As the director of Child Psychiatry Emergency Services at Massachusetts General Hospital, Laura Prager, MD, has seen countless families in moments of crisis. In an interview with childmind.org, Dr. Prager talks about the behaviors and problems that tend to send kids to the ER, the role parents play, and what we can do to get these kids help before they are in acute distress.

What are the most common psychiatric problems that send children to the ER?

The most common would be behavioral dysregulation. A child who is “out of control,” whether it’s a seven-year-old who attacked Grandma and scraped up her face with his fingernails, or the 17-year-old, 70-kilo guy who’s trashed his room. Those kids come to the ER because 911 has been called.

There’s also a huge percentage of kids who come in with self-injurious behavior or suicidal ideation or having made a suicide attempt.

And now there are also the kids who are sent directly from school, for either of those problems. So, a behavioral outburst, or somebody saying “I’m going to kill myself,” or “I’m going to kill somebody else.” That could be a manic kid; it could be a psychotic kid; it could be a conduct disorder kid—we see anybody who says anything about hurting themselves or anyone else.

Related: A Parents Guide to Getting Good Care for Your Child

And then we have the category of socioeconomic distress. The “I can’t manage anymore” case. That might be a four-year-old who’s brought in for agitation. He pushed his two-year-old sibling, but when you try to unravel that, you might find that it’s a single mother living in a hotel with four children under the age of five, and the four-year-old happens to be the identified patient, but it’s just a crazy situation and it’s untenable and nobody could manage it.

And then there are the intoxicated kids. Sometimes we know what they’re on; sometimes we don’t. Some 53% of our cases are between the ages of 15 and 19. Of that group, about 50% of those have co-morbid substance abuse issues.

Do most of the parents you see have a good understanding of what’s wrong with their kids?

Only a very small percentage. But the reason for that is not a lack of psychoeducation, because many of the kids who come to see us are kids who have been in the system, in one way or another, for a while. It’s more because of hope. It’s more because parents, I think, are always hoping that this is just a minor blip on the radar screen. And that, sure, things are not going well right now, but it will really be okay.

And it’s hard to argue with hope of that kind, of optimism, if you will. You could call it denial, but I like to call it hope—that the child who attacked his grandmother was just having a tantrum. Too much sugar. Or not enough sugar.

The lack of outpatient services is the biggest single reason kids with psychiatric problems end up in the ER—because the care simply don’t exist or because insurance doesn’t cover it.

It puts us in a complicated position when we feel a child needs to be hospitalized. I just dealt with this yesterday, when a child came in who had actually written something saying, “I hate myself. I want to die.” Had a plan. He had ideation, he had a plan, he had intent. This kid was fourteen or fifteen. The mother said, “Well, I just don’t think he’s going to do anything.”

Well, I don’t have a crystal ball. I don’t think you do either. I think you hope that he won’t do anything. But all of the things that we know about are suggesting that he actually has a plan, and he’s sort of written it out. And maybe he plans to carry it through and has the means to do so. And those cases are very labor-intensive, because you have to spend a lot of time helping the parent to get to the place where they’re saying, “Okay, I think the child needs more help than I can offer at this moment.”

The thing is that parents do probably know their child best. They certainly know their kids better than we do. But they may not be seeing the big picture. They may only be seeing the part of the picture that they can tolerate seeing.

Pediatricians are like this too: “The child will just grow out of it.” Because most of the things pediatricians have seen—the normal range of childish behavior—they will grow out of it! Development is wonderful like that! They are actually going to stop eating their oatmeal off the floor. It is going to happen that way.

But that’s not the case with the kids we see—people don’t come into a major metropolitan emergency room for things their kids are going to grow out of. It’s the rare case, the rare family, that comes into the ER without a real problem.

Have most of the kids you see in the ER been treated before they get to you?

Some kids really haven’t gotten any care. So things have kind of festered and gone on, they reach a breaking point, and the emergency room is where they turn. In the same way that if you have a stomach ache, and it gets a little worse, it gets a little better, it gets so bad, it’s 3:00 in the morning, finally you come in and you have your appendix out. It’s that kind of thing except that the timeframe is longer. It’s not days. It could be years.

We see a lot of “polypharmacy”—kids who come in on five or six different medicines. Sometimes the five or six medicines are necessary, and sometimes we can see that they’re just having the kitchen sink thrown at them, and that the medicines have now become part of the problem.

But there are also some children who are very, very sick, and even if they have really good outpatient care, there are going to be times when that is not sufficient, and when they’re going to need to go into a higher level of care. The route to a higher level of care is usually through an emergency room, primarily because of insurers, but also because many of these kids are involved with substances, or they may have taken less or more of a medicine that we need to evaluate, or they may have significant medical morbidities.

Do you see a lot of children who are taking multiple medications?

We see a lot of “polypharmacy”—kids who come in on five or six different medicines. Sometimes the five or six medicines are necessary, and sometimes we can see that they’re just having the kitchen sink thrown at them, and that the medicines have now become part of the problem.

Sometimes even just one medicine can cause a problem. I remember very clearly one of the first cases I ever saw, many, many years ago, was a lovely little girl who was five years old, who came in because she thought she could fly. And she was in one of our holding rooms trying to fly. In fact, we had to take everything out of the holding room, because she was leaping off of the stretcher, flapping her wings and hitting the wall. So we had put the mattress on the floor.

And her problem really was that somebody had thought that they should start her on Prozac, and they put her on a little bit, and then they thought that a little bit was good, so more would be better, and they upped the dose. And she had gotten quite manic on Prozac. And so, just one small medication being managed by somebody who wasn’t paying too much attention—that’s what you can get.

One of the things that we do not do in my emergency room is we do not ever prescribe psychotropic medicines for children. You cannot come in to get your scripts refilled. You cannot come in and have me start you on a medicine and go back into the community. And the reason that I do that is you can’t follow these kids—like my little girl on the Prozac. I will call the pediatrician and help them initiate something, if they feel comfortable and they want to follow the child. I will arrange for the child to have an outpatient caregiver if I can. But I will not do that from the ER.

We have in the emergency room full-time resource specialists who will arrange for every level of care, including inpatient beds. We tell them what kind of level of care we want, and they will arrange for that. Outpatient care is the most difficult thing to arrange, because there just simply isn’t enough. Even the academic medical centers in the state of Massachusetts don’t maintain outpatient clinics, because they’re not sustainable financially.

The lack of outpatient services is the biggest single reason kids with psychiatric problems end up in the ER—because the care simply don’t exist or because insurance doesn’t cover it.

Dr. Prager is assistant professor of psychiatry (child psychiatry) at Harvard Medical School and director of the Child Psychiatry Emergency Service at Massachusetts General Hospital. She is the author, with Dr. Abigail Donovan, of Suicide by Security Blanket, which is available at Amazon. Read an excerpt of the book here.

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