A distressed 17-year-old in tears who took a handful of pills following the break up with her boyfriend. A ruminating 13-year-old who has been bullied throughout middle school and wondering if the world would be better off without him. A restless 12-year-old who presents with breathing difficulty but later reveals that she was sexually assaulted years ago and periodically cuts along her forearms.
Rarely does a shift go by that I don’t come across at least one depressed, anxious, self-harming and/or suicidal adolescent in our buzzing pediatric Emergency Department.
Sounds like a downbeat environment?
Well, I find addressing a patient’s ultimate despair as ultra-rewarding and satisfying. I feel motivated to make the most of what is often no more than a 20-30 minute potentially powerful window in a life.
The hospital where I work as an evening/weekend crisis clinical social worker – Children’s Hospital Los Angeles – sees around 97,000 patients annually in its Emergency Department which is a designated Level I Pediatric Trauma Center.
There’s been an increased focus on holistic wellness for our youth in recent years. And our Emergency Department is no exception to this vital trend which acknowledges the correlation between mind and body.
We frequently evaluate patients who come through our doors with primary complaints of suicidal ideation or those following a self-injurious act or an actual suicide attempt. But beyond that, we screen almost all adolescent patients age 12 and up, regardless of the initial reason for their visit, for thoughts of self-harm and/or suicide as well as other high risk mental health behaviors and circumstances.
So, whether a patient presents with an asthma exacerbation or a fractured elbow, an 11-item behavioral health assessment tool called the Emergency Department Distress Response Screener (ED-DRS) conducted by our physicians will be a part of the comprehensive medical intake process. The questionnaire was designed and developed by our medical director, Dr. Alan Nager, who recognizes that the Emergency Department is a suitable environment for determining risk factors and stepping in to help. Some patients don’t meet criteria for this confidential screening – including those who are in a critical medical crisis or those who lack the ability to complete the assessment due to developmental delay. A small portion of patients opt out of the assessment.
In one study using the ED-DRS – Mental Health Screening Among Adolescents and Young Adults in the Emergency Department, Nager, AL, et al. Pediatric Emergency Care, 2017 – a total of 992 participating patients were examined. Symptomatic patients (those who responded “yes” to at least one of the 11 items) comprised 47.5% of the sample. Of those symptomatic patients, 33.8% had depressed mood, 30.4 % had anxiety, and 6.2% had thoughts of self-harm, suicide and/or homicide. Several other categories including a history of bullying, trauma and abuse were also screened.
Once a patient is identified with high risk symptoms such thoughts of self-harm or suicide on the survey, the Emergency Department clinical social worker conducts a more thorough assessment, determines level of risk and intervenes accordingly.
Since we don’t provide inpatient psychiatric care at our hospital, we occasionally arrange for our most affected patients to be transferred to a facility that can address their acute mental health needs. But more often, we send our patients home well-equipped with safety recommendations including counseling and hotline referrals.
With the use of screening tools like our customized ED-DRS developed by and for our Emergency Department, patients are often given an opportunity to vocalize serious concerns for the very first time.
And – that’s what I call a “power tool.”
About the author: Claudia Boles, LCSW is a clinical social worker at Children’s Hospital Los Angeles. She is also a member of the Los Angeles Suicide Prevention Network, the Los Angeles Child & Adolescent Suicide Review Team. Claudia volunteers for wellness organizations including Partnership for Awareness and volunteers for Crisis Text Line. She’s raising three adolescents and enjoys leisure walks, aromatherapy, perfumery and independent films.