Paediatric Mental Health in the Emergency Department – PEM Induction

Author & Questions: Sarah Edwards / Editor: Liz Herrieven / Codes: / Published: 24/01/2022

Paediatric mental health (MH) admissions to emergency departments (ED) and hospitals are increasing worldwide, including the UK, USA and Australia16. Over your time in the ED, you will meet many patients with MH issues. These cases can sometimes be challenging. The support you are able to offer will be dependent on services available in your local hospital. However, guidance is clear that all those patients who present to UK EDs with suicidal intent or self-harm should be seen by a MH practitioner/CAMHS before discharge7,8

This blog will guide you through some of the key principles to consider when seeing patient who presents with a MH issues. 

The Patient How do I approach them?

Like all patients, compassion and understanding are needed. Some patients may have been here before, for some its their first time.  

Like all patients in the ED there is an ABCDE approach even to mental health (adapted from the post found here)

  • A Assessment and Analgesia (Compassion)

Your history will be briefer than a psychiatric history but should cover the social circumstances, risks, intents and triggers.

HEEADDSSS can be a useful strategy for gathering the history

  • B Bloods and other physical investigations and treatments

If there has been an overdose, its important, if possible, to elicit whats been taken, how much and when. Also, what it was taken with. Toxbase is a really useful resource for understanding what needs to be done with each overdose.  

  • C Circulation The childs wider network

The child is the heart of their own network and their close family members are likely to be part of the solution to their difficulties.  Parents will need to help with risk management and care plans so they should be (in most situations) contacted if they are not already present.  

  • DEFG Dont Ever Forget (safe) Guarding!

Always think about safeguarding. 

The Law and Children in the Context of Mental Health

It is important to be aware of some of the legal aspects with mental health and children. Here is a brief summary


The same duties of confidentiality apply when using, sharing or disclosing information about children and young people as about adults. With the GMC guidance specifically mentioning:

  1. disclose information that identifies the patient only if this is necessary to achieve the purpose of the disclosure in all other cases you should anonymise the information before disclosing it
  2. inform the patientabout the possible uses of their information, including how it could be used to provide their care and for clinical audit
  3. ask for the patients consent before disclosing information that could identify them, if the information is needed for any other purpose other than in the exceptional circumstances described in this guidance
  4. keep disclosures to the minimum necessary.

It is important that we develop a rapport with children and to build their trust and confidence, like all patients. However, be honest with them and never promise you wont share some information. 

Capacity & Consent

Everyone under 18 is a child, according to the law in England, Wales and Northern Ireland. In Scotland its 16. Often, despite still being considered children in most of the UK, 16-year-olds are presumed to be able to consent to their own medical treatment. 

Children under the age of 16 MUST show that they are Gillick Competent in order to be able to give their own consent. We have to be sure they have sufficient intelligence and understanding to fully take on board what we are proposing. 

Gillick or Fraser Competence

In 1983 Victoria Gillick challenged Department of Health guidance which enabled doctors to provide contraceptive advice and treatment to girls under 16 without their parents knowing. The case led to the criteria for establishing whether a child under the age of 16 has the capacity to consent to contraception; the Gillick test, or other treatment, the Fraser test, after the judge involved. Children under 16 can consent if they have sufficient understanding and intelligence to fully understand what is involved in a proposed treatment, including its purpose, nature, likely effects and risks, chances of success and the availability of other options. 

Practically, its useful to think of the tests we use to assess capacity in adults, as per the Mental Capacity Act of 2005 (although the Act itself does not apply to people under 16):

Can the person understand the decision to be made and the information provided about the decision?

Can the person retain that information for long enough to make the decision? (notes and leaflets can be used to help)

Can the person weigh up the pros and cons of making the decision?

Can the person communicate their decision, given help if needed?

If a child passes the Fraser test, he or she is considered Fraser competent to consent to that medical treatment or intervention. This can vary with each treatment or intervention; this can also fluctuate such as in certain mental health conditions. However, as with adults, this consent is only valid if given voluntarily and not under undue influence or pressure by anyone else. Therefore, each individual decision requires assessment of Fraser competence.

If a child does not pass the Fraser test, then the consent of a person with parental responsibility (or sometimes the courts) is needed in order to proceed with treatment.

Under 13-year-olds

There is no lower age limit for Gillick competence or Fraser guidelines to be applied. It would rarely be appropriate or safe for a child less than 13 years of age to consent to treatment without a parents involvement. As children under the age of 13 arent able to consent to sexual activity, the Gillick Test does not apply here. 


Young people aged 16 or 17 are presumed in law, like adults, to have the capacity to consent to medical treatment. However, unlike adults, their refusal of treatment can in some circumstances be overridden by a parent, someone with parental responsibility or a court. This is because we have an overriding duty to act in the best interests of a child. This would include circumstances where refusal would likely lead to death, severe permanent injury or irreversible mental or physical harm.

Adapted from, with further information being found here and here.


There is an ever-increasing number of children presenting to our EDs with acute mental health issues. 

  • Remember to always be kind, compassionate and empathetic. 
  • Thing about your Mental Health ABCDE
  • Consider using the HEEADSSS to help with taking a psychosocial history.
  • Always think about safeguarding
  • Beware of the law surrounding consent, capacity and confidentiality when working with children. 


1. Lo, C. B. et al. Childrens mental health emergency department visits: 2007-2016. Pediatrics 145, (2020).

2. Irteja Islam, M., Khanam, R. & Kabir, E. The use of mental health services by Australian adolescents with mental disorders and suicidality: Findings from a nationwide cross-sectional survey. PLoS One 15, (2020).

3. Lawrence, D. et al. The mental health of children and adolescents: Report on the second Australian child and adolescent survey of mental health and wellbeing. AustrailianGovernment (Austrialian Government, 2015).

4. Tolentino, A., Symington, L., Jordan, F., Kinnear, F. & Jarvis, M. Mental health presentations to a paediatric emergency department. Emerg. Med. Australas. 1742-6723.13669 (2020). doi:10.1111/1742-6723.13669

5. Williamson, A. et al. Mental health-related emergency department presentations and hospital admissions in a cohort of urban Aboriginal children and adolescents in New South Wales, Australia: findings from SEARCH. BMJ Open 8, 23544 (2018).

6. UKParliment. Written questions and answers – Written questions, answers and statements – UK Parliament. UIN 181292 (2018). Available at: (Accessed: 3rd January 2021)

7. RCEM. Mental Health in Emergency Departments A toolkit for improving care. (2019).

8. NICE. Managing self-harm in emergency departments. Natl. Inst. Heal. Care Excell. 19 (2020).

Other useful resources

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