying the delivery models of psychiatric emergency care and crisis intervention. The process elements and practices used by individual programs differ greatly depending on community needs and underlying treatment philosophies.47 The number of process components that are involved in a program determines the organizational complexity of EPS/CIS.48 There were no theoretical models of emergency psychiatric service delivery (Fig. 1, item 8) found in the literature that address a pediatric population. Overall, 5 models were described for the delivery www.pec-online.com


1043


Janssens et al

of emergency mental health services in general,15,18,49Y51 and Table 1 gives an overview.

Structural Components In this section, we describe the organizational configuration (Fig. 1, item 3), which refers to the structure and principles involved in delivering EPS/CIS (Fig. 1, item 6). Structure relates to where, for whom, and by whom by these services are delivered, and it covers, among other aspects, the location, facilities, staff, accessibility and flexibility, as well as service costs. We will discuss the different structural components that are found, although not all researchers address all of the aspects (Fig. 1, item 6). Some emergency services focus exclusively on children and adolescents.54 Some are specifically developed to treat adolescents,27,55 others target an adult population but also include 16- to 18-year-olds,56,57 and still, others serve both pediatric and adult populations.8,39,54,58Y60 In addition, a distinction can be made between services that target life-threatening crisis situations/emergencies and those that target urgent but not lifethreatening situations. The main characteristics of the majority

&


of minors presenting with acute psychiatric problems are the following: female sex (although data on sex distribution are inconsistent), older age (adolescents more frequently than children), family referral, family psychiatric history, diagnosis of attention deficit/hyperactivity disorder, disruptive behavior disorder or adjustment disorder, school day presentation, arrival time between the hours of 4:00 P.M. and 11:00 P.M. and presenting complaint of suicidal ideation/attempt.3,19,61Y64 Little attention is given in the literature to the importance of sex and culture. Pumariega and Rothe53 noted that there are many cultural influences on health beliefs and practices. The determination of behavioral and emotional normality is largely determined by culture. An important topic is the staffing and competencies of the care providers. Professionals who are in positions to effect crisis intervention require higher levels of awareness and training with support from specialty services.9 Parker et al5 note that an experienced child psychiatrist is required, preferably one who is trained and interested in emergency psychiatry, and care requires a cohesive team with manager support. Hospital emergency staff is rarely trained to recognize mental health issues, especially as they present in children, and

TABLE 1. Emergency Psychiatric Care and CIS: Theoretical Models Triage Model Fortress Model

Gatekeeper Model Case Formulation Model

Crisis Intervention Model

System of Care Model

Treatment Model

Goals

Efficient care: rapid Quality care is linked to evaluation, containment efficient care: more and referral. Limited attention is given to resources; focus on diagnostics and determination of evaluation. priority for treatment by identifying those at risk for (self ) harm. Minimizing subtle diagnostic evaluations.

Location

Hospital based/ED

Triage/ stabilization Assessment: medical clearance Assessment: psychiatric evaluation Treatment Disposition

Yes

Crisis is seen as Services are to be Comprehensive a turning point; provided in the services that less emphasis least restrictive still serve a on long-term setting appropriate triage function hospitalization, to the needs of but are capable more attention the child and of providing on treatment family. Crisis comprehensive outside hospital and emergency assessment and and briefer services represent broader range psychotherapies. only one in a of services. continuum of both residential and nonresidential services, aimed at preventing hospitalization. Hospital based/additional Community based Community based Hospital based/ provisions required to additional ED provisions required to ED Yes Yes Yes Yes

Yes

Yes

Yes

Yes

(Risk of inadequate assessment)

Comprehensive

Comprehensive

Comprehensive

No Admission or discharge

No Admission, referral or discharge

Brief Admission, referral or discharge

Referral/followup

Limited

Brief Admission, referral or discharge Yes

References

1044

Yes

Yes, including guidance Yes toward ambulant services De Fruyt,17 2003; Chan and Noone,51 Kutash,29 1995; Chan and Noone,51 2000; Allen et al,52 2000 Londino et al,17 200340 Pumariega and 2002; De Fruyt,17 2003 Rothe,53 2003

www.pec-online.com

Comprehensive Brief Admission, referral or discharge Yes, including guidance toward ambulant services Allen et al,52 2002; De Fruyt,17 2003

* 2013 Lippincott Williams & Wilkins



&


they have no systematic way to identify or refer children to the appropriate services.65 In a policy statement, Dolan and Mace22 indicate that pediatric mental health emergencies are best managed by a skilled multidisciplinary team approach. Staffing varies with the nature of the service, but it generally requires a child psychiatrist, child psychiatric nurse, psychiatric social worker, mental health workers, and a utilization reviewer for insurance communication.42 The most challenging aspect of staffing occurs when the volume is too low to justify a dedicated staff and too high to be managed by the ad hoc deployment of staffing from other services.42 The competencies for the professionals relate to making an assessment, intervening therapeutically if possible, and making a useful and effective referral.37 The ED staff should be educated regarding the provision of effective mental health care. For example, a crisis assessment requires a thorough interview and is time consuming compared with other types of pediatric ED presentations. Dion et al66 suggest that the general ED staff is interested in training, particularly those who have the most experience and spend the most time in the ED. Several studies have shown that collaboration between agencies in response to psychiatric emergencies in children is a worthwhile strategy.9,27,37,67,68 Crisis intervention should be closely linked with a true continuum of services so that the initial interventions are continued uninterrupted in the next clinical setting.42 Based on a national consensus conference in the United States, Hoyle and White69 propose an integrated system for mental health emergencies. In their proposal, they stress that integrated systems for identifying and treating pediatric mental health emergencies would require the active participation and cooperation of numerous organizations. Many authors note that contextual factors are particularly relevant to child and adolescent psychiatric emergencies.15,37 There is a focus on strength-based approaches, in which natural supports are mobilized and enhanced and the services are delivered in the least restrictive environment and in the child’s community.56 Accessibility is a priority, and a comprehensive EPS or CIS is open 24 hours a day, 7 days a week, 365 days a year.29,60 Location and infrastructure are important structural factors. Dealing with psychiatric emergencies requires a safe environment for patients and staff and a physical space designed to minimize overstimulation and prevent access to potential weapons. The APA’s Task Force on psychiatric emergency services distinguishes 2 broad categories of services, hospitalbased and community-based services, and 2 approaches to providing the service, residential and ambulatory or mobile.52

Service Delivery Models The organizational configuration (Fig. 1, item 3) shows that crisis and emergency services for children and adolescents may range from nonresidential to residential and may involve various agencies, services, and personnel (Fig. 1, item 7).29,70Y73 Table 2 shows a summary of the organizational configuration options. The Mental Health of Children and Young People states that children and young people with severe mental health difficulties should be managed in the community wherever possible.80 One classification of service delivery models (Fig. 1, item 7) was proposed by the APA Task Force on EPS.52 In addition to the service models described by the APA, we describe several other services that were found in the literature. We summarize the different models with examples of some services that were created (Table 2). * 2013 Lippincott Williams & Wilkins


1. First, we describe services in medical emergency settings. The model of the psychiatric consultant to the ED (ie, the consultation/consultant model) has long been the mainstay for treating behavioral emergencies.31,41,52,81Y83 Many different procedural models or programs have been developed to guide the emergency care process. For example, Mahajan et al74 describe a child guidance model that is used to speed up the process from physical evaluation by the ED physician to final disposition, decreasing ED costs and burdens. In Canada, the rapid response model uses a similar approach; it was developed to meet the emergency needs of children and adolescents referred from the community.5 The model falls within the official American Academy of Child and Adolescent Psychiatry practice parameters highlighted for the management of children and adolescents with suicidal behavior. The rapid response model has 3 components: (1) emergency consultation; (2) urgent consultation; and (3) education of those who might use the service. 2. The psychiatric emergency service facility comprises many different models. By law, comprehensive psychiatric emergency programs (CPEP) in the United States implement the treatment model and need to provide emergency psychiatric evaluation, treatment and disposition, extended observation beds up to 72 hours, mobile crisis outreach services, and crisis residential beds.39 It is designed to rapidly assess and refer. The psychiatric emergency service (PES) model is founded on the CPEP model, as it prescribes immediate psychiatric assessment and provides a therapeutic environment where patients in psychiatric crises may receive proper psychiatric, medical, and social support.31,52,75 Feiguine et al76 describe a PES modelbased crisis service within a children’s hospital in Manhattan, providing both emergency assessment and short-term treatment services for children, adolescents, and their families. The service is also available for emergency consultations and evaluations to the pediatric ED. Currier and Allen75 report that 77% of the PES facilities are located within general hospitals. The integrated psychiatric emergency service model was presented by Kates et al77 in Canada; it has 5 separate hospitalrun EPS integrated into a single service. They offer comprehensive services by a multidisciplinary team that is familiar with community resources, and they have interview rooms located within the ED. The dedicated bed and scattered bed model was described in a trial by Cotgrove78 of an emergency admission service in a regional adolescent psychiatric unit in the United Kingdom in which beds were kept empty for admissions on short notice. The service is available 24/7. Although this organization is not always cost-effective and may be disruptive to the staff, the study also demonstrated a beneficial effect of the easy availability of an assessment and second opinion.78 Several more authors describe inpatient psychiatric units that offer crisis beds for children and adolescents, often within crisis stabilization services.24,84 Schweitzer and Dubey84 describe the rationale, development, and implementation of a countywide scatteredsite crisis bed program for seriously disturbed minors. The program was developed by an interagency coalition consisting of representatives of the mental health, social service, and juvenile justice systems in New York county and was implemented with no new funding, using available beds in facilities that were administered by the participating agencies. These beds are not dedicated to crisis care but represent the pool of available beds on a given day. The semi-institutional service model consists of day and partial hospitals that provide intensive treatment during the day; www.pec-online.com


1045


Janssens et al

&


TABLE 2. Summary Table EPS/CIS Organizational Configuration and Models Classification (Descriptive) Services in medical emergency settings

Psychiatric emergency facility

Organizational Model 31 52

Consultant model , Procedural models Child guidance model74 ED physician rapid response model5 Crisis intervention program20,30 CPEP39 PES model31,52,75,76 Integrated PES model77 Dedicated bed and scatter bed model

Semi-institutional service model79

Psychiatric urgent care facility

Mobile EPS Community-based services

Institutional service model

Semi-institutional service model Youth emergency services68 APA guidelines52 Out-of-hospital approaches Multisystemic therapy Intensive case management Assertive outreach Crisis stabilization program Home-based treatment Special service program

the patients return to their homes at night.79 They can include additional services such as emergency crisis beds or an on-call 24-hour response service.85 3. Psychiatric urgent care facilities provide ready access to psychiatric assessment and treatment for patients with urgent needs.52 Several authors describe an institutional service model11,54 where urgent consultations and taxation can take place and, if indicated, an admission to a crisis unit can follow. At a crisis unit admission, the duration is often limited to 14 days, and the treatment involves child psychiatric diagnostics, limited psychological test research, conversations with the family, a therapeutic package including psychodynamic group therapy and sociotherapy. Follow-up care needs to be provided by other services. Different systems are installed to provide 24/7 coverage for dealing with potential crises, such as a telephone advice service or a collaboration with adult psychiatry. A semiinstitutional service model is described by O’Hagan.79 4. Mobile psychiatric emergency services are very common in many US states, and they are intended to provide face-

1046

www.pec-online.com

Organizational Configuration Psychiatric consult to the ED on demand No specific structures required

Based on treatment model, providing triage, emergency psychiatric evaluations, treatment, and disposition Similar to CPEP, providing immediate psychiatric assessment, 24-h stabilization, 72-h extensive observation beds (EOB), and therapeutic environment. Integration of 5 hospital-run emergency services into a single emergency service 2 of 10 unit beds dedicated for emergency purposesVUnited Kingdom55,78 Inpatient unit in tertiary care pediatric teaching hospitalVCanada24 Partial hospitals and crisis respite, 24-h response service, crisis beds Small residential services outside hospitals, attached to community mental health centers Crisis intervention unit in child psychiatric hospital with outpatient services11 Collaboration of rural community clinics with emergency hotlineVUnited States54 Day and partial hospitals79 Interrelated programs and services, outreach Training, staffing, and community linkages Community-based crisis servicesVUnited Kingdom Crisis services 24/7 Prevention of hospitalization and stabilization of crisis situation. Evaluation, assessment, crisis intervention, stabilization and follow-up, and involving family Community-based acute servicesVNew Zealand Small home-like environments (mostly less severe crises)

to-face crisis assessment, intervention, and stabilization in the community. Most programs have a primary purpose of diverting youth from ED admissions and residential placements.52,68,86 Many provide a linkage function whereby they ensure that youth in crisis are referred to appropriate longer-term treatment options in the community. Staff members in these programs are highly trained mental health professionals. Youth emergency services is an experimental program that was developed through collaboration of 6 New York agencies to respond to psychiatric emergencies in children and adolescents.68 Independent of location, the clinicians see the child, stabilize the crisis, and perform an on-site assessment that is sufficient to ensure the child’s physical and emotional safety. They also stay with the family until the child enters the treatment process. Usually, this occurs in less than 24 hours. In 2002, the APA published guidelines for mobile psychiatric interventions. Organizational model considerations for mobile psychiatric emergency services focus on the structuring of these services, including training, staffing, and community linkages.52 * 2013 Lippincott Williams & Wilkins



&


5. Most community-based crisis services29,87 have the following characteristics: 24/7 availability; sharing of the common purpose of prevention of hospitalization and stabilization of the crisis situation in the most normalized setting available; offering on a short-term basis; having a limited capacity; typically including evaluation, assessment, crisis intervention, stabilization, and follow-up planning; involving families in all phases of crisis treatment; having a staff who tend to share similar characteristics; and being generally part of a larger agency that offers other services, such as inpatient day treatment and outpatient services. The original multisystemic therapy program was developed as an intensive, family-based approach for minors with serious antisocial behaviors and was adapted to psychiatric emergency situations by the integration of additional clinical staff, the integration of evidence-based pharmacological interventions, and by the planned and judicious use of out-of-home placements.88Y90 Intensive case management encompasses a number of approaches, including assertive outreach as well as wraparound and assertive/intensive community treatment.49,54,90,91 It is offered within the community and is a common strategy for increasing access to and coordinating services within the care system. It does not have time limitations. The crisis stabilization programs aim to reduce the number of hospitalizations and to provide multidisciplinary teams to perform interventions and follow-up evaluations.45,49 Home-based treatment is an intensive, rapid response acute service that is provided in the patient’s own home at any time. Members of a multidisciplinary team make up to several visits a day and provide medication, brief counseling, practical assistance, information and support.44,52,79,85,90,92,93 The primary goal is to defuse the presenting crisis so that the child can remain at home. The special service program provides 2 basic types of services: outreach services and short-term (G90 days) crisis placement services in a specialized unit.43 Finally, crisis and suicide hotlines (telephone crisis services) have the unique ability to offer some level of service at times when other services are unavailable. They offer confidentiality and anonymity to clients, provide information about other treatment sources, and provide a safe and nonjudgmental environment, enabling clients to articulate complex feelings.94

DISCUSSION This report presents an overview of the literature on the organization of psychiatric emergency care for children and adolescents. The literature review was hampered by the lack of a clear definition of ‘‘psychiatric emergency’’ (especially in a pediatric population). This topic has received little attention in the past. Although several authors express the need for clear definitions of emergency, urgency, and/or crisis in the mental health field, few studies explicitly define the concept of psychiatric emergency. An emergency is life threatening, requiring an immediate, life-preserving response. A crisis is not life threatening, but it requires an urgent response to prevent deterioration. To ensure all literature concerning the topic was included, we reviewed reports addressing the concepts of emergency and crisis. Few reports discuss these concepts on a content level. On a content level, the following 2 aspects of an emergency seem to be pervasive: (1) a high risk of harm to the patient or to others and (2) a need for immediate intervention. The specific characteristics of the child and adolescent population require EPCs to take into consideration parental legal responsibility and * 2013 Lippincott Williams & Wilkins


the child’s legal rights. In addition, EPC should be directed toward reactivating the child’s development and often may be considered the first opportunity for offering help within a child/ family/context. Overall, it can be concluded that a ‘‘psychiatric emergency’’ and ‘‘crisis’’ need to be distinguished and that the terms can be conceptualized using key dimensions such as time, the level of danger involved, diagnosis, and context. The general observation holds that little evidence is available about the organization of child and adolescent emergency services. Very few effectiveness studies are available. Effectiveness studies for inpatient treatment have been limited by poor methodology and difficulties in generating appropriate treatment controls for experimental studies. In addition, they are examples of complex interventions wherein the active agent of change may not be simple and systematic.95 No randomized evidence has been identified comparing intensive day treatment for young people in crisis with inpatient care or an alternative mode of care.85,96 It is often held that admission can offer containment and can rapidly reduce risk in acute crises. However, there is uncertainty as to the effective components of the intervention, the optimal length of admission, its suitability for prepubescent children, and whether any positive effects gained are maintained after discharge.95 The evidence suggests a need for a combination of complementary models of intensive mental health care provision, including intensive outreach services, crisis intervention teams, and age-appropriate day patient and inpatient provisions. It seems that crisis programs can serve as an effective means of reducing hospitalizations and other out-of-home placements for many children.57,91,93,97 There is insufficient evidence upon which we can decide what model is best for each group of young people, and further health service evaluation research is needed. This review shows that there are many topics that remain unstudied; therefore, many questions remain unanswered. Specifically for children and adolescents, the literature concerning registration systems, follow-up evaluations, and effectiveness is lacking. Little is known about the characteristics of children presenting for psychiatric emergency services, and virtually nothing is known about the outcomes that they experience across a range of referral options. Finally, evidence of the effectiveness of the different organizational structures and models is missing. Investigating an explanation as to why such research is so limited is not fruitful at this time. Child and adolescent psychiatry as a separate specialty is young and still expanding because of increasing needs. We notice that various specific services for child and adolescent EPC are still being described; however, they are often based on limited data. Many services are based on models of care from adult psychiatry, and they are often copied verbatim for child and adolescent populations. There are, however, some clear differences contraindicating this transfer. Minors are embedded in an ecological context (eg, parents or school), and this environment determines the level of emergency. Parents or guardians almost always maintain the responsibility of care for their child/minor. The goals of emergency care for children and adolescents include more than handling the acute crisis; the goals are also to make further development possible and facilitate adequate care. It should also be noted that emergency care for children and adolescents is provided by very different organizational structures (ie, welfare, health, and justice systems). This heterogeneity makes data, even if they are available, not easily accessible.

CONCLUSIONS Currently, EPC for children and adolescents is practiced within a wide range of care models. There is no consensus www.pec-online.com


1047


Janssens et al

on recommended care or recommended setting for this population. Worldwide, there is a tendency to provide care to a pediatric population in the least restrictive environment within the child’s community. The level of danger involved will determine whether the emergency care or crisis intervention needs to occur in a residential or nonresidential setting. More research is needed to make exact recommendations on the standardization of psychiatric care for young people in emergency settings. REFERENCES 1. Newton AS, Ali S, Johnson DW, et al. A 4-year review of pediatric mental health emergencies in Alberta. CJEM. 2009;11:447Y454. 2. Deboutte D, Smet M, Walraven V, et al. Spoedeisende psychiatrische hulp voor kinderen en adolescenten. Health Services Research (HSR). Brussel: Federaal Kenniscentrum voor de Gezondheidszorg (KCE). 2010.KCE Reports 135A. D/2010/10.273/49; 2010. 3. Goldstein AB, Horwitz SM. Child and adolescent psychiatric emergencies in nonsuicide-specific samples: the state of the research literature. Pediatr Emerg Care. 2006;22:379Y384. 4. Speranza M, Laudrin S, Guillemet I, et al. Emergency and crisis intervention in child and adolescent psychiatry. Neuropsychiatrie de l’Enfance et de l’Adolescence. 2002;50:562Y567.

&


20. Ayliffe L, Lagace C, Muldoon P. The use of a mental health triage assessment tool in a busy Canadian tertiary care children’s hospital. J Emerg Nurs. 2005;31:161Y165. 21. Baren JM, Mace SE, Hendry PL, et al. Children’s mental health emergenciesVpart 2: emergency department evaluation and treatment of children with mental health disorders. Pediatr Emerg Care. 2008;24: 485Y498. 22. Dolan MA, Mace SE. Pediatric mental health emergencies in the emergency medical services system. Pediatrics. 2006;118:1764Y1767. 23. Edelsohn GA, Gomez JP. Psychiatric emergencies in adolescents. Adolesc Med Clin. 2006;17:183Y204. 24. Greenham SL, Bisnaire L. An outcome evaluation of an inpatient crisis stabilization and assessment program for youth. Resid Treat Child Youth. 2008;25:123Y143. 25. Henggeler SW, Rowland MD, Halliday-Boykins C, et al. One-year follow-up of multisystemic therapy as an alternative to the hospitalization of youths in psychiatric crisis. J Am Acad Child Adolesc Psychiatry. 2003;42:543Y551. 26. Muroff J, Edelsohn GA, Joe S, et al. The role of race in diagnostic and disposition decision making in a pediatric psychiatric emergency service. Gen Hosp Psychiatry. 2008;30:269Y276. 27. Atlas JA. Crisis and acute brief therapy with adolescents. Psychiatr Q. 1994;65:79Y87.

5. Parker KC, Roberts N, Williams C, et al. Urgent adolescent psychiatric consultation: from the accident and emergency department to inpatient adolescent psychiatry. J Adolesc. 2003;26:283Y293.

28. Goldstein AB, Findling RL. Assessment and evaluation of child and adolescent psychiatric emergencies. Psychiatr Times. 2006;23:9.

6. Callahan J. Defining crisis and emergency. Crisis. 1994;15:164Y171.

29. Kutash KV. Effectiveness of children’s mental health services: a review of the literature. Educ Treat Child. 1995;18:443Y477.

7. Bruffaerts R, Demyttenaere K. Psychiatric emergency services in Belgium. Emerg Psychiatry. 2005;2005:16Y19. 8. Bonynge ER, Lee RG, Thurber S. A profile of mental health crisis response in a rural setting. Community Ment Health J. 2005;41: 675Y685. 9. Rosen A. Crisis management in the community. Med J Australia. 1998;167:633Y638. 10. Halamandaris PV, Anderson TR. Children and adolescents in the psychiatric emergency setting. Psychiatr Clin North Am. 1999;22: 865Y874. 11. Emmery P, De Corte J. Crisisopname in de jeugdpsychiatrie: evaluatie van een project. TOKK. 2003;28:154Y164. 12. Edelsohn GA, Braitman LE, Rabinovich H, et al. Predictors of urgency in a pediatric psychiatric emergency service. J Am Acad Child Adolesc Psychiatry. 2003;42:1197Y1202.

30. Kennedy A, Cloutier P, Glennie JE, et al. Establishing best practice in pediatric emergency mental health: a prospective study examining clinical characteristics. Pediatr Emerg Care. 2009;25:380Y386. 31. Woo BK, Chan VT, Ghobrial N, et al. Comparison of two models for delivery of services in psychiatric emergencies. Gen Hosp Psychiatry. 2007;29:489Y491. 32. Alvin P, Gasquet I, de Tournemire R, et al. Adolescents and emergency care. A survey conducted at the Assistance Publique-Hopitaux de Paris. Neuropsychiatrie de l’Enfance et de l’Adolescence. 2002;50:571Y576. 33. Goldstein AB, Horwitz SM. Child and adolescent psychiatric emergencies: the need for a clear research agenda. Pediatr Emerg Care. 2006;22:282. 34. Stapczynski JS. Children with mental health issues in the emergency department. ED Legal Lett. 2009;8.

13. Sadka S. Psychiatric emergencies in children and adolescents. New Dir Ment Health Serv. 1995;1995:65Y74.

35. Brooker C, Ricketts T, Bennett S, et al. Admission decisions following contact with an emergency mental health assessment and intervention service. J Clin Nurs. 2007;16:1313Y1322.

14. Baker AJ, Piotrkowski CS, Mincer C. Behavioral predictors of psychiatric emergency in a child welfare residential treatment center. Resid Treat Child Youth. 2003;21:51Y70.

36. Meunier-Sham J. Increased volume/length of stay for pediatric mental health patients: one ED’s response. J Emerg Nurs. 2003;29:229Y239.

15. Pumariega AJ, Winters NC. Trends and shifting ecologies: part II. Child Adolesc Psychiatr Clin N Am. 2003;12:779Y793.

37. Kaplan T. Emergency Department Handbook: Children and Adolescents With Mental Health Problems. UK: RCPsych Publications, The Royal College of Psychiatrists; 2009.

16. Horowitz L, Kassam-Adams N, Bergstein J. Mental health aspects of emergency medical services for children: summary of a consensus conference. J Pediatric Psychol. 2001;26:491Y502.

38. Olshaker JS, Browne B, Jerrard DA, et al. Medical clearance and screening of psychiatric patients in the emergency department. Acad Emerg Med. 1997;4:124Y128.

17. De Fruyt J. Urgentiepsychiatrie: zoekend naar een eigen plaats, woordenschat en middelen. De agenda Psychiatrie. 2003;27.

39. Sullivan AM, Rivera J. Profile of a comprehensive psychiatric emergency program in a New York City municipal hospital. Psychiatr Q. 2000;71:123Y138.

18. Christy A, Kutash K, Stiles P. Short term involuntary psychiatric examination of children in Florida. Adm Policy Ment Health. 2006;33: 578Y584. 19. Goldstein AB, Silverman MA, Phillips S, et al. Mental health visits in a pediatric emergency department and their relationship to the school calendar. Pediatr Emerg Care. 2005;21:653Y657.

1048

www.pec-online.com

40. Londino DL, Mabe PA, Josephson AM. Child and adolescent psychiatric emergencies: family psychodynamic issues. Child Adolesc Psychiatr Clin N Am. 2003;12:629Y647, vi. 41. Falsafi N. Pediatric psychiatric emergencies. J Child Adolesc Psychiatr Nurs. 2001;14:81Y88.




&


42. Woolston JL. The administration of hospital-based services. Child Adolesc Psychiatr Clin N Am. 2002;11:43Y65, vi. 43. Rudolph C, Lakin KC, Oslund JM, et al. Evaluation of outcomes and cost-effectiveness of a community behavioral support and crisis response demonstration project. Ment Retard. 1998;36:187Y197.


60. Edelsohn GA, Rabinovich H, Portnoy R. Hallucinations in nonpsychotic children: findings from a psychiatric emergency service. Ann N Y Acad Sci. 2003;1008:261Y264. 61. Christodulu KV, Lichenstein R, Weist MD, et al. Psychiatric emergencies in children. Pediatr Emerg Care. 2002;18:268Y270.

44. Evans ME, Boothroyd RA, Armstrong MI. Development and implementation of an experimental study of the effectiveness of intensive in-home crisis services for children and their families. J Emotional Behav Dis. 1997;5:93Y105.

62. Behar LJ, Shrier DK. Child and adolescent psychiatric emergencies: referral and discharge patterns. N J Med. 1995;92:236Y239.

45. Ruffin JE, Spencer HR, Abel A, et al. Crisis stabilization services for children and adolescents: a brokerage model to reduce admissions to state psychiatric facilities. Community Ment Health J. 1993;29: 433Y440.

64. Soto EC, Frederickson AM, Trivedi H, et al. Frequency and correlates of inappropriate pediatric psychiatric emergency room visits. J Clin Psychiatry. 2009;70:1164Y1177.

46. Baker AJ, Archer M, Melnick D. An alternative to hospitalizing youth in psychiatric crises: the children’s village crisis residence model. Resid Treat Child Youth. 2004;22:55Y74. 47. Vanderploeg J, Schroeder J, Franks R. Emergency mobile psychiatric services: Recommendations for model enhancement. 2008. Available at: http://www.ct.gov/dcf/lib/dcf/behavioral_health/pdf/emps_ccep.pdf. Accessed November 2012. 48. Arfken CL, Zeman LL, Koch A. Perceived impact by administrators of psychiatric emergency services after changes in a state’s mental health system. Community Ment Health J. 2006;42:281Y290.

63. Healy E, Saha S, Subotsky F, et al. Emergency presentations to an inner-city adolescent psychiatric service. J Adolesc. 2002;25:397Y404.

65. Geller J, Biebel K. The premature demise of public child and adolescent inpatient psychiatric beds. Psychiatr Q. 2006;77:251Y271. 66. Dion J, Kennedy A, Cloutier P, et al. Evaluating crisis intervention services for youth within an emergency department: a view from within. Child Care Pract. 2010;16:241Y256. 67. Zonana HV. Legal considerations in the child psychiatric emergency department. Child Adolesc Psychiatr Clin N Am. 2003;12:745Y761. 68. Shulman DA, Athey M. Youth emergency services: total community effort, a multisystem approach. Child Welfare J. 1993;72:171Y179. 69. Hoyle J, White L. Pediatric mental health emergencies: summary of a consensus panel. Prehosp Emerg Care. 2003;7:60Y65.

49. Blumberg SH. Crisis intervention program: an alternative to inpatient psychiatric treatment for children. Ment Health Serv Res. 2002;4:1Y6.

70. Brown JF. Psychiatric emergency services: a review of the literature and a proposed research agenda. Psychiatr Q. 2005;76:139Y165.

50. Stewart C, Spicer M, Babl FE. Caring for adolescents with mental health problems: challenges in the emergency department. J Paediatr Child Health. 2006;42:726Y730.

71. Baren JM, Mace SE, Hendry PL, et al. Children’s mental health emergenciesVpart 1: challenges in care: definition of the problem, barriers to care, screening, advocacy, and resources. Pediatr Emerg Care. 2008;24:399Y408.

51. Chan A, Noone J. Emergency Mental Health. Educational Manual. Mheccu. University of British Columbia.Vancouver. Available at: http://www.carmha.ca/publications/resources/pub_emhem/ EmergencyMentalHealthEducationalManual5B5D.pdf. 2000. Accessed November 2012. 52. Allen MH, Forster P, Zealberg J, et al Report and recommendations regarding psychiatric emergency and crisis services. A review and model program descriptions. APA Task Force on Psychiatric Emergency Services. APA 2002. Available at: http://archive.psych.org/ edu/other_res/lib_archives/archives/tfr/tfr200201.pdf. 2002. Accessed November 2012. 53. Pumariega AJ, Rothe E. Cultural considerations in child and adolescent psychiatric emergencies and crises. Child Adolesc Psychiatr Clin N Am. 2003;12:723Y744, vii. 54. Gillig PM. Child & adolescent psychiatry: an adolescent crisis service in a rural area. Psychiatr Serv. 2004;55:1363Y1365. 55. Corrigall R, Mitchell B. Service innovations: rethinking in-patient provision for adolescents. A report from a new service. Psychiatric Bull. 2002;26:388Y392. 56. Holdsworth N, Guy W. Problems of service assessment ab intra: research and evaluation relating to a new early intervention community psychiatric nursing service. J Adv Nurs. 1994;19:290Y298. 57. Brimblecombe N, O’Sullivan G, Parkinson B. Home treatment as an alternative to inpatient admission: characteristics of those treated and factors predicting hospitalization. J Psychiatr Ment Health Nurs. 2003;10:683Y687. 58. Pigott HE, Trott L. Translating research into practice: the implementation of an in-hone crisis intervention triage and treatment service in the private sector. Am J Med Qual. 1993;8:138Y144. 59. Nordentoft M, Bjarking L, Hemmingsen R. Psychiatric emergency outreach: a report on the first 2 years of functioning in Copenhagen. Nord J Psychiatry. 2002;56:399Y405.


72. Goeminne M, Leroi C, Schoenaers M. Crisiswerking in de jeugdpsychiatrie: evenwichten zoeken en valkuilen vermijden. Tijdschrift Klinische Psychologie. 2007;39:61Y67. 73. Snowden LR, Masland MC, Libby AM, et al. Racial/ethnic minority children’s use of psychiatric emergency care in California’s Public Mental Health System. Am J Public Health. 2008;98:118Y124. 74. Mahajan P, Thomas R, Rosenberg DR, et al. Evaluation of a child guidance model for visits for mental disorders to an inner-city pediatric emergency department. Pediatr Emerg Care. 2007;23: 212Y217. 75. Currier GW, Allen M. Organization and function of academic psychiatric emergency services. Gen Hosp Psychiatry. 2003;25: 124Y129. 76. Feiguine RJ, Ross-Dolen MM, Havens J. The New York Presbyterian Pediatric Crisis Service. Psychiatr Q. 2000;71:139Y152. 77. Kates N, Eaman S, Santone J, et al. An integrated regional emergency psychiatry service. Gen Hosp Psychiatry. 1996;18:251Y256. 78. Cotgrove A. Emergency admissions to a regional adolescent unit: piloting a new service. Psychiatric Bull. 1997;21:604Y608. 79. O’Hagan M. The acute crisis: towards a recovery plan for acute mental health services in New Zealand. Mental Health Commission. 2006;5:9Y14. 80. Simpson W, Cowie L, Wilkinson L, et al. The effectiveness of a community intensive therapy team on young people’s mental health outcomes. Child Adolesc Mental Health. 2010;15:217Y223. 81. Breslow RE, Erickson BJ, Cavanaugh KC. The psychiatric emergency service: where we’ve been and where we’re going. Psychiatr Q. 2000;71:101Y121. 82. Santiago LI, Tunik MG, Foltin GL, et al. Children requiring psychiatric consultation in the pediatric emergency department: epidemiology, resource utilization, and complications. Pediatr Emerg Care. 2006;22:85Y89.

www.pec-online.com


1049


Janssens et al

83. Breslow RE. Structure and function of psychiatric emergency services. In: Allen MH, ed. Emergency Psychiatry (Review of Psychiatry Series). Washington, DC: American Psychiatric Publishing; 2002:1Y34. 84. Schweitzer R, Dubey DR. Scattered-site crisis beds: an alternative to hospitalization for children and adolescents. Hosp Community Psychiatry. 1994;45:351Y354. 85. Lamb CE. Alternatives to admission for children and adolescents: providing intensive mental healthcare services at home and in communities: what works? Curr Opin Psychiatry. 2009;22:345Y350. 86. Vanderploeg J, Schroeder J, Franks R. Emergency mobile psychiatric services: Recommendations for model enhancement. 2008;Ref:A.T.JN.Y;V(I):P (John AB) 49. Vanderploeg J, Schroeder J, Franks R. Emergency mobile psychiatric services: Recommendations for model enhancement. 2008. Available at: http://www.ct.gov/dcf/lib/dcf/behavioral_health/pdf/emps_ccep.pdf. Accessed November 2012. 87. Walter UM, Petr CG, Davis S. Informing best practices for children in psychiatric crises: perspectives and insights from families. Families Soc. 2006;87:612Y620. 88. Rowland MD, Henggeler SW, Gordon AM, et al. Adapting multisystemic therapy to serve youth presenting psychiatric emergencies: two case studies. Child Psychol Psychiatr Rev. 2000;5:30Y43. 89. Henggeler SW, Rowland MD, Randall J, et al. Homebased multisystemic therapy as an alternative to the hospitalization of youths in psychiatric crisis: clinical outcomes. J Amer Acad Child Adolesc Psychiatry. 1999;38:1331Y1339.

1050

www.pec-online.com

&


90. Kurtz Z. The Evidence Base to Guide Development of Tier 4 CAHMS. United Kingdom: Department of Health, Children YpaFP; 2009. 91. Greenfield B, Larson C, Hechtman L, et al. A rapid-response outpatient model for reducing hospitalization rates among suicidal adolescents. Psychiatric Serv. 2002;53: 1574Y1579. 92. Bishop EG, McNally G. An in-home crisis intervention program for children and their families. Hosp Community Psychiatry. 1993;44:182Y184. 93. McDougall T, Worrall-Davies A, Hewson L, et al. Tier 4 CAHMSVinpatient care, day services and alternatives: an overview of Tier 4 CAHMS provision in the UK. Child Adolesc Mental Health. 2008;13:173Y180. 94. Gould M, Greenberg T, Munfakh J, et al. Teenagers’ attitudes about seeking help from telephone crisis services (hotlines). Suicide Life Threat Behav. 2006;36:601Y613. 95. Green J, Jacobs B, Beecham J, et al. Inpatient treatment in child and adolescent psychiatryVa prospective study of health gain and costs. J Child Psychol Psychiatry. 2007;48:1259Y1267. 96. Shepperd S, Doll H, Gowers S, et al. Alternatives to inpatient mental health care for children and young people. Cochrane Database Syst Rev. 2009;2009:CD006410. 97. Cotton MA, Johnson S, Bindman J, et al. An investigation of factors associated with psychiatric hospital admission despite the presence of crisis resolution teams. BMC Psychiatry. 2007;7:52.



Motor abilities of children and adolescents with a psychiatric condition: A systematic literature review.

Pathways to Psychiatric Care for Children and Adolescents at a Tertiary Facility in Northern Nigeria.

Psychiatric nursing care for adult survivors of child maltreatment: a systematic review of the literature.

Psychiatric aspects of epileptic children and adolescents.

Psychiatric Disorders in Iranian Children and Adolescents.

Reflections on short-term psychiatric hospitalization for children and adolescents.

Inpatient psychiatric treatment of children and adolescents: a review of outcome studies.

[Emergency radiographs in injured children and adolescents].

Nursing care for adolescents and young adults with cancer: literature review.

Sugar-Sweetened Beverages and Obesity among Children and Adolescents: A Review of Systematic Literature Reviews.

Screen time and sleep among school-aged children and adolescents: a systematic literature review.

Relations between patients in psychiatric and psychotherapeutic inpatient care: a literature review and conclusions for clinical practice and research.

Step-Count Guidelines for Children and Adolescents: A Systematic Review.

Communication between residential aged care facilities and the emergency department: a review of the literature.

A review of ECT for children and adolescents.

Quality of life among children and adolescents with neurofibromatosis 1: a systematic review of the literature.

Anterior cruciate ligament injuries in children and adolescents: a review of the recent literature.

Measuring Health Utilities in Children and Adolescents: A Systematic Review of the Literature.

Emergency medical services for children: thirty years of advancing high-quality emergency care for children.

Care in the home for seriously ill children with complex needs: A narrative literature review.

Malignant Catatonia Warrants Early Psychiatric-Critical Care Collaborative Management: Two Cases and Literature Review.

Integrative care therapies and pain in hospitalized children and adolescents: a retrospective database review.

Psychiatric risk factors predicting post-liver transplant physical and psychiatric complications: a literature review.

Personality disorder prevalence in psychiatric outpatients: a systematic literature review.