The year 2020 has presented tremendous challenges and changes to all fields of medicine. As this pandemic has grown in size and impact, there has been growing concern about the impact of social, economic and political stressors on mental health (MH). Early data from the CDC has shown rising prevalence of symptoms of anxiety, substance abuse, suicidal ideations, and depressive disorders across all ages, with a disproportionate prevalence amongst young adults (62.9% in 18-24yo vs 30.9% in all ages) and racial minorities.1 Data on children and teens is still being collected, but thus far points to similar increases in children and teens.2 As COVID continues to affect our communities, physicians must be on alert for these growing psychiatric concerns.
One of the major changes for youth has been the closure of schools and subsequent shift to online education. Children of all ages across the state are now learning virtually and screen time is surpassing the limits recommended by AAP. While public opinion often considers social media as having a negative impact on MH, the data around this is mixed.4,5 Rather than focusing on social media use itself, it may be more helpful to look at specific exposures to negative aspects of social media, such as online bullying, sexual exploitation, and trauma exposure.5,6 An example that has received considerable media attention this year is the prevalence across social media platforms of videos depicting police brutality of minorities. The American Academy of Child and Adolescent Psychiatry (AACAP) recommends parents have an active, hands on role in helping children process information they have learned from the news about tragedies.3 When children view these images on social media, they often lack the parental support and context, and may experience higher stress related responses.7 As screen time increases, parents should be advised to remain engaged in what their children are viewing and how they are processing that information. Physicians should also be ready to discuss in detail how patients are using their screen time and how it may be affecting their mood and thoughts.
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By: Kristin Weinschenk, MD and Michael Lowley, MD
The primary goal of the psychiatric evaluation in an ED setting is to assess the safety of the individual, and to connect them with resources at the appropriate level of care. This begins at triage with a screening tool called the ASQ (Ask Suicide-Screening Questions to Everyone in Medical Setting), a five-item questionnaire which flags patients for risk of recent or current thoughts of self-harm. A positive screen will then trigger referral for amore detailed evaluation by either the psychiatric social worker in the ED, or by a member of the Psychiatry Consult Liaison service. The MH professional will conduct a psychosocial assessment, and complete a more detailed suicide risk assessment tool called the BSSA. Once level of risk is established, the treatment plan will reflect the need for appropriate safety and monitoring, whether at an inpatient psychiatric hospital or in a less restrictive care setting.
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Many primary care providers are on the front lines of fielding questions and identifying symptoms of psychiatric illness in children and adolescents in the community setting. We have put together a quick guide that addresses some common questions and concerns on how to refer non-emergent psychiatric concerns to community outpatient resources and avoid unnecessary and costly ED visits
What kind of services are and are not available to children with psychiatric/behavioral complaints in the ED?
Psychiatric assessments in the medical ED setting are brief and focused. They are not full psychiatric evaluations and are not meant to provide new diagnosis or start new medications. They are simply a crisis assessment to evaluate for the child’s safety and the safety of others. If a patient is deemed unsafe to self or others, they will be transferred to a primary psychiatric facility for further treatment. It is an assumption of many community providers that patients with psychiatric complaints must first be directed to a medical facility for “medical clearance”. In fact, all psychiatric facilities are emergency receiving facilities and have the resources to provide medical clearance and directly accept healthy patients with behavioral and psychiatric complaints. Most psychiatric hospitals perform psychiatric assessments 24/7, and can place a patient on a 1013 or admit them voluntarily. Psychiatric facilities can also refer families to outpatient or lower levels of care if inpatient psychiatric hospitalization is not warranted. PLEASE NOTE CHOA DOES NOT HAVE INPATIENT PSYCHIATRY SERVICES.