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*

section to a description of the definitions related to psychiatric

Objectives: Over the years, increasing numbers of children and ado- care that are used in the literature.
lescents 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 METHODS
‘‘which care should be offered to children and adolescents presenting
Conceptual Approach
with a psychiatric emergency or crisis and how should it be organized.’’
Methods: We committed a literature review to find out if any recom- The concept of ‘‘psychiatric emergency’’ lacks a clear
mendations can be made regarding the organization of emergency care
definition in the literature.3Y7 The concepts of ‘‘psychiatric
for children and adolescents with acute mental health problems.
emergency’’ and ‘‘psychological or mental health crisis’’ are
Results: The lack of a clear definition of emergencies or urgencies frequently confused or erroneously used interchangeably.6Y9
hampered this review; we note the differences between adult and child
Because the definitions of emergency and crisis are often used
or adolescent psychiatry. The theoretical models of care found in the
interchangeably and because few authors have addressed the
literature are built up from several process and structural components,
issue of their definition, we used both terms in this literature
which we describe in greater detail. Furthermore, we review the main
analysis.
service delivery models that exist for children and adolescents.
The terms emergency psychiatric services (EPS) and crisis
Conclusions: Currently, emergency psychiatric care for children and intervention services (CIS) are used in this report to encompass
adolescents is practiced within a wide range of care models. There is
all services dealing with psychiatric emergencies or crises. For
no consensus on recommended care or recommended setting for this
adults, the distinction between an emergency and a crisis is
population. More research is needed to make exact recommendations
important for deciding where and how the patient can best be
on the standardization of psychiatric care for young people in emer-
treated. The American Psychiatric Association (APA) Task
gency settings.
Force on EPS distinguishes between emergency services (which
are able to address the full range of behavioral and psychiatric
Key Words: adolescent, psychiatry, psychiatric care, crisis emergencies immediately, including involuntary treatment) and
intervention services, models urgent services (which provide care in a short time frame to
(Pediatr Emer Care 2013;29: 1041Y1050) 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
O ver the years, increasing numbers of children and adoles-
cents have sought help for acute psychiatric problems.
Newton et al1 observed a 15% increase in pediatric mental
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
health presentations from 2002 to 2006, and a further increase is decision to seek help than are his/her symptoms in isolation. We
expected in the future. The responses to this treatment-seeking emphasize that the behavior of minors is determined and
behavior are heterogeneous in different settings and nations. reviewed within a specific context; therefore, the context is es-
In many European countries, as well as Australia, Canada, and sential when handling emergencies involving children and ad-
the United States, policy questions are being raised2 regarding olescents. A child’s or adolescent’s behavior or thoughts are
the content and organization of child and adolescent psychi- brought to psychiatric attention when an adult figure interprets
atric emergency care services. them as inappropriate or unmanageable in the environmental
We undertook a review of all available literature to deter- context.10 A multitude of potential referees might consider a
mine whether conclusions could be made concerning the opti- child’s behavior to be inappropriate and might request or initiate
mal organizational structure of child and adolescent psychiatric an emergency consult.4,10Y15
emergency care. This review aimed to address questions of
what types of care should be offered to children and adoles- Selection Procedure
cents who present with a psychiatric emergency or crisis We conducted a systematic literature search for reports
and how this care should be organized. We devote a separate that address the operationalization of emergency psychiatric
care (EPC) for children and adolescents. We searched the
journal articles that are available through electronic peer-
From the *Collaborative Antwerp Psychiatric Research Institute (CAPRI),
University of Antwerp, Antwerp; and †Belgian Health Care Knowledge
reviewed bibliographic databases, including PubMed at the
Centre (KCE), Brussels, Belgium. National Library of Medicine, all EBM Reviews in OvidSP,
Disclosure: The authors declare no conflict of interest. Francis, PsychINFO, Ovid MEDLINE(R), CSA, EonLit,
Reprints: Sarah Hayen, MD, Van Schoonbekestraat 20 B8, 2018 Antwerpen, EMBASE, and CRD (http://www.york.ac.uk/inst/crd/). All da-
Belgium (e-mail: [email protected], [email protected]).
This study was funded by the Belgian Health Care Knowledge Centre.
tabases were searched starting from 1993, which was the year
Copyright * 2013 by Lippincott Williams & Wilkins that the Institute of Medicine published a report on ‘‘Emergency
ISSN: 0749-5161 Medical Services for Children,’’ demonstrating the need for and

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Janssens et al Pediatric Emergency Care & Volume 29, Number 9, September 2013

discussing the efficacy of pediatric emergency services in the population, psychiatric emergencies often occur in the context
United States.16 of a crisis, and the connection between psychiatric emergencies
The research question was operationalized according to a and crises may warrant further attention. In addition, psychi-
SPICE (Setting, Perspective, Intervention, Comparison, Eval- atric emergencies in children and adolescents are different from
uation) format to identify the appropriate keywords. The fol- adult psychiatric emergencies because minors are embedded
lowing keywords were selected: in the context of their families, schools, neighborhoods, and
& Setting: psychiatry, child or adolescent psychiatry, psychiatric other social systems. There are additional age-related chal-
hospitals, mental health, community mental health services lenges given that the emergencies are most often defined by
or centers; someone other than the affected child or adolescent and given
& Perspective: child, adolescent, youth, p(a)ediatrics; that a multitude of potential referees are possible.
& Intervention: emergency services, crisis intervention; In the majority of studies on (pediatric) psychiatric emer-
& Comparison: voluntary versus compulsory, adult versus pe- gencies, the concepts of emergency and crisis are approached
diatric, community versus hospital based; from a functional perspective: each presentation at an emer-
& Evaluation: organizational system, financial system, efficiency. gency service is initially viewed as an emergency.17 Few stud-
ies have discussed these concepts on a content level. A clear
The study selection process was initiated by running the distinction of the terms emergency and crisis will benefit pa-
search algorithms in all databases. The search results were tients and their families by allowing more appropriate referrals
downloaded in a separate Endnote file (Thomson Reuters, and settings for intervention. Overall, authors seem to agree on
New York, NY) for each database. Subsequently, the search 2 aspects of an emergency: (1) it involves a danger of harm to
results from all databases were merged into an Endnote file, the patient or to others, as primarily determined by the patient’s
thereby automatically removing the majority of duplicate re- context, or it involves a context in which there exists a threat
sults. A first selection of studies was performed by one of to the child’s life or development and (2) immediate interven-
the researchers based on a review of the study titles and ab- tion is required.
stracts. The selection criteria for the title and abstract evalua- The goal of EPC is to provide immediate care and to as-
tion were as follows: sist in the provision of long-term care within the mental health
& Inclusion: emergency psychiatry (child, adolescent, pediatric system.18 The primary aim of EPC is to ensure a patient’s
psychiatry, or unspecified population) and mental health; safety: immediate danger must be controlled. Furthermore,
inside or outside of a hospital setting; crisis intervention in the emergency psychiatric interventions aim to improve the situa-
context of mental health problems; organizational, structural, tion and to allow the children to gain control and to maintain
and financial aspects of emergency psychiatry; populations themselves within their appropriate context.
using (psychiatric) emergency services; theoretical articles
focusing on definitions, history of emergency psychiatry; and Classification of Findings
English, French, and Dutch languages; The previous discussion illustrated that the terms emer-
& Exclusion: crisis intervention in the context of disasters caused gency and crisis are used interchangeably (Fig. 1). Therefore,
by either man or nature (eg, hurricanes, earthquakes, attacks both terms (emergency psychiatric services [EPS] and crisis
on 9/11 in the United States, school shootings) and school- intervention services [CIS]) are used in this report to encompass
based crisis intervention systems; prevention (eg, projects all services dealing with psychiatric emergencies or crises.
on suicide prevention); treatment strategies for specific dis- The organization of emergency mental health services dif-
orders within emergency departments (EDs); epidemiological fers between countries and regions and is very diverse. We
aspects of psychiatric disorders; languages other than English, discuss the following 2 elements regarding the organization of
French, and Dutch. EPC: process and structural elements (Fig. 1, items 5 and 6),
including the theoretical models and service delivery models
After the initial title and abstract selection, a full-text that are found in the literature.
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 Process Components
reviewed by a second reviewer for selection. Some adult- First, we discuss the process components that are found
based studies were included and evaluated for their potential in the literature on EPS/CIS, followed by an overview of the
ability to be translated to pediatrics. We identified a total of associated theoretical models (containing some or all of the
1234 potentially relevant articles from all electronic databases, process components) (Fig. 1, item 5). The process flow and
of which 284 full articles were reviewed for inclusion. After the components refer to the core functions involved in psychi-
selection process, 221 articles remained relevant and were atric emergency and crisis response care: ‘‘the set of activi-
analyzed. ties that go on within and between practitioners and patients,’’
response times and duration of service use. These process
RESULTS components form the building blocks of different theoretical
models.
Definition of Emergency The process components (Fig. 1, item 5) are not included
The definition of psychiatric emergency has received little by all authors in their descriptions, but the following compo-
attention in the literature. Although several authors express the nents were found in the literature: registration, stabilization,
need for a clear definition of ‘‘emergency,’’ ‘‘urgency,’’ and/or evaluation and assessment, disposition, treatment, referral, and
‘‘crisis’’ in the mental health field, only a few studies on the follow-up.
topic of psychiatric emergencies have explicitly defined the When a patient enters an emergency setting, he/she is
concept of psychiatric emergency.3Y7 first registered. Registration can be limited to the personal in-
Psychiatric emergencies in children and adolescents differ formation that is needed for enrollment, or it can be used to log
from those of adults in several important ways. In a pediatric additional data.11,19

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Pediatric Emergency Care & Volume 29, Number 9, September 2013 Emergency Psychiatric Care

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

After registration, medical stabilization is often a priority constraints of the mental health service delivery system need
for children and adolescents who report to the ED with men- to be considered. Despite the need, there may not be sufficient
tal health emergencies, particularly for patients who have at- numbers of community-based mental health programs avail-
tempted suicide.18,20Y23 After treating any acute medical needs, able. The pediatric EPS/CIS can make dispositions for dis-
the process focuses on ensuring the child’s safety and well- charge, admission to an inpatient psychiatric facility, extended
being.21 Crisis stabilization services are initiated upon admission observation units, hospitalization, detoxification programs, par-
or presentation and typically span the first 24 to 72 hours.24,25 tial hospital programs, and outpatient services.12,18,19,23,40,41
An evaluation process is next.12,13,18Y20,22,26Y30 The first The treatment process follows.12,18,22,26Y28 Crisis interven-
stage, triage, consists of an assessment of the degree of risk tion is expected to provide active treatment intervention rather
through direct, empathic questioning of the child regarding than serving as a holding station on the way to beginning ‘‘real’’
the actual or potential threat of harm to the child or oth- treatment in some other venue.42Y44 After a period of crisis sta-
ers.19,20,22,26,27,31Y33 Triage involves making a crucial determi- bilization and/or assessment, transitional care services may be
nation, within several minutes, about an individual’s course of provided that are linked to explicitly identified treatment goals.
treatment, and it determines the initial level of treatment needed These services are generally delivered within a 2- to 6-week
to ensure safety.20,34Y37 Triage can be performed with specific period.24,44
screening tools, and it requires specific staff skills. A somatic and Referral and follow-up end the process. This stage varies
psychiatric assessment is focused on risk. A physical examina- greatly, and the decision for referral or follow-up may be based
tion is required to exclude a medical cause (‘‘organic disease’’) on the availability of the resources to which the patient is
for the patient’s psychobehavioral symptoms or to stabilize the referred.12,18,22,26,35,39
patient.20,21,38 The cornerstone of medical clearance is a thorough Within the process flow (Fig. 1, item 4), we include the
history and physical examination, but assessment and evaluation response time, which refers to the speed at which services are
may also include a mental status examination, laboratory evalua- delivered once requested.45 We note a difference between an
tion (toxicology screen), or other assessments depending on emergency, which requires an immediate response, and a crisis,
the clinical scenario.21 The psychiatric assessment consists of which needs to be addressed when all participants in the crisis
a review of psychiatric symptoms, an assessment of risk factors and personal supports can be included.9 Generally, emergency
for suicide and/or violence toward others, and social factors that services respond within 24 hours of receiving a request.46
influence functioning.28 In most reports, the authors conclude Few authors discuss the theoretical basis underlying the
that the focus needs to lie on the assessment of risk rather than delivery models of psychiatric emergency care and crisis in-
on the diagnosis. tervention. The process elements and practices used by indi-
Goldstein and Findling19,20,23,28,39,40 describe the disposi- vidual programs differ greatly depending on community needs
tion as the most difficult aspect of the evaluation process. and underlying treatment philosophies.47 The number of pro-
The decision is made via 2 primary questions: whether the pa- cess components that are involved in a program determines the
tient is a clear danger to himself or others and what is the organizational complexity of EPS/CIS.48 There were no theo-
most appropriate level of care for the patient. Although the retical models of emergency psychiatric service delivery
emphasis in the clinical literature is on treating young people in (Fig. 1, item 8) found in the literature that address a pediatric
the least restrictive and most clinically appropriate setting, the population. Overall, 5 models were described for the delivery

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Janssens et al Pediatric Emergency Care & Volume 29, Number 9, September 2013

of emergency mental health services in general,15,18,49Y51 and of minors presenting with acute psychiatric problems are the
Table 1 gives an overview. following: female sex (although data on sex distribution are
inconsistent), older age (adolescents more frequently than
children), family referral, family psychiatric history, diagnosis
Structural Components of attention deficit/hyperactivity disorder, disruptive behavior
In this section, we describe the organizational configura- disorder or adjustment disorder, school day presentation, ar-
tion (Fig. 1, item 3), which refers to the structure and principles rival time between the hours of 4:00 P.M. and 11:00 P.M. and
involved in delivering EPS/CIS (Fig. 1, item 6). Structure re- presenting complaint of suicidal ideation/attempt.3,19,61Y64
lates to where, for whom, and by whom by these services are Little attention is given in the literature to the importance
delivered, and it covers, among other aspects, the location, fa- of sex and culture. Pumariega and Rothe53 noted that there
cilities, staff, accessibility and flexibility, as well as service are many cultural influences on health beliefs and practices.
costs. We will discuss the different structural components that The determination of behavioral and emotional normality is
are found, although not all researchers address all of the aspects largely determined by culture.
(Fig. 1, item 6). An important topic is the staffing and competencies of
Some emergency services focus exclusively on children the care providers. Professionals who are in positions to ef-
and adolescents.54 Some are specifically developed to treat ad- fect crisis intervention require higher levels of awareness and
olescents,27,55 others target an adult population but also include training with support from specialty services.9 Parker et al5 note
16- to 18-year-olds,56,57 and still, others serve both pediatric that an experienced child psychiatrist is required, preferably
and adult populations.8,39,54,58Y60 In addition, a distinction can one who is trained and interested in emergency psychiatry,
be made between services that target life-threatening crisis sit- and care requires a cohesive team with manager support.
uations/emergencies and those that target urgent but not life- Hospital emergency staff is rarely trained to recognize men-
threatening situations. The main characteristics of the majority tal health issues, especially as they present in children, and

TABLE 1. Emergency Psychiatric Care and CIS: Theoretical Models

Gatekeeper Crisis System

Triage Model Model Case Intervention of Care Treatment
Fortress Model Formulation Model Model Model Model
Goals Efficient care: rapid Quality care is linked to Crisis is seen as Services are to be Comprehensive
evaluation, containment efficient care: more a turning point; provided in the services that
and referral. Limited attention is given to less emphasis least restrictive still serve a
resources; focus on diagnostics and on long-term setting appropriate triage function
determination of evaluation. hospitalization, to the needs of but are capable
priority for treatment more attention the child and of providing
by identifying those at on treatment family. Crisis comprehensive
risk for (self ) harm. outside hospital and emergency assessment and
Minimizing subtle and briefer services represent broader range
diagnostic evaluations. psychotherapies. only one in a of services.
continuum of
both residential
and nonresidential
services, aimed at
preventing
hospitalization.
Location Hospital based/ED Hospital based/additional Community based Community based Hospital based/
provisions required to additional
ED provisions
required to ED
Triage/ Yes Yes Yes Yes Yes
stabilization
Assessment: Yes Yes Yes Yes Yes
medical
clearance
Assessment: (Risk of inadequate Comprehensive Comprehensive Comprehensive Comprehensive
psychiatric assessment)
evaluation
Treatment No No Brief Brief Brief
Disposition Admission or discharge Admission, referral or Admission, Admission, referral Admission, referral
discharge referral or or discharge or discharge
discharge
Referral/follow- Limited Yes, including guidance Yes Yes Yes, including
up toward ambulant guidance toward
services ambulant services
References Chan and Noone,51 De Fruyt,17 2003; Chan and Noone,51 Kutash,29 1995; Allen et al,52 2002;
2000; Allen et al,52 Londino et al,17 200340 2000 Pumariega and De Fruyt,17 2003
2002; De Fruyt,17 2003 Rothe,53 2003

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Pediatric Emergency Care & Volume 29, Number 9, September 2013 Emergency Psychiatric Care

they have no systematic way to identify or refer children to the 1. First, we describe services in medical emergency settings.
appropriate services.65 In a policy statement, Dolan and Mace22 The model of the psychiatric consultant to the ED (ie, the
indicate that pediatric mental health emergencies are best consultation/consultant model) has long been the mainstay
managed by a skilled multidisciplinary team approach. Staffing for treating behavioral emergencies.31,41,52,81Y83 Many dif-
varies with the nature of the service, but it generally requires ferent procedural models or programs have been developed
a child psychiatrist, child psychiatric nurse, psychiatric social to guide the emergency care process. For example, Mahajan
worker, mental health workers, and a utilization reviewer for et al74 describe a child guidance model that is used to speed
insurance communication.42 The most challenging aspect of up the process from physical evaluation by the ED physician
staffing occurs when the volume is too low to justify a dedi- to final disposition, decreasing ED costs and burdens. In
cated staff and too high to be managed by the ad hoc deploy- Canada, the rapid response model uses a similar approach;
ment of staffing from other services.42 The competencies for it was developed to meet the emergency needs of children
the professionals relate to making an assessment, intervening and adolescents referred from the community.5 The model
therapeutically if possible, and making a useful and effective falls within the official American Academy of Child and Ad-
referral.37 The ED staff should be educated regarding the pro- olescent Psychiatry practice parameters highlighted for the
vision of effective mental health care. For example, a crisis as- management of children and adolescents with suicidal behav-
sessment requires a thorough interview and is time consuming ior. The rapid response model has 3 components: (1) emer-
compared with other types of pediatric ED presentations. Dion gency consultation; (2) urgent consultation; and (3) education
et al66 suggest that the general ED staff is interested in training, of those who might use the service.
particularly those who have the most experience and spend 2. The psychiatric emergency service facility comprises many
the most time in the ED. different models.
Several studies have shown that collaboration between By law, comprehensive psychiatric emergency programs
agencies in response to psychiatric emergencies in children is (CPEP) in the United States implement the treatment model
a worthwhile strategy.9,27,37,67,68 Crisis intervention should be and need to provide emergency psychiatric evaluation, treat-
closely linked with a true continuum of services so that the ment and disposition, extended observation beds up to 72 hours,
initial interventions are continued uninterrupted in the next mobile crisis outreach services, and crisis residential beds.39
clinical setting.42 Based on a national consensus conference in It is designed to rapidly assess and refer.
the United States, Hoyle and White69 propose an integrated The psychiatric emergency service (PES) model is founded
system for mental health emergencies. In their proposal, they on the CPEP model, as it prescribes immediate psychiatric as-
stress that integrated systems for identifying and treating pedi- sessment and provides a therapeutic environment where patients
atric mental health emergencies would require the active par- in psychiatric crises may receive proper psychiatric, medical,
ticipation and cooperation of numerous organizations. and social support.31,52,75 Feiguine et al76 describe a PES model-
Many authors note that contextual factors are particularly based crisis service within a children’s hospital in Manhattan,
relevant to child and adolescent psychiatric emergencies.15,37 providing both emergency assessment and short-term treatment
There is a focus on strength-based approaches, in which natural services for children, adolescents, and their families. The service
supports are mobilized and enhanced and the services are de- is also available for emergency consultations and evaluations to
livered in the least restrictive environment and in the child’s the pediatric ED. Currier and Allen75 report that 77% of the
community.56 PES facilities are located within general hospitals.
Accessibility is a priority, and a comprehensive EPS or The integrated psychiatric emergency service model was
CIS is open 24 hours a day, 7 days a week, 365 days a year.29,60 presented by Kates et al77 in Canada; it has 5 separate hospital-
Location and infrastructure are important structural fac- run EPS integrated into a single service. They offer compre-
tors. Dealing with psychiatric emergencies requires a safe en- hensive services by a multidisciplinary team that is familiar
vironment for patients and staff and a physical space designed with community resources, and they have interview rooms lo-
to minimize overstimulation and prevent access to potential cated within the ED.
weapons. The APA’s Task Force on psychiatric emergency ser- The dedicated bed and scattered bed model was described
vices distinguishes 2 broad categories of services, hospital- in a trial by Cotgrove78 of an emergency admission service in
based and community-based services, and 2 approaches to a regional adolescent psychiatric unit in the United Kingdom in
providing the service, residential and ambulatory or mobile.52 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
Service Delivery Models study also demonstrated a beneficial effect of the easy avail-
The organizational configuration (Fig. 1, item 3) shows ability of an assessment and second opinion.78 Several more
that crisis and emergency services for children and adolescents authors describe inpatient psychiatric units that offer crisis beds
may range from nonresidential to residential and may involve for children and adolescents, often within crisis stabilization
various agencies, services, and personnel (Fig. 1, item 7).29,70Y73 services.24,84 Schweitzer and Dubey84 describe the rationale,
Table 2 shows a summary of the organizational configuration development, and implementation of a countywide scattered-
options. site crisis bed program for seriously disturbed minors. The pro-
The Mental Health of Children and Young People states gram was developed by an interagency coalition consisting of
that children and young people with severe mental health diffi- representatives of the mental health, social service, and juvenile
culties should be managed in the community wherever possible.80 justice systems in New York county and was implemented with
One classification of service delivery models (Fig. 1, item 7) no new funding, using available beds in facilities that were ad-
was proposed by the APA Task Force on EPS.52 In addi- ministered by the participating agencies. These beds are not
tion to the service models described by the APA, we describe dedicated to crisis care but represent the pool of available beds
several other services that were found in the literature. We sum- on a given day.
marize the different models with examples of some services that The semi-institutional service model consists of day and
were created (Table 2). partial hospitals that provide intensive treatment during the day;

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Janssens et al Pediatric Emergency Care & Volume 29, Number 9, September 2013

TABLE 2. Summary Table EPS/CIS Organizational Configuration and Models

Classification (Descriptive) Organizational Model Organizational Configuration

31 52
Services in medical Consultant model , Psychiatric consult to the ED on demand
emergency settings Procedural models No specific structures required
Child guidance model74
ED physician rapid response model5
Crisis intervention program20,30
Psychiatric emergency CPEP39 Based on treatment model, providing triage, emergency
facility psychiatric evaluations, treatment, and disposition
PES model31,52,75,76 Similar to CPEP, providing immediate psychiatric
assessment, 24-h stabilization, 72-h extensive
observation beds (EOB), and therapeutic environment.
Integrated PES model77 Integration of 5 hospital-run emergency services into a
single emergency service
Dedicated bed and scatter bed model 2 of 10 unit beds dedicated for emergency
purposesVUnited Kingdom55,78
Inpatient unit in tertiary care pediatric teaching
hospitalVCanada24
Semi-institutional service model79 Partial hospitals and crisis respite, 24-h response service,
crisis beds
Small residential services outside hospitals, attached to
community mental health centers
Psychiatric urgent care Institutional service model Crisis intervention unit in child psychiatric hospital with
facility outpatient services11
Collaboration of rural community clinics with emergency
hotlineVUnited States54
Semi-institutional service model Day and partial hospitals79
Mobile EPS Youth emergency services68 Interrelated programs and services, outreach
APA guidelines52 Training, staffing, and community linkages
Community-based services Out-of-hospital approaches Community-based crisis servicesVUnited Kingdom
Multisystemic therapy Crisis services 24/7
Intensive case management Prevention of hospitalization and stabilization of crisis
situation.
Assertive outreach Evaluation, assessment, crisis intervention, stabilization
and follow-up, and involving family
Crisis stabilization program
Home-based treatment Community-based acute servicesVNew Zealand
Special service program Small home-like environments (mostly less severe crises)

the patients return to their homes at night.79 They can include to-face crisis assessment, intervention, and stabilization in
additional services such as emergency crisis beds or an on-call the community. Most programs have a primary purpose
24-hour response service.85 of diverting youth from ED admissions and residential place-
3. Psychiatric urgent care facilities provide ready access to ments.52,68,86 Many provide a linkage function whereby
psychiatric assessment and treatment for patients with ur- they ensure that youth in crisis are referred to appropriate
gent needs.52 Several authors describe an institutional ser- longer-term treatment options in the community. Staff
vice model11,54 where urgent consultations and taxation members in these programs are highly trained mental health
can take place and, if indicated, an admission to a crisis professionals. Youth emergency services is an experimen-
unit can follow. At a crisis unit admission, the duration tal program that was developed through collaboration of
is often limited to 14 days, and the treatment involves 6 New York agencies to respond to psychiatric emergencies
child psychiatric diagnostics, limited psychological test re- in children and adolescents.68 Independent of location, the
search, conversations with the family, a therapeutic package clinicians see the child, stabilize the crisis, and perform
including psychodynamic group therapy and sociotherapy. an on-site assessment that is sufficient to ensure the
Follow-up care needs to be provided by other services. child’s physical and emotional safety. They also stay with
Different systems are installed to provide 24/7 coverage the family until the child enters the treatment process.
for dealing with potential crises, such as a telephone advice Usually, this occurs in less than 24 hours. In 2002, the APA
service or a collaboration with adult psychiatry. A semi- published guidelines for mobile psychiatric interventions.
institutional service model is described by O’Hagan.79 Organizational model considerations for mobile psychiatric
4. Mobile psychiatric emergency services are very common emergency services focus on the structuring of these ser-
in many US states, and they are intended to provide face- vices, including training, staffing, and community linkages.52

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Pediatric Emergency Care & Volume 29, Number 9, September 2013 Emergency Psychiatric Care

5. Most community-based crisis services29,87 have the following the child’s legal rights. In addition, EPC should be directed to-
characteristics: 24/7 availability; sharing of the common pur- ward reactivating the child’s development and often may be
pose of prevention of hospitalization and stabilization of considered the first opportunity for offering help within a child/
the crisis situation in the most normalized setting available; family/context. Overall, it can be concluded that a ‘‘psychi-
offering on a short-term basis; having a limited capacity; atric emergency’’ and ‘‘crisis’’ need to be distinguished and
typically including evaluation, assessment, crisis intervention, that the terms can be conceptualized using key dimensions such
stabilization, and follow-up planning; involving families in as time, the level of danger involved, diagnosis, and context.
all phases of crisis treatment; having a staff who tend to share The general observation holds that little evidence is avail-
similar characteristics; and being generally part of a larger able about the organization of child and adolescent emergency
agency that offers other services, such as inpatient day treat- services. Very few effectiveness studies are available. Effec-
ment and outpatient services. tiveness studies for inpatient treatment have been limited by
The original multisystemic therapy program was developed poor methodology and difficulties in generating appropriate
as an intensive, family-based approach for minors with serious treatment controls for experimental studies. In addition, they
antisocial behaviors and was adapted to psychiatric emergency are examples of complex interventions wherein the active agent
situations by the integration of additional clinical staff, the inte- of change may not be simple and systematic.95 No random-
gration of evidence-based pharmacological interventions, and by ized evidence has been identified comparing intensive day
the planned and judicious use of out-of-home placements.88Y90 treatment for young people in crisis with inpatient care or an
Intensive case management encompasses a number of ap- alternative mode of care.85,96 It is often held that admission can
proaches, including assertive outreach as well as wraparound offer containment and can rapidly reduce risk in acute crises.
and assertive/intensive community treatment.49,54,90,91 It is of- However, there is uncertainty as to the effective components
fered within the community and is a common strategy for in- of the intervention, the optimal length of admission, its suit-
creasing access to and coordinating services within the care ability for prepubescent children, and whether any positive
system. It does not have time limitations. effects gained are maintained after discharge.95 The evidence
The crisis stabilization programs aim to reduce the number suggests a need for a combination of complementary models
of hospitalizations and to provide multidisciplinary teams to of intensive mental health care provision, including intensive
perform interventions and follow-up evaluations.45,49 outreach services, crisis intervention teams, and age-appropriate
Home-based treatment is an intensive, rapid response acute day patient and inpatient provisions. It seems that crisis programs
service that is provided in the patient’s own home at any time. can serve as an effective means of reducing hospitalizations and
Members of a multidisciplinary team make up to several visits other out-of-home placements for many children.57,91,93,97 There
a day and provide medication, brief counseling, practical as- is insufficient evidence upon which we can decide what model
sistance, information and support.44,52,79,85,90,92,93 The primary is best for each group of young people, and further health ser-
goal is to defuse the presenting crisis so that the child can re- vice evaluation research is needed.
main at home. This review shows that there are many topics that remain
The special service program provides 2 basic types of unstudied; therefore, many questions remain unanswered. Spe-
services: outreach services and short-term (G90 days) crisis cifically for children and adolescents, the literature concerning
placement services in a specialized unit.43 registration systems, follow-up evaluations, and effectiveness is
Finally, crisis and suicide hotlines (telephone crisis ser- lacking. Little is known about the characteristics of children
vices) have the unique ability to offer some level of service presenting for psychiatric emergency services, and virtually
at times when other services are unavailable. They offer confi- nothing is known about the outcomes that they experience across
dentiality and anonymity to clients, provide information about a range of referral options. Finally, evidence of the effectiveness of
other treatment sources, and provide a safe and nonjudgmental the different organizational structures and models is missing.
environment, enabling clients to articulate complex feelings.94 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
DISCUSSION because of increasing needs. We notice that various specific
This report presents an overview of the literature on services for child and adolescent EPC are still being described;
the organization of psychiatric emergency care for children however, they are often based on limited data. Many services
and adolescents. The literature review was hampered by the are based on models of care from adult psychiatry, and they
lack of a clear definition of ‘‘psychiatric emergency’’ (espe- are often copied verbatim for child and adolescent popula-
cially in a pediatric population). This topic has received little tions. There are, however, some clear differences contrain-
attention in the past. Although several authors express the need dicating this transfer. Minors are embedded in an ecological
for clear definitions of emergency, urgency, and/or crisis in context (eg, parents or school), and this environment determines
the mental health field, few studies explicitly define the concept the level of emergency. Parents or guardians almost always
of psychiatric emergency. An emergency is life threatening, maintain the responsibility of care for their child/minor. The
requiring an immediate, life-preserving response. A crisis is not goals of emergency care for children and adolescents include
life threatening, but it requires an urgent response to prevent more than handling the acute crisis; the goals are also to make
deterioration. To ensure all literature concerning the topic was further development possible and facilitate adequate care.
included, we reviewed reports addressing the concepts of It should also be noted that emergency care for children and
emergency and crisis. adolescents is provided by very different organizational structures
Few reports discuss these concepts on a content level. On (ie, welfare, health, and justice systems). This heterogeneity
a content level, the following 2 aspects of an emergency seem makes data, even if they are available, not easily accessible.
to be pervasive: (1) a high risk of harm to the patient or to oth-
ers and (2) a need for immediate intervention. The specific CONCLUSIONS
characteristics of the child and adolescent population require Currently, EPC for children and adolescents is practiced
EPCs to take into consideration parental legal responsibility and within a wide range of care models. There is no consensus

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Janssens et al Pediatric Emergency Care & Volume 29, Number 9, September 2013

on recommended care or recommended setting for this popu- 20. Ayliffe L, Lagace C, Muldoon P. The use of a mental health triage
lation. Worldwide, there is a tendency to provide care to a pe- assessment tool in a busy Canadian tertiary care children’s hospital.
diatric population in the least restrictive environment within J Emerg Nurs. 2005;31:161Y165.
the child’s community. The level of danger involved will deter- 21. Baren JM, Mace SE, Hendry PL, et al. Children’s mental health
mine whether the emergency care or crisis intervention needs emergenciesVpart 2: emergency department evaluation and treatment
to occur in a residential or nonresidential setting. More research of children with mental health disorders. Pediatr Emerg Care. 2008;24:
is needed to make exact recommendations on the standardiza- 485Y498.
tion of psychiatric care for young people in emergency settings. 22. Dolan MA, Mace SE. Pediatric mental health emergencies in the
emergency medical services system. Pediatrics. 2006;118:1764Y1767.
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