Presentation of aggressive children and adolescents to paediatric emergency departments

Authors


Professor Peter Birleson, Wundeela Centre, 21 Ware Crescent, Ringwood East, Vic. 3135, Australia. Fax: +61 3 98717973; email: peter.birleson@maroondah.org.au

The article by Wolfenden et al.1 on the increasing presentation of aggressive children and adolescents to paediatric emergency departments (ED) is important. It highlights a phenomenon that seems related to changes in society as well as to shortages of primary care services. Despite the Commonwealth Government's espoused commitment to supporting families, increasing numbers of children are in trouble. At least 500 000 or 14% of Australian children and adolescents showed significant mental health problems in the recent National Survey2. The impact of these problems is often severe and creates major burden on children and others. Mental ill health is associated with poor physical health, increased rates of accident and injury, suicide and self-harm, poor emotional regulation, conflicted family and peer relationships, violence and aggression3. The same risk factors associated with poor mental health also increase rates of child abuse, family violence, substance misuse and delinquency4. These factors include low socio-economic status and poverty, large family size and single or blended family status, parental stress and mental illness or personality disorder, family conflict and incompetent parenting. Too many children are not being adequately parented, socialized or supported.

The National Survey also showed that parents present child mental health problems to paediatricians as they do not know of other services or are worried about expense2. Children's doctors are expected to understand behaviour problems and to know what to do when children act aggressively, antisocially or illogically. Access to specialist child and adolescent mental health services (CAMHS) is poorer for children than for adults across Australia2. On average, we spend $23 per head each year on mental health services for children and adolescents, compared to almost $95 per adult and $103 per aged person5. While under 18 year olds form almost 30% of the population, no states direct more than 10% of their total mental health funding to this age group. No states fund systematic crisis assessment teams for children and adolescents. Some adult psychiatry crisis assessment services provide limited coverage for children presenting to general hospital EDs, but  these are not available in all states. On-call services for hospital-based child and adolescent psychiatric inpatient units usually provide only limited back-up to paediatric EDs.

Planning for the 3rd National Mental Health Plan, has identified the need for prevention strategies to reduce prevalence of mental health problems and demand for services, as well as for better access to clinical services for established disorders6. The Wolfenden study shows that the children presenting to paediatric EDs with aggression and self-harm currently receive limited follow-up, although they are at risk of further self-harming and have increased mortality rates. This group should receive priority in planning new services. Antisocial children and adolescents incur greatly increased costs to our society, as well as to their families7. These young people are usually poor at problem-solving and have persistent vulnerabilities that impair their learning and emotional regulation. They are at risk of antisocial behaviour in adulthood, as well as for other mental health problems and substance abuse8. While the children and adolescents themselves may not always want help, their parents usually do, but may find difficulty in following through. Our current services leave children at risk and expose our hospital staff to risk of harm too.

Comprehensive action to address these problems should include the following:

  • 1Increasing research on conduct problems and aggression in childhood, its context and cost effective interventions.
  • 2Improving assessment at critical phases for children (school entry and school transition) and targeting interventions to those with emotional and social vulnerabilities.
  • 3Using brief psychiatric assessment tools in paediatric EDs to screen all children presenting with aggression, self-harming and extreme behaviours and identify those in need of help.
  • 4Developing protocols in paediatric EDs for ensuring more reliable pathways to care and follow-up by the most appropriate mental health service after presentation.
  • 5Seeking improved hospital consultation and liaison services to paediatric EDs with systematic linkages and supports from Child and Adolescent Mental Health Services.
  • 6Ensuring aggression management training of all ED staff, as a compulsory element of Hospital Occupational Health and Safety, with professional development to include additional training in assessing and managing mental health problems.
  • 7Strengthening systems of care to provide mental health expertise through ED staff after hours, and include processes for advising, educating and supporting parents.

Some of the above can be developed locally, while others need State government action. Arrangements for planning and funding Acute Health and Mental Health services in Australia are separate in all States, but should not be barriers to change. Wolfenden et al. have helped to identify the result of inaction, which include unnecessary deaths. Paediatricians and Mental Health Service managers now need to work together with each other, and with Health Departments, to implement and evaluate some solutions.

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