a b s t r a c t

Background: Pediatric and adolescent mental health complaints are growing problems for emergency depart- ments and inpatient facilities. We sought to investigate the relationship between weeks when school is in session (vs vacation) and presentation with concern for danger to self or others.

Methods: We retrospectively studied the risk of presenting with these complaints while school is in attendance compared to the risk while on vacation over a 4-year period (2009-2012) at an academic pediatric emergency department. The week of presentation was recorded for all children making psychiatric visits related to suicidality or homicidality, and these were correlated with the public school calendar for the local school district. The incidence rate ratio (IRR) was calculated for psychiatric visits while in school status vs vacation. Similar data were collected for a diagnosis of urinary tract infection to serve as a control.

Results: Of 3223 eligible patients (mean age, 13.8 years), 82.7% presented while in school, although the students only spent 68.6% of their time in school, yielding an IRR of 2.18. By comparison, the IRR for the diagnosis of urinary tract infection was 1.25.

Conclusions: Children and adolescents are more likely to present with concerns for danger to self or others while at- tending school compared with while on vacations. Causation and opportunities for intervention require further study.

(C) 2015

Introduction

Both suicide and homicide are leading causes of death in US youth. Suicide is the third most common cause of death for children older than 10 years [1]. It is estimated that 100 attempts occur for every com- peted suicide for children and adolescents [1]. Countless others express suicidal ideations, with 16% of high school students reporting serious consideration [2]. Psychiatric holds for danger to others, although less common, are also a concern.

Understandably, psychiatric referrals to emergency departments (EDs), involuntary psychiatric holds, and mental health-related admis- sions for youth expressing a danger to self or others are increasing [3-6]. Boarding times in the ED are often long [7] and place strain on ED re- sources. Overall, insufficient literature exists on adolescent suicide as- sessment and prevention [8]. Characterizing the patients who present to an ED for psychiatric care and the potentially modifiable factors that drive this need for emergent intervention represents an important first step in controlling the increasing mental health crisis among youth. Our pediatric ED (PED) anecdotally noted a variation in psychiatric visits that corresponded with the traditional school calendar. We postu- lated a temporal correlation between visits for potential danger to self

? No funding.

?? To be presented at PAS, April 27, 2015.

* Corresponding author. Tel.: +1 310 625 2918; fax: +1 323 226 6454.

E-mail address: [email protected] (I. Claudius).

or others and active school attendance, as compared with times that schools were out for vacation. Our objective was to compare psychiatric visits to a PED with school in session vs vacation status.

Methods

Patient identification

Records were identified for all patients younger than 18 years pre- senting to the ED at an urban level 1 trauma center with a dedicated PED with a priori-determined psychiatric discharge diagnoses for the years 2009-2011. The following diagnoses were included: 5150 or 5585 (California code for an involuntary psychiatric hold), danger to self, suicidality, suicidal ideations, suicidal tendencies, evidence of a sui- cide attempts, danger to others, homicidality, homicidal ideations, or homicidal tendencies. Patients were excluded if they had a psychiatric codiagnosis listed without active danger to self or others (eg, a patient with a history of danger to self but currently seen for an unrelated med- ical complaint), if they were incarcerated, if they left prior to being seen, or if there were no records available for the visit. Children prior to age of school matriculation were not represented in this patient group.

As controls with minimal anticipated seasonal variation, patients presenting with Urinary tract infections were chosen. Patients younger than 5 years at the time of presentation were eliminated, as this age group may have been less impacted by the standard school

http://dx.doi.org/10.1016/j.ajem.2015.02.055

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C. Lueck et al. / American Journal of Emergency Medicine 33 (2015) 682-684

calendar. All patients aged 5 to 18 years with a discharge diagnosis for cystitis, UTI, or pyelonephritis and not incarcerated from 2009 to 2011 were included in this group.

Institutional Review Board permission was obtained for this study.

Waiver of informed consent was obtained.

Data collection and analysis

683

The Los Angeles Unified School District (LAUSD) calendars for single- tract schools including any portion of the years 2009-2011 were accessed on line. The date of visit for included patients was recorded and assigned to a week of either “school in session” (SIS) or “vacation” (V) status based on the LAUSD calendar [9]. Thanksgiving, winter, spring, and summer breaks comprised the V time. Holiday weekends and single pupil-free days were not considered separate vacation time.

The units of analysis for the purpose of this study were the numbers of included patients for each SIS or V week. As this is count data, we chose to report it as an incidence rate ratio (IRR) or the ratio of Incidence rates during SIS weeks to those during V weeks. Negative binomial re- gression was used to calculate the IRR and P value because of the distri- bution and overdispersion of the data set.

Eligible patients with UTIs were categorized and evaluated using the same process.

All statistics were performed with STATA 12.

Results

A total of 4724 patients were identified, of whom 1376 did not have an acute included diagnosis, 121 were incarcerated, 1 had no acute diag- nosis given, and 3 Left without being seen. These were eliminated, leav- ing 3223 Psychiatric patients (mean age, 13.8 years) for analysis. There were 131 SIS weeks (68.6%) and 60 V weeks (31.4%), for a total of 191 weeks analyzed.

Two thousand six hundred sixty-eight patients (82.7%) presented on SIS weeks compared with 17.3% presenting on vacation weeks. The mean number of cases per week on SIS weeks was 20.3 (SD +8.2) com- pared with 9.3 (SD +4.8) on V weeks. The IRR was 2.18 (95% confidence interval, 1.90-2.51; P b .001). This is presented in Fig. 1.

For UTIs, 775 patients were identified (mean age, 11.6 years), of which 567 (73.2%) were diagnosed on SIS weeks. The IRR for this group was 1.25 (95% confidence interval, 1.05-1.48; P = .011). The sig- nificance of this was unexpected. A graphical comparison of UTIs com- pared with Psychiatric diagnoses is presented in Fig. 2, which highlights the differences between the 2 groups.

Fig. 1. Comparison of “In School” vs “Vacation” patients considered for an involuntary hold.

Fig. 2. Comparison of mental health visits (circle) vs UTI (square) by week.

Discussion

Psychiatric presentations occurred at more than double the rate while children were attending school when compared with vacation. Although this certainly does not assess causality, it does raise the poten- tial for an association.

One possible explanation is that exposure to school counselors, teachers, and administrators leads to increasED referrals to mental health care. The US Department of Health and Human Services offers a tool kit for high schools, which cites lawsuits referable to schools for stu- dent suicides and encourages recognition of risk factors [10]. School- based screening programs of teens have revealed 11.4% to be at risk of suicide [11]. It is possible that these referrals to emergency care are ubiquitously warranted and children may have gone unrecognized without the intervention of school personnel. However, when suicide guidelines and resource documents are reviewed, only about half ad- dress training [12]. It is also possible that unnecessary referrals are being made to EDs because of poor understanding of violence recogni- tion tools or lack of familiarity with community resources.

Another possibility is that stressors stemming from school attendance, such as bullying, academic requirements, and disengagement in the school community, contribute to students’ desire to harm themselves or others. School is a fertile environment for bullying, and 32% of students re- port having been bullied [13]. Victims are at higher risk for suicide than those uninvolved [14]. Perpetrators of school-based homicides often re- port feeling bullied as well [15]. Many more students receiving failing grades in school attempt suicide than those receiving As [16]. Poor school engagement has also been demonstrated as a risk factor [17].

Certainly, other factors motivating depression and self-harm (eg, Seasonal affective disorder, holidays) may cause more psychiatric visits to occur during times of the year that contain more vacation weeks (like summer) without a true association. However, other population studies of suicide in all ages (not limited to school-aged children) find a higher rate of attempts during the spring and summer [18-20]. This is different than our finding of lower rates during school vacation weeks, which cluster in the summer and winter, and lends credence to the postulate that school attendance is a driving factor. Further research is necessary to assess the causality of this association.

Limitations

This study was based on pooled data and did not exclude patients who do not attend LAUSD schools. This data collection occurred at a county facility serving a primarily Latino and uninsured or underinsured population. Nationally, about 10% of students attend private schools. In Los Angeles, the percentage reported is 16% [21]. The tracking of the schools is also not collected. In 2008, the LAUSD had 30 (or 3.9%) of schools off the single-track calendar, which fell to 3 schools (0.39%) by

684 C. Lueck et al. / American Journal of Emergency Medicine 33 (2015) 682-684

2012 (personal communication with LAUSD). Although some of our in- cluded participants may have attended school with a slightly different calendar and thus been misclassified, these schools represent a small percentage of LAUSD students within our catchment area; and this would be unlikely to alter our findings. In additional, this was a single- center study primarily enrolling underserved patients in the Western United States. We cannot attest to whether these findings extrapolate to other populations.

Conclusions

There is an association between weeks in attendance at school and psychiatric visits to the ED for danger to self or others compared to weeks of school vacation.

Study funding

None.

Conflicts of interest

There is no true conflict of interest, but (as a disclosure) Drs Claudius and Kearl receive an honorarium for CME lectures given through HIPPO on pediatric emergency medicine topics.

Contributorships

None.

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