Best Practices in Managing Behavioral Health Emergencies for Children and Adolescents
Updated 2 years ago on November 23, 2022
Behavioral problems are often assumed to be due solely to psychiatric causes. However, many medical pathologies can accompany behavior problems and should be ruled out. In this issue you will learn:
Behavioral disorders most commonly manifest as depression, suicidal behavior, aggression, and severe disorganization. Emergency physicians should avoid relying solely on medical history or previous psychiatric diagnoses, which may prematurely rule out medical pathology. Treatment of behavioral emergencies consists of de-escalation interventions to prevent agitation, aggression, and harm. This issue reviews the medical pathologies and underlying causes that can lead to psychiatric manifestations, and summarizes evidence-based methods for the assessment, management, and referral of patients with urgent behavioral disorders.
A 16-year-old teenage girl was admitted to the emergency room after swallowing an entire bottle of ibuprofen four hours earlier. The patient vomited several times before arriving at the emergency room. Initial vital signs: temperature 37°C (98.7°F); heart rate 90 beats/min; blood pressure 100/70 mmHg; respiratory rate 15 breaths/min; oxygen saturation 100% in room atmosphere. The girl is alert and oriented. On physical examination, mild tenderness in the epigastric region and numerous well-healed bilateral cuts on the wrists and thighs are noted. A quick neurological examination revealed no abnormalities. The patient was a high school student who was doing well in school, but had recently had poor exam results. One week earlier, her longtime boyfriend had broken off their relationship. The girl denies drug use. She claims that when she took the pills, she wanted to kill herself because "everything is horrible and overwhelming." While you are evaluating her in private, she doesn't make eye contact and is silent when you ask about her current suicide intentions. You begin to think about the precautions you should take to keep this patient safe, and what the next steps in treatment should be...
A 15-year-old was taken by police to the emergency room because he threatened his mother with a knife. The police report states that he "trashed the house. The patient's mother arrives at the emergency room and states that their altercation began because she would not allow her son to date a group of older friends who she believes are a bad influence. She reported that her son had been abusing "oxy," which was originally prescribed after a football-related back injury. After the injury, depression and truancy became serious problems. The patient's family history includes indications of depression and substance abuse. When you examine the patient, he has diarrhea and dilated pupils. He is initially cooperative and admits that he wants to "stop using pills." He adds that he has had fleeting thoughts of suicide, but that he has never planned or attempted suicide. As you continue to question the patient, his behavior begins to escalate and, despite redirection, he begins to scream. What should you do to ensure the safety of this patient and the ward staff? How should you respond if the patient's aggressive behavior escalates?
A 16-year-old teenage girl was admitted to your clinic. She had 4 previous psychiatric hospitalizations for depression and, most recently, 1 for psychosis. The medical evaluation for new psychosis at her last ED visit was negative. She was admitted to a psychiatric hospital for 15 days and discharged while taking risperidone. Her parents called 911 because they said she was acting very strange, moving stiffly and burning with a high fever. She was sweating, pale, and unresponsive. She seems disoriented, only responds to her name with a brief glance at you, she is drooling and shivering. Her vital signs are: temperature 41.5°C (106.7°F); heart rate 132 beats/min; blood pressure 144/88 mmHg; respiratory rate 26 breaths/min; oxygen saturation 100% in room air. As an attending physician, what would you immediately think of? What laboratory tests should you be ordered? What kind of consultations would you get in the emergency department?
The number of pediatric emergency department (ED) visits for behavioral health problems continues to grow, with the rate doubling over the past decade. Recent reports confirm that the trend has continued, increasing by more than 40% from 2008 to 2013, from an initial rate of 9.3 behavioral health visits per 1,000 emergency department visits to a peak of 13.7 behavioral health visits per 1,000 emergency department visits in 2013.Data from the U.S. Department of Health and Human Services show that 11.2% of children and adolescents ages 2 to 17 have a behavioral or developmental disability. The prevalence of behavioral problems leading to impairment is as high as 22.2% in the adolescent population, with up to 40% of these adolescents meeting the criteria for more than one mental illness. Recently published national trends in adolescent depression also revealed a dramatic increase, from 8.7% in 2005 to 11.3% in 2014. The situation is further complicated by the fact that about 2.3 million adolescents (9.4%) between the ages of 12 and 17 in the U.S. are involved in illicit substance use. In addition, violence and suicide remain serious problems among teens. Suicide is the second leading cause of death for 10- to 24-year-olds, resulting in 5,491 deaths in 2015. Homicide is the third leading cause of death in a similar age range, with 4,733 victims reported in 2015.
Despite the tremendous health care needs of these children and adolescents, severe lack of resources in the community continues to lead to an increase in hospital visits for behavioral health reasons. In a study of children and adolescents with serious mental illnesses and disorders, only 20% used specialized behavioral health services in the community setting. In addition, despite the American Association of Pediatrics (AAP) recommendation that pediatricians identify suicide risk factors, only about 10% of adolescents discuss them with their pediatrician, and that percentage has not changed in more than a decade. For all of these reasons, the ED is often the first contact for many children and adolescents who find themselves in crisis and may need unique psychiatric assessment, intervention and follow-up care coordination.
After first contact with a triage patient, the emergency physician must gather an appropriate history, determine immediate medical needs, assess safety issues, obtain appropriate laboratory tests, arrange for appropriate counseling, and develop a plan of action. In addition, various medical organizations/ settings have a variety of resources, ranging from no psychiatric care to telepsychiatry, a personal psychiatric consultant, a specialized behavioral health emergency team integrated into the emergency department, or a separate psychiatric emergency service. This issue of The Practice of Pediatric Emergency Medicine reviews common clinical manifestations of behavioral health emergencies and offers a practical approach to best practice based on current evidence and established consensus recommendations.
Critical appraisal of the literature
For a comprehensive literature review, a systematic PubMed search strategy was conducted using the following keywords in a Boolean search: child, children, adolescents, child and adolescent, pediatric, youth, behavioral, behavioral, mental, mental health, psychiatric, altered, delirium, aggression, violence, suicide, emergency, emergency. After reviewing the titles and abstracts of 9068 articles, 161 articles were selected for full-text review. The inclusion criteria were (1) the study was conducted in a child or adolescent population, (2) there was an ED delivery or management in an ED setting, and (3) the focus was violence, aggression, suicide, or delirium. Several review articles and retrospective studies on epidemiology, presentations, disparities in access, etiology, comorbidity, research, management strategies, practice gaps, and policy recommendations were identified. Despite a broad search strategy and additional searches related to the population of interest in the ED setting, very few randomized controlled trials comparing interventions were identified.
The pitfalls of risk management in the management of behavioral health emergencies
"I thought the patient's tachycardia was caused by hisrestlessness and strange behavior. I didn't even notice his fever.
Assessment of all patient vital signs in the emergency department is very important. In patients with behavioral disorders, tachycardia and fever may be a sign of NMS or serotonin syndrome, which are potentially life-threatening conditions and should not be missed.
"The child's mother says he doesn't like doing thethings he used to do, and now he doesn't want to go to school. He's obviously depressed."
This patient has the classic symptoms of depression, but it is also important to rule out other possible problems, including drug use. Opioid abuse and addiction have become a national epidemic. By not identifying this cause of depression, you are missing an opportunity for potentially effective interventions. Initiating referrals and connecting the patient to other resources can prevent a downward spiral of addiction and/or life-threatening overdose in the future.
"This child is out of control. Restrain him!"
Restraint is a high-risk procedure for patients and staff, and should never be the first line of treatment. Environmental, verbal, and pharmacological measures should always be attempted first; physical restraint should be used only when there is immediate danger and the measures have failed. If physical restraint is necessary when severe agitation threatens the patient or staff, chemical restraint should be used along with physical restraint to prevent self-harm.
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