Curr Psychiatry Rep (2016) 18:41
DOI 10.1007/s11920-016-0670-9
COMPLEX MEDICAL-PSYCHIATRIC ISSUES (MB RIBA, SECTION EDITOR)
Child Psychiatric Emergencies: Updates on Trends, Clinical Care,
and Practice Challenges
Beau Carubia 1,3 & Amy Becker 1,2 & B. Harrison Levine 3
# Springer Science+Business Media New York 2016
Abstract Over the past 15 years, the number of pediatric
patients presenting to the emergency room in psychiatric crisis
has nearly doubled. Suicidality and aggression are among the
most common presenting problems, making it important for
providers to have up-to-date knowledge about the assessment
and management of these frequently encountered clinical is-
sues. Psychometrically sound suicide risk assessment tools are
available for use in the emergency room setting, which can be
administered efficiently with minimal provider training. Rates
of off-label medication use in the pediatric population contin-
ue to increase and are often used in the management of acute
agitation in the pediatric population. The current literature will
be reviewed and summarized for application in emergent
treatment settings. Overall, evidence to inform best practice
is limited, leading to opportunities for innovation in health
care delivery, the development of new research aims, and dis-
cussion of challenging clinical dilemmas.
Keywords Pediatric . Suicide . Agitation . Chemical
restraint . Psychiatric emergency
This article is part of the Topical Collection on Complex Medical-
Psychiatric Issues
* Beau Carubia
Beau.carubia@childrenscolorado.org
1
Department of Psychiatry, University of Colorado, Aurora, CO, USA
2
Psychiatric Emergency Service, Childrens Hospital Colorado,
Aurora, CO, USA
3
B. Harrison Levine, MD, Inc., Denver, CO, USA
Introduction
It is estimated that 1020 % of children and adolescents suffer
from a mental disorder or substance use problem, which trans-
lates into nearly eight million youth in need of care [14]. The
Patient Protection and Affordable Care Act (ACA) signed into
law in 2010 allowed states to expand Medicaid eligibility and
simplify enrollment in the State Childrens Health Insurance
Program, reforms that took effect in early 2014 with the po-
tential to improve health care accessibility for children. In July
of the same year, the US Department of Health and Human
Services awarded over 54 million dollars in ACA funding to
support the development of mental health services in 47 states
and Puerto Rico, and a survey published by the National
Alliance of Mental Illness in December 2014 demonstrated
that 29 states and the District of Columbia increased funding
for mental health services for the fiscal year 2015 [5]. In spite
of these advances, however, it is estimated that as few as one
in six youth with mental health problems receive needed treat-
ment [6]. More than 3000 general inpatient psychiatric beds
were lost between 2009 and 2012, and the average wait time
for an appointment with a child and adolescent psychiatrist is
estimated to be nearly 8 weeks [5]. These waits are likely due
to the critical workforce shortage in child and adolescent psy-
chiatry. The American Medical Association estimates that as
of 2012, there are only 8300 practicing child and adolescent
psychiatrists in the country, whereas the projected need is 30,
000 [7, 8].
In the context of an overwhelmed and shifting mental
health system of care, pediatric patients are presenting to
emergency rooms in psychiatric crisis in increasing numbers.
Updated analysis of the National Hospital Ambulatory
Medical Care Survey data demonstrates the percentage of
emergency department (ED) visits for psychiatric conditions
increased from 4.4 % in 2001 to 7.2 % in 2011. Among
41 Page 2 of 8
children, those between the ages of 12 and 17 account for
the majority of psychiatric ED visits, and children who
are publicly insured or have no insurance are four times
more likely to be seen for a psychiatric emergency than
those with private insurance [9, 10]. The volume of
child psychiatric emergency room visits tends to vary
with the school calendar, with fewer visits occurring dur-
ing the summer months, and presentations tend to occur
most often in the evening [6, 11]. One Canadian study
demonstrated that acuity ratings for pediatric patients pre-
senting in psychiatric crisis has decreased between 2002
and 2012, a finding replicated during a 2010 review of
ED pediatric psychiatric services in Virginia, suggesting
that patients are utilizing the emergency department as a
way to have their non-urgent mental health needs ad-
dressed because they are unable to access care in an al-
ternate setting [12, 13]. Length of stay (LOS) in EDs
averages about 5 hours, consistently exceeding pediatric
ED visits for other conditions by over 1 hour. Longer
LOS is associated with patients leaving before receiving
assessment or critical intervention for their psychiatric
crisis; key factors associated with greater LOS are the
need for transfer and psychiatric admission. Length of
stay also varies geographically and is negatively correlat-
ed with the availability of inpatient child psychiatric beds
[14, 15]. There is a strong consensus among national pro-
fessional organizations, including the Institute of
Medicine, the American Academy of Pediatrics, and the
National Institute of Mental Health, that standards of care
and provider education are needed to address this
burgeoning clinical need; however, clinical practice is cur-
rently heterogeneous, often based on available expertise
and resources, and lacks evidence base to inform best
practice [16, 17, 18]. Pediatric patients present to EDs
with varied chief complaints and psychiatric crises, the
most common being depression, suicidal ideation, and vi-
olent behaviors [19].
Clinical Care: Suicide
According to the results of the 2013 National Youth Risk
Behavior Survey, 17 % of a sample of over 13,000 high school
students reported having Bseriously considered attempting
suicide^ during the 12 months prior to the survey. Nearly
14 % of students reported making a suicide plan, and 8 % a
suicide attempt [20]. Suicide is the second leading cause of
death for youth in the USA resulting in over 2000 deaths in the
1019 age group in the year 2012 [21]. The emergency room
is a crucial environment for suicide screening, intervention,
and prevention to occur. Studies have shown that the children
seeking health and mental health ED services are at high risk
for psychiatric problems including suicidality. One study
Curr Psychiatry Rep (2016) 18:41
found that the frequency of visits to the emergency room by
suicidal patients has increased in recent years from 0.8 to 1.5
per 1000 in the USA from 1992 to 2001 [2224]. With over
one million adolescents utilizing the emergency room as their
primary source of medical care, clinical encounters in the
emergency room present important opportunities to identify
patients at risk for suicide that would not otherwise be seen by
medical or mental health professionals. Additionally elevating
the importance of suicide screening at the time of an emergen-
cy room encounter is the knowledge that a significant propor-
tion of adolescents that go on to complete suicide seek med-
ical attention within the year prior to their attempts [2527].
While the public health and clinical concern for youth suicide
compel pediatric providers to seize opportunities for potential-
ly lifesaving intervention in the emergency room setting, sys-
tems of care are also required to respond to requirements of the
Joint Commission on Accreditation of Healthcare
Organizations to conduct suicide risk assessments with pa-
tients that present with emotional or behavioral problems [28].
Attitudes and Beliefs About Suicide Screening
Despite the importance of identifying youth at risk for suicide
in the emergency room, studies show that suicide screening is
completed by only a minority of general and pediatric emer-
gency room providers [23, 29]. Surveys of emergency room
providers, including both physicians and nurses, demonstrate
their awareness about the high prevalence of pediatric depres-
sion and suicidality and the need for suicide screening, but
they often cite concerns regarding patient acceptability of
screening, time constraints, and lack of training about suicide
screening as barriers for incorporating such screening into
routine clinical practice [29, 30].
Despite the concerns of providers, surveys of patients and
caregivers presenting to emergency rooms with chief com-
plaints that were both psychiatric and non-psychiatric in na-
ture consistently report high levels of acceptability of mental
health and suicide screening [27, 31]. A qualitative study of
pediatric patients that were screened for suicide risk noted that
screening was a way Bfor patients to feel known, heard and
understood^ by an unbiased listener. They also described
screening as an important way for Bindividuals who were at
risk (to) receive help that would prevent later suicidal
behavior.^ [32].
Studies of feasibility also suggest that provider-perceived
barriers may be overstated. For example, a 2007 study con-
ducted in a pediatric emergency room in an urban, tertiary care
hospital analyzed the addition of a self-administered, comput-
erized suicide screening to patient care. The screening was
completed in parallel to medical assessment and treatment,
and providers reported that the screenings did not impede their
ability to complete their clinical work [27].
Curr Psychiatry Rep (2016) 18:41
Suicide Risk Assessment Tools
Multiple factors should be considered in selecting a suicide
risk screening tool for use in the emergency room. Screeners
should not only be valid and reliable and have high sensitivity
and specificity for identifying those youth at risk but should
also be efficient and require minimal training for administra-
tion and interpretation of results. The evidence base to support
the preferential use of one screening tool remains limited.
Below is an overview of several pediatric screening tools that
have been used in ED settings.
The Reynolds Suicide Ideation Questionnaire (SIQ) is a
screening tool that has been studied in clinical and school-
based samples of youth and has established psychometric
properties in identifying the frequency and severity of suicidal
ideation [33, 34]. It is often the criterion standard against
which other rating scales are measured to determine their va-
lidity. The SIQ is a self-report measure and has the advantage
of the availability of normative scores to aid in the interpreta-
tion of results. The SIQ is available in two versions for youth:
a 30-item questionnaire for adolescents 15 years and older
(SIQ), and a 15-item questionnaire for those under the age
of 15 (SIQ-JR). It is estimated that the measure can be deliv-
ered in 10 minutes or less and is recommended that for suc-
cessful administration and interpretation, providers have spe-
cialty training and experience in the use of clinical behavioral
assessment instruments.
The Columbia Suicide Severity Rating Scale is another
screener that has been specifically studied in youth presenting
to the emergency room with a psychiatric chief complaint
[35, 36]. It is a semi-structured interview that not only iden-
tifies current suicide risk but also appears to have validity in
predicting future return to the ED with suicidal ideation or
post suicide attempt. The length of time to complete the as-
sessment is variable and dependent upon responses. Training
is required to administer this scale; computer-based training is
available.
The Ask Suicide-Screening Questions (ASQ) may be
particularly useful in pediatric ED settings as it is both
psychometrically sound and brief. This four-item ques-
tionnaire was developed from a set of 17 candidate
questions. The responses of 524 youth to the candidate
questions were compared via logistic regression analysis
models to the results of the lengthier SIQ to determine
which four-question combination most accurately
assessed suicide risk. The ASQ appeared not only to
have good sensitivity, specificity, and predictive values
but was estimated to take less than 2 minutes to admin-
ister [37]. The instrument has the advantage of being
studied with both psychiatric patients and those present-
ing to the emergency room with medical or surgical
complaints. Further study is necessary to establish the
best procedures for administering this screener.
Page 3 of 8 41
Clinical Care: Agitation
As previously mentioned, pediatric patients present to EDs
with various psychiatric crises, including depression, suicidal
ideation, and violent behaviors [19]. When these behaviors
threaten the safety of the patient or others, acute intervention
becomes necessary. The desired outcome in the management
of an agitated youth is the prevention of harm to self or others,
including family members and ED staff [38, 39]. As described
by Sonnier et al., Bacute agitation is defined as a state of
behavioral dyscontrol that will likely result in harm to the
patient or healthcare workers without intervention^ [40]. A
practitioner should strive to use the least restrictive means
possible to provide this level of safety to a youth, but when
this is not possible, physical and/or chemical restraint may
become necessary.
The use of restraint in the pediatric emergency setting has
become more common. A retrospective observational study,
conducted over two consecutive years, looked at youth who
presented to an urban pediatric ED requiring an emergent
psychiatric evaluation (n = 1125). Investigators found that
6.8 % of the youth required a restraint during their evaluation,
of which 49 % were physical restraint, 25 % medication re-
straint, and 26 % both physical and medication restraint. In
this study, out-of-control behaviors were correlated with re-
straint use [41]. Similarly, a retrospective chart review by
Baeza et al. examined the management of Baggressive events
requiring an intervention^ in an adolescent inpatient psychi-
atric unit over a 2-year period. Twenty-eight percent of the
adolescents had at least one aggressive event recorded, and
in 95.6 % of the cases, the first-line intervention used was
pharmacologic, specifically 29.5 % antipsychotic alone,
38.8 % combination or alternation of antipsychotics and sed-
atives, 23.3 % antihistamines, and 5.6 % sedative alone [42].
A recent paper discussing the rising trends in antipsy-
chotic prescriptions for youth with behavioral problems es-
timated an approximate twofold to fivefold increase in off-
label use of antipsychotics in preschool-aged children over
the past 1015 years [43]. Common off-label uses of anti-
psychotics in children and adolescents include treatment of
disruptive behaviors, aggression in typically developed and
developmentally delayed children, oppositional defiant dis-
order (ODD), conduct disorder (CD), posttraumatic stress
disorder (PTSD), attention-deficit hyperactivity disorder
(ADHD), sleep disorders, and depressive disorders [44,
45]. In a recent national survey sent to 1600 randomly se-
lected child and adolescent psychiatrists, 36 % reported
occasional off-label use of second generation antipsy-
chotics (SGAs), 65 % felt the best option for management
of aggressive behaviors in Autism Spectrum Disorder
(ASD) were SGAs, and 29 % believed SGAs were the best
option for management of children with aberrant behaviors,
including assaultiveness and destruction of property [46].
41 Page 4 of 8 Curr Psychiatry Rep (2016) 18:41

Considerations for Pharmacologic Management
of Agitation
Given the high prevalence of the use of emergency medica-
tions in the pediatric population, it is imperative that practi-
tioners are afforded the ability to make evidence-based treat-
ment selections in the management of behavioral emergen-
cies. First, it is important to consider the evidence base for
the most commonly used medication classes.
Several systematic reviews (including meta-analyses) and
guidelines have been published regarding the evidence-based
treatments for acute agitation in the pediatric population in the
last 5 years. Through a steering group of national experts, the
Resource for Advancing Childrens Health (REACH) Institute
and the Center for Education and Research on Mental Health
Therapeutics (CERT) developed the Treatment of
Maladaptive Aggression in Youth (T-MAY) guidelines [47,
48]. This group identified 28 placebo-control studies, 5 fo-
cusing on ASD, and the others on ODD, ADHD, and CD, that
directly measured aggression and evaluated a pharmacologic
intervention [48]. They found the SGAs had the most
favorable number needed to treat (NNT) of 3 (compared to 4
for both lithium and stimulants). In the reviewed studies com-
paring risperidone to placebo, the mean effect size (ES) for
aggression was 0.72 compared to 0.60 for stimulants and 0.47
for mood stabilizers. In the one, small study evaluating halo-
peridol versus placebo, the ES was noted to be 0.83 [48].
Building from the T-MAY guidelines, a multidisciplinary
Canadian consensus group also conducted a systematic re-
view with the aim of developing evidence-based treatment
guidelines for oppositional behavior, conduct problems, and
aggression in children and adolescents [49, 51]. Studies
were identified for risperidone, quetiapine, haloperidol,
valproate, lithium, and carbamazepine versus placebo in chil-
dren diagnosed with ODD or CD with or without ADHD
[49]. Valproate, lithium, and carbamazepine displayed little
positive effect [49]. The authors also found minimal
supporting evidence for the use of haloperidol in the treatment
of aggression in youth with CD and recommended strongly
against its use [49, 51]. One small study evaluating the
effectiveness of quetiapine on aggression in adolescents with
CD with or without ADHD found a standard mean difference

Table 1 FDA-approved first-

and second-generation antipsy- Drug name Age of approval Approved clinical indication
chotics for use in the pediatric
population FGA
Chlopromazine Age 112 years Schizophrenia; bipolar disorder, type I; severe behavioral problems
(i.e., explosiveness, combativeness); hyperactive behaviors with
CDs
Haloperidol 3 years of age Severe behavioral problems and hyperactive behavior;
schizophrenia; psychosis; Tourettes syndrome
Thioridazine 5 years of age Schizophrenia
Trifluoperazine 6 years of age Schizophrenia
Thiothixene 12 years of age Schizophrenia
Molindone 12 years of age Schizophrenia
Perphenazine 12 years of age Schizophrenia
Pimozide 12 years of age Tourettes syndrome
Prochlorperazine 2 years of age Schizophrenia
and 20 lbs
Droperidol BChildren^ Agitation
SGA
Risperidone Age 516 years Autism-irritability
10 years of age Bipolar disorder, type I
13 years of age Schizophrenia
Aripiprazole Age 617 years Autism-irritability
10 years of age Bipolar disorder, type I
13 years of age Schizophrenia
Quetiapine 10 years of age Bipolar disorder, type I
13 years of age Schizophrenia
Olanzapine 13 years of age Bipolar disorder, type I; schizophrenia
Asenapine 10 years of age Bipolar disorder, type I
Paliperidone 12 years of age Schizophrenia

FGA first-generation antipsychotic, SGA second-generation antipsychotic, CD conduct disorders

Curr Psychiatry Rep (2016) 18:41
ES of 1.6; however, the authors cautioned against over inter-
pretation of the large effect size given the very low quality of
this study and provided a recommendation of conditional
against its use [49]. In trials of risperidone versus placebo,
the authors found a standard mean difference ES of 0.72 in
conduct problems and aggression in youth with low intelli-
gence quotient (IQ) and ODD or CD, with or without ADHD,
and a standard mean difference ES of 0.60 in disruptive and
aggressive behavior in youth with average IQ and ODD or
CD, with or without ADHD. In this review, risperidone was
the only SGA or first-generation antipsychotic (FGA) to re-
ceive a recommendation of conditional in favor of use, with
caution advised secondary to the potential side effect burden
[49].
Three years ago, Pringsheim et al. published a systematic
review of SGAs for the treatment of disruptive behavior dis-
orders in children and found weak placebo-controlled evi-
dence for the use of SGAs other than risperidone, and also
found weak evidence for the use of the SGAs in youth with
average IQs [50]. Building off this initial review, Pringsheim
et al. conducted another systematic review and meta-analysis
evaluating trials of antipsychotics, lithium, and anticonvul-
sants in the treatment of youth with ADHD, ODD, and CD
with aggression and conduct problems [51]. In accordance
with the Canadian review, the authors found limited empirical
support for the use of haloperidol, quetiapine, and mood sta-
bilizers. In the one study of thioridazine in youth with sub-
average IQ and ADHD or CD, no primary outcome was
Table 2 Pharmacologic agents to
consider for pediatric chemical Drug class/drug name
restraint
FGA
Haloperidol
Droperidol
Chlorpromazine
SGA
Risperidone
Olanzapine
Benzodiazepine
Lorazepam
Midazolam
Antihistamine
Diphenhydramine
PO oral, IM intramuscular, IV intravenous, ODT oral disintegrating tablet, IN intranasal
a
Lexi-Comp Online, Hudson, Ohio: Lexi-Comp Inc.; 2015; Sept 26th, 2015. All doses should be determined
individually based on weight, age, and pertinent medical conditions
Page 5 of 8 41
measured. The authors concluded that risperidone has a mod-
erate effect on conduct problems and aggression in children
with average and sub-average IQ, with stronger evidence
supporting its use with the sub-average IQ population [51].
Seida et al. performed a comparative effectiveness analysis
of studies identified through a systematic review to evaluate
the efficacy and safety of antipsychotic use in youth with
psychiatric and behavioral problems [52]. The authors eval-
uated 64 trials and 17 cohort studies. They found minimal or
insufficient evidence for all comparisons of FGAs versus pla-
cebo, FGAs versus other FGAs, and FGAs versus SGAs
[52]. They did find moderate evidence for SGAs versus pla-
cebo in improvement of Clinical Global Impressions (CGI)
and decreased behavioral symptoms for disruptive behavior
disorders. In regards to tolerability, key findings included
olanzapine causing the highest levels of dyslipidemia and
weight gain and risperidone causing the most prolactin-
related events [52].
Another interesting FGA, droperidol, with a well-known
FDA black box warning for proarrhythmic effects secondary
to potential QT prolongation was recently reviewed in the
adult literature [53]. The authors found doses up to 10 mg to
be efficacious and safe for sedation and as an intervention for
agitation [53]. The American Academy of Emergency
Medicine recently released a position statement on droperidol
use in the ED setting, finding that Bdroperidol is an effective
and safe medication in the treatment of nausea, headache, and
agitation^ [53]. Swank et al. conducted a chart review over
Administration routes Initial dose rangea
PO, IM, IV PO: 0.5 to 5 mg
IM: 0.05 to 0.15 mg/kg; max 5 mg/dose
IM, IV IM/IV: 0.030.07 mg/kg/dose up to max 2.5 mg/dose
without cardiac monitor
PO, IM PO/IM: 0.55 mg/kg/dose
PO, ODT PO: 0.252mg
ODT: 0.252 mg
PO, ODT PO: 2.55 mg
ODT: 2.55 mg
PO, IM, IV PO/IM/IV: 0.050.1 mg/kg/dose to max dose 2 mg/dose
PO, IM, IN PO: 0.250.5/mg/kg/dose; max 20 mg
IM: 0.10.15 mg/kg/dose; max 10 mg
IN: 0.20.3 mg/kg to max of 10 mg
PO, IM PO/IM: 1 mg/kg/dose to max 50 mg/dose
41 Page 6 of 8
32 months for droperidol use in the ED setting for patients
<21 years of age [54]. They found that 86 % of the identified
cases were given droperidol for the management of agitation
(mean dose = 4 mg). The use of droperidol demonstrated
86.6 % effectiveness in controlling symptoms, and they found
no sign of arrhythmias in any patient [54].
There is little evidence in the literature supporting the use
of benzodiazepines to target agitation in the pediatric popula-
tion; however, it is largely known that these agents have pow-
erful sedation and anxiolytic properties, which may aid in
rapid sedation of an agitated youth [39]. Similarly, there is
also no empirical evidence for the use of antihistamines
targeting aggression or agitation in youth [42].
It is also important to consider current Federal Drug
Administration (FDA) approvals for medications commonly
used to treat aggressive behavior in children. As shown in
Table 1, only chlopromazine, haloperidol, droperidol, risperi-
done, and aripiprazole carry FDA indications for aggression
and/or irritability, often for select subsets of the pediatric
population.
A summary of pharmacologic agents to consider for chem-
ical restraint is listed in Table 2. Risperidone has the most
evidence supporting its use as an intervention for children
with disruptive behavior disorders and comorbid agitation,
especially children with ASD or lowaverage IQ [48,
49]. No other SGAs have empirical support for their use,
and there is limited data supporting the use of FGAs or mood
stabilizers. Given the unknown efficacy, the known side effect
burdens, and the unknown long-term risk of the use of many
or all of these agents, a practitioner must remain conservative
in the use of these agents as a chemical restraint.
Conclusions
Children and adolescents are presenting to emergency rooms
in psychiatric crisis in increasing numbers, and just as the
cause for this trend is likely multi-factorial, so must be our
professional response to address this burgeoning clinical need.
Standards of care and evidence-based models for practice are
often lacking, and our ability to build our collective knowl-
edge will be enhanced by our use of common definitions. One
important distinction to make will be clarifying the difference
between what constitutes Burgent^ and Bemergent^ condi-
tions. Diverting non-emergent patients from emergency
rooms is one possible approach to address the issue of over-
crowding. Indeed, novel programs are being developed and
piloted across the country, such as the School Based Referral
Program to the Urgent Evaluation Service (UES) at
Maimonides Medical Center in Brooklyn, New York, whose
aim is to collaborate with school providers in the diversion of
non-emergent referrals for urgent, same-day evaluations in an
outpatient setting [55].
Curr Psychiatry Rep (2016) 18:41
Suicide screening and prevention is also on the fore-
front of the minds of pediatric providers as clinical en-
counters in the emergency room present important op-
portunities for intervention. Developing the evidence ba-
se for accurate and efficient screening and intervention
is an important area that requires further investigation.
Promising work in this area includes the Emergency
Department Screen for Teens at Risk for Suicide (ED-
STARS), a national, multi-site collaboration funded by
the National Institute of Mental Health whose aim is to
develop a computer-based screening tool which will aid
our ability to effectively assess and stratify suicide risk
in our adolescent patients. This project is currently
ongoing.
In the management of behaviors placing a patient at risk of
harm to self or others, a practitioner has three main tools that
may be deployed: behavioral de-escalation techniques, seclu-
sion, and physical and/or chemical restraint. All measures
must be taken to exercise the least restrictive means possible
in affording safety to a patient and surrounding others [40, 45].
However, when these measures fail, a more restrictive inter-
vention becomes imminently necessary. Such situations are
fraught with a unique ethical and clinical challenge in the
day-to-day management of behavioral emergencies, the bal-
ance of non-maleficence and beneficence. One must afford a
safe environment to the patient and staff but must also accom-
plish the management of behavioral agitation and aggression
with the least amount of risk of harm to the patient.
Compounding this dilemma may also be a change in treatment
culture with more reliance on chemical restraint rather than
physical restraint. This shift in management approach is likely
the result of deaths of children that occurred and were publi-
cized in the late 1990s that had potential links to physical
restraint. Those tragic events led to changes in the regulations
governing the use of restraints from the Centers for Medicare
and Medicaid Services, as well as the Joint Commission for
the Accreditation of Hospital Organizations [18]. Given this
trend, it is critical that we develop a more robust evidence base
for the use of pharmacologic agents in these situations.
And, perhaps most important for our ability to compe-
tently address the psychiatric clinical needs of the emer-
gency room setting, including the assessment and treat-
ment of pediatric patients that present with depression,
suicidality, and agitation, is training and education that
equips pediatric providers with the requisite skills and
knowledge, thereby extending the reach of a limited spe-
cialty workforce. The American Association for
Emergency Psychiatry Education Committee has devel-
oped a model training curriculum, content which may
serve as a useful template for training our colleagues in
pediatrics and emergency medicine in the proper screen-
ing and assessment of suicidal behavior and the treatment
of agitation and aggression in pediatric populations [56].
Curr Psychiatry Rep (2016) 18:41
Compliance with Ethical Standards
Conflict of Interest Amy Becker, Beau Carubia, and B. Harrison
Levine declare that they have no conflict of interest.
Human and Animal Rights and Informed Consent This article does
not contain any studies with human or animal subjects performed by any
of the authors.
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