Mental Health Service Use Before and After a Suicidal Crisis Among Children and Adolescents in a United States National Medicaid Sample

IntroductionMental health follow-up after an emergency department (ED) visit for suicide ideation/attempt is a critical component of suicide prevention for young people.MethodsWe analyzed 2009 to 2012 Medicaid Analytic EXtract for 62,139 treat-and-release ED visits and 30,312 ED-to-hospital admissions for suicide ideation/attempt among patients ages 6 to 17 years. We used mixed-effects logistic regression models to examine associations between patients’ health care utilization prior to the ED visit and likelihood of completing a 30-day mental health follow-up visit.ResultsOverall, for treat-and-release ED visits, 49% had a 30-day follow-up mental health visit, and for ED-to-hospital admissions, 67% had a 30-day follow-up mental health visit. Having a mental health visit in the 30 days preceding the ED visit was the strongest predictor of completing a mental health follow-up visit (ED treat-and-release: adjusted odds ratio [AOR] 11.01; 95% confidence interval [CI] 9.82–12.35; ED-to-hospital AOR 4.60; 95% CI 3.16–6.68). Among those with no mental health visit in the 30 days preceding the ED visit, only 25% had an ambulatory mental health follow-up visit. Having a general health care visit in the 30 days preceding the ED visit had a much smaller association with completing a mental health follow-up visit (ED treat-and-release: AOR 1.17; 95% CI 1.09–1.24; ED-to-hospital AOR 1.25; 95% CI 1.17–1.34).ConclusionsYoung people without an existing source of ambulatory mental health care have low rates of mental health follow-up after an ED visit for suicide ideation or attempt, and opportunities exist to improve mental health follow-up for youth with recent general health care visits.     

Editorial: COVID-19: lessons learned for suicide prevention

This editorial discusses lessons learned from the COVID-19 public health emergency as they relate to the prevention of suicide, the second leading cause of death in adolescents and young adults globally. Recognizing that COVID-19 impact and response varied across nations, we offer a US perspective, addressing two questions: (a) what have we learned from this pandemic and mitigation strategies used to reduce cases of COVID-19 illness and deaths; and (b) how can our research advance knowledge and be advanced by work aimed at understanding the impact of this ‘unusual’ period? Provisional data indicate that during the pandemic and lockdown period, there were some declines in suicide rates for the total US population and no change in youth. However, data also indicate increases in reported suicidal ideation and behavior, mental health-related ED visits, and ED visits for suicidal ideation and behavior in youth. Heterogeneity of pandemic effects is noteworthy, with ethnic and racial minority populations suffering the most from COVID-19, COVID-19-related risk factors, and possibly suicide deaths. As vaccinations can prevent severe COVID-19 cases and deaths, we also have demonstrations of effective ‘psychological inoculations’ such as community-based interventions for reducing suicide attempts and deaths. During COVID-19, we mobilized to provide clinical care through telehealth and digital interventions. The challenge now is to continue to put our science to work to mitigate the adverse impacts of the pandemic on suicide and suicide risk factors, our children’s mental health, and enhance mental health and well-being in our communities.     

Psychosocial issues in primary care of lesbian, gay, bisexual, and transgender youth

Lesbian, gay, bisexual, and transgender youth are at risk for a multitude of physical, emotional, and social health problems. During the past decade it has been well documented that these youth have higher-than-average rates of depression, suicide attempts, substance abuse, sexually transmitted diseases, school failure, family rejection, and homelessness. The focus of this article is to outline skills and strategies that can assist the health practitioner in creating an optimal health care experience for sexual minority youth. Models of individual and family adaptation, a clinical path, and a referral list are presented. Current health care delivery sites are examined, and recommendations are given for improvement of both practitioner skills and health care programs targeting these youth.     

Preparation for emergencies in the offices of pediatricians and pediatric primary care providers

High-quality pediatric emergency care can be provided only through the collaborative efforts of many health care professionals and child advocates working together throughout a continuum of care that extends from prevention and the medical home to prehospital care, to emergency department stabilization, to critical care and rehabilitation, and finally to a return to care in the medical home. At times, the office of the pediatric primary care provider will serve as the entry site into the emergency care system, which comprises out-of-hospital emergency medical services personnel, emergency department nurses and physicians, and other emergency and critical care providers. Recognizing the important role of pediatric primary care providers in the emergency care system for children and understanding the capabilities and limitations of that system are essential if pediatric primary care providers are to offer the best chance at intact survival for every child who is brought to the office with an emergency. Optimizing pediatric primary care provider office readiness for emergencies requires consideration of the unique aspects of each office practice, the types of patients and emergencies that might be seen, the resources on site, and the resources of the larger emergency care system of which the pediatric primary care provider's office is a part. Parent education regarding prevention, recognition, and response to emergencies, patient triage, early recognition and stabilization of pediatric emergencies in the office, and timely transfer to an appropriate facility for definitive care are important responsibilities of every pediatric primary care provider. In addition, pediatric primary care providers can collaborate with out-of-hospital and hospital-based providers and advocate for the best-quality emergency care for their patients.     

A descriptive study of primary health care practices in Ontario’s youth custody facilities

BACKGROUND:

Adolescents admitted to youth custody facilities are often in need of physical and mental health care.

OBJECTIVES:

To describe primary health care practices in Ontario’s youth custody facilities.

METHOD:

A questionnaire regarding facility characteristics and primary health care practices was distributed to the directors of all youth custody facilities in Ontario.

RESULTS:

Most (87.8%) facilities obtained medical histories after the youth arrived, and 92% used health care professionals to perform that assessment. Intake medical examinations were performed on each youth admitted to custody at 94% of all facilities; however, only 57.2% of facilities reported that these examinations were performed by a doctor within 72 h of admission. Performing suicide assessments on all youth at intake was reported by 77.6% of facilities. Continuous health education was provided by 76% of facilities. Facility type and type of management appear to be related to some areas of health services provision.

CONCLUSIONS:

Youth custody facilities in Ontario are providing primary health care services. Weaknesses are, however, evident, particularly in relation to untimely intake medical examinations, failure to provide continuous health education and failure to conduct suicide assessments on all youth at intake. Future research on barriers to health service provision in Canadian youth custody facilities is recommended.     

Suicide Screening and Behavioral Health Assessment in the Emergency Department

Suicide is a leading cause of death among our young patients. Healthcare providers in acute care settings like the emergency department have an opportunity to identify and intervene with those at risk in order to prevent death from suicide, future psychiatric emergencies, and the considerable morbidity that patients with unmet behavioral health needs experience. This article describes the current state of depression and suicide among young people and the strategies for implementing and improving screening in the emergency department. Finally, the article will articulate how to prepare for the challenges that emergency care providers face, as we work to reduce barriers for all patients to access behavioral health resources and receive needed care.     

The suicidal pediatric patient: an emergency medicine focus

Suicide in children is an increasing concern to emergency physicians. Suicide is a leading cause of death and lost years of potential in children and adolescents. Children who are acutely suicidal often present to the emergency department for medical and psychiatric care and evaluation. This article will discuss the epidemiology of suicide in children and provide the emergency physician a framework in which to evaluate and manage children who are acutely suicidal.     

Editorial: Schools on the frontline of suicide prevention

The world has experienced an unprecedented mental health crisis associated with the COVID-19 pandemic (Liu et al., 2020). After more than two years navigating the associated uncertainty and distress, the impact on youth mental health continues to be a pressing concern. Those in the mental health field, as well as the children and families plagued by its impact, are inundated with seeing firsthand the impact on youth’s functioning. This includes increases in depression and suicide (Asarnow & Chung, 2021; Manzar et al., 2021), and having to navigate siloes in care and often even an inability when in crisis to access a continuum of services (Zhai, 2021). This has highlighted the significant issues with accessibility of mental health care and inequitable access to care for youth mental health both in the United States and globally. We continue to experience daily the impact of insufficient resources for youth behavioral health. For those in the field who prioritize the need for more robust intervention approaches, the child mental health crisis associated with the pandemic has highlighted the need for us to develop more novel and innovative interventions.     

Managed care and the pediatric emergency department

The growth of managed care has provided health benefits to millions of children while attempting to control the increase in health care costs. In adhering to these goals, MCOs are often at odds with emergency departments, and the emergency department physicians providing emergency care. The appropriateness or inappropriateness of emergency department visits can be disputed, but no criteria have been established. Even the definition of emergency is debated, although many states are adopting a prudent layperson standard. Emergency medicine physicians, primary care providers, and MCOs must cooperate to fully educate parents about the appropriate use of pediatric emergency services. Patients and MCOs should use facilities that can deliver pediatric emergency and critical care or provide appropriate transport systems to facilities that can. COBRA and EMTALA set the legal requirements to which emergency departments must comply when patients present for care. The basic caveats under COBRA require a medical screening examination for every patient and the stabilization of all patients with emergency medical conditions before inquiring about insurance or patients' ability to pay. A part of gatekeeping, MCOs often require authorization for treatment. MCOs authorize payment only. Evaluation and emergency treatment should not be withheld pending authorization. After the medical screening examination, recommended treatment should be in patients' best interests. All patients with potentially life-threatening conditions should be stabilized before transport, and all transfers must comply with the EMTALA. The transfer of unstable patients purely for economic reasons is a violation of the EMTALA. When stable, patients may be transferred to other facilities, but patients requiring specialty care should be taken to facilities best able to provide that care. Financial considerations should be superseded by medical necessity. Finally, improvements can be made in the way emergency medical service is provided to children within the current managed care system. The primary care provider is in a key position to inform parents about the types of pediatric emergencies, what to do in case one occurs, and to provide follow-up care. MCOs should incorporate clear information on pediatric emergencies. A mutual understanding of services needed, and how best to provide those services, are needed to forge a system that is responsive to children's emergency care needs.     

Supporting the health care transition from adolescence to adulthood in the medical home

Optimal health care is achieved when each person, at every age, receives medically and developmentally appropriate care. The goal of a planned health care transition is to maximize lifelong functioning and well-being for all youth, including those who have special health care needs and those who do not. This process includes ensuring that high-quality, developmentally appropriate health care services are available in an uninterrupted manner as the person moves from adolescence to adulthood. A well-timed transition from child- to adult-oriented health care is specific to each person and ideally occurs between the ages of 18 and 21 years. Coordination of patient, family, and provider responsibilities enables youth to optimize their ability to assume adult roles and activities. This clinical report represents expert opinion and consensus on the practice-based implementation of transition for all youth beginning in early adolescence. It provides a structure for training and continuing education to further understanding of the nature of adolescent transition and how best to support it. Primary care physicians, nurse practitioners, and physician assistants, as well as medical subspecialists, are encouraged to adopt these materials and make this process specific to their settings and populations.     

Patient complaints in a pediatric emergency department: averting lawsuits

All emergency departments (EDs) receive complaints from patients and their families. Consumers of pediatric emergency care are becoming more astute about the care they receive, and the malpractice climate is rapidly changing. In order to improve patient care services and reduce the frequency of lawsuits, it is crucial that pediatric emergency medicine physicians become facile at preventing and managing such complaints. All ED physicians should have a well-defined complaint management process in place. Lessons learned from the complaints should be shared with the ED health care providers. Complaints can illustrate the deficiencies in the provision of care and serve as an opportunity for improvement.     

Overcoming legal obstacles involving the voluntary care of children who are separated from their legal guardians during a disaster

A large-scale disaster may separate children from their parents or guardians and may strand many children in the care of temporary caregivers, including physicians and nurses. In general, unless a physician or nurse is a member of a public sector emergency response program (a "VHP"), parental consent is required for the treatment of minors outside of an emergency department unless the minor is suffering from an imminently life-threatening condition. Physicians or nurses who are not VHP's may be held liable (civilly, criminally and administratively) if they provide care without parental consent outside of an emergency room to a child who is not suffering from an imminently life-threatening condition. The existing rules regarding parental consent would, in many cases, limit (or at least discourage) the provision of optimal health care to children in a large-scale disaster by restricting care aimed to alleviate pain, the treatment of chronic conditions as well as the treatment of conditions, or potential conditions, that could worsen or develop in the absence of treatment.Additionally, "Good Samaritan" laws that generally limit the liability of health care providers who voluntarily provide care in an emergency may not apply when care is provided in a crude or makeshift clinic or when care is not provided at the scene of the emergency. Thus, benevolent physicians and nurses who voluntarily provide care during a large-scale disaster unjustly risk liability. The prospect of such liability may substantially deter the provision of optimal medical care to children in a disaster. This article discusses the shortcomings of current laws and proposes revisions to existing state laws. These revisions would create reasonable and appropriate liability rules for physicians and nurses providing gratuitous care in emergencies and thus would create reasonable incentives for health care providers to deliver such care. ("Gratuitous care" is the legal term for care provided voluntarily and without expectation of payment.).     

Health care for youth in the juvenile justice system

Youth in the juvenile correctional system are a high-risk population who, in many cases, have unmet physical, developmental, and mental health needs. Multiple studies have found that some of these health issues occur at higher rates than in the general adolescent population. Although some youth in the juvenile justice system have interfaced with health care providers in their community on a regular basis, others have had inconsistent or nonexistent care. The health needs of these youth are commonly identified when they are admitted to a juvenile custodial facility. Pediatricians and other health care providers play an important role in the care of these youth, and continuity between the community and the correctional facility is crucial. This policy statement provides an overview of the health needs of youth in the juvenile correctional system, including existing resources and standards for care, financing of health care within correctional facilities, and evidence-based interventions. Recommendations are provided for the provision of health care services to youth in the juvenile correctional system as well as specific areas for advocacy efforts.     

Redefining primary pediatric care for children with special health care needs: the primary care medical home

PURPOSE OF REVIEW: As considerations of the quality of health care have matured, the role of pediatric primary care providers and models for the delivery of primary care have received growing attention. Particularly for children with chronic conditions, the need for proactive, planned, and coordinated care delivered in partnership with consumers has become more apparent. The primary care medical home has emerged as a model favored by national organizations representing pediatricians and family physicians as well as national public health policy makers, yet implementation of this model remains limited and the evidence base for its value is not yet highly developed. RECENT FINDINGS: Most studies of primary care outcomes involve individual elements of the medical home such as care coordination and continuity of care. Limited data that are emerging from studies of the medical home model as a whole in practice settings suggest improvements in patient satisfaction and in some areas of utilization. No data are available that examine specific functional or physical health outcomes associated with primary care models like the medical home. SUMMARY: The pediatric primary care medical home provides a care model for both well children and those with special health care needs that expands primary care services beyond those provided in the examination room by individual providers to include systemic services such as patient registries, explicit care planning and care coordination, planned co-management with specialists, patient advocacy, and patient education. There is an immediate need for large-scale, practice-based studies of the outcomes for children and youth, providers, and the health care system when such improvements in primary care are implemented.     

Child welfare caseworkers as service brokers for youth in foster care: findings from project focus

Youth in the foster care system have substantially higher rates of mental health needs compared to the general population, yet they rarely receive targeted, evidence-based practices (EBPs). Increasingly emerging in the literature on mental health services is the importance of "brokers" or "gateway providers" of services. For youth in foster care, child welfare caseworkers often play this role. This study examines caseworker-level outcomes of Project Focus, a caseworker training and consultation model designed to improve emotional and behavioral outcomes for youth in foster care through increased linkages with EBPs. Project Focus was tested through a small, randomized trial involving four child welfare offices. Caseworkers in the Project Focus intervention group demonstrated an increased awareness of EBPs and a trend toward increased ability to identify appropriate EBP referrals for particular mental health problems but did not have significantly different rates of actual referral to EBPs. Dose of consultation was associated with general awareness of EBPs. Implications for practice and outcomes for youth are discussed.     

Homeless adolescents: common clinical concerns

Homeless youth are at alarmingly high risk for a myriad of physical and psychological problems as a result of both the circumstances that prededed their homelessness, and as a direct consequence of life on the streets. Sexually transmitted infections (STIs), pregnancy, trauma, tuberculosis, uncontrolled asthma, and dermatologic infestations are a few of the health problems with which these youth commonly present. These somatic problems are compounded by high rates of drug and alcohol abuse as well as depression and suicide. Despite the obvious need for medical services, homeless youth often do not receive appropriate medical care due to numerous individual and systems barriers impeding health care access by this population. In addition to the barriers experienced by the adult homeless population, homeless adolescents confront further hurdles stemming from their age and developmental stage. Some of these impediments include a lack of knowledge of clinic sites, fear of not being taken seriously, concerns about confidentiality, and fears of police or social services involvement. Improved access to appropriate health care is necessary if we are to better support and care for this population of young people. To effectively manage and treat homeless youth, individual providers must be aware of the diagnoses associated with homelessness, as well as the community resources available to these youth. Finally, providers need to be the voices advocating for improved services for this disadvantaged and silent population.     

Adolescent offenders with mental disorders

Thomas Grisso points out that youth with mental disorders make up a significant subgroup of youth who appear in U.S. juvenile courts. And he notes that juvenile justice systems today are struggling to determine how best to respond to those youths' needs, both to safeguard their own welfare and to reduce re-offending and its consequences for the community. In this article, Grisso examines research and clinical evidence that may help in shaping a public policy that addresses that question. Clinical science, says Grisso, offers a perspective that explains why the symptoms of mental disorders in adolescence can increase the risk of impulsive and aggressive behaviors. Research on delinquent populations suggests that youth with mental disorders are, indeed, at increased risk for engaging in behaviors that bring them to the attention of the juvenile justice system. Nevertheless, evidence indicates that most youth arrested for delinquencies do not have serious mental disorders. Grisso explains that a number of social phenomena of the past decade, such as changes in juvenile law and deficiencies in the child mental health system, appear to have been responsible for bringing far more youth with mental disorders into the juvenile justice system. Research shows that almost two-thirds of youth in juvenile justice detention centers and correctional facilities today meet criteria for one or more mental disorders. Calls for a greater emphasis on mental health treatment services in juvenile justice, however, may not be the best answer. Increasing such services in juvenile justice could simply mean that youth would need to be arrested in order to get mental health services. Moreover, many of the most effective treatment methods work best when applied in the community, while youth are with their families rather than removed from them. A more promising approach, argues Grisso, could be to develop community systems of care that create a network of services cutting across public child welfare agency boundaries. This would allow the juvenile justice system to play a more focused and limited treatment role. This role would include emergency mental health services for youth in its custody and more substantial mental health care only for the smaller share of youth who cannot be treated safely in the community. www.futureofchildren.org