Medical co-authors see more children in ER
By Timothy Gillis
As a desperate last resort, more young people with mental illness are showing up in emergency rooms, according to a new book called “Suicide by Security Blanket,” by Laura M. Prager, MD, and Abigail L. Donovan, MD.
That alarming trend holds true in the emergency room at Massachusetts General Hospital, where the two authors work. While the state of Maine has not seen a similarly dramatic increase, the Maine Medical Center has its hands full each day, employs round-the-clock psychiatrists, and uses several area agencies for inpatient pediatric psychiatric care. Despite some general claims of “poor parenting these days,” that is not the focus of the book, nor their authors’ main concern.
“Parenting has always been difficult,” said Prager. “Now, there are fewer and fewer community resources. Parents have nowhere to turn. Kids end up in emergency rooms for all sorts of reasons.”
The result of these ER visits is sometimes worse than the intended cure, with young kids often re-traumatized, simply by what they come to see in such a setting. “Imagine being a six-year-old, in a major metropolitan emergency room,” Prager said. Donovan agrees that the problem has an identifiable cause.
“What we’ve seen over the past several years is that there have been massive cuts for kids and adults for chronic mental illness. There are still a few community-based services left, but these don’t have the availability and depth of services to help kids who need help,” Donovan said. “Kids fall through enormously large cracks and end up in the ER.”
Maine is fortunate, for now, and local hospitals have avenues for assistance. But any given day, with a struggling economy and stressed family relationships, that luck could change.
“Overall, I think Maine is better off than some states when it comes to psychiatric services for children with the caveat that no mental health system is ‘perfect,'” said Nathan W. Mick, MD FACEP. An assistant professor at Tufts University School of Medicine, Mick is director of both Pediatric Emergency Medicine and Clinical Operations at Maine Medical Center.
“We have not seen a dramatic increase in pediatric psychiatric Emergency Department visits at Maine Medical Center, though we continue to care for children with mental health emergencies on an almost daily basis,” Mick said. “We’re fortunate to have access to board-certified psychiatrists and child psychiatrists 24 hours a day in the ED at MMC if needed.” When necessary, MMC can refer patients to an outside agency for help.
“We have three facilities for inpatient pediatric psychiatric care (St. Mary’s, Acadia, and Spring Harbor) and Sweetser helps us with ‘crisis response’ in the Emergency Department for pediatric patients,” Mick said. “We see a variety of mental health conditions in children including anxiety, depression, obsessive-compulsive disorder, and behavioral outbursts. Some of these psychiatric emergencies occur in the school setting and we can be asked if a child is ‘safe to return to the school’ which is an assessment we take very seriously.”
The book by Prager and Donovan is full of composites of characters the doctors have encountered during their years in the ER.
“We use the salient features,” said Prager. “There’s more universal relevance than you might expect.”
The book is from The Praeger Series on Contemporary Health and Living. Other titles in the series are how-to books or ones offering medical advice, Donovan explained. “We weren’t really doing any of those things, (but trying to) create some affective resonance to give emotions behind the data.”
“There’s no algorithm,” Prager said about diagnosing the cause of mental illness. “What we’re trying to point out is that taking the time to explore all the aspects of what happened yields the best result.”
“The devil is in the details,” Donovan said. “What Laura taught me is that there is no detail too difficult to explore.”
The book is a collection of vignettes, each involving a pseudonymous child with a mental illness who, for different reasons, ends up in an emergency room.
One chapter tells of a child with writing on her legs that seems too intricate and ill-placed to have been done by her. Doctors need to interpret whether or not the child might be in danger, and must decide whether or not to report. Another chapter tells of a threatening drawing a child did in school, and doctors must work with school officials to determine whether the child might be a danger to others. Other examples include the child who sees things, one who won’t move for fear of infection, and one who is so active she becomes a threat to hospital workers and has to be restrained.
Prager, who has run the child psychiatric emergency service at Mass. General for more than a decade, said these stories are all too familiar.
“I’ve had a book in my mind for many years,” she said. “Most important is I’m simply appalled with how we manage kids with psychiatric damage. Very distressing situations that bring kids to the ER finally prompted me to affect some change in the system. Kids with psychiatric illness are just as ill, yet even in our own ER, we don’t have adequate resources to treat them. I want this door to be open. This is a secret territory. I want the public to know what really happens.”
Donovan, who was a resident at MGH in 2008 and then joined the staff, is newer to the medical field than Prager, but she agrees that their local experience is suggestive of national trouble.
“In the grand scheme of ER, we are very lucky,” Donovan said. “We have a well-run and large hospital. Imagine what the conditions are like (for hospitals) that don’t have the staffing and resources that we have.”
The doctors each have an interest in writing, and they shared that enthusiasm as they created the book. “We would each start writing different chapters, trading back and forth,” said Prager, who has been writing short stories since an undergraduate. Currently, she is assistant editor for the Journal of the American Academy of Child and Adolescent Psychiatry. She has another book in the works, but wouldn’t say what it is about.
Donovan has written articles in journals, but this book is the “first journey into a piece that’s less for the academic community” and more for readers from all backgrounds, really anyone with children.
Most of the chapters tell sad tales of struggling kids, often with well-intended parents who are lost for a remedy. One story does end on a happy note, however, as a child is reunited with his beloved telescope. He still contacts MGH’s ER every New Year’s Eve to thank them for helping him. He cites their patient understanding as seminal in helping him recover. It’s a patience for which not all hospital ER’s have the time or services, a dearth often caused by public perceptions and fiscal policy.
“There’s a stigma associated with it,” Donovan said. “A lack of understanding exacerbated by socioeconomic situation, but it’s not limited to that: rich kids can have mental issues, too. Kids suffer in silence for a long time until the straw breaks. There’s so much shame that goes with mental illness.”