Mental Health Aspects of Emergency Medical Services for Children ...

ACADEMIC EMERGENCY MEDICINE • December 2001, Volume 8, Number 12

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SPECIAL CONTRIBUTIONS Mental Health Aspects of Emergency Medical Services for Children: Summary of a Consensus Conference LISA HOROWITZ, PHD, MPH, NANCY KASSAM-ADAMS, PHD, JACK BERGSTEIN, MD

Abstract. Objective: To address the mental health needs of children involved in emergency medical services (EMS). Methods: A multidisciplinary consensus conference convened to identify mental health needs of children and their families related to pediatric medical emergencies, to examine the impact of psychological aspects of emergencies on recovery and satisfaction with care, and to delineate research questions related to mental health aspects of medical emergencies involving children. Results: The consensus group found that psychological and behavioral factors affect physical as well as emotional recovery after medical emergencies. Children’s reactions are critically affected by age and developmental level,

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HE essential connection between physical and mental health is increasingly recognized in the health care arena (Institute of Medicine, 2001; U.S. Surgeon General, 1999). The interplay between psychological and emotional functioning and physical well-being is especially evident during pediatric medical emergencies and their aftermath (Athey, O’Malley, Henderson, & Ball, 1997). Ill or injured children receiving emergency medical care may experience psychological distress with potentially serious consequences for their physical and mental health. Without proper attention to the mental health concerns of patients presenting with medical emergencies, optimal health care outcomes for children and their families can be compromised. Nevertheless, in a busy emergency department (ED), psychological and behavioral symptoms often go unrecognized and untreated. From Children’s Hospital Boston (LH), Boston, MA; Children’s Hospital of Philadelphia (NKA), Philadelphia, PA; and West Virginia University Hospitals and Jon Michael Moore Trauma Center (JB), Morgantown, WV. Received March 21, 2001; accepted March 27, 2001. Address for correspondence and reprints: Nancy Kassam-Adams, TraumaLink, 3535 10th Floor, Children’s Hospital of Philadelphia, 34th Street & Civic Center Boulevard, Philadelphia, PA 19104. E-mail: [email protected] 䉷2001 Society of Pediatric Psychology. A related commentary appears on page 1182.

characteristics of the emergency medical event, and parent reactions. As frontline health care providers, EMS staff members are in a pivotal position to recognize and effectively manage the mental health needs of patients and their families. Conclusions: Ecological changes in emergency departments, such as linkages to mental health follow-up services, training of EMS providers and mental health professionals, and focused research that provides an empirical basis for practice, are necessary components for improving current standards of health care. Key words: emergency services; mental health services; medical treatment (general). ACADEMIC EMERGENCY MEDICINE 2001; 8:1187–1196

Formal mental health services for children are available in only a small minority of EDs (U.S. Consumer Product Safety Commission, 1997). Serving as frontline providers, emergency medical services (EMS) staff members are in a pivotal position to intervene to mitigate negative psychological sequelae. All multidisciplinary staff involved in pediatric emergency care and transport (including physicians, nurses, psychologists, social workers, emergency medical technicians, and others) have a potential role to play in addressing the emotional needs of children. This article presents a summary of a national consensus conference on the mental health needs of children involved in emergency medical services, convened by the American Psychological Association (APA) under the auspices of the Emergency Medical Services for Children (EMSC). The conference brought together expert clinicians and researchers representing most of the major disciplines involved in children’s emergency medical services practice and research, including emergency physicians, emergency nurses, paramedics and emergency medical technicians (EMTs), pediatricians, trauma surgeons, pediatric and child clinical psychologists, child psychiatrists, and social workers. The charge to this consensus group was to identify the scope of mental health needs of

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children and their families related to a pediatric medical emergency, to examine the impact of psychological aspects of emergencies on children’s recovery and on patient/family satisfaction with emergency care, and to identify research questions related to mental health aspects of medical emergencies involving children. By highlighting the results of the conference discussions, we hope to draw attention to the potential public health threat of overlooking important mental health factors in the treatment of pediatric medical emergencies. Strategies for improving emergency health care for children, as well as targeted areas for research, are forwarded. The consensus conference conclusions are grounded in and build on earlier reviews of the literature (Athey et al., 1997; Institute of Medicine, 1993) and a recently published annotated bibliography (Horowitz, Schreiber, Hare, Walker, & Talley, 1999). This report will focus on the psychological reactions of children and parents involved in emergency medical services, the implications of these reactions for children’s mental and physical recovery and for family satisfaction with services, barriers to addressing mental health needs in the ED, and consensus recommendations for intervention and research strategies. It is not intended to cover the specific needs of children whose presentation in the emergency department is for primary mental health concerns. For the purposes of this report, psychological reactions are the emotional, behavioral, and cognitive components of children’s responses to medical emergencies and emergency medical treatment.

CHILDREN’S AND FAMILIES’ PSYCHOLOGICAL AND BEHAVIORAL REACTIONS TO MEDICAL EMERGENCIES Children present to the EMS system for a broad range of illnesses and injuries. Children’s emotional response to a medical emergency depends on several key factors, such as the age and developmental level of the child; both the actual and perceived severity of the event; the severity of physical pain; and the child’s cognitive ability to understand, ask questions about, and discuss the event (Athey et al., 1997). How the event occurred is a critical factor. Illness, unintentional injuries, incidents of self-harm, abuse, and violence variably affect the child and his or her psychological response. Another mediating factor is the child’s relationship with his or her parents/guardians and family members (Athey et al., 1997). The manner in which a family reacts and supports the child through a medical crisis can greatly affect the child’s recovery. In addition, certain disease states and medication side effects can influence behavior

Horowitz et al. • MENTAL HEALTH ASPECTS OF EMSC

and mental status. For example, an acute asthma attack often evokes severe anxiety (Lapin & Clouthier, 1995). For these reasons, it is important for EMS staff to pay close attention to anxiety and to try to decipher its etiology. Children who are otherwise psychologically well-adjusted can experience high levels of emotional arousal and distress in a medical crisis. Providers are cautioned against interpreting the child’s or the family’s reactions as abnormal; rather, emotional and behavioral responses may be understandable reactions to acute psychological and physiological stressors (Koocher, 1996). Family Involvement. The consensus group emphasized the essential role of parents and other caretakers in a child’s health care experience. This is a unique aspect of pediatric emergency care compared to adult emergency services—the child is not the only patient who requires attention. Parents are central to children’s recovery—they are generally the child’s best resource for support and coping with stress and play a vital role in the child’s follow-up care after discharge from the ED. Attending to the needs of parents and family is crucial to the child’s healthy recovery (Athey et al., 1997; Roberts, 1992). Because communicating with parents is extremely important in obtaining historical information and consent for treatment, understanding the parent’s emotional experience can be critical to the child’s care. Because family structures vary, and these relationships can affect the behavior and interactions between child patients and the adults who accompany them to the ED, staff must be sensitive to family variations as they interview children and their adult caretakers. A child’s primary caretaker(s) may be single, married, or divorced parents; a child may live in a biological, adoptive, or foster family; and crucial caretaking responsibilities may be shared by extended family and informal family members. We will use ‘‘parent’’ and ‘‘caretaker’’ interchangeably throughout this article to refer to any important adult caretaker in a child’s life. Serious injury or illness of a child is a tremendous stressor for a caretaker. Parents react to emergencies in a number of ways, and their level of concern may not always be proportional to the severity of their child’s condition (Athey et al., 1997). Parental responses are mediated by a number of psychological factors, including guilt, fear, concern over finances, shock, anger, fatigue, confusion, and frustration. The parent’s own preexisting stress or health problems may make it more difficult to cope with the additional stress of a child’s health crisis. Parents of newborns are in a particularly high stress category for many reasons, including worry over the fragility of a newborn’s


life, sleep deprivation, and sudden alterations in their infant’s behavior and in their new role as parents (Seideman et al., 1997). Empathic communication between staff and parents can greatly reduce a parent’s anxiety (Wilman, 1997). Parent responses can strongly influence a child’s reaction, as witnessing a parent’s anxiety can be alarming to a child who typically looks to a parent to gauge his or her own responses to a situation. The parent’s own stress reactions may adversely affect his or her ability to comfort the child, to comprehend medical information and participate in decisions regarding the child’s medical care, and to remember instructions regarding caring for the child’s health needs after discharge from the hospital. Therefore, directly addressing a parent’s distress not only helps the parent but also benefits the child and the health care provider. Developmental Context. The consensus group noted the central importance of understanding the developmental context of medical emergencies for children and highlighted the following issues for each developmental stage. Infants. For infants and toddlers experiencing a medical emergency, discomfort is the primary stressor, usually caused by feeling pain, being in an unfamiliar setting, being handled by strangers, and experiencing basic needs like hunger and the lack of sleep that are exacerbated by a long visit in the ED. An infant’s or toddler’s attachment to parents is a key strength to draw on at this stage; a parent’s involvement in all aspects of treatment can be extremely helpful. Conversely, separation from parents, even during brief medical procedures, can in itself be a severe stressor for very young children. Preschoolers. Preschoolers experience similar anxieties and require soothing and comfort from those familiar to them. The key strength of this age group is that most preschoolers can express themselves verbally and engage in simple conversations. Nevertheless, because their communication skills are still quite limited, preschoolers may misinterpret what is occurring (i.e., perceiving that they are being ‘‘hurt’’ by the physician trying to treat them) and may feel anxious, helpless, or overwhelmed by the sensory overload of a busy ED. It is not unusual for a child of this age to display extreme behavior (temper tantrums, hyperactivity, incontinence, acting clingy, shy, or atypically silent) when normal life is suddenly disrupted. Again, parents are the primary source of comfort and support. Recognizing the importance of the parent–child relationship is key. Enlisting the parents in supporting the child during treatment is critical.

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School-age Children. These children can comprehend much more than their younger counterparts; greater language skills and increased understanding help them cope with challenges such as a medical emergency. Adults should remember, however, that a school-age child’s thinking is still very concrete. They may have only partial understanding of illness and injury and are often highly influenced by the reactions and responses of their parents. School-age children may feel guilty about what has occurred or excessively fearful about what will happen to them. Under stress, their behavior may include excessive modesty, crying, silliness, and stall tactics; some may become oppositional, uncooperative, angry, fearful, or withdrawn. If this behavior is misinterpreted, it can escalate stress levels for both the parents and the child (Athey et al., 1997; Hurn, Dupper, Edwards, & Waldman, 1991). Taking the time to consider what difficult behavior might represent (tapping parental knowledge of how this particular child functions under stress) can be highly important for EMS staff. Adolescents. Adolescence is a time of rapid change in psychological and social development, with increasing abstract thinking skills, physical growth spurts, social pressures, and intense self-examination. Adolescents have greater emotional (and legal) capacity for self-determination but can be quite ambivalent about parental involvement in their treatment, wanting the parent to be there to comfort them but feeling embarrassed at their own dependency needs. Coping strategies may include apathy, minimizing symptoms, and joking. Abstract thinking abilities are not usually fully developed until later adolescence. Younger teens’ true understanding of their condition and treatment may be less sophisticated than it appears, leading clinicians and parents to an erroneously positive assessment of their readiness to take responsibility for health care decisions and for self-care after discharge. During an ED visit, the intensity of adolescent self-examination may lead to extreme selfconsciousness, as well as concern about loss of autonomy, body image, and the effects of injury or treatment on their appearance, (i.e., what they will look like with a splint, or with a scar) (Seidel, 1991). In addition, adolescents with chronic illnesses can experience a deep sense of hopelessness and despair during medical crises, with anger at ED staff, family members, and the disease. A key strength of adolescents is the potential for effectively communicating their feelings and questions about their care, when they trust that EMS staff are honestly engaging with them. A provider who takes the time to connect with the adolescent and

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ask direct questions may be able to engage him orher more effectively in the treatment process.

IMPLICATIONS FOR CHILDREN’S PHYSICAL AND PSYCHOLOGICAL RECOVERY Anecdotal reports from parents and health care providers indicate that many children experience emotional and behavioral difficulties in the aftermath of acute illness or injury. Recent empirical investigations document the psychosocial consequences of medical emergencies. For example, following a traumatic injury, children are at increased risk for behavioral difficulties (Basson et al., 1991; Wesson et al., 1992) and posttraumatic stress (Aaron, Zaglul, & Emery, 1999; DeVries et al., 1999; Di Gallo, Barton, & Parry-Jones, 1997; Mirza, Bhadrinath, Goodyer, & Gilmour, 1998; Stallard, Velleman, & Baldwin, 1998). As much as one year after injury, posttraumatic stress symptoms have been observed in children (DeVries et al., 1999; Stallard et al., 1998), and a significant proportion of children are not ‘‘back to normal’’ by parent report (Wesson et al., 1992). Children’s emotional recovery has the potential to affect the course of their physical recovery. Studies of injured adults have documented the impact of emotional factors on physical recovery and functional outcome (Michaels et al., 1998, 1999; Richmond, Kauder, & Schwab, 1998). Similar prospective studies of children following EMS involvement are needed to specifically address the association between physical and emotional recovery for children and adolescents, but some aspects of this connection are already well established. Behavioral and emotional factors have an impact on the child’s or adolescent’s relative risk of future injury or repeated episodes of illness. In children with chronic disease such as asthma, psychosocial factors contribute to adherence to medication regimens, help predict number and frequency of ED visits, and play a role in the child’s response to treatment and functional outcome (Bender, Milgrom, Rand, & Ackerson, 1998; Wasilewski et al., 1996; Weil et al., 1999). Children and adolescents treated in the ED for violent injury are at significant risk for a subsequent injury; behavioral factors appear to play a role in this increased risk (American Academy of Pediatrics, 1996; Boney-McCoy & Finkelhor, 1996; Madden, Garrett, Cole, Runge, & Porter, 1997; Schwarz et al., 1994). Parents play a crucial role in the child’s or adolescent’s experience of emergency medical treatment and its aftermath. Parents’ own distress may diminish their ability to provide support and comfort to children, to recall medical instructions, and to carry out follow-up care for their child. Situa-


tions with an emotional charge are not conducive to learning new information (Grover, Berkowitz, & Lewis, 1994). Stress can affect memory and the ability to attend to important details. In pediatric emergency care, important information is often given to parents when they cannot properly digest it. For example, one study revealed that parents could not fully recall follow-up instructions 5 to 10 minutes after discharge from the ED (Grover et al., 1994). Emergency medical services and ED policies vary on parental presence during emergency transport or during medical procedures in the ED (Lewis, Holditch-Davis, & Brussen, 1997; Sacchetti, Lichtenstein, Carraccio, & Harris, 1996; Woodward & Fleegler, 2001). The ED staff ’s encouragement of parent presence and the availability of supports for parents during treatment and transport can positively affect a family’s experience of a crisis (Sacchetti et al., 1996; Woodward & Fleegler, 2000). However, even with support, parents may find medical procedures, and their child’s reactions, stressful (Haines, Perger, & Nagy, 1995). The emotional impact of pediatric medical emergencies for parents may persist long after discharge from medical care (DeVries et al., 1999; Wesson et al., 1992; Winje, 1996) and can be exacerbated by work-related and financial strains (Osberg, Kahn, Rowe, & Brooke, 1996). This longterm impact carries important implications for the continuing ability of parents to provide appropriate emotional support for the child. The consensus group concluded that nearly every aspect of health care in pediatric emergencies is affected when we fail to effectively address mental health issues. When attention is not paid to psychological aspects of child and parent responses that may complicate physical recovery (and when psychological strengths such as parent support are not harnessed effectively), care is less efficient, more complex, and may become more costly.

IMPLICATIONS OF PSYCHOLOGICAL REACTIONS TO EMERGENCIES FOR PATIENT AND FAMILY SATISFACTION The experience of service delivery one receives at a health care center can also affect one’s psychological reaction to a crisis. Often, the patient’s and family’s level of satisfaction with aspects of care such as communication between providers and patients, friendliness of staff, and cleanliness of exam and waiting areas can color the experience of an ED visit. With a greater focus on the patient as a customer of health care, emergency facilities have intensified quality improvement efforts, aimed at increasing patient satisfaction. ‘‘Quality’’ is defined


as achieving optimum measured outcomes and maximum customer satisfaction with efficient use of resources (Children’s Hospital Boston, 1996). Good quality improvement (QI) practice is driven by the patient’s needs, has a systems focus, is committed to continuous improvement, and is modeled by leadership. The consensus group noted that measuring patient satisfaction is not only an integral component of the QI process but also may help with improving mental health outcomes for patients involved in the EMS system. Facilities have a financial incentive to improve patient satisfaction, as disappointed customers may not return. However, when an ED focuses on improving patient satisfaction, it is also likely to be paying much needed attention to factors that ameliorate stressors and improve mental health outcomes of patients and families. Studies of patient satisfaction reveal that adequate staffing and effective staff–parent communication (Brown, Sheehan, Sawyer, & Raftos, 1995), along with parents’ sensing empathy from staff, and a willingness on the part of the clinician to be forthcoming with information (Raper, 1996), are critical factors in determining satisfaction. Although waiting times in a pediatric ED are inevitable, an extended wait can be a very frustrating and stressful experience, particularly for younger children and anxious parents. Whereas some studies have shown that an arduous wait was the main reason for walking out of an ED (Hanson, CliftonSmith, & Fasher, 1994) and the greatest source of dissatisfaction (Velin, Puig, & Dupont, 1992), other studies have noted that good communication can mitigate the adverse effects of delay. For example, one study concluded that providing information and managing wait time perceptions may be an effective strategy to improving patient satisfaction (Thompson, Yarnold, Williams, & Adams, 1996). In addition, the interior decor of an ED can contribute to making patients feel more comfortable. Making the pediatric ED environment less threatening to children, with child-friendly pictures on the wall, attractive and comfortable furniture, books and toys in the waiting areas, and children’s videos can help to reduce stress for both the child and family (Athey et al., 1997). The consensus group noted that useful and effective discharge instructions are a particularly important aspect of patient and parent satisfaction with ED care. There is strong evidence for providing written instructions to families before they leave the ED (Grover et al., 1994). For example, children whose parents received written asthma management plans were half as likely to require a subsequent ED visit or hospitalization as those who received oral instructions (Lieu et al., 1997; ‘‘Written asthma plans,’’ 1997).

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BARRIERS TO ADDRESSING EMOTIONAL AND MENTAL HEALTH NEEDS IN EMSC The consensus group identified a number of barriers to effectively addressing mental health needs of children and parents in the EMS system. Emergency health care providers have not historically received systematic training in addressing the psychological aspects of emergencies, and many providers are unsure how to respond. With repeated exposure to illness, injury, and death, engaging emotionally with each patient can be an added challenge for EMS staff members (Durham, McCammon, & Alison, 1985; Figley, 1995; Keller & Koenig, 1989), as they strive to maintain a balance between connecting with patients and the appropriate professional distance needed to remain effective as health care providers. In addition, the normal human reactions of staff to parents (of pediatric patients) who become angry or hostile may make it more difficult for those parents to have their concerns addressed. The consensus group recognized that EMS providers, with or without training and preparation, do in fact deal with emotional needs in many (if not all) of their encounters with ill or injured children. However, it may be difficult to introduce training to better prepare EMS providers for this role: implementing new training initiatives for EMS staff is problematic because of stringent time constraints on the training hours now allotted for other required subjects. Challenges of treating mental health concerns in the ED exist for psychologists and other mental health professionals as well. Although pediatric psychologists (and other mental health clinicians with a health care focus) have solid assessment and consultation skills and experience in the broader health care environment, their training and collaborative experience regarding the highly specialized needs of the ED setting may be limited. The most daunting obstacles identified by the consensus group involve inadequate availability of mental health resources and existing systems of payment that make integration of medical and psychological care more tricky. In a national survey of emergency departments providing pediatric care, only 24% of EDs reported having mental health resources available in-house (U.S. Consumer Product Safety Commission, 1997). Linkage to community resources, if they exist, is not easy. Many existing mental health service systems are underresourced and are not able to accommodate the immediate needs of children after ED discharge. Consequently, ED staff members are increasingly being given the responsibility of managing mental health needs in both medical and psychiatric patients (Press & Kahn, 1997). Third-party payer policies that ban or discourage billing for psycho-

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logical and medical care in the same visit or on the same day of service militate against integrated care. Although provision of psychological screening and care in the ED appears to raise costs in the short run, cost–benefit analyses that fail to assess long-term benefits of this practice may underestimate the net benefits of integrating psychological care in EMS.

CONSENSUS RECOMMENDATIONS Building on its findings regarding the scope of unaddressed mental health needs in pediatric emergency care, the consensus group proposed a range of strategies for addressing these needs. These recommendations also address the aforementioned challenges and barriers facing the EMS system, in particular those involving training of multidisciplinary EMS staff and increasing linkage to mental health resources. The following summarizes suggested strategies for both clinical practice and research. Practice Strategies for Addressing Children’s Psychological Needs in EMS. Children’s emotional and psychological needs during EMS care should be addressed through ecological approaches that improve the responsiveness of the health care setting to these needs. Though ambitious in their aim to reform attitudes and everyday practice, these ecological strategies are not inherently costly or complicated. On the other hand, more comprehensive changes are required to address systemic issues and to achieve broader goals such as comprehensive ED provider training and the resolution of complex issues of mental health resource availability and costs. The consensus group found it useful to identify more immediately practical strategies as well as those that require a comprehensive and longer-term approach to the issues at hand. All of the strategies identified by the consensus group require a renewed commitment from hospitals and providers to make mental health needs integral to EMS care for children. Parent Feedback and Patient Satisfaction. Support for children in the midst of a medical crisis should be part of the ‘‘ecology’’ of every ED. This requires careful attention to effective communication with children and parents. A parent advisory group, made up of recent and repeat ‘‘customers’’ of the ED, may be useful to medical, nursing, and administrative staff in identifying strengths and weaknesses of their ED’s services to parents and children. A patient satisfaction survey can also shed light on important areas for improvement. Information and Decision Making. Parents should be involved in decision making and receive


detailed information about all procedures. Parents (and children when developmentally appropriate) should be given an opportunity to be involved in decisions that will affect them. However, EMS clinicians should also recognize, and accept, that patients and parents may not feel able to participate fully in decisions during a crisis and may choose to be guided almost wholly by professionals. The EMS staff should provide frank and comprehensible information about what parents should expect in regard to both treatment and prognosis. Engaging the family in the treatment process can lead to effective problem solving (Cox & Davis, 1993). Empathy expressed by staff and effective staff–patient communication have been linked to improved patient satisfaction with ED treatment (Brown et al., 1995). Compassionate preparation also lays the groundwork for the family’s coping and resilience during the child’s recovery. Information given to children and parents should be simplified as much as possible, repeated more than once, and presented in written form. In the course of emergency medical treatment, children and parents are often asked to absorb much information that is new to them and to make quick decisions based on this information. Written instructions give parents a chance to digest the information and also serve as a guide for future crises. Written plans should teach parents how to recognize symptoms and how to respond appropriately. Written and oral discharge instructions should also include potential psychological responses and emotional support strategies. Support for Children and Parents. The EMS staff should be prepared to provide specific coping assistance to all children and parents involved in emergencies. Training of EMS providers should include specific skill building relevant to these issues. Parents often need assistance from EMS staff on how best to provide effective support for a child in pain, or a child who is extremely anxious. Guidelines for helping patients and families utilize their coping strategies have been developed (Koocher, 1996). Even though parents are the experts on their child’s particular needs and personality, professionals can provide a repertoire of methods of effective coping assistance, gleaned from the literature and from their clinical experience with children in crisis and in pain. EMS staff should be well-prepared to fill several roles in assisting parents: modeling provision of effective coping assistance to the child, coaching parents in providing coping assistance, and addressing parents’ own emotional reactions so that parents can more fully attend to their child. Staff should be aware of appropriate coping and soothing techniques for different developmental


stages. Distraction techniques can be quite helpful in soothing very young children (i.e., singing familiar songs, looking at a familiar—or a new and interesting—picture book). For older preschoolers and school-age children, preparing a child realistically for what will take place can ameliorate anxiety (McFarland & Stanton, 1991). Clinicians can also reduce stress by asking future-oriented questions such as, ‘‘When you go home, what is the first thing you are going to do?’’ This communicates to the child that he or she will be returning home to familiar surroundings and normal activities and is likely to be comforting. Staff should be aware of effective means of assisting parents with their own distress. When EMS staff understand the variety of parental needs and emotional reactions, they can best determine which interventions will be most effective in addressing parents’ stress. Interventions that help strengthen parents’ coping responses or problemsolving skills usually have the best outcome, helping parents to cope more effectively when future stressors occur (Kruger, 1992). Training of EMS Staff. Training of EMS personnel (EMTs, nurses, physicians, social workers, child life staff) should include a specific knowledge base relevant to the emotional responses of children and parents in crisis. This basic training should be systematized and recognized as a core part of EMS training. In current practice, this training occurs ‘‘on the job’’ and its availability varies greatly from site to site, depending on the commitment and skill of the attending physician, nursing supervisor, or senior EMT with whom a new provider gains initial training and experience. For this core training module, priority should be given to teaching skills and knowledge that are easily integrated into normal clinical practice, such as distraction skills, useful ‘‘child-friendly’’ phrases for explaining procedures, and simple strategies for involving and supporting parents. Also included in this training should be a basic understanding of developmentally normative reactions and an introduction to cultural issues (keyed to the local community) relevant to family responses to children’s pain, illness, injury, and medical care. Psychological Screening and Follow-up. Screening for mental health needs should routinely occur in the emergency department. Even with the best support during the EMS experience, some children will have mental health needs that require followup after emergency treatment is complete. Assessment of emotional and psychological needs in the ED requires a combination of basic screening methods practical for use by ED medical and nursing staff and the availability of specialized mental health resources (clinical social work, psychology,

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psychiatry) in the ED. The consensus group recommended the use of brief screening measures as triage tools for identifying mental health needs; for example, the screening of high-risk adolescents for suicidal behavior (Horowitz et al., 2001). The group also recommended research aimed at developing brief screening methods appropriate for assessing risk of common mental health problems/diagnoses and validated in a variety of child/adolescent populations. For more seriously ill or injured children who are admitted for inpatient care, the consensus group recommended providing mental health resources during the child’s acute hospital stay and addressing the same follow-up issues at discharge. Emergency department staff and mental health professionals should work to create effective linkages to mental health follow-up. The consensus group recognized the crucial role of linkage from the ED to follow up via primary care providers and school health and mental health resources. Creative solutions and more aggressive approaches are warranted, based on historically poor follow-up from the ED setting to mental health resources (Spirito, Lewander, Levy, Kurkjian, & Fritz, 1994). With patient satisfaction of increasing concern to payers and hospital administrators, the group recommended investigating the connection between effective follow-up care and patient/parent satisfaction with emergency care. Research Strategies Regarding the Mental Health Needs of Children in the EMS System. To provide a well-developed empirical basis for addressing the mental health needs of children involved in EMS, the following were identified as priority research goals. 1. Expand the evidence base regarding (1) the incidence of psychological distress and symptoms after medical emergencies, (2) the impact of psychological factors on physical and psychological recovery, and (3) risk and protective factors that affect child outcomes after medical emergencies. Prospective studies are needed to better describe the range of psychological outcomes experienced by children involved in EMS; for example, the incidence and severity of significant mental health needs among all children attending the emergency department, or among children hospitalized for acute illness or injury. Dependent measures should include functional outcome and should not consist solely of assessing psychopathology or psychiatric diagnoses. Investigations should include assessment of the psychosocial impact of low severity emergency situations (e.g., minor injuries). Prior research indicates that medical severity is not a good predictor of psychological severity. Investigators should also pay attention to clarifying useful distinctions between types of medical emergencies

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(e.g., mass disasters vs. individual accidents, injury vs. acute episodes of chronic illness) and the ways in which these affect children and parents. 2. Develop, refine, and validate brief screening tools for identifying children at highest risk of continued psychological distress. The utility of such tools should be evaluated for a variety of problems, diagnoses, and populations. Screening should be based on empirically validated predictors for psychological risk from medical emergencies. 3. Develop, implement, and evaluate practical intervention protocols for secondary prevention of disorders, such as PTSD or depression, that may follow medical crises. Emergency department identification of mental health risk holds the promise of targeting secondary prevention efforts to reduce this risk. Protocols for secondary prevention should be evaluated for feasibility, acceptability to ED staff, children, and parents, as well as effectiveness in reducing the incidence of negative outcomes. 4. Understand parent/caretaker responses and the interaction of these with child responses. Intervention studies should consider the role of parents and evaluate how best to empower parents/ caretakers to provide support to children. 5. Assess the potential connection between mental health aspects of emergency care and patient/parent satisfaction. Empirical studies should evaluate the extent to which patient satisfaction relates to better medical or psychological outcomes and the particular aspects of emergency care that affect both satisfaction and positive outcome. 6. Evaluate the cost of providing (and of not providing) mental health services in EMS. For example, cost–benefit studies might examine the cost of transport for future emergencies versus the cost of providing adequate social work and mental health coverage in the ED. Investigators might profitably utilize existing data sets (such as hospital or statewide trauma registries; AHCPR, NCQA, and CDC data sets) to better understand mental health needs, utilization of care, and the mental health– related costs of trauma and emergencies. Development of methodology to effectively link disparate data sets to address these issues is itself a research goal. 7. Locate and learn from successes. Establish demonstration projects to link ED care with followup through schools, community resources, and mental health providers. Identify communities where mental health services available to children after discharge from the ED are available and adequate, and where linkages to managed care organizations and other mental health providers are working well. How have systems reached that point and how might this ‘‘technology’’ be exported or translated for other community systems?


8. Develop and evaluate effective methods of training emergency medical services personnel at all levels regarding mental health and emotional issues for children in EMS. Training should emphasize ways in which support for children and parents, as well as assessment of their emotional needs, can be realistically integrated into emergency medical care. Developers of training approaches should consider how to make these ideas compelling and acceptable to emergency medicine clinicians and should evaluate the effectiveness of training in producing measurable changes in practice.

CONCLUSIONS The consensus conference concluded that awareness and acceptance of the importance of mental health aspects of emergency medical care are a necessary first step to providing optimal care for children in the EMS system. Training of EMS providers and mental health professionals and focused research that provides an empirical basis for practice are also necessary components for improving current standards of care. A recent Surgeon General’s report (the National Action Agenda for Children’s Mental Health) outlined goals to improve mental health care for children and families. One of these goals is to ‘‘train frontline providers to recognize and manage mental health issues’’ (U.S. Surgeon General, 2000). As frontline health care providers, EMS staff members are in a pivotal position to recognize and effectively manage the mental health needs of patients and their families. Acknowledging and responding to psychological issues as they arise may mitigate some of the negative effects of experiencing a medical crisis. Early identification and accurate ascertainment of mental health needs are clearly important for improving health outcomes of pediatric patients and their families. This article is being published jointly by the Journal of Pediatric Psychology and Academic Emergency Medicine. It is based on deliberations in a June 1999 Consensus Conference organized by the American Psychological Association and supported by a contract from the Emergency Medical Services for Children, Maternal and Child Health Bureau, Health Resources and Services Administration. The conference was designed to identify mental health needs of children and their families related to a pediatric medical emergency; to examine the emotional impact of such emergencies in terms of recovery, cost of care, and satisfaction with care; and to identify research questions related to mental health and medical emergencies involving children. The authors gratefully acknowledge the work of Bette Runck, who prepared a summary of the Consensus Conference and all of the Consensus Conference participants for their contribution to the ideas and recommendations summarized in this article. Consensus Conference participants were Jean Athey, PhD, Health Policy Research Group; Jane Ball, RN, DPh, EMSC National Resource Center; Renee Bar-


rett, MPH, PhD, EMSC National Resource Center; Jack Bergstein, MD, Eastern Association for the Surgery of Trauma; Debra Boehme, MA, PhD, Department of Health, State of New Mexico; Cathy Carrico, RN, MS, ARNP, CEN, Emergency Nurses Association; Mirean Coleman, MSW, National Association of Social Workers; Georgette Constantinou, PhD, National Association of Children’s Hospitals and Related Institutions; Cindy Doyle, RN, EMSC; Jacquelyn Gentry, PhD, Mary Campbell, MS, Isadora Hare, LCSW, and Beth Cooper Benjamin, American Psychological Association; Bryna Helfer, MA, CTRS, Traumatic Brain Injury Technical Assistance Center; Lisa Horowitz, PhD, MPH, Children’s Hospital Boston; Russell Jones, PhD, Virginia Polytechnic Institute; Nancy Kassam-Adams, PhD, Children’s Hospital of Philadelphia; Jane Knapp, MD, American Academy of Pediatrics; Stephen Knazik, DO, FACEP, American College of Emergency Physicians; Annette LaGreca, PhD, University of Miami; Hal Lipton, MSW; Jean Moody-Williams, RN, EMSC National Resource Center; Keith Neely, MPA, EMT-P, Oregon Health Sciences University; Karen Olness, MD, Ambulatory Pediatric Association; Betty Pfefferbaum, MD, University of Oklahoma Health Science Center; Bette Runck; Nels Sanddal, MS, REMT-B, National Association of Emergency Medical Technicians; Merritt Schreiber, PhD, County of Orange Health Care Agency; Anthony Spirito, PhD, Rhode Island Hospital. The first two authors of this article contributed equally; order was determined alphabetically.

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