Whether to admit “behavioral” children from ED

[Psyche0248]

I’m a CL psychiatrist who sees ED consults also (relatively new, <4 months) and am frequently seeing children presenting to the ED with the following:

- Behavioral issues, for example any combination of: threats at school toward peers, violence at home toward family, self-harming when dysregulated by banging head, hitting self, ingesting objects, etc.

- Most seem to carry diagnoses of ODD or DMDD, ADHD, conduct disorder, or ASD;

- They usually have an outpatient
psychiatrist who is at a loss of what to do and are hoping for inpatient admission for “stabilization”;

- They have had repeated acute hospitalizations that didn’t lead to an appreciable improvement / reduction in frequency or severity of symptoms;

- Inpatient psych hospitals (already limited in this area, especially for those with ASD) are now familiar with many of these children by name and are declining based on not being capable of providing treatment, never mind not having physical capacity;

- Parents “don’t feel safe” with the child at home, and I can’t really blame them;

- These children may sit in the ED for days or weeks without being placed and ultimately are discharged home with maybe a med change or two;

- These are kids too young for juvenile detention (also, police will only bring them to the ED even if parents want to press charges against their 13-18 year old);

- The wait to get into residential programs is over a year or more…

- DSS does little to nothing to help, even if they’ve been involved already;


What do you tend to do with these children, and what is your thought process? I’m sure the answer of whether to admit is “it depends”, but I’d like to know how others approach this. I’ve seen psychiatrists in other systems (I don’t have many colleagues here in psych unfortunately) recommend inpatient and wait until that happens regardless of how long it takes, and I’ve also seen them say this is not behavior that is modifiable by inpatient treatment and discharge regardless of parents’ objections.

These kids are undoubtedly at continued risk of harm to self or others, possibly even imminently, but the risks are chronic. Some of them will even continue to keep endorsing SI to try to stay in the hospital since they seem unhappy with a tumultuous home life, or they make a suicidal gesture at discharge so we will keep them (and these are often very young children who don’t really know about lethal methods and have unrealistic ideas of what can kill them).

I suppose the same question of whether to admit also extends to behavioral disturbances stemming from dementia (with no primary psychiatric disorder and no delirium at play).

---

Members don't see this ad.

 

[Shikima]

Honestly, you're making the argument for needing more therapists and case managers for teaching people how to live differently. We need 1000 fold increase in clinicians to teach people better living rather than bandaid and embellishment strategies hoping that will quiet down the use of services.

 

[wolfvgang22]

Honestly, you're making the argument for needing more therapists and case managers for teaching people how to live differently. We need 1000 fold increase in clinicians to teach people better living rather than bandaid and embellishment strategies hoping that will quiet down the use of services.

True, but this doesn't help us for today's disposition.

For me, if I have a good support team, I document why hospitalization isn't going to be helpful or appropriate and schedule frequent follow ups. If I don't have a lot of social work support, I continue to admit, continue make the needs for more support known to hospital and clinic and Child Protective Services administration and wait for admin and CPS to start listening. I document every single time I make recommendations that aren't followed. I also let our local and state reps and judges know.

 

[Psyche0248]

True, but this doesn't help us for today's disposition.

For me, if I have a good support team, I document why hospitalization isn't going to be helpful or appropriate and schedule frequent follow ups. If I don't have a lot of social work support, I continue to admit, continue make the needs for more support known to hospital and clinic and Child Protective Services administration and wait for admin and CPS to start listening. I document every single time I make recommendations that aren't followed. I also let our local and state reps and judges know.

Thanks for your reply. At my hospital social work does send out referrals to the psychiatric hospitals, but they don’t help schedule outpatient appointments or talk to the families much as intermediaries. They don’t coordinate with patients’ outpatient therapists or psychiatrists either (perhaps that is what I am meant to do as the psychiatrist, but due to patient volume this just isn’t usually possible).

Generally speaking, I’m in a smaller area that doesn’t have any PHP/IOPs for children. Getting a patient established with outpatient quickly is basically not possible. We are on the lower end nationally for number of psych beds per capita as well. It just feels like a system doomed to fail, yet whenever I get a consult down in the ED for one of these kids, it seems as if the buck stops with me (the liability, the kid’s safety, the family’s hopelessness, etc.).

 

[wolfvgang22]

Thanks for your reply. At my hospital social work does send out referrals to the psychiatric hospitals, but they don’t help schedule outpatient appointments or talk to the families much as intermediaries. They don’t coordinate with patients’ outpatient therapists or psychiatrists either (perhaps that is what I am meant to do as the psychiatrist, but due to patient volume this just isn’t usually possible).

Generally speaking, I’m in a smaller area that doesn’t have any PHP/IOPs for children. Getting a patient established with outpatient quickly is basically not possible. We are on the lower end nationally for number of psych beds per capita as well. It just feels like a system doomed to fail, yet whenever I get a consult down in the ED for one of these kids, it seems as if the buck stops with me (the liability, the kid’s safety, the family’s hopelessness, etc.).

This is literally social work. It's great you do what you can but ultimately the hospital or local government need to hire and assign a social worker to coordinate.

It is OK to document what the scope of your duties are, what you have tried to do to help, and what the patient actually needs, and who you informed about the needs that are not being met.

If no changes are made over several months of asking, I would be looking for a new position. Once I have other jobs lined up, or if I can afford to be jobless while I find a new job, I would inform administration they are about to lose their psychiatrist because of this situation. I have found when I've been able and willing to walk suddenly solutions begin to occur and everyone wants to have problem-solving meetings.

 

[splik]

This is a complex issue that you can't solve alone. And even the hospital system cannot but you can develop a standardized protocol of how to deal with this situation. Hospitals don't want psych patients clogging up ER beds for weeks on end. The EM docs hate it, and the hospital is almost certainly losing money on that and it is just terrible all round. I would suggest you (or your service line director if not you) convene a meeting with EM leadership, SW leadership, risk management, and peds and any other relevant stakeholders (sometimes the CMO may be interested in this) to discuss what to do. You don't have the power to make SW more helpful but other people do (though often staffing is a rate limiting step). While not ideal, it may be preferable to have these patients admitted to peds rather than board in the ER if there are no psych beds available or no hope in hell of admitting to psych. If the patients won't benefit from being in the hospital and it reinforces unhealthy behaviors then you may get blessing from risk management to discharge them over parent's objections.

Where I worked the hospital spent millions of dollars on partnerships to send adult pts who would clog up the ED into other settings because it was much cheaper than having them board endlessly in the ED or repeatedly present. People often get frustrated with C-L psych for not being able to deal with this issue, but ultimately this is a systems based problem and there has to be the political will from those who control the levers of power to develop creative solutions.

 

[clozareal]

I agree that this is a systems issue and agree with splik in spearheading a plan with the hospital leadership.

Other than that, getting them connected to outpatient care is critical. The type of services is individualized for each patient. mentioned a bunch of different case presentations, but each one requires a different type of intervention so it's hard to generalize.

• These patients need wrap around services in the community to thrive, not in hospital or residential settings. This can also help prevent patients from coming into the hospital. In my area, we have these wrap around services respond at school and at home, where the therapist or social worker comes every day.
• Families need help with safety planning, including strategies for managing aggressive behaviors and self-harm, as well as identifying sources of support for the family. The families need to feel confident in managing aggressive behaviors. Often times they lack the skills to do so.
• Families also need respite. I have many low functioning ASD kids who have 1:1 care because of their severity and even then they're destroying stuff and climbing over walls. At least the parents get some rest.
• If the patient has autism, then they need ABA or some other sort of daily help with problematic behaviors.
• The schools need to be involved in helping with special education services for these kids, including getting OT, speech therapy, 1:1 aide, and other supports so they can stay in school and families can have respite or work.

 

[Candidate2017]

Behavioral issues =/= psychiatric issues.

We need to accept this fact. Until we do, society/hospitals/school/police/judges/families will continue to expect us to medicate and/or hospitalize our way out of this.

 

[calvnandhobbs68]

Ahh bringing me back to ER call during fellowship...

Yeah this happens all the time in peds EDs. Higher risk of this happening if you don't have a robust system in your state of county mental health or developmental disability boards who can work on putting these kids into longer term family/home based therapy programs or residential programs if needed. Overall as others have mentioned this is mostly from either a lack of resources in the area, lack of parents connecting with these resources (which happens not infrequently actually) or both.

Typically systems resources tend to be higher with kids with an ASD or true developmental/intellectual disability diagnosis because it opens them up to getting support easier with behavioral consultants at school/home and ABA or a similar intense multiple day a week outpatient therapy. The kids who "just" have an ADHD diagnosis but are still having severely disruptive behaviors might be harder to connect but it's often helpful to learn the ins and outs of certain states...for instance where I did fellowship an ODD/DMDD diagnosis on top of ADHD would open up more resources since it indicated a higher level of severity.

You do end up having to discharge a significant amount of these kids from the ER because most inpatient psych units (legitimately in most cases) won't even consider taking them. The vast majority of the time this is primarily a lack of outpatient support or connection with outpatient support. It certainly depends on the level of violence but I absolutely discharged kids who were breaking things, destroying property, threatening people they were mad at, etc. The parents don't like it but most of this stuff is not gonna be modified by a 5 day hospital stay. If the parents "don't feel safe" taking them home, we would explain to them that they can either take the kid home or they essentially can give up their rights and give the kid up to DCFS...sometimes that actually happens and actually gets things moving faster because they're now in DCFS custody and they have a high incentive to place this kid somewhere (usually a residential program initially).

You need more robust social work support for sure. You might explain to the administration that paying a social worker to be in the ER 7AM-7PM to assist with this stuff is likely to be much more cost effective than keeping even a handful of these kids in the ER or medically boarded for days.

 

[comp1]

Not a CAP (thank goodness), but taking the age out of it these sure do sound like PHP/IOP cases to me. These particular patients don't generally stop their ED presentations when they turn 18. In person settings would definitely be best, but virtual is available while you are waiting for a residential program to open up. Lots of people don't feel safe about a lot of things, but sometimes we have to do them anyways...

 

[MedMan80]

It really is a case by case thing. In fellowship, patient/family would be seen by child psych and social workers and they would determine if admission or not, our lives were made easier as we had an adolescent unit at the least, so adolescents wouldn't linger forever. The chronic kids we wouldn't admit typically unless imminent acuity. We typically wouldn't fold into borderliny behavior to force an admission, I think it worked pretty well. It also helped that the hospital had good admin/reputation and we wouldn't take kindly to dumps from group homes/state facilities, but not every hospital is good like that

 

[Mad Jack]

It really depends on the situation. Some need inpatient, some need better outpatient resources, some need DCF intervention, etc. Figuring out which one needs what took me two years of fellowship and sometimes I still am at a loss because what they need just doesn't exist.

 

[Mad Jack]

Not a CAP (thank goodness), but taking the age out of it these sure do sound like PHP/IOP cases to me. These particular patients don't generally stop their ED presentations when they turn 18. In person settings would definitely be best, but virtual is available while you are waiting for a residential program to open up. Lots of people don't feel safe about a lot of things, but sometimes we have to do them anyways...

Problem is, most of these kids aren't stable enough to cooperate with IOP/PHP. If they are it is a great option for many though

 

[Merovinge]

Firstly, when making a flowchart in your head with these cases the first split should be ASD/neuroatypical or neurotypical. The ASD population has very different needs/treatment and shares essentially nothing in common with behavioral disturbances due to conduct d/o, SLS, or trauma.

If ASD/ID patient is not on meds and having severe aggression that threatens the lives of themselves or others, that's slam dunk admission to get things going with atypicals. Getting ABA or other in-home therapy resources will be huge. Making sure they have an outpatient doc to follow up with, ideally CAP, 2nd place adult psychiatrist, 3rd place PCP who is willing to carry forward meds until psych can see them. Respite care is a great idea to find resources for.

Conduct disorder/ODD patients that are chronic in nature may be better served in the juvenile detention system which, depending on your area, have more wrap around services. If they are aggressive enough to be in this situation off-lable meds can certainly be considered. Mentoring and social engagement (group and/or individually) is often more helpful than therapy or pharmacologic based interventions. If someone needs to cool off for a few days, there are worse things than an IP admission, but it will certainly not fix the problem and these patients can cause havoc on IP units.

Self-injury/ingestions in the complex trauma situation is at the very top of complexity to treat. Good RTCs that focus on SIB exist but are tough to come by, it never hurts to get on a wait list. Your hand may be forced using IP as a temporizing bandaid. If the patient can engage with PHP that is also a good option. You will need to make sure the caregiver has realistic expectations about what can be done and source control the enviornment as best as possible. Some places have more long-term IP units which can be a good option as well.

At the end of the day, you need to eval for acute changes in circumstances that warrant IP and when these are not present, let families know the best available resources in the area. The later part should come through your social work team, but it never hurts to have conversations and familiarize yourself with what is out there. If the system is too broken for this to work, I echo the idea of finding a different job. It's not worth burning out over when you can add value to thousands or tens of thousands of lives over a career.

 

[smalltownpsych]

Firstly, when making a flowchart in your head with these cases the first split should be ASD/neuroatypical or neurotypical. The ASD population has very different needs/treatment and shares essentially nothing in common with behavioral disturbances due to conduct d/o, SLS, or trauma.

If ASD/ID patient is not on meds and having severe aggression that threatens the lives of themselves or others, that's slam dunk admission to get things going with atypicals. Getting ABA or other in-home therapy resources will be huge. Making sure they have an outpatient doc to follow up with, ideally CAP, 2nd place adult psychiatrist, 3rd place PCP who is willing to carry forward meds until psych can see them. Respite care is a great idea to find resources for.

Conduct disorder/ODD patients that are chronic in nature may be better served in the juvenile detention system which, depending on your area, have more wrap around services. If they are aggressive enough to be in this situation off-lable meds can certainly be considered. Mentoring and social engagement (group and/or individually) is often more helpful than therapy or pharmacologic based interventions. If someone needs to cool off for a few days, there are worse things than an IP admission, but it will certainly not fix the problem and these patients can cause havoc on IP units.

Self-injury/ingestions in the complex trauma situation is at the very top of complexity to treat. Good RTCs that focus on SIB exist but are tough to come by, it never hurts to get on a wait list. Your hand may be forced using IP as a temporizing bandaid. If the patient can engage with PHP that is also a good option. You will need to make sure the caregiver has realistic expectations about what can be done and source control the enviornment as best as possible. Some places have more long-term IP units which can be a good option as well.

At the end of the day, you need to eval for acute changes in circumstances that warrant IP and when these are not present, let families know the best available resources in the area. The later part should come through your social work team, but it never hurts to have conversations and familiarize yourself with what is out there. If the system is too broken for this to work, I echo the idea of finding a different job. It's not worth burning out over when you can add value to thousands or tens of thousands of lives over a career.

Great answer. The first group, with an autism diagnosis, should be able to get more community services and involvement and a brief stay in the hospital to calm everyone down and add a med that can help with this and seek more support can make sense.

100% agree that the more defiant/aggressive types, unless there is some obvious psychiatric issue like psychosis or mania, really heed to be punted out as soon as possible and psychotherapy and meds are not the answer at all. These angry kids are just going to be more angry that they have to see me in outpatient.

The final group, trauma and self-harm, SI types, is where the system really falls short and these are the ones that can most be helped by psychotherapy, but we tend to underdose it. I charge $2500 a month for this group in an IOP that involves each week: two individual sessions, two to three hours of community based mentoring, 30 minutes of parent update, coaching, and treatment planning, and one hour of group. Effective medication strategies can also be helpful with the group so long as everyone is crystal clear that it is not the cure.

 

[Merovinge]

Great answer. The first group, with an autism diagnosis, should be able to get more community services and involvement and a brief stay in the hospital to calm everyone down and add a med that can help with this and seek more support can make sense.

100% agree that the more defiant/aggressive types, unless there is some obvious psychiatric issue like psychosis or mania, really heed to be punted out as soon as possible and psychotherapy and meds are not the answer at all. These angry kids are just going to be more angry that they have to see me in outpatient.

The final group, trauma and self-harm, SI types, is where the system really falls short and these are the ones that can most be helped by psychotherapy, but we tend to underdose it. I charge $2500 a month for this group in an IOP that involves each week: two individual sessions, two to three hours of community based mentoring, 30 minutes of parent update, coaching, and treatment planning, and one hour of group. Effective medication strategies can also be helpful with the group so long as everyone is crystal clear that it is not the cure.

Love the model, absolutely agree we are failing some/many of these teens. That's a very reasonable price for all that it entails, sure would be nice if it were covered by insurance so everyone could access it.

As an aside, I would partner directly with an MD if I were you to have that full continuity of care instead of having to be in contact with dozens of different outpatient psychiatrists. People could even opt out if they had a strong relationship with an outpatient psychiatrist.

 

[smalltownpsych]

Love the model, absolutely agree we are failing some/many of these teens. That's a very reasonable price for all that it entails, sure would be nice if it were covered by insurance so everyone could access it.

As an aside, I would partner directly with an MD if I were you to have that full continuity of care instead of having to be in contact with dozens of different outpatient psychiatrists. People could even opt out if they had a strong relationship with an outpatient psychiatrist.

Completely agree and I keep trying to find one. 🤨
We have three in our town. One does mostly ketamine, the other does mostly tms, and the other won’t work with Bipolar or history of psychotic disorder or kids which are most of patients I have that most urgently need psychiatry. Going to try a teledoc next and the next option is a 45 minute drive.
My dream is to build a business big enough that I could pay or share enough revenue for a good psychiatrist. I could build it quicker if I had a psychiatrist along with me, but looks like I’ll have to do the legwork and then see if I can find one down the road.