Emergency Mental Healthcare for Juveniles

“Ambulance 34, respond to 104 Wyoming Ave. for a report of an EDP [emotionally disturbed person]. Police are responding.”

You and your partner, as per your protocols, travel without lights and sirens to the scene. You stage a few houses down until law enforcement arrives and advises you the scene is safe to enter. You walk in to find your patient, a 16-year-old in severe emotional crisis acting out so loudly that his mother, not knowing what to do, called 9-1-1. What are some things you and your partner can do to help the patient?

The EMT curriculum does not spend a great deal of time on mental health issues, and even less on mental health issues that affect children, adolescents, and teens. This article will briefly discuss some of the different mental health calls you might encounter with minors and treatment plans you can use.

Suicidal Ideation

Suicide is a leading cause of death among minors. In 2018, according to the American Foundation for Suicide Prevention, there were 1.4 million suicide attempts in the United States, and more than 48,000 of them were successful.¹ Suicide mortality rates, rising over the past two decades, combined with the current pandemic for a “perfect storm” of increased risk in 2020, found a JAMA study published in April.²

Signs a juvenile might be considering suicide include giving away possessions, anxiety, irregular sleep patterns, withdrawing from friends and family, expressing hopelessness or thinking they’re a burden, seeking access to drugs or firearms, and, most important, actively threatening to hurt or kill themselves. If there has been a recent suicide among family or friends, that creates an even greater risk. The greater the level of detailed planning a patient shares, the greater the seriousness of their threat and intent.

Responders should be direct with their questioning and ask, “Are you thinking of harming or killing yourself?” While the patient may not be fully truthful with responders, they should absolutely be taken seriously and their behavior observed.

Mental Health First Aid strategies for these patients include expressing concern and a desire to help, as well as empathy for the hardships they’re experiencing.³ EMTs can also share that thoughts of suicide are not uncommon and help is available to discuss these thoughts with medical professionals. Tell them thoughts of suicide do not have to be acted upon.

During transport to the emergency room or crisis center, keep the patient talking and avoid being too clinical. Certainly do not be judgmental. Continue to ask open-ended questions and avoid the need to respond to everything they say. It is not suggested to use the phrase, “I know how you feel.” When possible, transport the minor patient with their parent or guardian.

Nonsuicidal Self-Injury

If a juvenile is self-injuring for reasons other than suicide, it’s still a mental health emergency. Different types of behaviors may be observed, including severe scratching or cutting of the skin, carving words or patterns into the skin with pens or other objects, chronically ripping off scabs or disturbing healing wounds, burning skin with lit objects like cigarettes, pulling out hair, and self-piercing or -tattooing.

Typically these are classified as “self-harming” behaviors. It is thought that up to 20% of middle and high school students engage in these behaviors at some time. They may do it in response to dark thoughts, to exert influence, to punish themselves for perceived or real actions, or to help manage painful feelings.

To assist these patients, you will clearly care for any medical issues, such as bleeding or trauma. From a Mental Health First Aid point of view, you can express your concern for their well-being, remain calm and avoid acting shocked by the behavior, and be a good listener without judgement.³  

Even if the injuries are not severe, the EMS provider will have a challenging time discerning if this is an acute incident or longer pattern of behavior. A professional clinical assessment by a mental health professional may be warranted.

Acute Psychosis

A person who is suffering from psychosis has a difficult time differentiating between reality and nonreality. Acute psychosis can develop gradually or without warning. Causes can include significant stress, medication noncompliance, and exposure to a traumatic event. Symptoms of acute psychosis are delusions, hallucinations, confused thinking, and disruptive behavior.

In a crisis situation EMS providers should remain as calm as possible. If the patient is violent, enlist law enforcement to keep the patient from harming themselves or others. Communicate in a calm voice and use simple phrases. Try to deescalate the situation without agitating the patient. If the patient is delusional or hallucinating, do not affirm or deny what they’re seeing; instead, repeat that you are there to help and listen.

Assisting a juvenile having a psychotic episode can be a very intense experience for all concerned. Do your best to not let a dynamic scene affect your calm demeanor. When you transport the patient, consider having law enforcement accompany you if the patient could be violent. If needed, an officer can reasonably restrain the patient.

It is of paramount importance for all patients experiencing an altered mental status that EMS conduct a thorough medical assessment to ensure there is not a medical cause, such as hypoglycemia, use of drugs or alcohol, severe dehydration, or head injury.

Aggressive Behaviors

Depending on your response area, EMS might be dispatched to assist law enforcement for a juvenile behaving uncontrollably. Children encountering traumatic stress may act out with aggressive behaviors in ways that are out of the norm. Aggression has different components, including physical (punching, kicking, throwing), verbal (profanity, threats), and emotional (crying, lashing out).

To deescalate the situation, remain calm and speak slowly and confidently with a caring tone. Do not respond to their aggression with a disciplinary or challenging manner; this tends to increase aggression. Do not argue with or threaten the patient. If the patient is not an active danger to themselves or others, let them move, such as pacing back and forth. Do not feel the need to keep talking—allow the patient a break in the conversation to calm down. Do not tower over the patient. Consider getting down to their level at a safe distance away. Maintain nonthreatening postures, such as hands at your sides instead of folded in front of you.

Much like psychosis, it is essential with altered mental status or uncharacteristic behavior that EMS conduct a thorough medical assessment.

Final Thoughts

Some areas have mobile crisis response units whereby a mental health practitioner may be able to respond to the scene. EMS crews should work with law enforcement and their local protocols if this is an option.

The patient’s parent or guardian can be a useful source of information in terms of previous behaviors, medications, allergies, and alerting crews to patient triggers. At the same time, by the time parents call 9-1-1, they may be exasperated or anxious and unsure what else they can do. Be supportive and empathic to them as well.

Be careful not to simply dismiss a call as simply an emotionally disturbed person. While mental health crisis calls are not typically lights-and-siren calls, each patient needs to have a medical assessment, including full vital signs taken, to ensure there is not a separate or concurrent medical cause to their behavior.

The more knowledgeable EMS providers are about behavioral health issues, the more they will be able to help defuse tense situations and offer better support for juvenile patients (and their parents/guardians). It is recommended that EMS providers pursue further training in behavioral health crisis responses for juveniles and adults.

References

1. American Foundation for Suicide Prevention. Suicide statistics, https://afsp.org/suicide-statistics/.

2. Raman S. Pandemic’s effect on already rising suicide rates heightens worry. Roll Call, 2020 Aug 5; www.rollcall.com/2020/08/05/pandemics-effect-on-already-rising-suicide-rates-heightens-worry/.

3. Mental Health First Aid. Mental Health First Aid for Youth, www.mentalhealthfirstaid.org/population-focused-modules/youth/.

Barry Bachenheimer, EdD, FF/EMT, is a frequent contributor to EMS World. He is a career educator and university professor with more than 34 years in EMS and fire suppression. He is currently an EMT with the South Orange (N.J.) Rescue Squad, a firefighter with the Roseland (N.J.) Fire Department, an instructor at the National Center for Homeland Security and Preparedness in New York.