2023 14th Annual NUBE Conference

A common presentation to the pediatric emergency room is that of a return to school evaluation. A child is commonly sent to the ER after a statement is made that they are going to hurt themselves or others and the consultant is tasked with answering whether there is an acute risk, or not, i.e., can they go back to school, or not? With mental health-related pediatric emergency room visits increasing by 8% annually between 2011 and 2020 (accounting for more than 13% of all emergency room visits among youth)1, and the American Academy of Pediatrics, the American Academy of Child and Adolescent Psychiatry, and the Children’s Hospital Association declaring a national emergency in child and adolescent mental health in the fall of 20212, physicians will be faced with these types of evaluations more often, and discussion around how to best evaluate and treat these cases is key to helping children and adolescents facing mental health crises.A child can present to the emergency room with a request from the school for a physician to comment on whether they can return to school or not. This is asking for a consultant to evaluate chronic vs acute risk and often what was the mitigating factor, and if it can be changed. One must ask a series of questions to begin to evaluate the risk such as: What was said? To whom was it said? Have there been other times when this has been said? It is helpful to know who the audience was and what was the setting when the comment was made. Did the child have a goal in mind when the statement was made? For this question, particularly looking at any history of tardiness, school refusal, or truancy. Chronic risk factors are also evaluated such as, do they have a history of self-harm, suicidal ideation, or attempts, and are weapons in the home, or do they have access to them at all? We would also look at any history of violence or aggression. Substance use, and whether they were under the influence is also an important point in a comprehensive assessment. The evaluation does not stop with the child, but often includes parents (or legal guardians) and their involvement. At times one must also involve law enforcement or Child Protective Services. Typically, once the child arrives in the emergency room, their presentation is vastly different, and it helps to ask, “What has potentially changed since this behavior took place?” During this session we will look at these questions, how to decide if a psychiatric consult is needed, and potential dispositions through brief case reviews. Our goal in these scenarios is to assess for general safety, discuss when it is necessary to involve psychiatry, potential outcomes, and dispositions, as well as highlight needs for reporting/considerations for reporting. We will also look at challenges in evaluation, particularly in those with intellectual disabilities or on the autism spectrum.

Learning Objectives:

1. To discuss school “ordered” evaluations and what they are requesting; Does it need to involve psychiatry?
2. To review key elements of a safety evaluation.
3. To discuss potential dispositions. Is reporting to authorities necessary? Ensuring there is a plan in place for safety. Discuss documenting the presence of the safety plan in specifics.