Chapter 147: Behavioral Disorders in Children

Pediatric mental health emergencies encompass a range of conditions, including psychological disorders such as mood and anxiety disorders (depression, bipolar disorder, suicidal ideation, obsessive compulsive disorders, posttraumatic stress syndrome), exacerbations of behavioral disorders (attention-deficit/hyperactivity disorder, aggressive outbursts, conduct disorders), deteriorating neurodevelopmental disorders (autistic spectrum disorders, tic disorders, intellectual disabilities), addictive disorders, and eating disorders. The psychological and sometimes physical aftermath of child maltreatment, mass casualty incidents and disasters, and exposure to violence and unexpected deaths are also likely causes of mental health emergencies.^1,2,3,4

The role of the emergency physician includes medical stabilization, differentiating physical from mental health issues, performing a psychosocial assessment, and directing patients and families toward appropriate resources for acute and long-term needs. Initial management may include pharmacologic therapy, physical restraint, and referral for inpatient admission.^2,5

The mental health crisis involves all socioeconomic and ethnic groups and is not unique to any one geographic area, state, or region. The cause of the dramatic rise in pediatric mental health emergencies is multifactorial and complex. A Centers for Disease Control and Prevention report of a 5-year (2005 to 2011) mental health surveillance among children in the United States cited a prevalence of mental health disorders of 13% to 20% and suicide as the second most common cause of mortality among children 12 to 17 years old in 2010.⁶ The National Comorbidity Survey–Adolescent Supplement data found the lifetime a prevalence of any one Diagnostic and Statistical Manual of Mental Disorders class disorder among adolescents of 51%.⁷ In Canada, 14% to 25% of children and youth are affected by at least one diagnosable mental disorder.^8,9 Factors contributing to high prevalence of mental illnesses among children and youths include family instability or dysfunction, economic crisis or financial hardship, inadequate numbers of mental health professionals (especially those with pediatric expertise), lack of access to care, shortage of funding for mental health services, and failure to seek care due to cultural stigma.¹ In addition, social networking exposes youths to cyberbullying, online harassment, social isolation, and "Facebook depression," adding further risks for developing mental health illnesses.¹⁰

Multiple economic forces negatively impact the availability and delivery of mental health services^1,4,5,11,12 and have transformed EDs into the safety net for a fragmented mental health infrastructure.⁵ Mental health follow-up or aftercare is also a problem. Of patients discharged from psychiatric emergency facilities, 40% to 60% do not receive aftercare, which increases the risk of repeat ED visits.¹¹

It is therefore not surprising that ED use for mental health care by children and youth is increasing. In the United States, both the absolute number (from 565,000 to 823,000) and proportion of all ED visits (from 2.0% to 2.8%) by children and youth for a mental health problem are on the rise.¹³ The Pediatric Emergency Care Applied Research Network reported that 3.3% of all participating pediatric ED visits were made for psychiatric-related visits. These visits are more frequently arriving by ambulance, are associated with longer length of stays, and result in admission to the hospital more commonly than other causes for ED visits.¹⁴ Pediatric psychiatric emergencies show seasonal variation and are more common during the school year, peaking in May and November, while reaching a nadir in July and August. While the visit distribution over days of the week appears to be even, visits occur more frequently in the evening, coinciding with a time period when most outpatient community mental health resources are not easily reachable.¹⁵

GENERAL GOALS

The first goal in the assessment of children with mental health emergencies is to identify and treat acute life-threatening medical emergencies. The second goal is to determine whether the child in a medically stable condition poses an imminent threat to his or her own life or the life of others, because this determines the need for hospitalization. Next, exclude organic causes. The general approach to making this determination is outlined here, and individual psychiatric conditions are further detailed below in "Management of Psychiatric Presentations." Table 147-1 lists medical and psychiatric conditions that may present with agitation, psychosis, or obtundation. Table 147-2 enumerates some general characteristics that may distinguish organic from psychiatric causes of psychosis.

HISTORY

Focus the history on the chief complaint and details of the presenting symptoms, circumstances, and precipitating events (e.g., social stressors). The timing and sequence of events and associated symptoms may help to distinguish organic from psychiatric conditions, and a thorough review of systems aids in this regard. Auditory hallucinations are associated with psychosis, whereas visual hallucinations may indicate intoxication or organic causes. A history of head injury, chronic or progressive headaches, visual changes, vomiting (especially morning vomiting), and deterioration of motor skills or gait suggests an intracranial process such as a brain tumor or subdural hematoma. Constitutional symptoms that may provide clues to an organic etiology include temperature instability, palpitations, and changes in appetite, stool patterns, hair, or skin.

The past medical history and family history will help identify the pattern and chronicity of the presenting symptoms. Similarly, a review of medications, including adherence to prescribed medication regimens, and their efficacy will guide the treatment plan and disposition. A family history of psychiatric or organic disease may indicate a potential genetic predisposition.

In addition to noting these standard components of history, pay particular attention to the social history. Many psychosocial screening tools exist, and some have been validated, such as the HEADS-ED (Table 147-3). The HEADS-ED assesses the degree of acute distress in domains pertaining to the home, education, activities and peers, drugs and alcohol, suicidality, emotions and behavior, and discharge resources.¹⁶ In addition to facilitating the assessment, this tool also guides management decisions.

PHYSICAL EXAMINATION

Assess vital signs and the airway, breathing, and circulation status, and perform a detailed neurologic examination. Alterations in vital signs may provide clues to potential intoxication, ingestions, or organic pathology (endocrinologic and metabolic). Tachycardia, hypertension, pyrexia, and tachypnea may suggest intoxication with stimulants such as amphetamines, cocaine, and "ecstasy" (3,4-methylenedioxymethamphetamine). Assessment for toxidromes may help identify anticholinergic symptoms or salicylate toxicity. The pupillary responses, presence or absence of nystagmus, skin temperature and moisture, and condition of the mucous membranes are all helpful in identifying toxidromes.

Focus the neurologic examination on level of consciousness, gait and coordination, and reflexes, and administer the Mini-Mental State Examination. Note the child's affect and general appearance, content and organization of thought, and articulation and expression of speech. Pressured speech with flight of ideas may signal acute mania, whereas echolalia, "word salad," and other disordered thought may indicate acute psychosis.

LABORATORY TESTING AND IMAGING

Laboratory tests and imaging are dictated by the history and physical examination. Pubertal girls should have a urine pregnancy test, because many psychiatric medications can affect the fetus. Urine drug screening can be helpful when intoxication from drugs of abuse is suspected. Obtain serum acetaminophen (Tylenol) and aspirin levels in children who have ingested drugs or attempted suicide. Hyperglycemia, hypoglycemia, and hyperammonemia can cause alterations in mental status, and measurement of glucose and ammonia levels may be useful in obtunded patients. A 12-lead ECG is useful in cases of potential ingestion or intoxication to identify interval prolongation or conduction abnormalities. Document normal sinus rhythms at baseline, before initiating psychotropic medications that may accentuate long QT disorders. Screening laboratory tests performed in psychiatric emergencies vary by institution. Many inpatient psychiatric facilities require basic chemistry panels and screening for thyroid disorders. See chapter 137, "Altered Mental Status in Children" for further discussion of altered mental status.

Imaging studies are rarely indicated or helpful except as dictated by the findings of the history and physical examination. Chest radiographs may identify aspiration in the obtunded vomiting patient. Abdominal radiographs may identify radiopaque foreign objects or ingestions. Neuroimaging can exclude intracranial mass lesions in those with suggestive clinical signs and symptoms.

A detailed summary of child and youth mental health issues is beyond the scope of this book. Formal diagnoses of mental health conditions usually occur after the ED presentation. Therefore, this section will focus on the approach to, and treatment of, psychiatric presentations. Many care environments use social workers, youth care workers, nurses, and other clinicians to conduct significant portions of the mental health assessment in the ED.

SUICIDAL IDEATION AND ATTEMPTS

Suicide is complex. Although it is one of the most common causes of death in youth (4.9 per 100,000 per year between the ages of 10 and 19, more than neoplasm, respiratory, and cardiovascular deaths combined),¹⁷ the vast majority of youth who have suicidal thinking or behaviors do not go on to complete suicide (Table 147-4).^18,19,20 Risk prediction is currently not possible.²¹ Therefore, the standard of care in an approach to suicide is not risk prediction; rather the focus should be on risk/protective factor identification and acuity assessment, collateral history, clinical synthesis, and safety management.

A number of risk factors are associated with increased suicide risk, and suicide risk is fluid and can change rapidly. Identification of risk factors should be carried out with the goal of separating chronic (longstanding and unlikely to change) from acute (recent and possible to change) risk factors. Chronic risk factors convey ongoing risk and are important for informing systemic, rather than individual approaches. Acute risk factors allow for individual approaches for suicide safety planning to occur. Protective factors reduce risk overall and should be considered in risk factor identification. A representative, noncomprehensive list of risk and protective factors is presented in Table 147-5.^{22,23,24,25,26}

Assessment scales and tools for assessment should be used to gather information to contribute to the assessment process rather than rigid structures to guide decision making. In the ED, brief screening questionnaires like the Ask Suicide-Screening Questions can help identify patients with suicidal thinking.²⁷ The Ask Suicide-Screening Questions consists of four questions: (1) current thoughts of being better off dead; (2) current wish to die; (3) current suicidal ideation; and (4) past suicide attempt. A positive response to any one question identified 97% of those at risk for suicide (sensitivity 96.7%, specificity 87.6%).²⁷ The Columbia–Suicide Severity Rating Scale (available for download at http://www.cssrs.columbia.edu/scales_practice_cssrs.html) can help guide assessment of suicidal thinking and behaviors and has been validated for use in multiple settings including the ED for both adolescents and adults.^28,29 Internal validity and usability rate high for such scales. Some more commonly used scales, such as the SADPERSONS, have little evidentiary support, contain many inaccurate assumptions about suicide risk, and do not accurately predict suicide.^{30,31,32,33,34}

Clinical interview, impression, and analysis are crucial aspects of suicide risk assessment. Collateral history for the youth (parents, caregivers, clinicians, teachers, etc.) adds to the confidence of the assessment and can significantly affect the quality of the risk assessment. If an interview has poor reliability or rapport, the "collected data" may be inaccurate. The tone of the patient themselves, their family, and the support network around them can alter the impression of hope or despair. The importance of clinical and interpersonal factors cannot be understated and is why a reliance on rigid data, forms, or quantities is perilous.³⁵

Safety management, following an adequate risk assessment, flows naturally from identified risk and protective factors. By dividing risk factors into acute and chronic categories, targeted interventions for any acute risk factors can be made. Creating safety plans for families and youth to use when suicidal ideation occurs can increase compliance with follow-up programming,³⁶ encourages appropriate re-presentation to the ED, and provides a sense of structure and support to families struggling with suicide concerns. Figure 147-1 provides an emergency approach to suicidal presentations, and the approach can be done in a multidisciplinary way—a physician is not required for any one step.

Determination of the risk factors will influence the services consulted; social issues require social support services, whereas psychiatric issues require mental health supports. Rigid consultation of all suicidal patients to psychiatric care is neither necessary nor effective; inpatient and involuntary approaches to patients are beneficial when the risk profile is simply too high to manage in the outpatient environment and inpatient services are required to reduce the identified risk factors. Examples of nonpsychiatric risk reduction maneuvers include removing lethal means, securing firearms, creating safety plans, referring to social support services, providing family supports, and addressing social and school concerns. Resolution of any triggering crisis severely reduces severity risk.

NONSUICIDAL SELF-INJURY

Nonsuicidal self-injury is "the deliberate, self-inflicted destruction of body tissue without suicidal intent and for purposes not socially sanctioned,"³⁷ and refers to a wide variety of behaviors including cutting, burning, carving, punching, and picking. Approximately 18% of adolescents have engaged in nonsuicidal self-injury in the past year, and recent studies report that as many as 47% of females have tried it, even briefly. Nonsuicidal self-injury begins in puberty and is twice as common in females, peaking in middle adolescence and declining thereafter. Although it increases suicide risk, over 90% of youth presenting to crisis services with nonsuicidal self-injury have no intent of suicide.³⁸ Biologic predispositions to self-injury include an absent stress cortisol response, sensitivity of opioid receptors, and genetics.

First, address the sequelae of the injury, and focus on the distress and events that led to self-injury. Avoid overreaction to superficial injuries; comments such as "you could have killed yourself" or "these injuries look awful" may harm the patient and even increase subsequent behavior. Such comments can confuse the message that self-injury is different from suicide. Second, conduct suicide risk assessment, especially for new or changing self-injury, or in the presence of other developing mental health issues. Explain the difference between nonsuicidal self-injury and suicidal behaviors to caregivers. Finally, provide social and mental health support resources to improve distress tolerance, stress management, and family supports.

AGGRESSION

Aggression can occur prior to ED presentation, before or during assessment, and in subsequent care. Consider patient and environmental safety, potential trauma to the child or family, engagement and deescalation whenever possible, and safe medication and restraint policies.³⁹

Pharmacologic interventions require consideration of the intention of the intervention. If the underlying issue is psychosis or mania, potent antipsychotic medications are warranted. However, if agitation is behavioral, reactionary, or anxiety-driven in nature, and the goal of intervention is sedation, many less potent and potentially less dangerous approaches can be taken.

An approach to aggression in the ED is outlined in Table 147-6, with pharmacologic options in Table 147-7.^40,41

ANXIETY AND DEPRESSION

ED presentations for anxiety and depression are common. For anxiety, this is often in the form of panic, dysregulation, or regressive behavior. In depression, common presentations include irritability, hopelessness, or sadness. Signs and symptoms of anxiety and depression vary with age: younger children exhibit more regressive, agitated, or withdrawn behaviors, whereas adolescents tend to be able to express their emotional state through direct conversation. Both anxiety and depression in youth can also present with impaired concentration, fatigue, and insomnia. Perform suicide risk screening and assessments as appropriate.

Anxiety or irritability can be relieved in the ED through the use of sublingual lorazepam. Most often, treatments of anxiety and depressive disorders are combination approaches;⁴⁷ proper treatment includes the use of therapeutic approaches (cognitive behavioral therapy, interpersonal therapy) and medications (selective serotonin reuptake inhibitors) that usually exceed the scope of an ED. Severe, disabling, or suicide-related anxiety or depression concerns should warrant a consultation to psychiatric service; for more mild issues, referral to appropriate mental health supports can be made.

PSYCHOSIS

Psychosis is a generic term that describes a process in which someone's thought or sensory process no longer conforms to reality. Often it is confused as a diagnosis (for example, schizophrenia), when in fact, the presentation of psychosis can be brought about by a variety of conditions,⁴⁸ including benign (hypnagogic hallucinations that occur in sleep-wake transition, normal bereavement), medical (CNS tumors, delirium), psychiatric (schizophrenia, bipolar mania), and substance-induced (steroids, drugs of abuse). Psychosis is a syndrome of exclusion; potentially dangerous medical diagnoses must be considered and ruled out prior to psychiatric treatment (see Tables 147-1 and 147-2, above).

Psychiatric causes of psychosis are rare in prepubertal children; in fact, these disorders usually manifest at around 20 years of age. However, many adolescents can have prodromal presentations, and early-onset bipolar disorder, schizophrenia, and other psychiatric causes of psychosis are possible. Predictors of psychosis include a family history (especially first-degree relatives), progressive decline (rather than abrupt), and a history of subclinical psychotic symptoms.⁴⁹

The approach to psychosis varies depending on the cause (Table 147-8). In the ED, the antipsychotic medications in Table 147-7 can be tried for agitation or urgent symptom concerns; however, caution must be used, because delirium or substance intoxication as a root cause of the psychosis could be worsened by the addition of psychotropic medications.

BEHAVIORAL DISORDERS

Behavioral disorders is a broad term, generally focused on maladaptive behaviors that have progressed to a point of severe dysfunction, risk, or negative outcome. They are seen as a pathologic extension of normal behavioral issues. Oppositional defiant disorder is a persistent pattern of provocative, hostile, and noncompliant behavior, characterized by low temper threshold.⁵⁰ Conduct disorder is a more severe, antisocial pattern of rule-breaking behavior that includes aggression to people and animals, deceitfulness and theft, serious rule-breaking, and destruction of property.⁵¹ Treatment is largely environmental and familial, and pharmacologic interventions are of mixed benefit. Behavioral disorders have extremely high psychiatric comorbidity, particularly with attention-deficit/hyperactivity disorder, and treatment of comorbid conditions is necessary. Stimulants, nonstimulant ADHD medications, clonidine, guanfacine, antiepileptic medications, and antipsychotic medications have mixed evidence, but trials are often necessary to reduce impulsivity, sometimes induce sedation, and are used off-label.⁵²

SUBSTANCE MISUSE AND WITHDRAWAL

Alcohol use and misuse have decreased over the past 20 years in youth, with record-low numbers being seen in recent surveys, both in extreme (<13 years) underage drinking and overall alcohol use.¹⁸ However, the 1-year prevalence of being drunk at least once is 20% in adolescence, and 6% of adolescents will drink more than 10 drinks in a row, making acute intoxication a common adolescent event. Marijuana use has remained stable, with 40% of adolescents reporting ever using. However, cocaine, hallucinogen, inhalant, ecstasy, and methamphetamine use has halved in the past 15 years.

The management of individual toxidromes is described in the Toxicology section of this book. A very small percentage of adolescents with alcohol misuse experience any withdrawal symptoms, and an even smaller percentage require pharmacologic treatment. Paced alcohol discontinuation is a successful approach to managing alcohol withdrawal in teens, and treatment of severe symptoms can be carried out as in adults, using benzodiazepines such as diazepam and chlordiazepoxide.⁵³ Refer any youth with a substance use problem to available substance misuse services; the remission rates are low, but a nonjudgmental, continuous, motivational approach reduces rates of misuse.

CHILD ABUSE AND NEGLECT

Worldwide, 1 in 5 female children and 1 in 10 male children are sexually abused.⁵⁴ Approximately 25% of children are emotionally abused by their caregivers, and physical abuse affects 18% of children under the age of 18. Neglectful care of a child occurs in 6.5% of children every year.⁵⁵ Overall, these numbers are staggering and reflect a dire need for increased assessment, screening, and recognition of child maltreatment. It is mandatory to report any suspected child abuse to the legal authorities, and this should be done in any injury for which the mechanism is not explained; any behavior, phrase, or suggestion of abuse must be reported. The psychological, medical, and quality-of-life impacts of child maltreatment are severe, and early recognition and intervention can reverse these impacts. Children and adolescents presenting to the ED with behavioral or psychiatric emergencies should be asked about exposure to violence at home or school. See also chapter 148, "Child Abuse and Neglect."

SPECIAL CONSIDERATIONS IN THE DEVELOPMENTALLY DISABLED PATIENT

Assessing psychiatric emergencies in patients with a developmental disability is tremendously challenging (see chapter 146, "The Child with Special Healthcare Needs"). The following principles can be applied both in children and adults with developmental disabilities:⁵⁶

1. Establish a baseline. In developmental disability, age cannot be relied upon to understand normal behavior. Ask caregivers what is normal for the patient, what has changed, and when.

2. Use developmentally appropriate approaches. Use visual scales, toys, language cards, gestures, and simple words as required. Ask the caregiver for advice on interaction.

3. Consider medical/pain sources. Especially in patients with limited verbal output, changes in behavior, mood, and aggression can be due to simple issues such as urinary tract infections, dental pain, or headaches.

4. Be pharmacologically conservative. Use the minimum doses of medications (e.g., the child dosing in Table 147-7), resist polypharmacy, and make sure the medication has an observable effect prior to long-term prescription.

5. Consider comorbidities. Many patients with developmental disabilities have a high rate of psychiatric and medical comorbidities. Treatment of these comorbidities is necessary, and all efforts must be made to diagnose these conditions.