INTRODUCTION & DEMOGRAPHICS OF PEDIATRIC MENTAL ILLNESS
Children present in increasing numbers to the emergency department with psychiatric-related complaints. An estimated 21% of children aged 9-17 years have an identifiable mental health disorder. There are several drivers behind the increase in psychiatric cases presenting to the emergency department, including increased demand for pediatric psychiatric services unable to be met in the outpatient arena, decreased comfort by primary care physicians with psychiatric conditions, decreased practitioners of child and adolescent psychiatry, and various cultural phenomena. The increase in children presenting with psychiatric disorders is also leading to an increase in children admitted for mental health reasons.
Many children who present to the emergency department live in environments with risk factors for poor mental health. These include poverty, single parenthood, witnessed domestic abuse, parental mental illness, and substance abuse in the home. As primary care physicians are increasingly less comfortable with psychiatric complaints and the pool of child/adolescent psychiatrists has not been able to match demand, the emergency department is increasingly viewed as the patient’s access point to the mental health system.
Because emergency department physicians are thrust into the role of evaluating children with psychiatric needs, it is imperative that they have the proper knowledge to screen children appropriately for organic causes of their symptoms and identify psychiatric illness when it presents. Indications that an organic disorder may be causing a patient’s symptoms include a relatively new onset of symptoms, substance use/abuse, and abnormal vital signs or physical examination findings.
A key aspect of the history and physical examination of the pediatric psychiatric patient is the mental status examination (Table 48–1).
Table Graphic Jump Location Table 48–1.Essential elements of the mental status examination. ||Download (.pdf) Table 48–1. Essential elements of the mental status examination.
|Element ||Description |
|Orientation ||Determine level of consciousness and orientation in all spheres: person, place, time, and situation |
|Appearance ||Assess physical size, personal hygiene, clothing, neatness, grooming, posture, and gait |
|Memory ||Evaluate both short- and long-term memory |
|Cognition ||Assess gross level of intelligence, fund of knowledge, and ability to think or reason according to age |
|Behavior ||Observe activity to determine age appropriateness for goal directedness and speed. Assess degree of distraction and ability to manage anger |
|Relating ability ||Assess the ability to relate to the examiner based on eye contact, spontaneous conversation, trust, and desire to seek approval |
|Speech ||Evaluate speech for spontaneity, coherence, articulation, content (vocabulary), and the quality of the thought process |
|Affect ||Determine overall state of affect and observe for fluctuations |
|Thoughts ||Determine content and process, looking for predominant themes as well as hallucinations, delusions, grandiosity, ideas of reference, and past or present suicidal or homicidal tendencies |
|Insight and judgment ||Evaluate degree of understanding of the current problem and the ability of the child to think before acting |
|Strengths ||Determine areas of interest, competence, and motivation as a prelude for ...|