What to do in a children's mental health crisis

When a mental health crisis or severe behaviors such as self-harm or out of control aggression occur, parents often don’t know what to do.

A crisis can occur even when a parent has used de-escalation techniques or other options to address the crisis. It’s often nobody’s fault. Children’s behaviors and crisis situations can be unpredictable and can occur without warning.

If you are worried that your child is in crisis or nearing a crisis, seek help. Assess the situation before deciding whom to call.

• Is your child in danger of hurting themselves, others or property?
• Do you need emergency assistance?
• Do you have time to start with a phone call for help and support from a mental health professional or crisis team?
• Most importantly—safety first! Ensure the safety of any/all individual(s) in the situation. In a crisis situation, if you feel the situation is unsafe for you or others, go out.

De-escalation Techniques

Children cannot always communicate their thoughts, feelings or emotions clearly or understand what others are saying to them during a crisis. As a parent it is important to empathize and understand your child’s feelings. If safe to do so, try to de-escalate the crisis, and assess the situation to decide if you need emergency assistance, help or support. Seek outside resources listed in the back of this booklet when what you are doing is not helping. 

De-escalation techniques that may help handle a crisis:

• Keep your voice calm
• Avoid overreacting
• Listen to your child
• Don’t make judgmental comments
• Don’t argue or try to reason with your child
• Express support and concern
• Avoid continuous eye contact
• Ask how you can help
• Keep stimulation level low—low noise and low lighting if possible
• Move slowly
• Offer options instead of trying to take control
• Avoid touching your child unless you ask permission
• Be patient
• Gently announce actions before initiating them
• Give them space, don’t make them feel trapped

If you haven’t been able to de-escalate the crisis yourself, you will need to seek additional help from trained mental health professionals to help figure out the level of crisis intervention that your child requires. A trained mental health professional may be able to help a family deescalate the situation or prevent the crisis from happening.

If your child is in crisis, remain as calm as possible and continue to reach out for the guidance and support until the crisis is resolved. Most importantly— safety first! In a crisis situation, when your or anyone else’s safety is in doubt, back off or get out.

Not in immediate danger

If you do not believe you, your child, or others are in immediate danger, call your child’s psychiatrist, clinic nurse, therapist, case manager or family physician that is familiar with the child’s history. This professional can help assess the situation and offer advice. The professional may be able to schedule an immediate appointment or may be able to admit the child to the hospital. If you don’t have a connection to any of these professionals, cannot reach one or if the situation is worsening, do not hesitate to call your county mental health crisis team. If safety is a concern, call 911. However, be sure to tell them this is a mental health crisis.

Mental Health Crisis Phone Lines and Crisis Response Teams

In Minnesota, each county has a 24-hour mental health crisis phone line for both adults and children. Some 24-hour phone lines serve more than one county. These crisis lines are staffed by trained workers who assist callers with their mental health crises, make referrals and contact emergency services if necessary. If the call is made after normal business hours, the crisis line will connect the caller to a mental health professional within 30 minutes.

​Right now there are more than 40 crisis numbers, but if you call **CRISIS or **274747 from a cell phone you will be connected to the closest crisis team. In addition to 24-hour crisis phone lines, all counties have a mobile crisis response team. Mobile crisis teams are teams of two or more licensed mental health professionals or practitioners that can meet the child where the crisis is happening or wherever the child will feel most comfortable. How long it takes for mobile teams to arrive may vary depending on your location and the location of the mobile team staff.

Crisis teams are meant to be accessible to anyone in the community at any time. They are available 24 hours a day, seven days a week and 365 days a year to meet face-to-face with a child in a mental health crisis, conduct a mental health crisis assessment and create a crisis treatment plan. A child does not have to have a mental health diagnosis to receive crisis services. Crisis teams will respond and address the situation whether or not the child has insurance. If the child in crisis does have insurance, the crisis team will bill their insurance company for services they provide. Some crisis teams offer interpreter services for nonEnglish speakers who require assistance, although those who need an interpreter may have to wait longer to receive crisis services depending on the interpreter’s availability.

Ways that crisis teams can help:

• Cope with immediate stressors
• Develop practical behavioral strategies to address the child’s short-term needs
• Identify what issues led to the crisis
• Suggest techniques to avoid a crisis in the future
• Conduct a diagnostic assessment
• Identify available resources and supports
• Develop and write a crisis plan
• Provide phone consultation and support
• Make a referral to a hospital
• Consult with outside mental health professionals as needed
• Respond in non-urgent situations to help prevent a future crisis

Questions the crisis team may ask: 

• Your name and the name of the person in crisis
• Your relationship to that person
• The address where the crisis is occurring
• A phone number to call in case you are disconnected
• The nature of the problem
• If safety is a concern
• If the child has harmed themselves or is threatening harm
• The possible cause of the crisis
• Mental health and hospitalization history
• Health insurance information

The crisis team is required by law to maintain a file on anyone who receives mobile crisis intervention or crisis stabilization services.

The crisis team file will include: 

• The crisis treatment plan for the child receiving services
• Signed release forms
• The child’s health information and current medications
• Emergency contacts
• Case records detailing the intervention
• Any clinical supervision that may be required
• Summary of any case reviews
• Any other information the team would like to have in the file

When you call your mental health crisis team, they will triage the call to determine the level of crisis service needed. If the child experiencing a crisis is in immediate danger to themselves or others, the crisis team will refer the situation to 911, and law enforcement will respond. Sometimes law enforcement and crisis team staff will respond together. If the situation is not as urgent, the crisis team will assess the level of intervention required and provide either information and referral, a phone consultation, an emergency room visit or an immediate site visit.

When the crisis team makes a site visit, they assess the situation to determine if the child is a danger to themselves or others. Crisis staff may decide that law enforcement needs to intervene, that the child should be seen at the nearest emergency room or that the child should be directly admitted to a psychiatric unit at the nearest hospital. Some mobile crisis teams will transport people to emergency rooms; if they don’t and transportation is needed, the crisis team may contact paramedics or law enforcement or request that you provide transportation.

A new mode of transportation under Medical Assistance is called protected transport, which is for someone who is experiencing a mental health crisis and needs to be driven to the ER or transferred to another hospital. The crisis team or a physician in an Emergency Department can determine that this mode is appropriate. The vehicle cannot be an ambulance or police car, but must have safety locks, a video recorder, a transparent thermoplastic partition and drivers/aides who have specialized training. This is a more dignified way to transport people with mental illnesses in crisis. There are not many in the state.

Stabilization Services

The crisis team may recommend crisis stabilization services. Stabilization services are short-term services whose goal is to help the person in crisis return to their level of functioning before the crisis. These services may be provided in the child’s home, the home of a family member or friend, or in the community. Services are available for up to 14 days after crisis intervention.

​Stabilization involves the development of a treatment plan that is based on the diagnostic assessment and the child’s need for services. It must be medically necessary and must identify the child’s emotional and behavioral concerns, goals and objectives. The treatment plan will also identify who is responsible for the interventions and services, the frequency or service intensity needed and the desired outcomes. Treatment plans must be completed within 24 hours of beginning services and must be developed by a mental health professional or a mental health practitioner under the supervision of a mental health professional.

At a minimum, a treatment plan will include:

• A list of problems identified in the assessment
• A list of the child’s strengths and weaknesses
• Concrete and measurable short-term goals and a timeline for achieving these goals
• How each goal will be achieved
• Documentation of who will be involved in the service planning
• What kind of services will be initiated and how frequently they will occur 
• A crisis response action plan in case of a new crisis
• Clear notes on desired outcomes

Stabilization services may also include brief solution-focused strategies, referrals to long-term care agencies, rapid access to psychiatrists, coordinated crisis plans and a referral to a county’s children’s mental health services.

In immediate danger

If the situation is life-threatening or if serious property damage is occurring, call 911 and ask for law enforcement assistance. When you call 911, tell them your child is experiencing a mental health crisis and explain the nature of the emergency. Tell the law enforcement agency that it is a crisis involving a child with a mental illness and ask them to send an officer trained to work with people with mental illnesses called CIT, Crisis Intervention Training. Be sure to tell them—if you know for certain—whether your child does or does not have access to guns, knives or other weapons.

When providing information about a child in a mental health crisis, always be very specific about the behaviors you are observing. Instead of saying “my son is behaving strangely,” for example, you might say, “My son hasn’t slept in three days, he has barely eaten anything for five days, and he believes that someone is talking to him through his iPod.” Report any active psychotic behavior, significant changes in behaviors (such as not leaving the house, not taking showers), threats to other people or increases in manic behaviors or agitation (e.g., pacing, irritability). You need to describe what is going on right now, not what happened a year ago. Be brief and to the point.

Finally, in a crisis situation, remember: when in doubt, back off or go out. Do not put yourself in harm’s way.

Law Enforcement Response

When the law enforcement officer arrives, provide them with as much relevant and concise information about your child as you can, including the child’s diagnosis, medications, hospitalization history, and previous history of violence or criminal charges. If the child has no history of violent acts, be sure to point this out. Lay out the facts efficiently and objectively, and let the officer decide the course of action. Remember, once 911 has been called and the officers arrive on the scene, you do not control the situation.

Depending on the law enforcement officers involved, they may take your child to detention instead of to a hospital emergency room. Law enforcement officers have broad discretion in deciding whom to arrest, whom to hospitalize and whom to ignore. You can encourage and advocate for the law enforcement officers to view the situation as a mental health crisis. Be clear about what you want to have happen without disrespecting the law enforcement officer’s authority. But remember, once 911 is called and law enforcement officers arrive on the scene, they determine if a possible crime has occurred, and they have the power to arrest and take into custody a person that they suspect of committing a crime. If you disagree with the officers, don’t argue—later call a friend, mental health professional or advocate for support and information.

Law enforcement can (and often does) call the county mental health crisis teams for assistance in children’s mental health crises. The crisis team may assist law enforcement in deciding what options are available and appropriate for the child and their family. The crisis team may decide to respond with law enforcement. Law enforcement may decide to transport the child to the emergency room.

Some cities have CIT officers. CIT stands for Crisis Intervention Training. CIT officers are specially trained to recognize and work with individuals who have a mental illness. CIT officers have a better understanding that a child’s behaviors are the result of a mental illness and know how to de-escalate the situation. They recognize that people with mental illnesses sometimes need a specialized response, and they are familiar with the community based mental health resources they can use in a crisis. You can always ask for a CIT officer when you call 911, although there is no guarantee one will be available.

Body cameras are now more commonly being worn by police officers. State law is not clear about the privacy rights of the individual being taped. You may ask if the officer is wearing a body camera and ask about confidentiality.

Emergency Department

If the situation cannot be resolved on site or it is recommended by the crisis team or law enforcement officer, your child may be brought to the emergency department (ED) which may be the best option. It is important to know that bringing your child to the emergency department does not guarantee admission. The admission criteria vary and depend on medical necessity as determined by a doctor. Mental health crisis teams can assist with the triage process and refer a child to the hospital for assessment, which may make it easier for them to be admitted. County mobile crisis teams do not typically transport children to emergency rooms; if transportation is needed, the crisis team may contact paramedics or law enforcement or request that you provide transportation.

When you arrive at the ED, be prepared to wait several hours. You may want to bring a book, your child’s favorite toy, iPod, game or activity if that helps the child in crisis stay calm. Bring any relevant medical information, including the types and doses of all medications. If you have a crisis kit, bring a copy with you to the emergency department or hospital. (See the section on crisis kits in this booklet to learn more.)

If your child is not admitted to the hospital and the situation changes when you return home, don’t hesitate to call the crisis team again. The crisis team will re-assess the situation and make recommendations or referrals based on the current situation. Your child may meet the criteria for hospital admission later. If your child is hospitalized and you believe they will need more intensive services and possible residential treatment, be certain to read about your rights and responsibilities under a voluntary foster care agreement (For more information, see NAMI’s booklet, "Keeping Families Together").

Emergency Holds (a term used under the commitment law)

Sometimes when a person with a mental illness is no longer able to care for themselves or if they pose a threat to self or others, and will not agree to treatment, an emergency hold will be ordered to temporarily confine the person in a secure facility, such as a hospital. Emergency holds last for 72 hours each (not including weekends and holidays). The purpose of the hold is to keep the person safe while awaiting a petition for commitment to be filed or while the pre-petition screening team reviews the matter. An emergency hold doesn’t necessarily initiate the commitment process; it’s simply a way to assess the individual to determine if commitment is necessary. In order to be committed, the person must have recently: attempted or threatened to physically harm themselves or others, caused significant property damage, failed to obtain food, clothing, shelter or medical care as a result of illness, or be at risk of substantial harm or significant deterioration.

You should know that the commitment law applies to people ages 18 and over. Minnesota laws are confusing about how commitment applies to teenagers ages 16 and 17. Some counties apply the commitment law to teenagers at these ages, providing all the due process requirements. Other counties may allow parents to consent to treatment, use juvenile courts or even use the CHIPS petitions for 16 or 17 year olds that are refusing treatment. Because the practice varies so much, check with your county. (For more information about Minnesota’s commitment law, see NAMI’s booklet "Understanding the Minnesota Civil Commitment Process.")
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Learn more by reading NAMI Minnesota's "Mental Health Crisis Planning for Children" booklet.

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Author: NAMI MINNESOTA

This information was taken from NAMI Minnesota's Mental Health Crisis Planning for Children booklet.