Of 23 reported occurrences of moral distress, 61% involved pediatric mental health cases, found a recent study.1 “Concerns stemmed from an influx of mental health patients and lack of training and experience by staff,” says April Kam, MD, MScPH, FRCPC, the study’s lead author.

Additional resources have since been made available to the pediatric ED. These include social workers and a mental health assessment unit. Better communication is evident between psychiatrists and ED clinicians.

“There still is moral distress around cases where there is little either team can do,” notes Kam, an associate professor of pediatric emergency medicine at McMaster University in Canada.

Limited community resources, such as lack of available inpatient beds, are disheartening to everyone involved. “Often, ED staff bear the brunt of the frustrations of exhausted family members who are finding it challenging to cope,” says Kam.

Douglas S. Diekema, MD, MPH, has seen these three pediatric mental health ethical issues lead to provider distress:

• There is a lack of resources, both in terms of mental health providers and inpatient beds.

“The number of patients presenting with mental health concerns has really taxed the resources that exist,” says Diekema, director of education at Treuman Katz Center for Pediatric Bioethics at Seattle Children’s Research Institute.

Many patients could benefit from an inpatient admission, but limited beds allow only those who represent a threat to themselves or others to be admitted. Outpatient therapy is similarly difficult to access. “This makes it difficult for kids to get the kind of counseling and care they need during times of personal crisis,” says Diekema.

• Many states passed laws that permit teens to access mental health services without the consent of a parent.

“This is a good thing,” Diekema says. The problem is that the laws require confidentiality and disallow an admission or required mental healthcare without the adolescent’s consent. Some explicitly state this, while other laws are interpreted as such. Regardless, providers may feel restricted in their ability to notify a parent even when it is in the teen’s best interest. In some cases, the adolescent clearly would benefit from treatment or admission. “Laws that require the teen’s consent may hamper a parent’s ability to get the help they need for their child,” says Diekema.

• Patients with eating disorders, particularly anorexia nervosa, may refuse help.

The patients may not realize their behaviors represent a grave danger to themselves. How best to care for these patients is a source of great concern among healthcare providers.

“It is difficult to treat without patient cooperation,” says Diekema. “Forced treatment rarely improves long-term outcomes.”


1. Colaco KA, Courtright A, Andreychuk S, et al. Ethics consultation in paediatric and adult emergency departments: an assessment of clinical, ethical, learning and resource needs. J Med Ethics 2018; 44:13-20.


• April Kam, MD, MScPH, FRCPC, Associate Professor, Pediatric Emergency Medicine, McMaster University, Canada. Phone: (905) 521-2100 ext. 73983. Email: kama@mcmaster.ca.

• Douglas S. Diekema, MD, MPH, Director of Education, Treuman Katz Center for Pediatric Bioethics, Seattle Children’s Research Institute. Phone: (206) 987-4346. Email: douglas.diekema@seattlechildrens.org.