Emergency Admissions of Children and Young People with Mental Health Needs to the Paediatric Ward
M. Wallis, F. Akhtar, M. Azam
Department of Paediatrics, Wexford General Hospital, Ireland
We have experienced a high level of emergency paediatric admissions following presentations of children and young people with perceived mental health and behavioural problems. There is a national shortage of paediatric liaison psychiatry services1 as well as a lack of agreed guidelines or explicit standards for delivering care in this context.
To help develop a strategy we therefore aimed to quantify these admissions in terms of: type of presentation; risks and associated staffing requirements; involvement of Child and Adolescent Mental Health Service (CAMHS) and other services; discharge plan.
All paediatric emergency admissions (up to the 17th birthday) between 1 August 2016 and 31 July 2017 with mental health and behavioural problems were identified from ward records and data extracted retrospectively from the charts. There were 111 admissions of 83 individuals totalling 475 bed-days. Self-harm or suicidal ideation was the presentation in (44(40%) admissions); other psychiatric symptoms (severe anxiety, depression, psychosis) in 20(18%); challenging behaviour in 22(20%); substance misuse in 19(17%); eating disorders in 4(4%) (occupying 192(40%) bed-days); and psychosomatic symptoms in 2(2%). 18 (16%) admissions were inappropriate for the paediatric ward due to challenging or intoxicated behaviour. In 48 admissions (362 bed-days) there was a high risk to patient or others; 22 (276 bed days) received individual supervision. Secondary CAMHS provided a ward assessment in 40(36%) admissions and an urgent outpatient assessment in 37(33%); 18 (16%) referrals went to the Substance Misuse team, 15 (14%) to TUSLA, 4(4%) to Community Psychology and 3 (3%) to in-patient CAMHS. 26(23%) admissions received a discharge plan in some form.
We conclude that increased provision of community CAMHS is needed to assess mental health admissions and facilitate discharge planning and production of an individual care plan 2. The National Clinical Programme for Paediatrics and Neonatology1 identified under-resourcing of CAMHS nationally, and the need for more paediatric liaison psychiatry services. As well as secondary services (the Specialist Community CAMHS Team) and tertiary services (in-patient CAMHS and specialty services such as Substance Misuse), children and adolescents with social, emotional, and behavioural difficulties may require services such as social work, primary care psychology, education psychology, and intellectual disability services. Hardly any of our patients were referred to primary care psychology, however in our area there is a long waiting time which is unhelpful for individuals presenting in crisis.
Clinical guidelines on self-harm, eating disorders and challenging behaviour, including triaging and managing risks, would have assisted us in 301 (63%) bed-days and these are now in development.
There is a high prevalence of self-harm in teenagers, and many who deliberately self-harm do not come to the attention of hospital services. A school-based survey in HSE Ireland South identified that 9.1% of 15 to 17 year olds reported previous self-harm 3. Whilst we lack evidence-based interventions to reduce the risk of recurrence or suicide in individuals who self-harm, there is evidence that mental health promotion programmes in school students reduce suicide attempts and severe suicidal ideation, and these should be made widely available 4.
Dr Maybelle Wallis, Consultant Paediatrician, Wexford General Hospital, Newtown Road, Co. Wexford, Ireland
T: 053 915 3000
1.A National Model Of Care for Paediatric Healthcare Services in Ireland. Chapter 13: CAMHS. 2015, HSE/RCPI www.hse.ie/eng/services/publications/clinical-strategy-and-programmes/child-and-adolescent-mental-health-services.pdf (Accessed 19th February 2018)
2.Child and Adolescent Mental Health Services Standard Operating Procedure. 2015, HSE CAMHS Improvement Project Group www.hse.ie/eng/services/list/4/mental-health-services/camhs/camhssop.pdf (Accessed 19th February 2018)
3.Morey C, Corcoran P, Arensman E, Perry IJ. The prevalence of self-reported deliberate self-harm in Irish adolescents. BMC Public Health 2008 Feb 28; 8:79.
4.Wasserman D, Hoven CW, Wasserman C, Wall M, Eisenberg R, Hadlaczky, G Kelleher I, Sarchiapone M, Apter A, Balazs J, Bobes J, Brunner R, Corcoran P, Cosman D, Guillemin F, Haring C, Iosue M, Kaess M, Kahn J-P, Keeley H, Musa GJ, Nemes B, Postuvan V, Saiz P, Reiter-Theil S, Varnik A, Varnik P, Carli V. School-based suicide prevention programmes: the SEYLE cluster-randomised, controlled trial. Lancet 2015 Apr; 385(9977):1536-44.