Emergency Department Mental Health Presentations in Young Children Letter to the Editor “Addressing the Unique Challenges of Paediatric Mental Health Emergency Care” Response

Abstract

In reply:

We thank the authors for their thoughtful response to our article Emergency department mental health presentations in young children: a retrospective chart review [1]. Their efforts to highlight potential interventions for young children with autism spectrum disorder (ASD) who present to the Emergency Department (ED) with acute behavioural disturbance are commendable.

We agree that utilising strategies to reduce or eliminate the use of restrictive interventions including mechanical and physical restraint is a high priority when caring for young people presenting to the ED with behavioural disturbance. This is true regardless of whether the young person is neurotypical or neurodiverse. There is limited literature assessing the experience of young people when restrictive interventions are used in the context of behavioural disturbance management. Adults who were physically restrained during an episode of behavioural disturbance have reported feelings of dehumanisation as well as anxiety relating to seeking healthcare in the future [2]. Due to the negative effects of restrictive interventions, alternate strategies to manage acute behavioural disturbance are vital.

The suggestion from Chen et al. regarding the use of non-pharmacological strategies to de-escalate the young person's behaviour is logical. It is worth noting though that currently there have been no studies which have objectively assessed the effectiveness of these strategies for young people experiencing acute behavioural disturbance in the ED setting. A concerted focus on establishing an evidence base for which non-pharmacological strategies are most effective is therefore a high research priority.

We support the suggestion from the authors to consider the involvement of caregivers in guiding the most effective non-pharmacological strategies for these young people. However, an episode of acute behavioural disturbance—and in particular one that has necessitated an ED presentation—can be a unique situation. Evidence suggests that in this particular circumstance the caregivers of these young people are often overwhelmed, exhausted and have tried every strategy that would normally assist in calming their child down prior to presenting to ED [2]. These parents may therefore need to take a step back from guiding their child's management to provide them with a physical and emotional break.

It is also worth highlighting that although using least restrictive strategies is a priority in these presentations, this needs to be balanced against the risk of physical and psychological harm that these young people pose to themselves, their caregivers and to healthcare staff [3, 4]. Emergency care workers report the highest rates of occupational violence and aggression across the health system, and acute behavioural disturbance presentations account for a large proportion of these incidents [5]. The situation therefore needs to be assessed on a case-by-case basis considering the risk of both using and not using restrictive management strategies to achieve behavioural containment.

Young people with acute behavioural disturbance, in particular those with a diagnosis of ASD represent a considerable challenge in the acute care setting. We need to use all the tools available to optimise their care and develop the evidence for the most effective non-pharmacological strategies.

The authors declare no conflicts of interest.