A Safe Place for Kids in Crisis
CONTACT: Dr. RUTH GERSON
Why the C-CPEP Exists
One in five children will experience a mental illness before they turn eighteen years old—yet few children receive appropriate or effective psychiatric treatment. Without effective psychiatric care, children struggling with mental illness are at a higher risk for falling behind in school, struggling socially, becoming involved with drugs or alcohol, or developing lasting mental health problems that can continue to impair them into adulthood.
The lack of accessible and effective mental health care has led to a dramatic increase over the past 20 years in emergency room visits for children and adolescents experiencing a psychiatric crisis. Ideally, emergency departments would provide high quality evaluation and treatment planning for young patients in psychiatric crisis. Instead, families often encounter a system poorly equipped to evaluate and then safely and effectively manage their young child’s or teenager’s mental health needs. Across the United States, our youngest patients are often evaluated in medical emergency rooms or adult psychiatry settings, which are often neither safe nor therapeutic and also lack access to specialist child and adolescent psychiatric clinicians.
We believe that all children deserve access to uncompromising mental health care. The Children’s Comprehensive Psychiatric Emergency Program (CCPEP) at New York City Health + Hospitals/Bellevue is the only psychiatric emergency care environment in New York State and one of only three in the world dedicated solely to the care of children and adolescents.
We provide safe, child- and family-focused, specialized care 24 hours a day, 7 days a week. Our young patients and their families come to Bellevue from all five boroughs of New York City as well as New Jersey, Westchester and Long Island—and even as far as Pennsylvania and Florida. Through multidisciplinary collaboration, multi-systemic engagement, innovation, and the sharing of knowledge, we overcome stigma and systemic constraints to create a mental health system devoted to supporting the development of children and their families.
What Makes Us Different
Whether it is a high school student with severe depression contemplating suicide, a young child with autism and seizures who gets aggressive at home, a girl struggling with nightmares after being sexually assaulted, or a child in foster care who develops obsessive-compulsive behaviors due to the stress of being moved to a new foster home, the CCPEP is their safe haven that provides effective, high-quality care, regardless of the family’s ability to pay.
The CCPEP is the only place where New York City’s children and families can see a specialized child psychiatrist and receive effective, individualized treatment—at any time of day or night. Each child who walks through our doors immediately receives in-depth evaluation by our multidisciplinary clinical team, which consists of trained and experienced child and adolescent psychiatrists and psychologists, psychiatric social workers with advanced training in child mental health, experienced psychiatric nurses, psychiatric technicians, and case managers. This extensive, specialized evaluation allows accurate diagnosis and connection to the most effective, appropriate, and individually tailored services to stabilize the child and treat their specific ongoing mental health needs.
The CCPEP has three main components: the Emergency Evaluation Area, the Pediatric Observation Unit, and our Outpatient Acute Care Services. In the emergency evaluation area, children and their families are triaged by an experienced child psychiatric nurse and then seen by a child psychiatrist and a child psychiatric social worker for evaluation and diagnostic assessment. Over 60% of the youth evaluated in the CCPEP can be stabilized, connected with outpatient treatment and discharged that same day. Many of these children are seen for follow up in our Interim Crisis Clinic or Home-Based Crisis Intervention program, described below.
Children who present with more severe and acute symptoms can be held overnight or for several days for treatment in the extended observation and brief stabilization six-bed unit, called the Pediatric Observation Unit. There, the CCPEP physician, nursing and social work staff can safely manage highly acute youth whose mental illness presents a danger to themselves and others. This unique environment, operating 24 hours a day, 7 days a week, provides a high quality alternative to triage in medical ERs or admission to adult psychiatric ER settings. Many children can be stabilized, started on medication or with intensive therapy, and discharged to home after a short time. More acutely ill children, such as those who are suicidal or experiencing psychosis, can be admitted to one of Bellevue’s Inpatient Psychiatric Units or to
one of our other acute care programs, such as our Partial Hospitalization Program.
A Model for Child-Centered Care:
CCPEP’s Outpatient Acute Care Services
Psychiatric hospitalization can be traumatic for children and families, and the CCPEP’s unique acute care services allow us to provide intensive, effective treatment to keep children safe as outpatients and avoid unnecessary hospitalizations. We consider this work essential to the CCPEP mission, preventing unnecessary admissions and meaningfully engaging families with the mental health service system, often
for the first time. These services include Interim Crisis Clinic services, Home-Based Crisis Intervention services and Mobile Crisis services, as described below.
Interim Crisis Clinic
Bridging the gap between emergency evaluation and outpatient follow-up care: Children who are evaluated in the CCPEP can be seen for up to five follow-up visits at the CCPEP. The CCPEP serves as the primary point of access to the mental health system for many families, many of whom have a great deal of difficulty accessing care due to insurance problems and long wait lists at outpatient clinics. Currently the delay to be seen by a psychiatrist at community outpatient clinics can be as long as 3-6 months, and many clinics will not treat high-acuity patients due to concerns about liability. The Interim Crisis Clinic provides short-term services so that children are not left without care during a time of acute clinical need.
Ongoing monitoring of symptoms, functioning, and safety: Often children do not warrant an inpatient admission but present with symptoms and issues that require immediate intervention with ongoing monitoring. The Interim Crisis Clinic provides an opportunity for these children to be seen and to continue to receive care within days of the initial evaluation. This service can prevent an unnecessary admission that would have been necessary without this ability for close and immediate follow-up. Initiation of medication or provision of medication when child does not have access to an outpatient psychiatrist: At times it becomes clear that initiation of medication is indicated. Children can be started on medication during an initial CCPEP evaluation or during an initial crisis clinic visit. The CCPEP team is able to continue to monitor the child’s response to the medication, evaluate for potential side effects, and titrate dosage during crisis clinic visits, to provide immediate symptom relief.
Providing psycho-education, brief psychotherapeutic interventions and family interventions: Patients and their families receive extensive psychoeducation about their diagnosis and treatment. Children and families are given proven, evidence-based cognitive behavioral treatments which can immediately address symptoms and alleviate distress. We also provide intensive family therapy focusing on improving communication, reducing conflict and enabling families to weather the crisis more effectively.
Bellevue Home-Based Crisis Intervention (HBCI)
The New York State Office of Mental Health supports a network of Home-Based Crisis Intervention programs across NYC, providing short term (6-12 weeks) in-home and community services to prevent psychiatric hospitalization in at-risk youth. HBCI clinicians work with the child and family to stabilize the crisis and connect them to ongoing mental health services.
Bellevue Mobile Crisis Services
Mobile Crisis Services provide a team of mental health clinicians who are available to evaluate patients in their homes and authorized to request EMS transport of those patients to the CCPEP if necessary. We utilize this service when high risk patients do not attend scheduled follow-up appointments in the Interim Crisis Clinic (all patients referred to Interim Crisis Clinic are stratified in terms of risk of danger to self or others). This ensures that patients do not fall through the cracks of the emergency management system.
Together, these programs provide a flexible safety net of comprehensive hospital and home-based psychiatric services, allowing us to create individualized treatment plans specific for the needs of each child and family.
Setting the Standard for Emergency Child
We at the Bellevue CCPEP are committed to providing the highest quality of care to our patients and families, and to setting the standard for emergency psychiatric care for children nationwide. Through a number of outreach, education and advocacy programs, we are serving as thought leaders in emergency child psychiatry.
Training and Education for Emergency Child Psychiatry
The CCPEP serves as a training site for close to a hundred child psychiatry residents, fellows, emergency medicine residents, pediatricians, medical students, nurse practitioner students, and social work interns each year. Our trainees work under the direct supervision of our highly experienced attendings and staff to learn how to provide the highest quality of care to patients and families. Our trainees have graduated and have gone on to pioneer and lead emergency psychiatric programs at other hospitals and in other cities, spreading excellent care beyond our borders.
The CCPEP has also hosted department chairs, hospital administrators and public health officials from cities as far as Philadelphia, Atlanta, and Los Angeles who look to us as the national model for a high-quality acute care child psychiatry service. We have consulted with several hospitals and municipalities to assess their service utilization patterns and patient needs and design the best possible program for their institution.
The First Annual Conference on Emergency Child Psychiatry
We are proud to be organizing and hosting the first ever conference on emergency child psychiatry in March 2014. With the generous support of the Lowenstein Foundation, we have been able to bring together leaders in the field for an educational event that will bring hundreds of clinicians from across the country together for an intensive training in emergency assessment, stabilization and treatment. The conference will also provide tools for program development for clinicians looking to set up acute care services in their home institution.
The First Textbook of Emergency Child Psychiatry Since 1975
In collaboration with American Psychiatric Publishing, we developed Helping Kids in Crisis: Managing Psychiatric Emergencies in Children and Adolescents; the first book about child psychiatric emergencies since 1975, when Dr. Gilbert Morrison published his book Emergencies in Child Psychiatry: Emotional Crises of Children, Youth and their Families. Since 1975 there has been an explosion of research and new clinical knowledge about child psychiatry and psychology that has led to a paradigm shift in the assessment and treatment of children. This new book provides the most up-to-date clinical assessment and treatment information to help all clinicians working with children in crisis provide the best possible care.
Creating a Network of Experts for Research Collaboration and Dissemination
We have led the creation of both local and national networks of emergency child psychiatric clinicians to collaborate on research into effectiveness of different models of care and improving patient outcomes. Similar collaborative networks have made vast improvements in quality of care for cancer centers and pediatric emergency programs. We are confident that by using these networks we can advance the field
of emergency child psychiatry through research and dissemination of knowledge and expertise.