Emergency mental health presentations in children with autism spectrum disorder and attention deficit hyperactivity disorder

Abstract

Aim To characterise the key features and management of young people presenting to the emergency department (ED) with a mental health (MH) complaint and a known diagnosis of autism spectrum disorder (ASD) or attention deficit hyperactivity disorder (ADHD). Methods Retrospective review of all ED MH presentations in children aged 7–17 years, presenting over a 12‐month period from the 1st of January 2018 to the 31st of December 2018, to the Royal Children's Hospital in Melbourne, Australia. Univariate analyses were carried out to examine the relationship between an underlying diagnosis of ASD and/or ADHD and a number of key presentation variables. Relative risks (RRs) and 95% confidence intervals (CIs) were calculated for ED management outcomes. Results There were 374 presentations in this cohort, representing 28% of the total MH presentations in 2018. The most common reason for presentation was acute severe behavioural disturbance. Young people with ASD and ADHD were at increased risk of having an acute crisis team response activated (ASD RR 2.3, CI 1.6–3.3, ADHD RR 2.2, CI 1.2–4.1). Compared to those without either diagnosis, young people with ASD were more likely to be physically restrained (RR 2.8, CI 1.7–4.6), managed in seclusion (RR 3.3, CI 1.7–6.4) and to receive medication to assist with behavioural de‐escalation (RR 2.8, CI 1.6–4.9). Conclusions Children with ASD and/or ADHD represent one‐quarter of all children presenting to the ED with MH complaints. They experience high rates of acute severe behavioural disturbance. Future research is needed to co‐design, implement and evaluate better approaches for their management.

Management of paediatric acute severe behavioural disturbance in emergency departments across Australia: A PREDICT survey of senior medical staff

“…autism spectrum disorder (ASD) are over-represented. 12 There is also a strong female preponderance, whereas in adult ASBD the majority are male. 10,11,13 A step-wise approach is endorsed for the management of these young people.…”

Seeing the unseen: Neurodiversity in the emergency department

“…For some young people, self‐harming behaviours necessitating emergent care may actually represent a first presentation of a previously undiagnosed neurodevelopmental condition 24 . A retrospective review from the Royal Children's Hospital Melbourne found that young people with a diagnosis of ASD and/or ADHD make up a quarter of mental health presentations to ED, with the most common complaint being acute severe behavioural disturbance 25 . These findings highlight the need for emergency clinicians to have a sound knowledge base and understanding of these conditions and appropriate management approaches.…”

Parent-reported factors associated with the emergency department presentation of children and adolescents with autism spectrum disorder and/or intellectual disability with behaviours of concern: a qualitative study

“…Studies from the USA, Australia and Canada have found that children and adolescents with autism represent a high proportion of the total mental health (MH) emergency department (ED) presentations in this age group, with high rates of repeat and after-hours presentations 10–13. This includes for severe acute behavioural disturbance, self-injurious behaviour and aggression.…”

“…This can cause increased patient distress, worsening behaviour and safety risks. Children with autism and/or ID who present with MH complaints and BOC are more likely to require complex management including involvement of an acute crisis team (an inpatient multidisciplinary team activated to de-escalate high risk behaviours), physical or chemical restraint 10 13…”