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.
TABLE 147-4Relative Frequency of Suicide-Related Thoughts and Behaviors in Adolescents ||Download (.pdf) TABLE 147-4 Relative Frequency of Suicide-Related Thoughts and Behaviors in Adolescents
| ||1-Year Prevalence ||Frequency |
|Feeling sad or hopeless for 2 weeks* ||30.0% ||1:3.3 |
|Nonsuicidal self-injury ||18.0% ||1:5.6 |
|Suicidal ideation* ||17.0% ||1:5.8 |
|Suicide planning* ||13.6% ||1:7.4 |
|Suicide attempt (any)* ||8.0% ||1:12.5 |
|Suicide attempt (potentially lethal)* ||2.7% ||1:37 |
|Death by suicide† ||0.005% ||1:21,000 |
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
TABLE 147-5Selection of Common Chronic and Acute Risk Factors and Protective Factors for Suicide ||Download (.pdf) TABLE 147-5 Selection of Common Chronic and Acute Risk Factors and Protective Factors for Suicide
|Chronic Risk Factors |
|History of suicidal thinking or behavior ||Any suicidal factor by history is one of the only consistent predictive measures for suicide risk. |
|History of mental health disorder ||Lifetime risk of suicide is increased in almost all mental health disorders. |
|Age ||Exceedingly rare <10 y of age. Risk starts at approximately age 10 and increases consistently until the age of 24. Adolescents are less at risk for suicide than adults. |
|Sex ||Males 4–5 times more likely by adolescence. |
|Ethnic or cultural risk group ||Aboriginal youth, homeless youth, LGBTQ youth. |
|Chronic illness ||Any chronic illness causing pain, disability, or fatigue. |
|Family history of suicide ||Closer-degree relatives infer a greater risk. |
|History of trauma, abuse, neglect, loss ||Duration, frequency, and severity of trauma is additive. |
|Acute Risk Factors |
|Recent suicidal thoughts or behaviors || |
Ideation < planning < nonlethal attempt < lethal attempt.
New/changing suicidality should prompt full assessment.
|Suicide planning ||Passive (nonspecific wish to die) confers less risk than active (specific, formed plan). |
|Accessibility to lethal means ||Unsecured substances, medications, firearms. Feasibility of plan. |
|High agitation/anxiety presentation ||Strong (yet poorly specific) prediction of acute suicide risk. |
|Current mental health/substance use disorder ||Lack of treatment response, noncompliance to treatment, worsening or rapidly changing disorders, should be targets of suicide risk reduction. |
|Family dysfunction/caregiver unavailable ||Chaotic, dysfunctional homes confer suicide risk. A responsible caregiver must be in place to institute safety management measures. |
|Lack of professional supports ||Can include supports that are not effective. |
|Recent crisis/major life change ||Conflicts, relationships, school, failures, losses, etc. Directly addressing these crises reduces risk. |
|Protective Factors |
|Parent connectedness ||Sport/activity participation ||Positive social supports |
|Safety of environment ||Strong professional supports ||Future orientation |
|Good therapeutic connection ||Strong cultural identity ||Responding to treatment |
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.
Approach to suicidality in the ED.
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 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 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
TABLE 147-6Approach to the Pediatric Aggressive Patient ||Download (.pdf) TABLE 147-6 Approach to the Pediatric Aggressive Patient
|Safety ||Secure patient and staff safety. Recognize the compromise between security and safety: higher security measures (such as pharmacologic or physical restraint) may also confer greater risk for patient harm. Use these measures when appropriate. |
|Engagement ||Youth often use aggression as their last resort to express or achieve something: expressing anger, being left alone, interfering in treatment, or receiving something desired. Engaging the youth whenever possible to help achieve these goals can reduce the need for further measures. ALWAYS allow the situation to "step down." (i.e., reoffer oral medications before injection) |
|Interventions, in the order they should be attempted when possible: |
1. Environment and engagement
2. Pharmacology (voluntary)
3. Pharmacology (involuntary)
4. Seclusion and restraint
Secure the environment so the patient can safely be agitated and engagement is possible. Environments with safe furniture and objects, full observation abilities, and adequate staffing are required.
See Table 147-7. Consider low doses and reengage as necessary.
See Table 147-7. Minimize the need for reinjection of medications by choosing dosing appropriately. Physical restraint is often necessary. Offer oral medications immediately before intramuscular medications.
Ensure the facility has appropriate seclusion and restraint policies; both can be fatal if used incorrectly or inappropriately. All seclusion and restraint should mandate 1:1 observation levels. Remove whenever possible. Special consideration should be given to the possibility of rhabdomyolysis with physical restraints and asphyxia with person-to-person holds.
TABLE 147-7Pharmacologic Management of the Agitated Child ||Download (.pdf) TABLE 147-7 Pharmacologic Management of the Agitated Child
|Drug ||Child Dosing ||Adolescent Dosing ||Notes |
|Appropriate for Sedation in Children |
May repeat q30min
25–50 milligrams PO/IM
Maximum: 200 milligrams/24 h
50–100 milligrams PO/IM
Maximum: 300 milligrams/24 h
|Anticholinergic. Directly treats dystonia from antipsychotic treatment. Liquid form available. |
May repeat q30min
0.5–2 milligrams PO/IM
Maximum: Until sedated or ataxic
1–2 milligrams PO/IM
Maximum: Until sedated or ataxic
|Paradoxical reaction possible. Respiratory depression. Sublingual tablet available. |
|Appropriate for Sedation and/or Psychosis in Children |
May repeat q30min
2.5 milligrams PO/IM
Maximum: 5 milligrams/24 h
5–10 milligrams PO/IM
Maximum: 20 milligrams/24 h
|QTc sparing. Dystonic reaction can occur but unlikely. Warning: IM preparation coadministered with benzodiazepine IM is not recommended because it can cause bradycardia and hypotension. Dissolvable tablet available. Anticholinergic. |
May repeat q60min
0.25–0.5 milligram PO
Maximum: 2 milligrams/24 h
0.5–1 milligram PO
Maximum: 4 milligrams/24 h
|QTc sparing. Dystonic reaction can occur. Dissolvable tablet and liquid form available. |
1 milligram/kg PO
0.5 milligram/kg IM
May repeat q30min
25 milligrams PO/25 milligrams IM
100 milligrams/24 h PO
75 milligrams/24 h IM
50 milligrams PO/12.5 milligrams IM
200 milligrams/24 h PO
100 milligrams/24 h IM
|Hypotension, QTc prolonging, lowers seizure threshold. Anticholinergic. |
|Appropriate for Psychosis in Children (when other treatments unavailable or failed) |
May repeat q60min
0.5–2 milligrams PO/IM
Maximum: 5 milligrams/24 h
2–5 milligrams PO/IM
Maximum: 10 milligrams/24 h
|QTc prolonging. Extrapyramidal symptoms very likely in youth,42,43,44,45,46 especially dystonia. Consider coadministration of prophylactic anticholinergic (e.g., diphenhydramine as above or benztropine 1–2 milligrams PO/IM). |
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 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.
TABLE 147-8Approach to Psychosis in the ED by Suspected Cause ||Download (.pdf) TABLE 147-8 Approach to Psychosis in the ED by Suspected Cause
|Unknown ||Rule out medical causes after thorough history and physical examination. Treat agitated patients or patients with distressing symptoms with the antipsychotics as per Table 147-7. Consult psychiatry when medically appropriate. |
|Substances ||Use antidote/countering medication if available or necessary. Use environmental controls to reduce stimulation. May need to use medications as per Table 147-7, but cautiously due to interaction with intoxicant. Often clears as substance is metabolized. |
|Medical ||Treat the underlying medical cause. Caution in using Table 147-7 medications that have anticholinergic properties. Consult psychiatry to manage psychiatric comorbidities. |
|Psychiatric || |
Primary psychosis (schizophrenia, etc.): use medications as per Table 147-7. Mania/psychotic depression: use antipsychotics as per Table 147-7 with combination of sedative medications as necessary. The goal in mania is to "settle the brain down" first; in psychotic depression, urgent psychiatric treatment is required.
When psychiatric causes are suspected, consult psychiatry.
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.
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
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.
Use developmentally appropriate approaches. Use visual scales, toys, language cards, gestures, and simple words as required. Ask the caregiver for advice on interaction.
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.
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.
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.