Telehealth Webinar Series Pediatric Behavioral Health Emergencies in the Field

Telehealth Webinar Series:

Pediatric Behavioral Health

Emergencies in the Field

Presented by:

Jeremiah D. Simmons, PhD

Christoph Isbjorn, DO

October 21, 2026

Presenters



Jeremiah D. Simmons, PhD

Jeremiah D. Simmons, PhD, (Navajo/Yankton Sioux), is a licensed

clinical psychologist and Assistant Professor in the Division of Community

Behavioral Health, within the Department of Psychiatry and Behavioral

Sciences, at the University of New Mexico Health Sciences Center. Dr.

Simmons’ clinical, teaching, and research efforts focus on improving

behavioral health outcomes for Native American communities, with an

emphasis on youth and school-based mental health systems. Dr.

Simmons specializes in culturally responsive adaptations of evidence-

based practices, integrating community-based participatory approaches

to enhance engagement, access, and effectiveness of care. His work

spans direct clinical service delivery in tribal communities, supervision

and training of interdisciplinary behavioral health providers, and the

development of community-informed prevention and intervention models.

He has contributed to state and federal initiatives focused on suicide

prevention, systems of care development, and behavioral health

workforce capacity building. His long-term goal is to advance culturally

grounded behavioral health systems that reduce disparities and promote

resilience among American Indian and Alaska Native populations.

EMS

Content Matter

Contributor



Christoph Isbjorn, DO, MPH

Dr. Christoph Isbjorn brings a multidisciplinary background in

emergency medicine, public health, psychiatry, and nonprofit

leadership. He spent 10 years as an EMT, including 911 ALS

ambulance service in Denver and several years in Iraq. He earned

his MPH from St. George’s University and his DO from Rocky Vista

University. He founded Vital Start, creating healthcare pathways for

at-risk youth, and served as CEO of House Lucky Bear, supporting

migrant women. He is currently completing his psychiatry residency,

with interests in trauma prevention and recovery, Child and

Adolescent Psychiatry, justice-involved youth, and interpersonal

relationships following traumatic experiences.

Training

Purpose

&

Learning

Objectives

Purpose of Session:

Review common pediatric behavioral health presentations in

prehospital care and practical approaches to assessment, risk

stratification, and scene safety. Examine age-appropriate

communication, trauma-informed de-escalation, transport

decisions, and coordination with emergency departments and

behavioral health providers.

Learning Objectives:

1. Identify common pediatric behavioral health presentations

and associated risk indicators.

2. Apply age-appropriate, trauma-informed de-escalation and

communication techniques.

3. Determine transport considerations and interagency

coordination strategies.

Disclosure Statement

Disclosure Statement: As a jointly accredited provider of continuing education, the IHS

Clinical Support Center must ensure balance, independence, objectivity, and scientific

rigor in its educational activities. Course directors/coordinators, planning committee

members, faculty, reviewers and all others who are in a position to control the content of

this educational activity are required to disclose the existence of all financial

relationships with ineligible companies within the prior 24 months. Safeguards against

commercial bias have been put in place. Faculty will also disclose any off-label and/or

investigational use of pharmaceuticals or instruments discussed in their presentation. All

those who are in a position to control the content of this educational activity have

completed the disclosure process and have indicated that they do not have any relevant

financial relationships or affiliations with any manufacturers or commercial products to

disclose.

There is no commercial interest support for this educational activity.

Disclaimer

The views expressed in this presentation are those of the speaker and do not

necessarily represent the views, policies, and positions of the Indian Health Service

(IHS), or the U.S. Department of Health and Human Services (HHS).

Scope & Shared

Roles

• Field priorities are safety, medical stability, calm engagement,

focused risk assessment, and a clear handoff.

• Behavioral health responders contribute communication,

suicide risk formulation, coping support, and culturally

responsive coordination.

• EMS clinicians contribute medical assessment, physiologic

monitoring, treatment within protocol, and destination decisions.

• CHAs, CPSWs, BHAs, school responders, and tribal providers

work within local scope, policy, supervision, and law.

Pediatric

Behavioral

Health in EMS

• Behavioral health concerns accounted for 11.3% of 2.74 million

pediatric EMS encounters in a national 2019 to 2020 analysis.

• Most patients were adolescents, but younger children and youth

with developmental or communication disabilities need adapted

approaches.

• Sedating medication and physical restraint were uncommon,

which supports early use of environmental and verbal

strategies.

• Field presentations may reflect psychiatric illness, substance

effects, medical illness, trauma, developmental needs, or

several factors at once.

(Wnorowska et al., 2024; Boland et al., 2023)

Case 1

NSSI in School-

Based Setting

• Composite case: A 15-year-old is found in a school restroom

with several superficial forearm cuts.

• Bleeding is controlled. The student says, "I was trying to calm

down. I did not want to die."

• A breakup, online conflict, and poor sleep occurred this week.

The student used cannabis last night.

• A counselor is present. A caregiver is 35 minutes away. The

nearest pediatric emergency department is 70 miles away.

• Discussion: What must be assessed before deciding whether

and where to transport?

NSSI & Suicidal

Behavior

• Nonsuicidal self-injury, or NSSI, is intentional damage to body

tissue without intent to die.

• A suicide attempt includes at least some intent to die, even

when the injury appears medically minor.

• Intent may be mixed, uncertain, or change quickly. Ask about

the purpose of the act and what the youth expected would

happen.

• NSSI is non-suicidal by definition, but repeated NSSI is

associated with later suicidal behavior. Assess both every time.

(Grandclerc et al., 2016; Valencia-Agudo et al., 2018)

Functions of

NSSI

• Emotion regulation is the most commonly reported

function, including relief from intense distress or

numbness.

• Other functions include self-punishment, interrupting

dissociation, communicating distress, or changing an

interpersonal situation.

• The same youth may report several functions, and the

function may change across episodes.

• Ask with curiosity: "What did the injury do for you in that

moment?" Avoid labels such as attention-seeking.

(Taylor et al., 2018)

Direct Suicide

Questions

• Ask plainly about a wish to die, suicidal thoughts, a plan, current

intent, past attempts, and access to the proposed method.

• Whenever feasible, speak with the youth privately, then obtain

caregiver or collateral information.

• Asking about suicide does not increase suicidal thoughts or self-

harm in available meta-analytic evidence.

• The four-item ASQ has high sensitivity in pediatric emergency

settings, but a positive screen requires further assessment.

(Horowitz et al., 2012; Polihronis et al., 2022; NIMH, n.d.)

Field Risk

Formulation

• Current state: suicidal intent, plan, agitation, psychosis,

intoxication, severe hopelessness, or inability to collaborate

with safety.

• History: prior attempts, recent NSSI, psychiatric care,

substance use, violence, trauma exposure, and recent loss or

humiliation.

• Environment: supervision, access to firearms or medications,

caregiver capacity, distance, weather, and reliable follow-up.

• Protection: trusted adults, cultural and family connections,

reasons for living, willingness to accept help, and an actionable

care pathway.

• A checklist supports judgment. No single item determines risk

or disposition.

Age-appropriate

Communication

• Begin with name, role, and what will happen next. Use one

calm speaker whenever possible.

• Use short sentences and one question at a time. Match

language to developmental and communication needs.

• Offer limited choices that preserve safety, such as where to sit

or which supportive adult remains nearby.

• Validate the emotion without agreeing with unsafe behavior or

a delusional belief.

• Tell the youth what information must be shared for safety and

who will receive it.

(Gerson et al., 2019; Saidinejad et al., 2024)

De-escalation

Sequence

• Reduce noise, crowding, lights, and visible equipment when

clinically safe.

• Create physical space, maintain an exit route, and remove

bystanders who increase distress.

• Identify triggers, pain, hunger, sensory needs, communication

barriers, and preferred calming strategies.

• Use respectful repetition, concrete choices, and time. Avoid

arguing, sudden touch, threats, or rapid commands.

• Escalate to medication or restraint only when less restrictive

measures cannot maintain safety.

(Gerson et al., 2019; Foster et al., 2024)

Brief Coping

Skills

• Paced or box breathing: invite a slow, comfortable rhythm.

Stop if breath holding increases panic, dizziness, or distress.

• 5-4-3-2-1 grounding: identify five things seen, four felt, three

heard, two smelled, and one tasted or appreciated.

• Use sensory grounding only with consent and adapt it for

disability, trauma history, culture, and the environment.

• These skills may lower arousal. They do not replace suicide

assessment, medical evaluation, or transport when indicated.

• DBT for adolescents reduces self-harm and suicidal ideation,

although evidence for a single field skill is limited.

(Kothgassner et al., 2021)

Case 1

Next Steps

• Treat the wound and assess for other injuries, ingestion,

intoxication, or medical instability.

- Call Poison Control if known ingestion

- 1-800-222-1222

• Ask directly about suicide, prior attempts, NSSI pattern, access

to means, current intent, and ability to stay safe.

• Obtain collateral information and identify the adult who can

assume continuous supervision.

• Follow local protocol for transport or urgent evaluation. NSSI

alone does not establish either transport or non-transport.

• Provide a concise handoff that separates reported intent,

observed behavior, medical findings, and responder judgment.

Case 2

Cannabis and

Psychosis

• Composite case: A 16-year-old becomes frightened and paranoid

after repeated high-potency cannabis vaping.

• The youth has slept about three hours across two nights and says

people outside are monitoring the home.

• A caregiver reports recent trauma and an uncle with

schizophrenia. The youth is pacing and refuses transport.

• Discussion: Which findings suggest intoxication, delirium, mania,

trauma, or a first psychotic episode?

• What would make this encounter medically or behaviorally unsafe

to manage in place?

Cannabis and

Psychosis

Evidence

• Adolescent cannabis use was associated with later psychosis

in a meta-analysis of 18 studies, with pooled relative risk 1.71.

• Heavier use shows a dose-response relationship. The

heaviest-use group had about four times the odds of psychotic

outcomes compared with non-users.

• Cannabis-associated psychosis can resolve, but a meta-

analysis found substantial later transition to schizophrenia after

cannabis-induced psychosis.

• Association does not mean certainty. Most youth who use

cannabis do not develop psychosis.

(Kiburi et al., 2021; Marconi et al., 2016; Murrie et al., 2020)

Psychosis Risk

Modifiers

• Higher concern: younger onset of use, frequent use, high-

potency products, and use of several substances.

• Childhood trauma and recent adversity may add vulnerability,

but they do not determine diagnosis.

• Family history of schizophrenia-spectrum or bipolar disorder

increases concern and should prompt careful follow-up.

• Clarify abbreviations. Bipolar disorder and borderline

personality disorder are not interchangeable when a family

reports "BPD."

• Avoid causal certainty. Assess the whole pattern, including

sleep, mood, functioning, medical findings, and time course.

(Kiburi et al., 2021; Varese et al., 2012; Kendler et al., 2024)

Field Response

to Psychosis

• Reduce stimulation and use one primary communicator. Ask

permission before moving closer or touching.

• Do not argue about hallucinations or delusions. Acknowledge

the fear and focus on immediate safety.

• Use concrete language, extra processing time, and simple

choices. Avoid rapid questioning.

• Ask about content of hallucinations, screen for commands,

suicidal or violent thoughts, access to weapons, and the ability

to resist unsafe commands.

• Treat first-episode psychosis, severe functional change, or

inability to care for basic needs as requiring urgent evaluation.

(Gerson et al., 2019; Saidinejad et al., 2024)

Medical and

Toxicologic

Assessment

- Complete primary and secondary surveys. Be sure to assess

vitals, pupil size and reaction to light, blood glucose, orientation,

and the 3F's that effect the brain: Force (Trauma), Flow

(Cardiovascular), Fuel (Oxygen/Glucose)

- Look for fluctuating attention, abnormal vital signs, fever,

hypoxia, seizure, head trauma, severe headache, rigidity, or

focal findings.

- Ask what was used, how much, when, by which route, and

whether products could contain other substances.

- Consider intoxication, withdrawal, medication effects, endocrine

or metabolic illness, infection, neurologic illness, and delirium.

- Assessment and de-escalation occur together. Do not assume

a psychiatric cause before medical threats are addressed.

(Gottlieb et al., 2018; Gerson et al., 2019)

Transport and

Destination

• Urgent transport is indicated for medical instability, significant

injury or ingestion, current suicidal intent, severe agitation, first-

episode psychosis, or inability to maintain safety.

• Caregiver availability, means restriction, distance, weather, and

reliable follow-up affect the safety of any non-transport pathway.

• Use a pediatric-capable emergency department, if available,

when medical evaluation is needed or eligibility for a psychiatric

destination is uncertain. However, a non-pediatric specific

emergency room is an appropriate alternative if required.

• Direct psychiatric transport can be safe when an approved

protocol defines eligibility, exclusions, and re-transport

procedures.

• Use local policy, medical control, and applicable tribal, state,

and federal requirements.

(Glomb et al., 2023; NIMH, n.d.)

Medication and

Restraint

Guardrails

• Use medication only for a clinical indication and according to

age, weight, likely cause, local protocol, and medical direction.

oWhat agitation medications are you using?

oParadoxical reactions (1%-2%) = Stop the drug

• Offer oral first vs. IM. Aim for calm and safe assessment, not

punishment or unnecessary deep sedation.

• Physical restraint is a last resort. Use the least restrictive

method for the shortest possible time.

• Never transport prone or use a position that compromises the

airway, ventilation, circulation, head, or neck.

• Any medication or restraint requires continuous observation,

physiologic monitoring, frequent reassessment, and detailed

documentation.

(Kupas et al., 2021; Gerson et al., 2019)

Tribal and

Reservation

Contexts

• Tribal Nations and communities are distinct. Ask what local

practices, roles, language, and supports the youth and family

want involved.

• Honor tribal sovereignty and local response pathways.

Coordinate with tribal programs rather than assuming an

outside pathway fits.

• Historical and ongoing harms can shape trust. Explain each

action, request consent when possible, and avoid unnecessary

law-enforcement presence.

• Protect privacy in small communities. Share only what is

necessary for safety and continuity within applicable policy and

law.

• Offer traditional or cultural supports when requested and

available. Do not assume that every family wants the same

supports.

(Gone & Trimble, 2012; Allen et al., 2022; Grande et al., 2022)

Strengths and

Protective

Factors

• Family, peer, school, community, and cultural connectedness are

documented protective domains for many AI/AN youth.

• Cultural identity and continuity can support resilience when they

are defined and led by the community.

• Ask, "Who helps you remember who you are and what matters to

you?"

• Activate strengths in the immediate plan: a named adult, a safe

place, transportation, follow-up, and culturally meaningful support.

• The intervention evidence remains limited, but culture-centered

community engagement is a consistent feature of promising

programs.

(Henson et al., 2017; Allen et al., 2022; Grande et al., 2022)

Rural and

Frontier

Operations

• Long distance, weather, limited staffing, and lack of pediatric

behavioral health destinations change the risk of every plan.

• IHS and tribal EMS agencies report pediatric training and

medical-direction gaps similar to other rural systems.

• Rural EMS behavioral encounters can require more time

where child psychiatry and hospital resources are limited.

• Plan before the call: eligibility criteria, receiving contacts,

teleconsultation, backup transport, and who owns follow-up.

• A warm handoff may include EMS, the receiving facility,

caregiver, school or CPSW, and a tribal or community crisis

contact.

(Genovesi et al., 2014; Fishe & Lynch, 2019)

Interagency

Coordination

• Identify one operational lead and one primary communicator

for the youth.

• State what each agency needs to know, what each can do,

and who has authority for medical and safety decisions.

• Confirm the destination before departure when feasible,

especially during long-distance transport. Attempt to contact

family to inform where the child will go.

• Use closed-loop communication for supervision, belongings,

medications, caregiver travel, and follow-up.

• Avoid parallel plans that leave the youth or family repeating

the same story to several teams.

Structured

Handoff

- ID statement: age/sex, past medical hx, past psych hx, current

meds, medication allergies, substance use hx, and reason for

transport or consultation.

- Subjective of current situation: Why was 911 called and by who?

was this an attempted suicide/violence/NSSI, any

hallucinations/delusions, recent stressors/intoxication, trauma?

- Objective: Vital signs, physical assessment, Mental Status Exam

- Assessment/Plan: Primary diagnoses, interventions/response,

transport plan?

o Parents/guardians aware and how to contact?

Integrated

Reservation

Case

• Composite case: A 14-year-old at home reports cutting, hears

a threatening voice, and used an unknown THC concentrate.

• The youth is calm now, denies wanting to die, and asks to

speak with an aunt and a traditional helper.

• The caregiver reports a firearm in the home. The nearest

pediatric-capable emergency department is 95 minutes away.

• Decision points: intoxication, medical threats, suicide and

violence risk, means safety, preferred supports, transport,

destination, and handoff.

• A calm moment creates an assessment opportunity. It does

not erase the earlier risk picture.

Documentation

that Supports

Care

• Use the youth's own words for suicidal intent, NSSI function,

hallucinations, threats, and requests for help.

• Separate observed behavior from interpretation. Describe

actions, speech, orientation, attention, and change over time.

• Record collateral sources, access to means, supervision

capacity, and barriers created by distance or weather.

• Document alternatives attempted before medication or

restraint, plus monitoring and reassessment afterward.

• Record consultation, receiving acceptance, caregiver

communication, and the exact transfer of responsibility.

Field Response

Algorithm

• BSI Scene Safety: Weapons contained? Safe

environment? Patient showing aggression? Gloves at a minimum.

• Medical stability: ABCs, vital signs, glucose when available,

injury, ingestion, and delirium red flags.

• Calm engagement: reduce stimulation, one speaker, caregiver

input, developmentally matched language, and real choices.

• Focused risk assessment: suicide, NSSI function, psychosis,

violence, substance use, prior history, means, and current

supports.

• Disposition: apply local protocol, medical control, caregiver

capacity, distance, destination capability, and cultural

preferences.

• Handoff and continuity: objective documentation, closed-loop

transfer, with parent/guardian contact information

Key Takeaways

• NSSI is defined by absent suicidal intent, but it still requires

direct suicide assessment and thoughtful follow-up.

• Cannabis can precipitate acute psychotic symptoms and is

associated with later psychosis, especially with earlier and

heavier use.

• Calm, developmentally appropriate communication and

environmental modification are first-line responses to agitation.

• Medical causes, intoxication, and delirium remain part of the

differential throughout the encounter.

• Culturally responsive care respects tribal sovereignty, local

pathways, family and community strengths, and the youth's

preferences.

Questions and

Discussion

Thank you for the work you

do with youth, families, and

communities.

References

• Boland, L. L., Anderson, M. K., Powell, J. R., Patock, M. T., & Panchal, A. R. (2023).

EMS responses for pediatric behavioral health emergencies in the United States.

Prehospital and Disaster Medicine, 38(6), 784-791.

doi:10.1017/S1049023X2300657X

• Fishe, J. N., & Lynch, S. (2019). Pediatric behavioral health-related EMS encounters:

A statewide analysis. Prehospital Emergency Care, 23(5), 654-662.

doi:10.1080/10903127.2019.1566423

• Wnorowska, J. H., Naik, V., Ramgopal, S., Watkins, K., & Hoffmann, J. A. (2024).

Characteristics of pediatric behavioral health emergencies in the prehospital setting.

Academic Emergency Medicine, 31(2), 129-139. doi:10.1111/acem.14833

• Glomb, N. W., Trivedi, T., Grupp-Phelan, J., Schriger, D. L., & Sporer, K. (2023).

Safety of a prehospital EMS protocol for an alternative destination for pediatric

behavioral emergencies. JACEP Open, 4, e12930. doi:10.1002/emp2.12930

• Genovesi, A. L., Hastings, B., Edgerton, E. A., & Olson, L. M. (2014). Pediatric

emergency care capabilities of IHS EMS agencies in rural and frontier areas. Rural

and Remote Health, 14(2), 2688. doi:10.22605/RRH2688

• Gerson, R., Malas, N., Feuer, V., Silver, G. H., Prasad, R., & Mroczkowski, M. M.

(2019). Best practices for evaluation and treatment of agitated children and

adolescents in the emergency department. Western Journal of Emergency Medicine,

20(2), 409-418. doi:10.5811/westjem.2019.1.41344

References

• Saidinejad, M., Foster, A. A., Santillanes, G., et al. (2024). Strategies for optimal

management of pediatric acute agitation in emergency settings. JACEP Open, 5(4),

e13255. doi:10.1002/emp2.13255

• Foster, A. A., Saidinejad, M., & Li, J. (2024). Approach to acute agitation in the

pediatric emergency department. Current Opinion in Pediatrics, 36(3), 245-250.

doi:10.1097/MOP.0000000000001337

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department patient. Journal of Emergency Medicine, 54(4), 447-457.

doi:10.1016/j.jemermed.2017.12.049

• Kupas, D. F., Wydro, G. C., Tan, D. K., Kamin, R., Harrell, A. J., IV, & Wang, A.

(2021). Clinical care and restraint of agitated or combative patients by EMS

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References

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harm in asking? Archives of Suicide Research, 26(2), 325-347.

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• Grandclerc, S., De Labrouhe, D., Spodenkiewicz, M., Lachal, J., & Moro, M. R. (2016).

Relations between nonsuicidal self-injury and suicidal behavior in adolescence: A

systematic review. PLOS ONE, 11(4), e0153760. doi:10.1371/journal.pone.0153760

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• Taylor, P. J., Jomar, K., Dhingra, K., Forrester, R., Shahmalak, U., & Dickson, J. M.

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injury. Journal of Affective Disorders, 227, 759-769. doi:10.1016/j.jad.2017.11.073

• Kothgassner, O. D., Goreis, A., Robinson, K., Huscsava, M. M., Schmahl, C., &

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and suicidal ideation. Psychological Medicine, 51(7), 1057-1067.

doi:10.1017/S0033291721001355

• Kiburi, S. K., Molebatsi, K., Ntlantsana, V., & Lynskey, M. T. (2021). Cannabis use in

adolescence and risk of psychosis: A systematic review and meta-analysis. Substance

Abuse, 42(4), 527-542. doi:10.1080/08897077.2021.1876200

References

• Marconi, A., Di Forti, M., Lewis, C. M., Murray, R. M., & Vassos, E. (2016). Meta-

analysis of the association between the level of cannabis use and risk of psychosis.

Schizophrenia Bulletin, 42(5), 1262-1269. doi:10.1093/schbul/sbw003

• Murrie, B., Lappin, J., Large, M., & Sara, G. (2020). Transition of substance-induced,

brief, and atypical psychoses to schizophrenia. Schizophrenia Bulletin, 46(3), 505-516.

doi:10.1093/schbul/sbz102

• Varese, F., Smeets, F., Drukker, M., et al. (2012). Childhood adversities increase the

risk of psychosis: A meta-analysis. Schizophrenia Bulletin, 38(4), 661-671.

doi:10.1093/schbul/sbs050

• Kendler, K. S., Abrahamsson, L., Sundquist, J., & Sundquist, K. (2024). The nature of

the familial risk for psychosis in bipolar disorder. Schizophrenia Bulletin, 50(1), 157-

165. doi:10.1093/schbul/sbad097

• Henson, M., Sabo, S., Trujillo, A., & Teufel-Shone, N. (2017). Identifying protective

factors to promote health in American Indian and Alaska Native adolescents. Journal

of Primary Prevention, 38(1-2), 5-26. doi:10.1007/s10935-016-0455-2

• Allen, J., Wexler, L., & Rasmus, S. (2022). Protective factors as a unifying framework

for culturally responsive AI and AN suicide prevention. Prevention Science, 23(1), 59-

72. doi:10.1007/s11121-021-01265-0

References

• Grande, A. J., Elia, C., Peixoto, C., et al. (2022). Mental health interventions for suicide

prevention among Indigenous adolescents: A systematic review. Sao Paulo Medical

Journal, 140(3), 486-498. doi:10.1590/1516-3180.2021.0292.R1.22102021

• Gone, J. P., & Trimble, J. E. (2012). American Indian and Alaska Native mental health:

Diverse perspectives on enduring disparities. Annual Review of Clinical Psychology, 8,

131-160. doi:10.1146/annurev-clinpsy-032511-143127