How to assess pediatric mental health emergencies

By Sara Moore-Gruver and Rachel Moore

Many people enter EMS eager to learn about taking vitals, recognizing the signs of a stroke, and how to quickly assess and treat trauma patients. They imagine car wrecks and fires, cardiac arrests and heart attacks.

What we don’t often imagine are the other images, like the 12-year-old in the back of the police car after having an aggressive meltdown in school or the 15-year-old, staring blankly as you ask how much Tylenol they overdosed on. We are often called upon to treat patients with medical and traumatic complaints, but more and more, we are asked to treat patients who are also having a mental health emergency, including pediatrics.

According to the CDC, 17.4% of children, or 1 in 6, now have a diagnosed mental health, behavioral, or developmental disorder. While not all of these children will ever have a mental health emergency that requires hospitalization, the COVID-19 pandemic has seen a sharp increase in pediatric mental health emergency room visits. During the first 42 weeks of 2020, there was a weekly average of 3,025 pediatric mental health emergency room visits. The exact numbers are unclear, but it is likely that many of these patients were transported to the ED by EMS.

Pediatric mental health emergencies: Signs and symptoms

Differential diagnosis is important when treating pediatric mental health emergencies, particularly because some calls that are medical in nature may initially present with psychiatric symptoms. Hypoglycemia commonly presents with disorientation, crying, aggressiveness and altered mental status. Head injury, stroke, and even seizure without tonic-clonic movement can all present as an altered mental status. As such, EMS providers should always consider and rule out root or comorbid medical conditions when presented with patients who are displaying psychiatric symptoms.

Likewise, sometimes a mental health emergency can disguise itself as a medical emergency. Patients with anxiety who hyperventilate will often present as if having localized seizure activity. Overdose patients may present with medical symptoms and not mention what they took or that they are depressed. The patient history will help correct possible wrong assumptions from scene size up.

Assessment

Assessment for mental health emergencies, or other emergencies that involve a behavioral barrier to treatment, begins just like any other call. During the scene size up, it’s likely that the patient presents with a high level of agitation and arousal due to the increased stress of lights, sirens, and strange people on top of the initial injury or illness. Maintaining a calm approach can help regulate the nervous system of the patient. This can be done by limiting the number of people interacting with the patient, approaching without lights or sirens, and using a calm demeanor and tone of voice.

A psychiatric or behavioral patient who is yelling or aggressive is displaying an unregulated nervous system that is most likely stuck in “fight or flight” mode. Speak loudly if you must in order to be heard, but do not yell or lose control of your own emotions. You’re the professional on scene and you set the tone. Others will increase or decrease their emotional levels to match yours, so direct supporting agency staff to follow your lead.

Obtaining a history of behavioral, emotional, and psychiatric diagnoses is imperative, including any medications or recent hospitalizations for such. The standard OPQRST method for obtaining a history of the presenting problem can be altered for mental health emergencies to help you cover the important information.

• O – How long have you struggled with [problem]?
• P – What makes it better or worse for you, and what triggered it this time?
• Q – Can you describe how it feels in your body and what thoughts you’re having?
• R – How has this gotten worse, or how will I know if this is getting worse for you?
• S – On a scale of 1 to 10, how bad is this making you feel right now?
• T – That time did this specific incident start for you?

Additionally, not requiring the patient to use words can be helpful as the language center of the brain can be blocked in hyperarousal states. Offering materials for drawing or writing an answer can be helpful, as can asking a parent or guardian to answer if appropriate.

Questions that may not help diagnose the patient but that can help support the patient during transport are “what can I do to make you feel safe right now?,” and “would you like to call your parents?,” along with offering distractions, music if possible, and physical comfort such as blankets or a weighted object across the lap.

Treatment

There are some considerations to adhere to de-escalate agitated patients and emphasize safety when treating patients experiencing a mental health emergency.

Do not touch the patient without first asking permission, even if they are in a heightened state of crisis and may not respond to you. Physical exams should be done distally to proximally while explaining everything as you go. Do not make surprise moves or fail to warn the patient that a blood pressure cuff or IV start will hurt. This will only aggravate the patient and cause them to lose whatever trust they may have in you.

Special considerations

With pediatric patients, let the parent or caregiver take the lead on de-escalation if necessary. Ask if there are any special interests, such as Pokemon or a movie series. Use those interests to build rapport with your patient. For example, if the patient has an interest in Pokemon, ask which one is their favorite or favorite type. You can also tell the patient you don’t know anything about their interest and ask questions. If the patient likes a specific song or music and you have the capability on a smart phone, go ahead and play the favorite song. Building rapport is important with any patient, but especially with those who are in a mental health emergency.

If a patient is excessively aggressive, follow your local protocols for chemical and physical restraints while still calmly verbalizing what is happening to them. Documenting patient restraint and continuous patient monitoring after restraint are essential and cannot be overemphasized.

All patients, regardless of complaint, history, or disability, are ultimately people first. Treating your patients with kindness and respect will always help defuse tense situations and help the patient in their recovery. Remembering that safety is not just physical, but also cognitive and emotional, is the starting place for making a positive difference in pediatric mental health crises.

About the authors

Sara Moore-Gruver has been a paramedic for 13 years, most recently working for Erway Ambulance in Elmira, NY. She also holds a master’s degree in education and frequently speaks on topics concerning EMS and special populations, particularly autism and mental health emergencies.

Rachel Moore holds a master’s degree in social work and specializes in the treatment of first responders. She has been involved in fire and EMS since 2003 and is a retired critical care paramedic. As sisters, Sara and Rachel grew up in a family dedicated to the volunteer fire service and bring a fresh perspective to the issues surrounding EMS and patients with special needs.

This article, originally published in January 2022, has been updated.