The Current Practices and Responses to Adolescents in North America That Are Seeking
Psychiatric Care from an Emergency Department
By
Kelly Ridder
Bachelor of Social Work, University of the Fraser Valley 2015

MAJOR PAPER SUBMITTED
IN PARTIAL FULFILLMENT OF
THE REQUIREMENTS FOR THE DEGREE OF
MASTER OF SOCIAL WORK
in the
School of Social Work and Human Services
© Kelly Ridder 2020
UNIVERSITY OF THE FRASER VALLEY
April 2020
All rights reserved. This work may not be
reproduced in whole or in part, by photocopy
or other means, without permission of the author.

Approval:
Name:

Kelly Ridder

Degree:

Master of Social Work

Title:

The Current Practices and Responses to Adolescents in North America That
Are Seeking Psychiatric Care from an Emergency Department

Examining Committee:
Dr. Leah Douglas, BSW, MSW, Ph.D., RSW
Primary Supervisor
Faculty, School of Social Work & Human Services

Dr. Lisa Moy, BA, BSW, MSW, Ph.D., RSW
Second Reader
Faculty, School of Social Work & Human Services

John Hogg, BA, BSW, MSW, RSW
MSW Chair
Faculty, School of Social Work & Human Services

Approved: April 21, 2020

ii

Abstract

Adolescence and early adulthood are typically when most mental health disorders present
(Gandhi et al., 2016; Kessler et al., 2005). Emergency departments frequently play a crucial part
in treating mental health crises and are the entry point for individuals needing hospitalization for
their mental health care (Saunders et al., 2018). The purpose of this literature review is to gain an
understanding of the North American current practices and interdisciplinary approaches to youth
that seek psychiatric care at an emergency department for a mental health concern or crisis. The
review will look at the common presenting mental health issues at hospital emergency
departments such as anxiety, depression, suicidality, and self-harm. Furthermore, an in-depth
examination will be taken to address why youth have been showing up in increasing numbers at
emergency departments seeking mental health care. The review will explore some of the current
assessments and screening tools being utilized in emergency departments. Additionally, the
review will examine youths’ perspectives and experiences while accessing psychiatric care in
hospital emergency departments and look at how some of the hospital emergency departments
are attempting to provide more effective services to adolescents seeking psychiatric care. Lastly,
the literature review will look at gaps in the literature and explore how social workers could be
playing a more significant role in supporting adolescents and working within the
interdisciplinary team when adolescents present at the hospital with a mental health crisis or
concern.

iii

Acknowledgments

I would like to express my gratitude and thanks to Dr. Leah Douglas for her positive
encouragement, guidance, and ongoing support as my major paper supervisor and professor
while in the MSW program at UFV. Additionally, I would like to express my appreciation to Dr.
Lisa Moy for her advice and insight as my second reader, and to Dr. Darrell Fox, my practicum
supervisor and professor for his sense of humour and encouragement.
Lastly, I would like to acknowledge my husband Alan and our children Mikaela, Anaesha,
Gabriel, Isaiah, Nataeya and Shae, for their unwavering support and encouragement throughout
this journey.

iv

Table of Contents
Abstract…………………………………………………………………………………………. iii
Acknowledgments………………………………………………………………………………. iv
Table of Contents ………………………………………………………………………………...v
List of Acronyms………………………………………………………………………………. vii
1. Introduction……………………………………………………………………………………..1
2.Background……………………………………………………………………………………...3
3. Methodology……………………………………………………………………………………5
4. Findings………………………………………………………………………………………....7
When Adolescents Present at the ED in a Mental Health Crisis……………………………….....10
The ED’s Response to Adolescents with a Mental Health Concern……………………………..12
Repeat Visits …………………………………………………………………………………….14
Self Harm………………………………………………………………………………………...16
Suicide……………………………………………………………………………………………17
Suicide Screening Tools………………………………………………………………………….20
Screening and Assessment ……………………………………………………………………….20
Canadian Governments’ Response to Address Adolescents Mental Health……………………..23
Longer Wait Times and Boarding………………………………………………………………..25
Prevention and Early Detection…………………………………………………………………..27
Connecting Youth to Outpatient Mental Health Care…………………………………………….28
Barriers and Stigma………………………………………………………………………………30
Adolescents Perspectives on Accessing MH care in the ED…………………………………….32
Engaging Youth and Getting their Perspective on Accessing MH Care………………………....33
5. Models and Theoretical Frameworks………………………………………………………….34
Family-Centred Approach …………………………………………………………………….....34
Family-Based Crisis Intervention ………………………………………………………………..36
Multi-Systemic Therapy …………………………………………………………………………37
Strengths-Based Approach……………………………………………………………………….38
6. Gaps in the Literature………………………………………………………………………….39
7. Implications……………………………………………………………………………………40
v

Social Workers Role …………………………………………………………………………….40
8. Conclusion………………………………………………………………………….................44
9. References……………………………………………………………………………………..46

vi

List of Acronyms
ASQ- Ask Suicide-Screening Questions
CBT- Cognitive-Behavioral Therapy
CYMH- Child and Youth Mental Health
ED- Emergency Department in a Hospital Setting
ER- Emergency Room in a Hospital Setting
EDSTARS- Emergency Department Screen for Teens at Risk for Suicide
EDMHCP- Emergency Department Mental Health Clinical Pathway
FBCI- Family-Based Crisis Intervention
FISP- Family Intervention for Suicide Prevention
HEADS-ED- Home, Education, Activities and Peers, Drugs and Alcohol, Suicidality, Emotions
and Behaviours, and Discharge resources.
HEARTSMAP- Home, Education and Activities, Alcohol and Drugs, Relationships and
Bullying, Thoughts and Anxiety, Safety, Sexual Health, Mood, Abuse, Professional and
Resources
LCSW- Licensed Clinical Social Worker
MH- Mental Health
MST- Multi-Systemic Therapy
POC- Perceptions of Care
SH- Self-Harm
SU-Substance Use

vii

Introduction

As a result of the limited services for youth needing mental health care, hospital
emergency departments in North America have gradually developed into a primary center where
families show up for assistance (Jabbour et al., 2016). For youth with a psychiatric concern, the
hospital emergency department plays a critical role in their care (Dolan & Fein 2011; Leon et al.,
2017). When youth are experiencing a mental health crisis and have failed to access treatment
elsewhere, hospital emergency departments are a vital contact point (Dolan & Fein 2011; Dolan
& Mace, 2006; Newton et al., 2012; Leon et al., 2017).
Youth in psychiatric need are showing up at hospital emergency departments (ED) in
growing numbers, “and just as the cause for this trend is likely multi-factorial, so must be our
professional response to address this burgeoning clinical need” (Carubia, Becker & Levine 2016,
p. 41). For this reason, it is imperative that emergency room hospitals are adequately prepared to
treat youth in a mental health crisis because the youth may leave the hospital with inadequate
treatment, which could potentially place them at significant risk or even death, particularly in
cases of adolescents who are presenting as suicidal.
The literature review includes research primarily from Canada, and the United States of
America (North America) as Canadian studies on the research question were more limited
(Carlisle et al., 2012; Gandhi et al., 2016). It is important to note that fundamentally, the
Canadian and United States healthcare systems are very different, the Canadian health care
system is grounded in a publicly funded health service (Cawthrope, 2013) and healthcare
coverage is universal (Ridic, Gleason & Ridic, 2012). While the USA health care system “has no
single nationwide system of health insurance” (Ridic et al., 2012, p.115). In the USA health care

1

system, individuals can access EDs even in circumstances where the individuals do not have
insurance or the means to pay (Asarnow, Babeva & Horstmann, 2017). It is not the intent of this
literature review to discuss or examine these differences. However, despite the difference in
health care systems, and as the literature review will reveal, Canada and the United States face
similar challenges and issues when adolescents seek MH care from an emergency department.
The research questions being addressed in this literature review include what are the
current practices and responses in place in North America for adolescents seeking psychiatric
care from an ED and what are their perceptions and experiences of that treatment? This paper has
two goals. The first is to gain an understanding of the current practices and interdisciplinary
approaches in place in North American emergency departments for adolescents seeking
psychiatric care. Secondly, this paper will uncover a clearer picture of adolescent’s experiences
and perceptions of receiving psychiatric care at the hospital emergency department.
The problem that this research paper is examining is how adolescents who are seeking
psychiatric care from a hospital emergency department due to a mental health crisis or concern,
may not be receiving adequate or effective community care and treatment plans when they are
discharged from the hospital ED. According to the United Nations, ‘youth’ is described as a
development period between the ages of 15 and 24 (Hawke et al., 2019; United Nations
Department of Economic and Social Affairs, 2013). Although, for the purposes of this research,
“youth” includes individuals from the age range of 12-24, since some of the research studies
included youth as young as age 12. Other terms used in this paper to describe this population are
adolescents and, in some cases, pediatrics is also utilized.
The research topic is significant because several emergency departments fail to provide
clear, consistent and integrated referral procedures to suitable community service providers
2

(Jabbour et al., 2016). This is an essential process in regard to treatment planning. This is a gap
that could be addressed and handled more effectively with input from a hospital social worker.
Identifying this gap through research could potentially demonstrate the need for the presence of
more clinical social workers in hospital emergency departments to assess adolescents that are
presenting with a mental health crisis or concern.
Further research in this area is crucial as it could potentially provide better responses and
more adequate services for adolescents seeking mental health services from a hospital emergency
department. In addition, gaining an understanding of adolescents’ experiences within the
hospital-based system of psychiatric care allows their voices to be heard and acknowledged. This
is often overseen or not considered and could lead to recommendations and possible changes in
policies and guidelines in response to this particular research. The potential outcomes of this
research paper could assist hospital staff in altering treatment approaches and recognizing more
effective operative practices (Bate & Robert, 2007; Chenail, 2011). At the very least, dialogue
and awareness around these issues could be generated and a possible re-examination of current
policies and practices in place at hospital EDs that service adolescents seeking psychiatric care
for a mental health concern or crisis.
Background
In Canada, approximately one million youth are living with an MH condition (Virk,
Stenstrom & Doan, 2018). One in every three adolescents aged 13-18, on average, will report
having experienced a psychotic symptom such as a delusion or hallucination (Kelleher et al.,
2012; Soleimani, Rosychuk & Newton, 2016). Canadian adolescents with a psychiatric disorder
have exceeded bodily injuries as the central cause for admittance to the hospital (Carlisle
Mamdani, Schachar, 2016 & To, 2012; To, Guttmann & Dick, 2001). In the USA, in the last 15
3

years, presentations to the emergency department for youth and children in a mental health crisis
have almost doubled (Carubia et al., 2016). Similarly, in Canada, adolescent psychiatric service
users’ attendance had an upsurge of more than 50 percent from 2010 to 2011 (Children’s
Hospital of Eastern Ontario, n.d.; Jabbour et al., 2016).
Even though families attempt to gain psychiatric care and treatment for their youth,
emergency departments are not prepared nor equipped to handle this specific population
(Jabbour et al., 2016). While there appears to be a broad spectrum of adolescents that present at
emergency rooms for mental health concerns, there is also a variance of presenting psychiatric
disorders; suicidality and aggression are reported to be some of the most frequent presenting
mental health concerns (Carubia et al., 2016).
Gandhi and colleagues (2016) discovered that the most frequent presentation of MH
concerns to the ED was related to anxiety disorders, whereas mood and affective disorders were
the greatest reason for hospital admissions. In another study conducted by Cloutier and
colleagues (2010), the top five primary explanations that were given by adolescents and their
caregivers for presenting at the ED were suicidal ideations, depression or mood, suicide attempts,
anxiety and self-injury (Leon et al., 2019). Moreover, Newton and colleagues (2009) conducted a
study in Alberta, looking at pediatric MH presentations at the ED; they found that out of the
16,154 youth with documented presentations, 21.4% were associated with mood disorders and
32.5% to anxiety disorders. In addition, Newton and colleagues (2009), discovered that the most
predominant reason for MH presentations was for substance misuse at 41.3 %. While there was a
variance of the percentages and a range of the types of mental health presentations to the ED,
overall, the most commonly observed in the research were depression, anxiety, suicidality, selfharm, aggression, and substance use.
4

Methodology
In creating this thematic literature review, the author utilized the University of the Fraser
Valley library database, which included the use of Academic Search Complete, CINAHL
Complete, MEDLINE with Full Text, PsycARTICLES, PsycINFO, Social Sciences
Abstracts, SocINDEX with Full Text and Social Work Abstracts. In addition to this, the Google
Scholar database search engine was also employed. Keywords utilized in the search included:
“adolescents,” “youth” “psychiatric care” “youth engagement,” “mental health,” “emergency
department,” “hospital,” “adolescent psychiatric care,” “suicidal youth,” “social workers” and
“adolescents’ perspectives and experiences.”
To create a parameter for the articles chosen for the literature review, the author focused
on research that was conducted primarily within the last 5 to 7 years, approximately inside the
period of 2012 to 2019. Most of the articles and journals utilized came from North America,
although some of the articles included came from outside of North America, and those articles
originated from the United Kingdom and Iceland.
The articles selected for the literature review were generally comprised of peer-reviewed
research articles that were taken from an extensive range of journals that included: Child and
Adolescent Psychiatric Clinics of North America, Social Work in Health Care, Current
Psychiatry Reports, Pediatric Emergency Care, Journal of Child and Adolescent Psychiatric
Nursing, Pediatrics, CJEM: Canadian Journal of Emergency Medicine, Journal of the American
Academy of Child & Adolescent Psychiatry, Clinical Pediatric Emergency Medicine, Hospital
Pediatrics, Canadian Journal of Psychiatry, CMAJ: Canadian Medical Association Journal,
BMC Emergency Medicine and Health Services Research, Managing Psychiatric Emergencies in
Children and Adolescents, Psychiatric Services, Journal of Child & Family Studies, Canadian
5

Journal of Community Mental Health, Implementation Science, Psychological Medicine,
Paediatrics & Child Health, Journal of the Canadian Academy of Child & Adolescent
Psychiatry, Clinical Psychology: Science & Practice, Journal for Healthcare Quality:
Promoting Excellence in Healthcare, Social Psychiatry & Psychiatric Epidemiology, The British
Journal of Psychiatry, Patients Child and Adolescent Psychiatric Clinics of North America,
Mental Health Services Research, Archives of Suicide Research, Research on Social Work
Practice, Administration, The Western Journal of Emergency Medicine, and Policy in Mental
Health and Mental Health Services Research.
Government sources and provincial reports were also included, such as The mental health
and wellbeing of Ontario students, Youth engagement toolkit resource guide, Canadian Institute
for Health Information (CIHI, 2018), The human face of mental health and mental illness in
Canada, National Vital Statistics Reports, Government of Canada (2006), Out of the shadows at
last: Transforming mental health, mental illness, and addiction services in Canada (2006),
Changing directions, changing lives: The mental health strategy for Canada (2012), and
Walking the talk: A toolkit for engaging youth in mental health (2012).
In the initial search, abstracts were reviewed for relevance to the research questions
“What are the North American current practices and interdisciplinary approaches to youth that
seek psychiatric care at an emergency department for a mental health concern or crisis?” and
“What are the experiences adolescent’s experiences and perceptions of receiving psychiatric care
at the hospital emergency department?” Many articles were discovered by utilizing several
mixtures of key search terms, as listed above. Articles searched pertaining to mental health,
youth and emergency departments generated a large number of articles used in the paper.

6

However, there were some gaps and limited research in relation to youths’ perceptions and
experiences with receiving psychiatric care at the hospital emergency department.
The articles selected utilized a blend of qualitative and quantitative methods, which included data
sources such as population-based cross-sectional cohort studies, interviews, health record audits,
national ambulatory care reporting system, administrative databases, secondary analysis from an
online discussion forum and patient surveys.
Findings
Consistent throughout the literature was the concept that emergency departments are the
primary point of contact (Cappelli et al., 2019; Dolan & Mace, 2006; Jabbour et al., 2016;
Newton et al., 2012) and the attendance has increased in numbers over the last few years
(Carubia et al., 2016, Leon et al., 2017). In fact, “[f]or more than half of youth with a first mental
health-related ED visit, the visit represents their first contact for outpatient mental health care”
(Gill et al., 2017; Rosic et al., 2019, p.83). In Canada, individuals between the ages of 5 and 24
years who attended the ED for an MH issue rose by sixty-six percent from 2007-2017 (CIHI,
2018; Rosic et al., 2019). The literature showed growth in adolescents attending emergency
departments in both Canada and the USA (Carlisle et al., 2016).
Some of the researchers contended that hospital emergency departments should not always be
the first point of contact for an adolescent that is experiencing a mental health concern. There
were contrasting opinions on this matter, as there were some researchers that suggested ED’s
where a good point of contact because it provided the opportunity to identify, screen, and assess
for MH concerns (Asarnow et al., 2017; Babeva et al., 2016; Chun et al., 2013; Esposito, 2019).
However, other literature (Anderson et al., 2013; Bhui, Ullrich & Coid, 2014; van der Post et al.,

7

2012) suggested that ED’s were not optimal settings for adolescents to “engage with the mental
health system for the first time, as such visits are associated with worse outcomes, including
more severe disease at presentation, longer duration of untreated illness and higher future use of
acute care services” (Saunders et al., 2018, p. E1183). Furthermore, the literature highlighted the
importance of early intervention and prevention by enhancing early identification in schools,
along with connecting students to effective mental health services (Cawthrope et al., 2018;
Patten et al., 2015).
Some of the researchers’ theories proposed in the literature are that the growing numbers
of adolescents seeking MH care in emergency departments are due to a lack of community MH
services, as well as barriers to accessing MH services within the community (Dolan & Fein,
2011; Gill et al., 2017; Leon et al., 2017). In addition, “ED utilization can also highlight the need
for increased attention to mental health services in the greater health system” (Hoffmann, Stack,
Samnaliev, Monuteaux & Lee, 2019, p.386). Furthermore, there was a consistent
acknowledgment in the literature around the high number of repeat visits following a
presentation to ED (Dolan and Fein, 2011; Cloutier et al., 2017; Roman et al., 2018). As Dolan
and Fein (2011) highlight, as much as fifty percent of youth that had presented to the ED came
back within two months.
The general consensuses in the literature are that adolescents are showing up in high
numbers because of the shortage of adolescent psychiatric services (Jabbour et al., 2016). This
shortage has been noted across both Canada and the United States (Jabbour et al., 2016).
Cappelli and colleagues (2019) point out that further studies should examine impediments to
community outpatient mental health intervention to gain a better understanding of why
adolescents are utilizing emergency departments as the entry point to receiving psychiatric
8

treatment. Newton and colleagues (2009) proposed that mental health services in the community
may not be immediately accessible, and those services may not be adequately meeting the needs
of the service user. In the United States, as MH presentations to ED’s have grown, gaining
access to MH services remains inadequate, which is a consequence of the psychosocial
inequalities and the confines in health insurance plans (Sheridan, Sheridan, Johnson & Marshall,
2017; Mental Health America, 2016). American researchers Lynch and colleagues (2015) point
out that impoverished families maybe going to the ED for MH care because there is a limited
amount of primary care providers that accept Medicaid, the public health insurance in the USA,
that is provided to low-income families (Redic et al., 2012). Moreover, Lynch and colleagues
(2015) assert that the shortage of public funding for MH services is frequently the reason for the
lack of accessibility and range of MH treatment options.
In addition, the literature highlighted the necessity for further clinical guidelines and a
framework when adolescents do show up at hospital emergency departments with a mental
health concern (Cappelli et al., 2019). Organized clinical practice strategies are absent in EDs,
and the scope of MH services provided in the ED is significantly varied (Cappelli et al., 2019;
Leon et al., 2013). There also appears to the absence of “clear standards for assessments,
treatments, clinical tools, and MH training for ED physicians” (Capelli et al., 2012; Chun, Katz,
Duffy & Gerson, 2015; Leon et al., 2017, p.178). Cappelli and colleagues (2019, p.84) identified
two essential areas around ED clinical management: “1) clinical pathways using a set of
evidence-based standards to facilitate the management and transition of care from EDs to
outpatient and community resources (Jabbour et al., 2016; Barwick et al., 2015; “Clinical
Trials.gov,”n.d.); and 2) an integrated system linking EDs, primary care, and community MH
agencies” (Cappelli et al., 2017).

9

When Adolescents Present at the ED in a Mental Health Crisis
ED’s have steadily become a “safety net” for adolescents who need mental health and
psychiatric care and are unable to receive those services in an appropriate timeframe (Cooper &
Masi 2007; Mapelli, Black & Doan, 2015, p.906). Mapelli and colleagues (2015), emphasize that
frequent usage of the emergency departments for “psychiatric needs points to the failure of EDs
in establishing long-lasting and stable mental health services to prevent recurrent crises,
particularly in the face of the chronic nature of mental health diseases and their associated lack of
absolute and effective treatments” (p.907). According to Soleimani and colleagues (2016), a
current emergency department study showed that a clearer understanding of the role that
emergency departments play in an adolescent’s journey to mental health help is required to
advance first detection and intervention strategies.
The health care teams in ED’s are expected to identify any severe and life-threatening
illnesses (Esposito, 2019). Some patients present with concerns that are easily recognizable,
while others necessitate further assessment and diagnostic examination (Esposito, 2019). When a
patient arrives in ED, the health care team is expected to respond in a manner “according to
current evidence and expert consensus” (Esposito, 2019, p.63). This approach by the health care
team in ED should also apply to adolescents seeking psychiatric care, although the research
suggests that this may not always be the case. As Doupnik, Esposito, and Lavelle, (2018) point
out, adolescents who show up at an ED with either an apparent or even less obvious mental
health issue warrant an organized and methodical approach to appropriate and competent
psychiatric care. Regrettably, Doupnik and colleagues (2018), suggest that developments in
prevention and treatment in adolescents with mental health conditions have not seen the
incredible advances as seen in the prevention and treatment of physical illnesses in youth.
10

The literature suggests that there is a variation of emergency psychiatric services that are
available when an adolescent present at the hospital. Conversely, there is a lack of clinical
organization and clinical intervention procedural guidelines (Leon et al., 2013; Cappelli et al.,
2019). This can make the process complicated and convoluted, particularly when dealing with an
adolescent who is experiencing symptoms of complex mental illness and substance use and may
have never sought mental health assistance previously. A few hospitals assimilate a mental
health specialist into the ED process such as a psychiatrist, nurse, or social worker, whereas other
hospitals depend on community service providers or telemedicine access for a full assessment
(Esposito, 2019). While not as prevalent in Canada as in the United States, telemedicine is an
alternative way of accessing healthcare, which allows the individual to virtually connect and
consult with a health care provider such as a physician or nurse practitioner (Owens, 2018).
Sheridan and colleagues (2017) suggest that the beneficial approach to developing
improved psychiatric care for youth in a mental health crisis at the ED is to begin the therapeutic
intervention while they are in the hospital awaiting disposition. Disposition in this setting refers
to the emergency health care team making the choice of whether the patient will be admitted or
discharged from the hospital (Calder et al., 2012). Research studies have demonstrated positive
outcomes from starting interventions at this stage (Rotheram-Borus, Piacentini, Cantwell, Belin,
& Song, 2000; Wharff, Ginnis, & Ross, 2012). Yet, Brown, Green, Desai, Weitzman, and
Rosenthal (2014) emphasize the importance of establishing follow-up outside of the hospital,
immediately after discharge as being just as critical.
According to Havens and Marr (2014, p.192), in the United States, “30%–40% of current
presentations of youths in psychiatric emergency result in in-patient admission” (Case et al.,
2011; Mahajan et al., 2009; Pottick et al., 1995; Sills &Bland 2002). Another identified concern
11

with adolescents seeking psychiatric care is that when they are admitted to the hospital, they
often are placed in adult psychiatric settings (Havens & Marr, 2014). The adult psychiatric units
frequently do not have ongoing access to adolescent psychiatric clinicians, and access is even
more limited on nights and weekends (Havens & Marr, 2014). Fundamentally, combining youths
and adults in a psychiatric unit is not optimal, and yet this occurs frequently for youth requiring
hospitalization for mental health treatment.
The ED’s Response to Adolescents with a Mental Health Concern
The ED does present some difficulties in supporting adolescents with MH concerns. They
are frequently packed, loud and do not have sufficient quiet space, and adolescents may be
reluctant to have a conversation about their MH challenges with a clinician that they just
encountered (Asarnow, Babeva & Horstmann, 2017). Sheridan and colleagues (2017) found that
one of the central reasons stated “by patients and their families is how initiating therapy in the
hospital and being able to continue with the same provider after discharge greatly increases
satisfaction and the efficacy of the intervention” (p.178). While this arrangement is not
frequently available in most current practices in hospitals, it does speak to the importance and
value of consistency for youth and their families following a visit to the hospital for a mental
health concern.
In the ED, the accessibility of MH specialists is inadequate, and frequently, the staff is
minimally trained in MH (Chun et al., 2015; Cloutier et al., 2017). Oftentimes, emergency
departments are not equipped with psychiatric screening tools or competent mental health
experts (Jabbour et al., 2016). These shortfalls in the ED are a strain on an overstretched and
limited funded MH system, which ultimately negatively influences patient outcomes (Dolan &
Fein, 2011; Holder, Rogers, Peterson, Shoenleben & Blackhurst, 2017).
12

Essentially, this puts the adolescent at risk – they are not adequately being assessed nor
given the necessary treatment for their mental health needs. In response to these challenges, a
group of Canadian hospital and community-based professional service providers was appointed
by Provincial Council on Maternal Child Health in Ontario to produce a clinical pathway,
identified as the Emergency Department Mental Health Clinical Pathway (EDMHCP) for
children and adolescents showing up with psychiatric concerns (Jabbour et al., 2016; Provincial
Council for Maternal and Child Health, 2013). In 2013, the EDMHCP was developed, and its
primary goals were to “(i) improve early identification and intervention for CYMH issues, (ii)
provide more timely access to community MH services, and (iii) reduce service gaps for
vulnerable children and youth” (Jabbour et al., 2016, p.2). Moreover, the EDMHCP objective is
to deliver a “seamless transition of care for children/youth and caregivers between the ED,
outpatient hospital services and community MH agencies (CMHA), with tailored linkages to
community resources through the [Home, Education, Activities and Peers, Drugs and Alcohol,
Suicidality, Emotions and Behaviours, and Discharge resources] HEADS-ED screening tool”
(Jabbour et al., 2016, p.2).
In 2016, Jabbour and colleagues started a clinical trial utilizing a mixed method that
examined the effects of EDMHCP at four different ED’s in Ontario, and their study included
data from qualitative interviews, health record audits, administrative databases, and patient
surveys. While the outcomes of this particular study are not yet available at this time, Jabbour
and colleagues (2016), proposed that their clinical trial on EDCMHCP “will standardize
language and care provided through improved communication and explicit expectations for [the]
transition between ED and CMHA settings” (p.8).

13

Carubia, Becker, and Levine (2016) point out that “[s]tandards of care and evidencebased models for practice are often lacking, and our ability to build our collective knowledge
will be enhanced by our use of common definitions” (p. 40). Furthermore, there is a growing
awareness on the advancement and translation of evidence-based approaches for various medical
circumstances in the ED, and it is just essential for the psychiatric staff to adopt these practices
(Ginnis, White, Ross & Wharff, 2015; Iyer, Reeves, Varadarajan & Alessandrini, 2011).
Repeat Visits
Overall, most children and youth that attend ED for psychiatric care are discharged
(Roman et al., 2018). However, the return rate is high (Roman et al., 2018). Repeat visits make
up for a considerable amount of all MH visits to the pediatric emergency departments, with
roughly 50% revisiting the ED within two months of their first visit (Cloutier et al., 2017; Dolan
& Fein, 2011; Sobolewski, Richey, Kowatch & Grupp-Phelan, 2013). This could suggest that the
youth are not receiving the appropriate care upon presentation to the ED and a possible lack of
connecting to mental health services in the community. The large number of youth MH repeat
visits to the ED are contributing to ED congestion and may paint a picture of the clinical needs
not being met (Leon et al., 2019).
Alternatively, the high number of repeat visits could also indicate that youth with MH
concerns have more crisis-related issues that require them to attend the ED for repeat visits to
access acute care. Studies suggest that factors contributing to ED recidivism—specifically, the
probability that the youth will present again at the ED— are involved with child welfare systems,
social determinants of health, historical and current involvement in MH services, prescription
medications, mood disturbances, and identification as female (Cloutier et al., 2017; Leon et al.,
2017; Roman et al., 2018).
14

Similarly, in a recent study conducted on repeat visits by Rosic and colleagues (2019),
five identified factors are being “older age (14-17 years), female sex, receiving a risk assessment
by the psychiatry team, having an inpatient psychiatric admission, and – for female but not for
male patients – receiving a discharge diagnosis of a depression-related disorder” (p.86). Rosic
and colleagues (2019), also found that similar to other studies, about one in five adolescents
presenting to the ED for a mental health issue had a return visit within six months. Moreover,
Soleimani and colleagues (2016), found that youth under age 18 who came to the ED with
psychotic symptoms had the most significant risk of a repeat presentation to the ED in
comparison to repeat presentations for other psychiatric challenges (Newton et al., 2010).
Whereas, Gardner and colleagues (2019) found in their study that “adolescents who presented
with self-harm were almost five times more likely to have repeat emergency department visits or
hospital admissions related to self-harm, with about 1 in 3 having a repeat admission” (p.E1213).
In another study conducted by Leon and colleagues, (2019) the researchers looked at
family characteristics connected to repeat ED visits, and they discovered that “post-visit MH
services, prior psychiatric hospitalization, higher severity of symptoms, and living closer to the
hospital increased the odds of repeat visits” (p.9). In addition, Leon and colleagues, (2019) found
that “caregiver history of MH treatment decreased the odds of having a repeat ED visit, family
functioning, and perceived family burden were not associated with repeat visits” (p.9). Based on
the outcomes of this study, Leon and colleagues (2019) recommend that healthcare service
providers must take into account caregiver and youth service use aspects to advise patient
management and disposition preparation. Another noted additional challenge with adolescents
who are repeat visitors is that they are more often less inclined to follow-up with mental health
services in the community (Dolan & Fein, 2011; Sobolewski et al., 2013).

15

Self-Harm
Attending the ED for intentional self-harm, such as a self-inflicted injury or overdose, is a
multifaceted situation with overt and unseen components (Owens, Hansford, Sharkey & Ford,
2016). In Ontario, ED presentations for adolescents who have self-harmed have over doubled
since 2009 (Gardner et al., 2019). According to Owens and colleagues (2016), many who selfharm are treated without a hospital visit because of emotional shame or feelings of
worthlessness. Those adverse feelings are further validated when they attend the ED and interact
with hospital staff who comes across as unempathetic and stigmatizing (Owens et al., 2016).
In the United Kingdom, researchers Owens and colleagues (2016) conducted a secondary
analysis of qualitative data from an experimental online discussion forum study on youth that
self-harmed and had attended an ED. Owens and colleagues (2016) found that participants
evaded the ED because of their own or others’ past negative experiences. When they attended the
ED, the youth experienced feelings of shame, unworthiness and “undeserving of treatment”
(Owens et al., 2016, p.287).
These emotions were further perpetuated when they received punitive, stigmatizing, and
unempathetic interventions from the ED health care team (Owens et al., 2016). The participants
reported that helpful interactions with the health care team occurred when “they received
‘treatment as usual,’ i.e. non-discriminatory care, delivered with kindness, which had the
potential to challenge negative self-evaluation and break the cycle” (Owens et al., 2016, p.286).
Gardner and colleagues (2019) conducted a study on health outcomes for youth that selfharmed and attended the ED, and they found that an ED presentation connected to intentional
self-harm elevates the risk of recurring intended self-harm and suicide. Gardner and colleagues

16

(2019), propose that the creation “of algorithms and interventions that can identify and help
adolescents at highest risk of recurrent self-harm is warranted” (p. E1207). This population of
adolescents is a highly vulnerable group and a “largely hidden population,” and when they
present to the ED, this is a crucial moment for “engagement and even possible suicide
prevention” (Owens et al., 2016; Royal College of Psychiatrists, 2010, p.286).
Suicide
In Canada, the second most common cause of death among youth is suicide (Hawke et
al., 2019; Statistics Canada, 2015). Similarly, in the USA, suicide is the second leading cause of
death, which translates to “over 2000 deaths in the 10–19 age group in the year 2012” (Heron,
2013; Carubia et al., 2016, p. 41). Additionally, Plemmons and colleagues (2018) found that
hospital admissions for youth that have attempted suicide or had suicidal thoughts from 2008 to
2015 have over doubled (Esposito, 2019). Carubia and colleagues (2016) suggest that it is
imperative to increase the capacity to adequately respond to the clinical MH demands of a
hospital emergency department environment. This includes assessment and treatment of youth
that shows up with depression, suicidality, and anxiety, and to further train staff with the
necessary expertise and ability to respond in this limited environment (Carubia et al., 2016).
Hughes and Asarnow (2013) propose that frequently suicidal adolescents fail to obtain MH
treatment following discharge from the ED, and interventions are essential to increase
connection to out-patient services.
In a randomized controlled trial study, American researchers Hughes and Asarnow
(2013) compared the Family Intervention for Suicide Prevention (FISP) with the usual ED care
received. FISP is a brief “family-based cognitive behavior therapy session designed to increase
motivation for follow-up treatment, support, coping, and safety, augmented by care linkage
17

telephone contacts after discharge” (Hughes and Asarnow, 2013, p.28). Hughes and Asarnow
(2013) found that the FISP intervention was linked with enhanced connection to outpatient
follow-up MH care. A critical component of the FISP intervention is the follow-up call by the
clinician within 48 hours following discharge (Hughes and Asarnow, 2013). This contact
provides the opportunity for the clinician, client, and family to collaborate and to discuss any
obstacles or challenges that have presented following the adolescent's discharge from the ED
(Hughes and Asarnow, 2013). The second-generation Emergency Department/Family
Intervention for Suicide Prevention (ED/FISP) seeks to advance and strengthen adolescents'
skills for managing suicidal desires and assembling support and increasing family connectedness
(Asarnow et al., 2017). Asarnow and colleagues (2017), describe the ED/FISP as:
Balanc[ing] the need for evaluation and treatment using a brief behavioral assessment of
imminent risk which evaluates the youth’s ability to generate behaviors incompatible
with [Substance Use] SU/SH, [Self-Harm] specifically: 1. recognizing personal strengths;
2. identifying ≥3 persons from whom to seek support; 3. discriminating emotional states
and identifying SU/SH prompting situations using an “emotional thermometer”; 4.
developing a SAFETY plan with concrete steps for safe-coping (activities, thoughts,
behaviors, support persons); 5. committing to using the SAFETY plan versus SU/SH for
a specified period. (pp. 4-5)
According to Ginnis and colleagues (2015), “[t]here is little evidence in the literature or
in clinical practice of psychiatric intervention that occurs exclusively in the ED” (p.173). In
response to this, Ginnis and colleagues (2015) developed Family-Based Crisis Intervention
(FBCI), a one-time session intervention created explicitly for the ED to work with the youth and
their family in the moment of crisis, with the aim of decreasing the suicidality in the youth. FBCI
18

is a collaborative approach that includes CBT skills building, psycho-education, safety planning,
therapeutic readiness, and treatment planning (Ginnis et al., 2015). The FBCI objective is to
decrease the youth’s suicidal symptoms and give the youth, their family and clinician the chance
to create a safety plan (Ginnis et al., 2015). The FBCI approach will be examined further in this
paper in the models and theoretical frameworks section.
Ongoing studies and further advancement for medical (i.e. “physical”) conditions have
contributed to better outcomes, whereas unfortunately, funding, research, and improvement for
MH conditions such as suicide prevention for adolescent patients have lagged behind (Esposito,
2019). This is despite the fact that during the last five years, hospitals have come to understand
the significance of prevention and assessment in relation to suicide (Ginnis et al., 2015).
Considering the frequency of suicidal adolescents that present at emergency departments,
this setting is “a crucial environment for suicide screening, intervention, and prevention to
occur” (Carubia et al., 2016, p. 41). Adolescent visits to the ED can present a space to assess and
screen adolescents with psychiatric and suicide risk, prioritize adolescents established on need
and provide adequate follow-up mental health services (Babeva, Hughes & Asarnow, 2016).
Taking into consideration the usual wait times, there is often a sufficient amount of time in the
ED for the adolescents and their family or caregiver to fill out a brief-self report instrument
(Babeva et al., 2016). Most importantly, it is critical that the information provided on the
questionnaire is thoroughly analyzed by the clinician as the youth may reveal suicidal risks that
they may fail to address in the interviews (Babeva et al., 2016). Unfortunately, according to
Sobolewski and colleagues (2013) and Hughes and Asarnow (2013), there has been minimal
research conducted on youth who are discharged from ED following an assessment for suicidal
behaviour or thoughts.
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Suicide Screening Tools
The literature highlighted a variety of suicide screening tools. Some were identified that
were explicitly designed for the ED, such as the ASQ (Ask Suicide-Screening Questions)
(Esposito, 2019). ASQ was created specifically for the ED setting, although it can be utilized in
various clinical situations (Esposito, 2019), and the ASQ has demonstrated predictive validity
(Asarnow et al., 2017; Horowitz et al., 2012). The ASQ is a very brief screening tool that

consists of four yes or no questions, and it can be completed in fewer then 2 minutes and if the
youth answers “yes” to any of the four questions it is considered a positive screen and question 5
is then asked, “Are you having thoughts of killing yourself right now?” (National Institute of
Mental Health, n.d.). Under these circumstances, the patient will then be required to have a
complete safety/full mental health evaluation (NIMH, n.d.).
While providing suicide screening for adolescents that present to the hospital with MH
concerns is critical, it is vital for hospital staff to be prepared to deal with a positive screen and
this preparation works best with a multidisciplinary team, that encompasses medical personnel
such as nurses and doctors but also allied health care workers such as social workers and
community mental health specialists (Esposito, 2019). Furthermore, developing connections to
MH services after ED discharge is vital for youth, specifically those experiencing suicidality
(Grupp-Phelan, Delgado & Kelleher, 2007; MacWilliams, Curran, Racek, Cloutier & Cappelli,
2017; Roman et al., 2018).
Screening and Assessment
Roman and colleagues (2018) suggest that despite the fact that several clinical reports
and guidelines highlight the need for greater staff competency in treating children and

20

adolescents in the ED with MH needs, there is still a small number of evidence-based practices
being utilized in response to the growing number of youths showing up at ED in an MH crisis.
In addition, Carubia and colleagues (2016) suggest that it is imperative to increase
capacity to adequately respond to the clinical mental health demands of a hospital emergency
department environment, including assessment and treatment of youth that show up with
depression, suicidality, and anxiety, to further train staff with the necessary expertise and ability
to respond in this limited environment. Emergency departments have begun to create and assess
new mental health processes among emergency departments and community mental health
service providers to formalize adolescent psychiatric care (“ClinicalTrials.gov.” n.d.; Leon et al.,
2017).
However, establishing an evidence-based method for rigorous and competent screening
and intervention is a significant component that necessitates additional research (Carubia et al.,
2016). An ongoing effort in this field encompasses “the Emergency Department Screen for
Teens at Risk for Suicide [EDSTARS], …. whose aim is to develop a computer-based screening
tool which will aid [the] ability to effectively assess and stratify suicide risk in our adolescent
patients.” (Carubia et al., 2016, p.41).
In addition to this screening tool, there is an interview tool named “the HEADS-ED
[which] is a rapid screening and disposition planning tool for emergency clinicians”
(MacWilliams et al., 2017, p.778). Cappelli and colleagues (2012) created “HEADS-ED,” as an
instrument to be used by clinicians to rate the degree of psychosocial challenges across seven
segments to evaluate whether the youth needs urgent psychiatric treatment or can be sent to an
on-site mental health team (Lee et al., 2019, p.88). The HEADS-ED has the ability to recognize
the necessity for improved “discharge planning, complete charting, and standardized assessments
21

for the increasing population of pediatric mental health patients who present to [emergency
departments]” (MacWilliams et al., 2017, p.778).
Despite HEADS-ED’s value as a screening tool, “it currently does not provide guidance
as to the types or urgency of services required and does not distinguish psychiatric from social or
behavioural needs” (Lee et al., 2019, p.88). To address this need, “HEARTSMAP” was
developed, which unlike HEADS-ED, has two additional pieces that include sexual health and
abuse, to assist with deciding what the most suitable adolescent health or social work
requirements (Lee et al., 2019, p.88) is. HEARTSMAP created at British Columbia Children’s
Hospital, gives clinicians the ability to conduct an extensive psychosocial assessment with a
tailored tool-developed report to provide youth and families with detailed recommendations as
well as a “suggested level of urgency” (Virk, Stenstrom & Doan, 2018, p.504). Moreover,
“HEARTSMAP is one of few known clinician-administered, digital and broad-based
psychosocial assessment tools for youth, designed exclusively for the ED” (Virk et al., 2018,
p.505).
Virk and researchers (2018) conducted a cross-sectional study that examined the interrater reliability of HEARTSMAP when utilized by clinicians of diverse backgrounds such as ED
doctors, nurses, social workers, and psychiatric nurse liaisons. Virk and colleagues (2018) found
“moderate to near excellent agreement, overall among clinicians for all 10 of the tool’s
psychosocial sections (κ=0.43 to 0.93) and domain scores (κ=0.75 to 0.90), with acceptable
agreement across all tool-triggered service recommendations (κ=0.36 to 0.65)” (p.503).
HEARTSMAP has demonstrated to the have the capacity to be a dependable tool in providing a
comprehensive and standardized MH assessment that can be utilized by various clinicians

22

(physicians and allied health workers) that practice in ED settings, and it is being implemented in
community EDs throughout British Columbia (Virk et al., 2018).
While these screening tools are a good start for establishing some clinical guidelines for
assessing adolescents who present at emergency departments, it is also essential to ensure that
adolescents are being released with a comprehensive psychiatric intervention plan.
Canadian Governments’ Response to Address Adolescents Mental Health
In 2006, the Government of Canada published a report titled “Out of the shadows at last:
Transforming mental health, mental illness, and addiction services in Canada.” This report
highlighted the profound concerns around the competence of the mental health system in relation
to the MH treatment needs of children and adolescents (Keon & Kirby, 2006). The concerns
highlighted in the report were “fragmentation, coupled with under-funding, a shortage of mental
health professionals, and a failure to involve younger people, and their families in long-term
treatment solutions have resulted in the delayed application of inadequate treatment
interventions” (Keon & Kirby, 2006, p.155). Unfortunately, even though this report came out in
2006, it appears that the same ongoing issues that were highlighted in the report continue to
negatively impact youth and the mental health system.
According to Gandhi and colleagues (2016), “[l]ess is known about the proportion of
health care use attributable to mental health care use among children and youth in Canada” (p.
120). In their study in Ontario, the researchers led a population-based cross-sectional study on
children and youth aged 10-24 to look at the trends in mental health visits to the ED, psychiatric
hospitalizations and MH connected outpatient physician visits between the period of 2006 and
2011. Gandhi and colleagues (2016) discovered substantial growth in outpatient visit rates,

23

although increases were double for ED visits and triple for hospitalizations connected to
outpatient visit rates.
The literature highlighted that most of the government initiatives and research appeared
to be taking place in Ontario; perhaps this is due to the fact that Ontario holds the largest
population in Canada. For example, in Ontario, the Ministry of Health and Long-Term Care
(MOHLTC) have initiated some substantial expenditure in a provincial action centred on
enhancing MH services with a specific focus on “right care, right time, right place meaning
having access to timely and appropriate services in the community when mental health and
addictions issues arise” (Gandhi et al., 2016, p.120; Ontario Centre of Excellence for Child and
Youth Mental Health, 2016; Ontario Ministry of Health and Long-Term Care, 2012).
Another initiative in Ontario named the Be Safe was created in partnership with youth
with MH lived experience (Boak, Hamilton, Adlaf, Henderson & Mann, 2016; Huggett, Flynn,
Jaouich, Taylor-Gates, & Davidson, 2017). In creating Be Safe, the London Service Collaborative
joined with mindyourmind, a national youth mental health program (www.mindyourmind.ca) located
in London, Ontario (Huggett et al., 2017). The Be Safe “is a mobile application (app) with a

paper-based pocket guide companion designed to help youth manage mental health and
addictions crises and identify appropriate supports based on their level of need” (Huggett et al.,
2017, p.122).
In the development of this systems navigation tool, youth were integral to the process and
provided input and ideas that resulted in an app that:
1. A customized safety plan, which youth are encouraged to complete when they are not
in crisis and with the assistance of a trusted person in their support network (e.g., service

24

provider, family member, friend, etc.). 2. A decision aid to support identification of
appropriate community resources based on level of need at any given point in time.
Youth provide responses in real time to a series of guided questions (e.g., about current
emotions and level of safety); the output that is generated by the app provides relevant
details for suggested services or supports, such as agency contact information, to help
users access these resources.3. A comprehensive listing of mental health services and
supports in the community.4. A personalized “Get Help” script, generated from data
provided by users (e.g., name, specific concerns, medications, etc.) to facilitate their
communication with professionals and other supports at times of crisis. 5. Information on
how to wait safely for help, what youth can expect when they access resources, and youth
rights as a client. (Huggett et al., 2017, p.124).
When factoring in the high costs of ED visits, Newton, Rosychuk, Niu, Radomski, and
McGrath (2015), highlight that expensive ED care could be decreased by employing approaches
that increase doctors' use of evidence-based treatment and caregiver access to coordinated
community treatment. Unfortunately, the current adolescent mental health systems in Canada are
frequently splintered among various organizations, ministries and service providers (Jabbour et
al., 2016), which can create challenges for youth and families navigating these systems.
Connecting youth to outpatient MH services has additional problems in that contact among these
organizations is frequently insufficient, which in turn generates gaps in service (Jabbour et al.,
2016).
Longer Wait Times and Boarding
The United States experiences similar issues like Canada in relation to adolescents
seeking psychiatric care due to limited numbers of MH staff and inpatient beds, which in turn
25

has led to long waits and, frequently results in adolescents leaving the ED without being
adequately assessed (Asarnow et al., 2017; Zeller, Calma & Stone, 2014). Consequently, this
puts the adolescent at risk for not being formally evaluated and treated when they are potentially
in a vulnerable state and needing psychiatric care. In comparison to a youth, who presents with
general medical illness to the ED, the youth that presents with an MH issue will typically wait
longer (Asarnow et al., 2017; Zeller et al., 2014). In a recent study in the United States,
conducted by Hoffmann and colleagues (2019), the researchers analyzed the length of stay
(LOS) in the ED and found that “[m]ental health visits were more likely than non−mental health
visits to have a length of stay between 24 and 47 hours (11.1% vs 0.2%) and a length of stay ≥48
hours (2.6% vs 0.1%)”(p.388). The lack of specifically trained MH and psychiatric staff and the
shortage of psychiatric beds all increase greater waiting times and LOS (Asarnow et al., 2017;
Zeller et al., 2014). Regrettably, in this situation, the LOS is not equated with more time spend
on interventions and treatment while in the ED, but instead merely waiting to be seen by the
appropriate MH healthcare team.
Extended periods of waiting in the ED have clinical and systematic consequences (Ginnis
et al., 2015). One of the issues that came in the literature review was “boarding,” which is
characterized as prolonged waits in the ED or a different non-psychiatric location while waiting
for a psychiatric placement, and suicidal youth are particularly at risk for boarding (Ginnis et al.,
2015; Mansbach, Wharff, Austin, Ginnis & Woods, 2003; Wharff, Ginnis, Ross & Blood, 2011).
Boarding among youth needing psychiatric care remains a continuing challenge (Wharff et al.,
2011; Sheridan et al., 2017). In their retrospective cohort study, Wharff and researchers (2011)
discovered that over a third (34.1%) of patients who were assessed and required psychiatric
hospitalization, resulted in boarding in the ED. In another study on pediatric boarding,

26

researchers Claudius, Donofrio, Lam, and Santillanes (2014) found that of the youth admitted to
a general medical ward with a psychiatric condition, “94 percent were for boarding, with only 6
percent receiving any type of counseling” (Sheridan et al., 2017, p.177).
Prevention and Early Detection
Adolescence is a period in an individual’s life where there is significant developmental
growth that takes place, their bodies and minds are in continuous flux, and this sometimes can
present challenges around mental health assessment. In other words, mental health professionals
must determine whether presenting behaviour is typical or if it is indicative of an underlying
mental health concern. Typically, psychiatric disorders start between adolescence and early
adulthood, which emphasizes the necessity for access to early intervention at the beginning of
the mental health concern (Gandhi et al., 2016; Kessler et al., 2005). According to the
Government of Canada (2006), 70% of MH challenges initiate during childhood or adolescence.
Early MH detection and treatment increase the everyday functioning in developing adolescents,
and proper screening in the ED can save lives (Esposito, 2019).
Gill and colleagues (2017) conducted a study that looked at the first contact for MH
concerns for youth, and they found that over half of the youth needing ED care had failed to seek
outpatient MH treatment (Gill et al., 2017). In the overall population of Canada, 54 % of adults
and 32 % of children and adolescents received a psychiatric diagnosis over a 16-year period,
with the per-person rate for children and adolescents doubling over the interval (Cawthrope
2013).
Given these statistics, it would be advantageous to standardize mental health services by
concentrating on early intervention (Cawthorpe, 2018). Furthermore, given the increase of youth
27

presenting at the ED in an MH crisis and the prevalence of return visits, Newton and colleagues
(2009) propose that this is an opportunity for prevention by utilizing community-based services.
The overcrowding and the high expenses associated with ED presentations could be decreased
by increasing access to competent MH services that are connected to a system of care (Baren et
al., 2008; Lynch, Bautista, Freer, Kalynych & Hendry, 2015). In addition, an ED that can enable
early interventions and provide connections to community MH services may possibly decrease
future crises and have a positive impact on short- and long-term behavioural outcomes (Cloutier
et al., 2010: Roman et al., 2018).
Connecting Youth to Outpatient Mental Health Care
In the literature, there was the recognition that attending an ED when an adolescent is in a
mental health crisis was not necessarily the best option. Roman and colleagues (2018) highlight
that EDs are not an optimal space for individuals with complex psychiatric needs, given that it is
an exceedingly stimulating setting that can further aggravate symptoms and lead to a more
significant decline. Contrary to this opinion, researchers Chun, Duffy, and Linakis, (2013) argue
that the ED is uniquely situated to identify various high-risk youth that would not be recognized
in other environments, as several adolescents do not have a family physician and encounter
obstacles when trying to access a family physician.
According to Roman and colleagues (2018), children and youth presenting with
psychiatric concerns, similar to children and youth with multifaceted medical and physical needs,
are regarded as a significantly vulnerable group that needs a diverse combination of service
providers and resources. Given that the number of ED presentations by adolescents is increasing
to a greater degree than outpatient presentations, it appears adolescents are gaining access to

28

mental health services in the ED instead of the outpatient services when psychiatric care is
required (Gandhi et al., 2016). The literature highlighted several reasons for barriers and
challenges to accessing outpatient MH care following an ED visit. Some of the most common
obstacles were the lack of connecting youths to the appropriate mental health care in the
community and the limited availability of outpatient mental health services for youth (Dolan &
Fein, 2011; Gill et al., 2017; Leon et al., 2017; Sheridan et al., 2017).
According to Frosch, dosReis, and Maloney (2011), ED’s are frequently viewed as the
“front doors to care, that is, points of access to mental health care” and there appears to be a
“disconnection of the emergency department from other services” (p. 648). This presents
challenges for youth that require continuing psychiatric care once they have been discharged
from the hospital. Lynch and colleagues (2015) suggest that it is critical that ED’s be involved
inside the greater child and youth mental health care system to decrease “service fragmentation”
(p.477). Furthermore, establishing community contacts can further limit additional pressure and
reduce the likelihood of the “deterioration of functioning” (Auerbach & Mason, 2010, p.316).
Lynch and colleagues (2015), propose that it is the shortage of accessible outpatient
community MH services, in addition to families’ difficulties with transportation to MH
appointments, that could point families to the ED for psychiatric care. The ED may be the
nearest health facility in their neighbourhood (Lynch et al., 2015). Furthermore, Doupnik,
Esposito, and Lavelle (2018) suggest that both stigma and logistical difficulties can stop patients
from accessing mental health care following a hospital visit.

29

Barriers and Stigma
In general, the stigma associated with mental illness can produce secrecy, shame, and
lead to the inability to pursue psychiatric care (Esposito, 2019; Schnyder, Panczak, Groth &
Schultze-Lutter, 2017). Hoyle and White (2003) highlighted the barriers that youth encounter
when accessing effective psychiatric care in an ED setting as the following:
(1) a lack of information relating to pediatric psychiatric illness, (2) limitations of the ED
setting that influence timely and comprehensive evaluation, (3) need for education and
training of ED staff regarding identification and management of pediatric psychiatric
illness, and (4) a lack of access to and effectiveness of inpatient and outpatient mental
health services (as cited in Dolan & Fein, 2011, p.1358)
In a study conducted by Owens and colleagues (2016), they found that youth who had
attended the ED for self-harm had experienced stigma and judgment as they reported “unfair
discrimination and of having been denied usual care, including pain relief, on account of having
caused their own injuries” (p.288). While Owens and colleagues (2016) study did draw attention
to the discrimination and stigma that occurs for youth that attends the ED for self-harm, there
were positive reports from the participants towards their experience such as being shown
“sensitivity and a genuine desire to understand the functions of self-harm” (p.288).
Frosch and colleagues (2011) point out that there may be stigma connected to accessing
outpatient MH treatment, which in turn may be contributing to the higher numbers of youth and
their families accessing psychiatric care from an ED when they are in an MH crisis.

30

Another identified issue why connecting youth to MH services following an ED visit is
challenging is due to the fact that there is a deficiency in “public funding for mental health
services [that] is often a cause of the limited availability and scope of mental health services”
(Lynch et al., 2015, p.473). According to Lynch and colleagues (2015), the consequences of this
result in limited accessibility of community MH services and may produce a “shift [of] the
provision of care from the specialty mental health system into EDs in the physical health system”
(Lynch et al., 2015, p.473). While Lynch and colleagues (2015) identified this as an issue in the
United States, lack of funding and inadequate availability of MH services for youth is similarly a
recognized concern in Canada (Keon & Kirby, 2006).
Doupnik and colleagues (2018), emphasize that following discharge, there should be an
arrangement of follow-up from the hospital MH care team that can help the youth navigate
through any identified barriers to accessing MH care in the community. This is a role that could
be well-suited to a hospital social worker, given social workers' expertise in systems navigation
and supporting patients around addressing any systematic barriers that impede their ability to
access and receive mental health treatment. Doupnik and colleagues (2018), further suggested
that this role should involve a nurse or community health worker and the expertise of a social
worker.
Adolescents Perspectives on Accessing MH in the ED
There is limited research in the area of adults' experiences with seeking mental health
care in an ED. Wise-Harris and colleagues (2016), confirm that this is an area that is infrequently
examined. Qualitative research on adolescents' experiences and perceptions of accessing
psychiatric care from a hospital ED was even more limited. The greatest amount of research in

31

this area has been conducted in outpatient MH care settings (Biering & Jensen, 2017). Presently,
there is minimal research or understanding around youth’s perception of what elements of mental
health inpatient care are significant to them (Madan, Sharp, Newlin, Vanwoerden & Fowler,
2016). Currently, no valid measures exist to examine these adolescent-specific concepts in the
context of patient satisfaction (Madan et al., 2016). Though, recently Biering and Jensen (2017)
conducted a qualitative study in a psychiatric ward for adolescents that analyzed what ways
youth identify values and quality of mental health care in a hospital setting. Biering and Jensen
(2017) discovered in their study five elements that lead to patient approval: “secure place, tough
love, peer solidarity, self-expression, and person not patient” (p.162).
Madan and colleagues (2016) conducted an exploratory study of adolescent psychiatric
inpatients and their guardian’s approval with treatment and compared their perceptions’
association with treatment results. One hundred twenty-nine adolescents (n= 129; 62.6%
participation rate) and 101 parents (49.0% participation rate) completed a measure of patient
satisfaction, [Perceptions of Care] POC (Madan et al., 2016). The POC survey is a 20-item
measure of satisfaction the inpatient care they received across four areas interpersonal aspects of
care, continuity/coordination of care, communication/information received from treatment
providers, and global evaluation of treatment (Madan et al., 2016). The youth and their parents
separately completed the POC at discharge. Interestingly, Madan and colleagues (2016)
discovered that most of the adolescents (83.7%) and parents (94.1%) provided general positive
assessments of the treatment they were given. Although Madan and colleagues (2016) noted that
one of the weaknesses in their research was a lack of sociodemographic representation and ethnic
diversity as most of the participants were Caucasian (86.9%). It is imperative to gain an
understanding of the population being served, to best develop programs and interventions that

32

reflect their specific needs, instead of the service provider making assumptions about their needs
(Cloutier et al., 2010; Lyons, 2004). Despite this, there is still be a limited amount of research
around adolescent needs and how they feel that their mental health needs could be better
understood and met.
Engaging Youth and Getting their Perspective on Accessing MH Care
Current statistics in Ontario, show that 17% of students aged 12-18 report their mental
health as being fair or poor, while 28% indicated that they wanted help for their MH concern, but
they were unaware of how to find support or assistance (Boak, Hamilton, Adlaf, Henderson, &
Mann, 2016; Huggett et al., 2017). These statistics have identified a gap in services for
adolescents who need mental health services and given this insight; it could be one of the factors
contributing to adolescents showing up in higher numbers in EDs seeking MH services.
Empowering youth with lived experience to be a part of initiatives to better improve
services “requires meaningfully collaborating with them to plan, organize, deliver, and evaluate
services, resources, and supports” (Huggett et al., 2017; Mental Health Commission of Canada
[MHCC], 2012, p.122). Furthermore, taking part in the initiative can legitimize the youth’s
perspectives and knowledge and allow them to actively contribute to the development of MH
resources and services (Huggett et al., 2017). This results in the enhancement and application of
accessibility of MH care specifically for youth (Huggett et al., 2017; Ontario Centre of
Excellence for Child and Youth Mental Health, 2016). Engaging youth to have a collaborative
role and active partnership in the process of program development can provide the service
providers with a clearer picture of the youth’s strengths, needs, and abilities, in addition to
different perspectives on how to deal with some of the presenting concerns (British Columbia
Ministry of Children and Family Development [BC MCFD], 2013; Huggett et al., 2017; Ontario
33

Centre of Excellence for Child and Youth Mental Health, 2016). Hawke and colleagues (2019)
point out that it is vital to be inclusive in this process; it is essential to include youth from diverse
backgrounds, cultures, and identities.
Models and Theoretical Frameworks
In the literature review, there were some models and theoretical frameworks that were
presented as appropriate approaches to the issues that this paper is examining. The models and
theoretical frameworks included in the next section are family-centred approaches, family-based
crisis intervention, multi-systemic therapy, and strengths-based approach. While the models and
theoretical frameworks listed below are just a small number of theories and models that guide the
practice of supporting youth, families and their mental health concerns. These particular models
and theoretical frameworks provide a rich understanding of how to view the issue and proceed
with providing effective MH care and supporting youth and their families when challenged with
an MH crisis or concern.
Family-Centred Approach
Unlike adults, adolescents frequently rely on their parents or caregivers to connect with
MH services and are typically involved first hand in the process of acquiring MH care (Leon et
al., 2019; Logan & King, 2001). According to Leon and colleagues (2019), 56-62% of
adolescence are escorted by a caregiver upon presentation to the ED (Cloutier et al., 2010;
Grupp-Phelan et al., 2009), and centering all the attention on the adolescent fails to gain an
understanding of the caregiver’s perspective of the situation (Logan & King, 2001). It is
estimated that 40 % of families with a youth that has a psychiatric illness report needing

34

assistance with managing their youth’s care (Brown et al., 2014; Roman et al., 2018). Moreover,
“[t]he role of caregivers has been largely neglected within this context” (Leon et al., 2019, p.15).
Cloutier and colleagues (2010), suggest that vigilant attention of parents and caregivers’
insights concerning the precipitating events, their perceptions of the needs of their youth, and
their hopes for treatment are just as significant as those of the youth. Facilitating a conversation
with youth and their caregivers on what triggered the ED visit could also assist with establishing
a starting point that leads to appropriate recommendations for future treatment (Newton et al.,
2009). Unfortunately, research of MH emergencies in youth suggests that there are no regulated
and consistent methods for gathering information from caregivers, despite the fact that caregiver
viewpoint plays a key part in the clinician’s assessment and may even impact the diagnoses and
follow-up recommendations (Cloutier et al., 2010).
As a result of their research study, Cloutier, and colleagues (2010) recommend the
caregiver and youth complete a brief assessment before the interview with the clinician, to gain
appropriate data. Additionally, recognizing the caregivers’ and youths’ needs creates an essential
basis for the interview with the caregivers and can identify the triggers for the youth’s
presentation to the ED (Cloutier et al., 2010). Leon and colleagues (2019) recommend that by
involving “both caregiver and clinician perspectives as part of standard care can indicate areas of
agreement and discrepancy and help the clinician to tailor services and recommendations to meet
their patient needs” (p.80). Most importantly, the “[i]nvolvement of family members and friends
who attend the ED with pediatric patients has been shown to increased adherence with follow-up
care” (Baren et al., 2008; Newton et al., 2009, p.452).
While involving caregivers and family in the process is important, it is imperative to talk
to the youth in privacy, as they may not feel comfortable disclosing how they are actually feeling
35

in the presence of their caregivers (Esposito, 2019). Information could be suppressed, and this
could make it difficult to get an idea of those who are at high risk (Esposito, 2019).
Family-Based Crisis Intervention
Family-based crisis interventions (FBCI) include CBT, brief family systems therapy and
a blend of therapeutic strategies to support the youth and caregiver with a reframing of the crisis,
recognizing how to create and sustain safety, increase communication and respond to beliefs
about seeking psychiatric care (Havens & Marr, 2014; Rotheram-Borus et al., 2000; Wharff et
al., 2012). FBCI incorporates the joint crisis narrative where the clinician utilizes the chance to
“help the caregivers and adolescent understand each other’s perspective, thereby creating a
single, unified crisis narrative that incorporates aspects of their previously disparate accounts of
what transpired” (Ginnis et al., 2015, p.174). The joint crisis narrative is the central component
of FBCI and distinguishes this treatment from typical psychiatric care given in the ED (Ginnis et
al., 2015). The joint crisis narrative helps the youth and their families come to “a mutual
understanding” around what triggered the MH crisis and what they can do together to assist in
evading a future MH crisis (Ginnis et al., 2015, p.174). FBCI intervention aligns with the values
and practices of the social work perspective by recognizing the youths’ and families’ intrinsic
strengths while connecting them to the necessary supports (Ginnis et al., 2015).
FBCI is centered on the belief that inpatient hospitalization is not always the best
direction for mental health treatment for suicidal youth (Wharff et al. 2012). Interventions
incorporating the family members such as the FBCI empowers families and adolescents with
knowledge and education (Ginnis et al., 2015). Although the adolescent is demonstrating suicidal
behaviour, there are strategies and tools that can help the youth to lessen or cope better with their
psychological discomfort (Ginnis et al., 2015). Interventions such as FBCI that involve the
36

family perspective and supporting the family will be more time consuming (Ginnis et al., 2015).
However, when FBCI is utilized in the ED, patients can have symptoms alleviated and be
released home to circumvent a lengthy stay in the ED (Ginnis et al., 2015). Moreover, FBCI
engenders hope for families who come to the ED in an MH crisis and the joint crisis narrative
“allows the family and adolescent to develop empathy and mutual understanding that promotes
reduced symptoms and improved family functioning” (Ginnis et al., 2015, p.177).
Following FBCI intervention, youth are only released from the ED when there is an
agreement among the patient, family, psychiatrist and social worker that the patient is going
home with a reduction in acute suicidal symptoms and a thorough safety plan in place (Wharff et
al. 2012).
Multi-Systemic Therapy
Other alternative approaches have demonstrated in the literature to be effective, such as
multi-systemic therapy (MST) (Havens & Marr, 2014). MST incorporates “family, behavioral,
and psychosocial interventions to assist families in identifying and using available resources and
family strengths to enact change” (Havens & Marr, 2014, p.194). A study conducted on youth
randomly allocated to MST or inpatient hospitalization demonstrated much lower rates of selfreported attempted suicide at 1-year follow-up for the MST group in comparison to the sample of
youth that had been admitted to inpatient care at the hospital (Ginnis et al., 2015; Henggeler et al.
1999). Moreover, the MST approach stopped inpatient hospital admissions for 57% of patients
enlisted in a randomized controlled study of MST versus inpatient hospital admissions after a
mental health crisis (Schoenwald, Ward, Henggeler & Rowland, 2000) and decreased suicide
attempts for youth who were suicidal or self-harming and had been referred for hospitalization
(Havens & Marr, 2014; Huey et al. 2004). According to Frosch and colleagues (2011), systems37

based approaches have concentrated on access to and sustained use of community MH services,
as well as the application of portable crisis services to avert youth from going to the ED for
mental health care.
Strengths-Based Approach
The strengths-based approach, which is inherent to social work practice explores the
“strengths, alliance with the patient and the patient’s self-confidence are enhanced, both of which
are essential in working together toward solving the problems that have led to a psychiatric
crisis” (Sams, Garrison & Bartlett, 2016, p.110). A strengths-based approach to assessment is
imperative in a psychiatric setting in hospital, as this framework can “bring alliance and
confidence within the family to persevere through the crisis after hospitalization” [and] “allows
for increased focus on exploring patient’s goals, strengths, relationships, skills, and family
communication” (Sams et al., 2016, p110). Furthermore, utilizing the strengths-based approach
when working with adolescents is essential, particularly for adolescents who present with
depression and suicidal thoughts as there is often a sense of hopelessness and a frame of mind
that life will not change.
Sams and colleagues (2016) conducted a study on strengths-based interventions for
children and adolescents in an inpatient psychiatry ward, and the feedback that patients and
families provided was that the strengths-based interventions such as learning coping skills and
gaining a better understanding of family communication presented in the ED during admission
was beneficial and these skills were utilized post-admission to hospital. In addition, Sams and
colleagues (2016) also found positive outcomes on their evaluation of the program, which
included strengths-based exercise in narrative therapy. The narrative therapy exercise consists of
the clinician meeting with the patient to collect information and then to craft a positive,
38

strengths-based story of the patient (Sams et al., 2016). Following an evaluation with the
patient’s primary team, the patient is given the opportunity to hear the story and provide
feedback and make any amendments, which are “to be made in the context of therapeutic
reflection and processing” and then the patient is encouraged to read the story in a family session
(Sams et al., 2016, p.115). This strengths-based narrative therapy exercise was found to be a
“powerful experience of processing the reactions, emotions, and perspectives of the others in the
room” (Sams et al., 2016, p.115).
Gaps in the Literature
North American literature that examines the attitudes of youth hospitalized for
psychiatric care is vastly limited (Gros, Parr, Wright, Montreuil and Frechette, 2017). There is
minimal research examining service user’s satisfaction with adolescent psychiatric care given in
emergency wards (Cappelli et al., 2019) as several of the research studies in the literature
focused on adult mental health satisfaction and their understanding of psychiatric care (Madan et
al., 2016). In general, studies around adolescents’ perceptions of their MH issues are absent
(Cloutier et al., 2010), as this was identified consistently as a gap throughout the literature.
Greater research is required to gain a clearer understanding of adolescents' experiences and
perspectives when they seek mental health, to better equip and prepare ED hospital staff when
adolescents present for psychiatric health care.
Another gap in the literature was the lack of use of social work researchers, and their
perspectives as most of the research examined for this paper came from a medical perspective
and from health care providers such as psychiatrists, physicians, and nurses. The social worker's
role and involvement with the adolescents as they sought mental health care from a hospital
setting was very limited in the research. Future research studies that include social work
39

researchers and perspectives are warranted. Social worker researchers would provide a vastly
different lens and approach to research than the medical model perspective that is frequently
taken by medical professionals.
Implications
Social Workers Role
Creating multidisciplinary teams within the ED to service children and adolescents with
psychiatric needs generates a space for sooner identification, symptom awareness, and suitable
treatments while managing proper interventions and care transitions (Baren et al., 2008; Roman
et al., 2018). Adequate treatment of an MH concern or crises in the ED requires an
interdisciplinary team that can provide competent and evidence-based treatment to adolescents
who present with multifaced MH concerns (Doupnik et al., 2018). Dolan and Fein, (2011)
highlight that by establishing “a skilled, culturally sensitive, multidisciplinary approach, EDs can
safely and effectively manage child and adolescent patients” (p.1363). Morevoer, Larson (2008)
suggests that mental health is socially constructed and urges that social workers take a more
active role in understanding other cultures and worldviews because the Western medical
approaches fail to understand or accommodate cultural and gender variances.
Hospital social workers are going to be more invested in understanding the social and
environmental features connected to mental health than their medical colleagues, such as
physicians and nurses, although this presents a challenge as foundations of care generally derive
from the medical model (Larson 2008). Arguably, social workers are adequately skilled and
encompass the required competencies to support and work with this population. In addition, their
interventions also provide a more holistic approach to mental health treatment.

40

While there was recognition in the literature around the value and importance of the
involvement of multi-disciplinary teams in hospitals there appeared to be a lack of social
workers' voices or role involved in the multidisciplinary team that could screen, assess and
provides intervention to the youth that presents at the emergency department in hospitals.
For example, Sam and colleagues (2016) conducted a study on a multidisciplinary team
that included psychiatrists, psychologists, nurses, and social workers that utilized a strengthsbased framework in an acute inpatient unit. Sam and colleagues (2016) stated that “[in] a
collaborative effort, between nursing, psychology, and psychiatry, CBT-based psychoeducational
and skills-based worksheets were developed” (p. 111), the social worker's role was not identified
as being part of the collaboration. Unfortunately, according to Auerbach and Mason (2010), the
social worker's role and involvement in the ED are not always well understood by the medical
health staff. This is surprising given that it is approximated that social workers are the nation’s
biggest providers of mental health services, exceeding psychiatric nurses, psychologists, and
psychiatrists (Forenza & Eckert, 2018; National Association of Social Workers, 2016).
Despite this, there were some examples of social workers roles in treating youth in
hospital settings, such as the care model program at Oregon Health & Science University
Hospital, which consists of an LCSW (licensed clinical social worker) who provides clinical
counselling, care management at admission, and follow-through post-discharge while working
with community providers to establish a plan of further treatment (Sheridan et al., 2017). In
Ontario, at McMaster Children’s Hospital, some of the youth patients who get a referral for a
further psychiatric risk assessment may include a one-on-one assessment with a psychiatrist or a
clinical mental health professional such as a social worker (Rosic et al., 2019). In addition to this,
Eposito (2019) highlighted the importance of the social work role in the ED by acknowledging
41

that they can conduct an ED assessment and start teaching the youth about MH strategies for
coping with mental health concerns related to panic, anxiety and relationship stressors.
Unfortunately, in the literature, there appeared to be a lack of representation of social
workers involved in supporting adolescents that presented to the ED in a mental health crisis.
Often the hospital staff that assists adolescents seeking psychiatric care are comprised of nurses
and doctors, and while they have an important role to play in the process, social workers have an
integral and valuable role in this process and should also be included in a greater capacity.
Newton and colleagues (2009) highlight that a greater comprehensive examination of a
multidisciplinary team approach to emergency department MH services involving “dependent,
interdependent and independent health care role functions, as well as the role of patients and
families, is needed” (p.452).
There was a model that explicitly outlined the social work role in an ED setting and
dealing with psychiatric adolescent patients. The model was “the child guidance model (Mahajan
et al. 2007), a team comprising a psychiatric social worker and a child psychiatrist evaluates all
children and adolescents presenting with psychiatric complaints” (Havens & Marr, 2014, p.196).
The psychiatric social worker is accessible 24 hours a day in the ED and is equipped to deliver
psychiatric assessment and complete a discharge plan (Havens & Marr, 2014).
Additionally, Wharff and colleagues (2012) describe the active role that the clinical
social worker in their research study on FBCI and suicidal youth in the ED led. The social
worker utilized a narrative approach in facilitating a separate meeting with the family and youth
to evaluate the course of events and to gain a picture of the various understandings of what lead
to the suicidal presentation (Wharff et al. 2012).

42

Furthermore, Sheridan and colleagues (2017) found in their study where the LCSW had a
prominent role in the model they were researching, that there were decreased numbers in the
length of stay and a reduction in admissions to inpatient psychiatry. Sheridan and colleagues
(2017) highlighted that “[h]aving a dedicated LCSW who can initiate psychotherapy and care
coordination during admission, as well as follow up after discharge home, supports the identified
intervention” (p.180).
The literature review revealed that there is a very sparse amount of qualitative research
conducted on youth and their experiences and perspectives of seeking MH care from an ED. This
is surprising given the growing number of adolescents that have been presenting at emergency
departments for mental health care as consistently noted throughout the literature. As such, it is
imperative to include youth voices with lived experiences in this research.
Hospital emergency departments need to be better prepared to deal with adolescents in a mental
health crisis, and when the youth leaves the hospital, a more comprehensive discharge plan that
refers them to the appropriate services is also necessary. Currently, youth and their families have
to navigate a fragmented system following a visit to the ED, which often does not lead them to
access or receive appropriate and effective mental health treatment care. Greater communication
and partnerships between the ED health care teams and the outpatient services in the community
necessitates greater attention in order to provide a more congruent system of mental health care
to adolescents.
Further research in this area is necessary to better inform policies and practices that
directly impact this population. In addition to this, the research findings could provide additional
education for hospital social workers that want to specialize in this area of practice.

43

Conclusion
It is well documented in the literature that there is an increasing number of adolescents
that are presenting in EDs seeking help for a mental health concern or crisis. While there are
some effective screening tools being utilized in Canada and the USA, such as HEADS-ED,
HEARTSMAP, EDSTARS, and ASQ. There, however, does not appear to be any clear path or
systematic process in place in North America for adolescents and their families when they do
seek help from an ED, which can make his often confusing and complicated journey of treating
mental illness even more challenging and overwhelming.
Overall, the literature did provide some examples of how social workers are involved in
the interventions and supporting youth in an ED in a hospital setting, although their presence in
the literature was not as overt as the other hospital team members such as nurses, doctors, and
psychiatrists. Hospital social workers’ expertise in systems navigation, family systems, crisis
intervention, and their skills in working with adolescents and supporting their mental health
needs should encourage them to be more actively involved in the process of supporting
adolescents that present at the ED in a mental health crisis.
While adolescences have had greater participation in their healthcare than previously, it is
vital that clinicians and service providers also increase their understanding of adolescents' needs
and satisfaction around treatment (Madan et al., 2016). The choice to admit or release a youth
after a psychiatric crisis and the recommendations linked to this choice are significantly
important (Cappelli 2019), and it is imperative that the care they receive when they attend the
emergency department meets their specific psychiatric needs. While there are awareness and
acknowledgment in the literature of this need, further research is warranted into the ways in

44

which the mental health needs of adolescents can be understood and met as this is a vulnerable
population that could be better served.

45

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