Children with Mental Health Issues in the Emergency Department

What do parents do when their child is out of control? Often, they all end up in the ED. The child is sullen and defiant, occasionally agitated. The parents are frustrated and often at the end of their rope. So, as the emergency physician on duty, how do you evaluate this situation?

My first piece of advice is to reset your expectations and that of the family; this is going to be an extended and complex assessment. It likely will take hours and require the involvement of multiple individuals. There is no quick solution. My second piece of advice is to utilize any and all behavioral health experts you can locate and call in. Make this a team process. And my last piece of advice is to remember the principles of this review.

—J. Stephan Stapczynski, MD, Editor

Introduction

Children and adolescents frequently are brought to the emergency department (ED) with psychiatric complaints. A review of the data from the 1993-1999 National Hospital Ambulatory Medical Care Survey (NHAMCS) determined that 1.6% of all pediatric visits to the ED were for psychiatric complaints.1 Our review of the latest data from the 2006 NHAMCS shows continued increases, with 2.3% of pediatric visits arising from psychiatric complaints. For perspective, minors account for 25.4% of all ED visits in this nationwide sample.2 The average age of minor patients presenting to the emergency department with psychiatric complaints is 14.6 years, with 71% in their teenage years.1 Children and adolescent patients also frequently present to the ED with the most severe psychiatric complaints, including recent suicide attempt (13.6%) and psychosis (10.8%). Treating children and adolescents in the ED presents a variety of challenges to providers, as evidenced by a reported duration of six hours for an average pediatric psychiatric visit.2

Assessment of Children and Adolescents in ED

Arriving at the Emergency Room and Emergency Room Environment. Children and adolescents usually are brought to the emergency department when their behavior or thoughts come to the attention of parents, teachers, social workers, after-school programs, or their pediatricians. Pediatric psychiatric visits to the ED tend to peak on Mondays and Tuesdays when school is in session, with fewer visits on weekends, vacations, and school holidays.3 Seeking psychiatric care can be a result of a significant change in the family's or school's tolerance for disturbed behavior.

Arriving at the ED can be a stressful experience for adults, and for children and adolescents it can be perceived as unpleasant and even traumatic. Young children may be so scared that they cannot provide any history or, in the case of adolescents, the assessment may be hampered by their attitude.

A child should be evaluated in a quiet room or a section of ED that is separated from adult patients. Potentially hazardous equipment and materials should be removed. While the parents or others who accompany the patient can be utilized for support, they should not be relied upon to supervise suicidal or behaviorally disregulated children. Instead, the staff should closely supervise the patients to ensure safety. Parents who appear to have a calming effect on a child should be encouraged to stay with the child, while those judged as provocative should be kept separate from the child. Because evaluation of children in the ED typically is a lengthy process, the children can be offered age-appropriate distractions like reading material or a pad of paper for writing and drawing.

First and foremost, the most important goal of the evaluation of children in the ED is an assessment of safety. Restraining children and adolescents is uncommon but may be necessary for combative or violent patients. The decision to use restraints should be made by an attending physician, and the patient should be closely monitored with time-limited orders. The Joint Commission (TJC) carefully regulates patient restraints and considers them to be a measure of last resort. Per TJC regulations, the patients require frequent safety checks, monitoring of vital signs, evaluation of limbs, and evaluation of nutritional and bathroom needs.4 Chemical restraints, defined as medication used to control behavior or to restrict a patient's movement, are indicated when patients remain agitated in physical restraints or when patient behavior needs to be rapidly controlled. (See more on restraints in section on agitation, violent behavior.)

The Interview. Techniques for interviewing children and adolescents in an emergency setting, as discussed by Goldstein and Finding,5 suggest that children younger than 12 years should be interviewed after information is obtained from the parents or another referral source. In this way, the clinician can obtain information efficiently regarding the child's history, functioning, behaviors, developmental milestones, past treatment, and medical and social history. Later, the clinician may obtain the child's perspective on the precipitant of the ED visit.

Adolescents may be able to tell most of their own story, and it is recommended that they be interviewed prior to talking with the parent or guardian. It is not uncommon to encounter a discrepancy between the child's behavior in the ED and a description of out-of-control behavior from school staff or family members. In general, collateral information is an essential part of the psychiatric assessment of minors and is crucial for decision making. Multiple sources for collateral information may be needed to appropriately assess children in different arenas of their lives, including home, school, and peer relations. In an ED where social workers are available, their assistance may be utilized in obtaining collateral information.

The psychiatric interview of children includes the same elements as for adults and should begin with open-ended questions. (See Table 1.) It is best to avoid beginning an interview with challenging or upsetting questions, such as chief complaints or family problems. Instead, consider beginning the interview with an inquiry about neutral topics, e.g. general interests or friends. For children between the ages of 7 and 12, their ability to tolerate the interview is the best guide to the appropriate duration. Children who appear agitated at the outset of the interview may benefit from a demonstration of nurturance, e.g., a small amount of food or drink to aid in relaxation and adjustment to the ED.

The mental status examination includes an assessment of an individual's emotional and intellectual function. It should be conducted through observation and specific concrete and developmentally appropriate questions. Key points include level of suicidality, thoughts of harming others, and impaired thought processes, e.g., hallucinations. Careful observation of the child's behavior and looking for evidence of abuse, neglect, and intoxication are essential.

Presenting Clinical Syndromes

Agitation, Violent and Aggressive Behaviors. The basic concepts of the evaluation of patients who present with agitation or violent or aggressive behaviors include safety of the patients, family, and staff; excluding medical and substance-related conditions prior to making a psychiatric diagnosis; stabilizing the presenting condition; and facilitating an appropriate and safe disposition.6

Aggressive behavior may be a result of a variety of underlying psychiatric diagnoses. In a large study at a teaching hospital, risk factors for violence in pediatric patients were shown to be inadequately screened and documented.7 In one study of minors presenting with violent behavior, 63% had a previous history of violence and 60% had a previous history of abuse.7 One striking finding in this study was the lack of documentation regarding gun access, although firearms are a common method of homicide and suicide in youth.8 Hence, screening for risk factors for violence, including access to a gun, should be ascertained and carefully documented. Historical factors (e.g., early initiation of violence, academic failure, truancy, family maladjustment), clinical factors (e.g., substance use, psychopathy, impulsivity), and contextual factors (e.g., gang involvement, neighborhood crime, community disorganization) are cited as important elements in a risk assessment for violence.9

The initial step in the management of aggressive behavior is to diagnose and treat the underlying psychiatric illness. Clinicians should use their clinical judgment and intuition to assess their own risk of harm from agitated or out-of-control patients and whether to utilize interventions such as seclusion, restraints, and medications. Clinicians also should consider the circumstances of the child's presentation. For example, a patient with a pervasive developmental disorder may become agitated or have out-of-control behavior as a result of an infectious process such as otitis or an abscess that is causing discomfort or pain. Hence, a thorough search for physical causes should be conducted. The initial assessment also should identify any cognitive deficits that may be due to medical causes or intoxication.

In less agitated patients, de-escalation strategies, including stress reduction techniques, may be used. Such techniques are favored by experienced clinicians whenever possible.10 Simple strategies such as speaking with a soft voice, validating feelings, offering distractions (like movies, video games, and sensory toys), and clear limit-setting can be helpful. Attempting to reason with the child in the midst of an agitated state is largely ineffective. Often, when children are angry about something, there may be elements of truth to their complaints. A clinician should try to find that little bit of truth in the child's story to agree with. This may minimize resistance and facilitate a positive therapeutic alliance, reducing the need for seclusion and restraints.

Medications for agitation or "chemical restraint" are indicated when the patient continues to be agitated, restless, and hyperkinetic while in physical restraints or when patient behavior needs to be controlled rapidly. There are no specifically FDA-approved medications for the treatment of agitation in pediatric patients, although risperidone, a second-generation antipsychotic, has been FDA-approved for the treatment of children with irritability, including aggression, deliberate self-injury, and temper tantrums that are associated with autism. Also, there are no published investigational trials comparing treatments.10 Recommendations (see Table 2) are drawn from treatment guidelines,11 recent reviews,10,12,13,14 and authors' emergency psychiatry experience.

Suicide. According to 2006 data, suicide is the fourth leading cause of death in children aged 10 to 14 and the third leading cause of death in those 15 to 19 years old in the United States,15 with a male to female ratio of approximately 5:1.16 Suicide rates among Native American and Alaskan Native children and adolescents ages 10 to 19 years old are significantly higher than the national average — for this group, suicide is actually the second leading cause of death.8 Suffocation and hanging are the most common methods of suicide in the 10-14-year-old age group (63%), followed by firearms (29%). Among the 15-to-19-year-old age group, firearms are the most common method of suicide (45%), followed by suffocation/hanging (42%). Poisoning/overdose accounts for only about 5% of all youth suicides, and cutting for less than 1%.

Suicide attempts also are high among adolescents and young adults. In the 15-to-24-year-old age group, there is one suicide for every 100-200 attempts.17 In 2007, 14.5% of U.S. high school students reported that they had seriously considered attempting suicide during the 12 months preceding the survey, with higher rates for females than males. Almost 7% of students reported that they actually had attempted suicide one or more times during the same period.

Management and Assessment. Medical stabilization of the patient who has attempted suicide is the first priority, and psychiatric evaluation should be implemented as early as the patient can be interviewed. During medical stabilization, children and adolescents with suicidal behavior should have one-to-one observation, and potentially harmful medical supplies and equipment should be removed from the examination room. Once a child or adolescent has disclosed suicidal ideation, assessment of suicidal risk should be performed. As proposed by the guidelines of the American Academy of Child and Adolescent Psychiatry for the assessment and treatment of children and adolescents with suicidal behavior, the goals of the psychiatric evaluation include:16

• determination of the risk of death by suicide completion or repetition (immediate subsequent attempt);

• assessment of underlying diagnosis and promoting factors; and

• identification of predisposing and precipitating factors that can be treated or modified.

A thorough suicide risk assessment always should include collateral information and in-depth evaluation of the following elements:

• the content, nature, and chronicity of the suicidal thoughts;

• the existence and details of a suicide plan;

• access to lethal means;

• other factors related to motivation, emotional/behavioral regulation, support systems, and stressors.18

The risk factors for completed suicide include preexisting psychiatric disorders and both biological and social-psychological factors. Stress often precedes adolescent suicide, including loss of a romantic relationship, disciplinary actions in school, academic failure, or domestic turmoil. Among adolescents, suicide risk factors include age between 16-19 years, current mental disorders such as depression, mania, hypomania, or mixed states, especially in the context of co-morbid substance abuse, irritability, agitation, or psychosis.16 Additional risk factors include prior suicide attempts, still thinking of suicide, and those who used a method other than superficial cutting or ingestion. Such patients should not be discharged without a psychiatric evaluation.

There are a number of facilitating factors that may contribute to suicide. These include maladaptive coping styles, biological factors (specifically dysregulation of the serotonin system), family history of suicide, and parental psychopathology. Social-psychological factors are associated with increased suicide risk and include media coverage of prominent cases and the phenomenon of suicide cluster.19 Last but not least, due to the recent concern that widely used antidepressant agents might be associated with an increased risk of suicidality in pediatric patients, patients evaluated for suicidal ideation in the emergency department should be asked about antidepressant use. Some studies have found that use of antidepressant drugs in pediatric patients is associated with a modestly increased risk of suicidal ideation.20 However, larger epidemiological studies of minors show an association between increased use of SSRIs and decreased completion of suicide.21

Protective factors also should be taken into consideration, particularly when opting not to hospitalize a child or adolescent who expressed suicidal ideation. These include the presence of effective coping strategies and problem-solving skills, supportive parents, social support outside the family, future orientation, a positive attitude toward treatment, and established outpatient treatment.22

Children and adolescents with acute suicidal ideation or a recent suicide attempt should never be discharged from the emergency service without receiving a suicide risk assessment. Intervention options may include hospitalization, access to outreach crisis intervention services, optimizing outpatient psychological services, and family support. The level of intervention should depend on the level of suicide risk, available support, and the ability of the child or adolescent to keep him- or herself safe.

Child Abuse and Neglect

According to the 2006 National Child Abuse and Neglect Data, more than 3.5 million referrals were made to Child Protective Services. An estimated 905,000 children were victims of maltreatment, with an estimated 1,520 fatalities. More than 64% of cases were due to neglect, 16% of children were abused physically, and 8.8% sexually. More than 40% of fatalities from child maltreatment were associated with neglect alone.23

It is important for a clinician to recognize that a child may have been exposed to physical or psychological abuse, particularly in children who refuse to go home or appear frightened of the parents or guardians. Signs and symptoms of physical abuse include bruises in unusual locations, unexplained burns, lesions in different stages of healing, and black eyes. Signs of neglect may include poor grooming and clothing, frequent school absence, malnourishment, and substance abuse.

The goal of evaluating children for suspected abuse is to ensure safety and prevent repeated abuse and long-term consequences. Child maltreatment has been associated with increased rates of psychiatric disorders, alcohol and drug use, criminal activity, and dysfunctional family life in the future.24 Children and adolescents who have been sexually abused are additionally at risk of developing post-traumatic stress disorder (PTSD). Child abuse and neglect are subject to mandatory reporting for professionals in all states, and failure to report may result in legal consequences.

Fire-Setting

According to the Office of Juvenile Justice and Delinquency Prevention (2005), roughly 300 people die and $300 million worth of property is destroyed annually by juvenile fire-setting.25 Adolescent fire setters may be brought to the ED because of the potential for injury and destruction, although these children rarely present with acute psychiatric symptoms. Their mental health problems most often are chronic and include attention deficit hyperactivity disorder in children or conduct disorder in adolescents. A distinction is made between fire play and fire-setting. Fire play, which typically involves children aged 5 to 9, is characterized by curiosity and fascination and does not imply malice. Contrary to that, fire-setting is a deliberate, planned malicious act. ED evaluation most often is lengthy due to multi-system involvement that may include law enforcement.

Runaways

Children who run away usually do not present to the ED but most commonly are brought in by a case worker or a family member. Runaway children are at risk of physical and sexual abuse and drug and alcohol use. Careful screening is suggested with subsequent referrals to address these issues.

Childhood Psychiatric Disorders

Anxiety Disorders. As in adults, children may suffer from panic disorder, generalized anxiety disorder, acute and post-traumatic stress disorder, obsessive-compulsive disorder (OCD), and specific phobias. However, the primary symptoms may present differently in children.

Minors may present to the emergency department complaining of symptoms of panic. Panic attacks are discrete episodes of severe anxiety that peak within 10 minutes. It has been suggested that children may suffer from the physical symptoms of panic attacks but are unlikely to meet the cognitive criteria of catastrophic thinking and avoidance necessary for a diagnosis of panic disorder. The most commonly reported symptoms were somatic and included palpitations, nausea, trembling, and shortness of breath. Adolescents were more likely to complain of cognitive symptoms including the "fear of losing control" than were pre-pubertal children. Panic disorder is co-morbid with another psychiatric diagnosis more than 90% of the time, with separation anxiety and generalized anxiety disorder being the most common co-occurring disorders. Acute management consists of a low dose of a benzodiazepine, although this rarely is advised as a long-term treatment in children.6 SSRIs are the most commonly used long-term treatment.26

Unlike a panic attack, which involves a discrete episode of intense anxiety, generalized anxiety disorder involves nearly constant anxiety over 6 months, with many different spheres of worry. This disorder also includes overanxious disorder of childhood. Unlike in adults, in children the DSM-IV requires only one associated symptom of either restlessness, easy fatigue, difficulty concentrating, irritability, muscle tension, or insomnia.27 Generalized anxiety may be seen in younger children with an average age of onset of approximately 6 years old in a sample from a pediatric psychiatric clinic.28 Generalized anxiety disorder may be difficult to differentiate from major depression, as both can present with prominent irritability. However generalized anxiety disorder may be differentiated by the prominence of symptoms of worry without the loss of interest found in major depression. Studies have shown cognitive behavioral therapy (CBT) to be effective in treating generalized anxiety symptoms in 8- to 13-year-old children.29 The addition of family management educational groups increased the efficacy of CBT in another study of 7- to 14-year-old children.30 Benzodiazepines and SSRIs both have shown efficacy in treating generalized anxiety disorder in children and adolescents.31

A traumatic precursor with subsequent symptoms from three clusters of re-experiencing, avoidance, and arousal suggests either acute stress disorder or post-traumatic stress disorder, depending on the duration of symptoms. Unlike in adults, where the DSM-IV describes helplessness or horror after a traumatic event, in children the response may be seen with disorganized or agitated behavior.27 Children may show signs of re-experiencing differently than adults and may include nightmares without recognizable content and repetitive play in which themes of the trauma are expressed and reenacted.

Traumatized children meeting the criteria for PTSD may be at increased risk of development of other anxiety disorders later in life.32 Acute management might include a low dose of a benzodiazepine. Although propranolol is reported to be effective in the management of symptoms of PTSD, there are no studies to support its use in the prevention of PTSD symptoms after a traumatic event in children.31,33 Long-term management includes cognitive behavioral therapy and SSRIs.34

Specific phobias are an excessive or unreasonable fear cued by the presence of anticipation of a specific object or situation.27 In children, the anxiety response may be expressed by crying, tantrums, freezing, and clinging. Specific phobias often have an early onset in children, with an average of 4.1 years old.28 As children may not acknowledge the source of their excessive or unreasonable fear, they may present in the emergency department with frustrated and distraught parents. The acute management includes reassurance. Long-term management includes systematic desensitization.35

Although many minors suffer from symptoms of OCD, patients with this diagnosis are less likely to present in emergency departments seeking treatment. The DSM-IV criteria for children are similar to those for adults, except that children are not required to have acknowledged that their obsessions and compulsions are unreasonable or excessive. Long-term management includes cognitive behavioral therapy and SSRIs.31,36

Attention Deficit and Disruptive Disorders. This DSM-IV category is unique in that a diagnosis usually is made in childhood or adolescence. This category includes attention deficit hyperactivity disorder (ADHD), conduct disorder, and oppositional defiant disorder.27 These diagnoses are associated with increased risk-taking behavior, but studies are mixed as to whether children with this group of disorders present in the ED more frequently with accidental injuries.37

The diagnosis of ADHD requires symptoms to be present in multiple settings, with symptom clusters of inattention, hyperactivity, and impulsivity. They frequently are brought to the ED because of aggressive behavior, sometimes impulsively punching or kicking their siblings, teachers, or parents. Frequently they are brought in by school officials or police. For longer-term treatment of ADHD, psycho-stimulants frequently are prescribed.1

Conduct disorder describes a pattern of violating the basic rights of others and includes aggression to people or animals, destruction of property, deceitfulness or theft, or other serious violations of rules, including truancy or running away. Conduct disorder is the required childhood precursor for the diagnosis of antisocial personality disorder to be made later as an adult.27 By definition, children and adolescents with conduct disorder have an elevated risk of violence.

Oppositional defiant disorder describes behavior that is less severe than in conduct disorder. Behaviors typical of oppositional defiant disorder include arguing with adults, frequently losing temper, deliberately annoying people, and being easily annoyed with spiteful, angry, and vindictive behavior.27 Patients with this diagnosis often present a challenge to clinicians working in the ED as they often will de-escalate when brought to the ED, highlighting the importance of obtaining collateral information for a complete evaluation. If they are agitated, they may require techniques for de-escalation listed above. Many patients with this diagnosis also have a comorbid diagnosis of ADHD and many respond to treatment with stimulants.

Mood Disorders. Mood disorders include the specific diagnoses of major depression and bipolar disorder.

Major depression may present differently in children than in adults. Instead of presenting with a primarily depressed or sad mood, children and adolescents with major depression may present with a primarily irritable mood. As in adults, children and adolescents with major depression may experience a decrease in appetite, but instead of having weight loss, they may fail to make expected weight gains.27 Children and adolescents may present with other primary symptoms of major depression, including loss of interest and pleasure, insomnia, fatigue, and difficulty concentrating evident in difficulty completing school work. It is important to screen for symptoms of depression, as the presence of depression, diagnosed or not, raises the risk of substance abuse, early sexual involvement, and decreased participation in organized social activities. Antidepressants have been shown to be an effective treatment for major depression in minors and are credited in part for the 10-year decline in the pediatric suicide rate that ended in 2003.40 In 2004, the FDA added a black box warning based on reviews of short-term treatment studies that stated, "antidepressants increase the risk compared to placebo of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults." The black box warning has led to a significant decline in the amount of antidepressants prescribed to minors and is associated with a subsequent elevation in the rate of pediatric suicide,41 reversing the 10-year decline noted earlier. Current recommendations include antidepressants and cognitive behavioral therapy for treatment of major depression in minors.42

Adolescent patients presenting with bipolar disorder may present a diagnostic challenge to providers working in the emergency department. For instance, it may be difficult to differentiate symptoms of mania from ADHD, as both disorders include the same primary signs of increased activity, distractibility, and difficulty concentrating. There is an active debate in child psychiatry as to how the diagnosis of bipolar disorder is made, with some asserting that any child with significant mood lability is bipolar, and others recommending far more stringent diagnostic criteria. Most experts agree that if children have episodes of several days' duration with hallmark manic symptoms like mood elation, grandiosity, hypersexuality, and decreased need for sleep, a bipolar diagnosis should be considered.43

Psychotic Disorders. With psychotic symptoms, it is important to rule out organic causes of psychosis, including general medical conditions and substance abuse. Any clouding of consciousness is suggestive of a medical- or substance-induced etiology. As in adults, the primary psychotic symptoms include disorganized speech, disorganized or catatonic behavior, hallucinations, and delusions. However in children, hallucinations may be present in normal development. Signs suggesting that hallucinations are not psychotic include the absence of co-occurring delusional beliefs, incongruous mood, bizarre behavior, or social withdrawal, and the presence of normal language production and motor activity.44 Non-psychotic hallucinations must be interpreted in the child's biological, psychological, and social framework for an accurate assessment, as many children never develop further symptoms of psychosis or loss of functioning.45 Minors presenting with psychotic symptoms may require anti-psychotic medications for the control of agitation.

Eating Disorders. Eating disorders include anorexia nervosa and bulimia nervosa. Anorexia nervosa is defined in children as a failure to meet expected weight gain leading to a body weight less than 85% of expected.27 Patients with anorexia typically have a disturbance in the way their body shape is experienced and have an intense fear of gaining weight or becoming fat, even though they are underweight. Additional criteria include 3 months of amenorrhea in females after reaching menarche. The onset of anorexia is typically between the ages of 14 to 18 years. Rarely, anorexia may have onset before puberty, and in such cases it is associated with worse prognosis and more severe psychopathology. Anorexia is ten times more common in females than in males. Anorexia occurs in two patterns, the restricting type and the binging/purging type. Medical evaluation is crucial for patients presenting with anorexia, as the severe weight loss may affect most major organ systems. Treatment is multidisciplinary, with one key team member being a nutritionist. Besides acute medical stabilizations, most anorexia care should occur on an outpatient basis.

Patients with bulimia nervosa may maintain an appropriate weight but frequently experience a loss of control and eat an unusually large amount of food in any two-hour period, at least two times a week for three months.27 As in anorexia, patients with bulimia are unduly influenced by body shape and weight. Patients may engage in self-induced vomiting, abuse of laxatives or diruretics, fasting, or excessive exercise to control their weight. These purging behaviors may cause metabolic abnormalities. As in anorexia, the medical evaluation is crucial for patients with bulimia.

Substance Abuse. Substance-related disorders are the most common diagnostic category in minors presenting to the emergency department. Alcohol is the most common substance used by adolescents. Thirty-five percent of teenagers report having used alcohol in the past 30 days, according to data from the 2007 National Survey on Drug Use and Health.46 More than 5% of adolescent individuals meet the more severe criteria for alcohol abuse or dependence, which include tolerance, withdrawal, use in dangerous situations, trouble with the law, or interference with major obligations at work, school, or home during the past year.

Marijuana is the most common illicit substance to be used by adolescents. Other than marijuana, the two most common illicit substances among adolescents are inhalants and prescription medication. According to the 2007 National Survey on Drug Use and Health, more than 3% of individuals aged 12 to 17 reported the non-medical use of prescription drugs in the past month, and 1.2% acknowledge the use of inhalants.46 Over-the-counter medications commonly are abused by minors, with several studies finding increasing incidence of abuse of dextromethorphan.47,48

Substance use during childhood and adolescence has been shown to be a risk factor for teen pregnancy, incarceration, and suicide. Substance use during adolescence has been shown to increase the risk of psychiatric disorders and poor global functioning as an adult.49,50 Emergency physicians should take the time to discuss the negative consequences of continued substance use with adolescent patients.

Adolescents have been shown to benefit from chemical dependency treatment in various settings, including Alcoholics Anonymous and other 12-step programs.51 Motivational interviewing techniques have been shown to be effective in pediatric populations.52 Cognitive behavioral therapy also has been shown to be effective in adolescent patients in reducing substance use.53

Medical Illnesses that May Present with Psychiatric Manifestations

Like adults, children who present with psychiatric symptoms should be assessed fully for underlying medical illness. Delirium is a complex neuropsychiatric syndrome characterized by clouding of consciousness with cognitive and perceptual disturbance. The first step in recognizing delirium is to suspect it from history. The diagnostic challenge comes from the multitude of potential causes of delirium. (See Table 2.) Pediatric patients may present with either a hypoactive or hyperactive state. Delirium is suggested by the presence of disorientation, visual hallucinations, emotional lability, and fluctuating mental status with onset over hours to days. Consideration should be given to infectious, metabolic, and toxic etiologies. Other factors that suggest a medical cause or organic etiology include abnormal vital signs, or abnormal neurological or physical examination. Younger patients may be less able to describe hallucinations and delusions, so observing for behaviors such as picking, pulling IV, or talking to themselves may indicate visual hallucinations. Compared to delirium in adults, childhood delirium is characterized by a more acute onset, more severe perceptual disturbances, more frequent visual hallucinations, more severe delusions and mood disturbance, and greater agitation. However, children have less severe cognitive deficits and sleep-wake cycle disturbance.54

Thought disorganization, mood, anxiety, and psychotic symptoms may result from a number of different medical conditions. Hence, extensive screening may be needed in pediatric patients with new-onset psychiatric symptoms and in children younger than 12 years of age, when psychiatric illness is less common.

Legal Issues

Consent. Consent is defined as voluntary agreement made without coercion or duress. In medical settings, a consenting individual also must have adequate knowledge of the treatment and associated risks and benefits. Most states require the patient to be a competent adult older than 18 years of age to be able to give informed consent for medical care. In most cases involving minors, informed consent must be obtained from the child's parents or legal guardian before treatment can proceed. Exceptions exist for emergencies when delay in treatment would increase the risk to the minor's life or health. Determining who the legal guardian is may be difficult when the parents are divorced or if the child is in physical custody of Child Protective Services (CPS). Usually foster parents, case workers, juvenile correction officers, and second-degree relatives do not have legal custody.6 Efforts should be made to obtain documentation of legal custody before initiating non-emergent care.

It is important to note that the capacity for consent is not static. Providers should assess the capacity of minors to participate in medical decision-making over normal development and during episodes of illness. The Tennessee Supreme Court suggested a rule of 7s, with children younger than age 7 having no capacity, children between the ages of 7 and 14 presumed to have no capacity with the burden of proof on the minor to show capacity, and minors older than age 14 presumed to have capacity, but can be proved otherwise by others.55 Although most states designate the age of consent for medical care to be 18, important exceptions include emancipation and context-specific cases. A minor may be emancipated if he or she is performing the role of an adult. Examples include minors who are living alone and financially supporting themselves, are in the military, who have children themselves, or who are married. Finally, some states allow minors to give consent for specific services including birth control, treatment for pregnancy, sexually transmitted diseases, substance abuse, or mental health.56 Knowledge of local and state law is crucial for emergency physicians.

Confidentiality. Confidentiality and privacy are paramount in the treatment of psychiatric illness. Privacy is particularly important in mental health because of the significant stigma associated with mental illness. Disclosure of confidential information requires consent of the patient or his or her parent or guardian. The limits of confidentiality should be explained to each patient or his or her parents. The Health Insurance Portability and Accountability Act (HIPAA) prohibits the disclosure of clinical information, with exceptions for treatment, payment, or when mandatory reporting laws supersede (e.g., when child abuse is suspected). Patients should be informed that information may be released in emergency situations without their consent when the patient or others are in danger.

Discretion must be used in releasing clinical information in emergency situations. When assessing danger, no more clinical information should be released than necessary to obtain crucial collateral information. For example, it may be necessary to acknowledge that a patient is being evaluated without releasing the diagnosis or treatment plan.

Because of significant stigma associated with mental illness, adolescents may be more likely to seek treatment when they perceive that their treatment will be confidential. Many states have lowered the age of consent for various services including mental health in an effort to lower barriers to treatment and improve access to care.

Involuntary Treatment. The least restrictive setting should be sought to ensure patient safety and appropriate care. The indications for hospitalization include danger to self or others and an inability to safely care for oneself. In many states, the child's parents may give consent for psychiatric hospitalization without consent of the patient. Problems may arise when the child's legal guardian does not consent to hospitalization of the minor. In many states, the only mechanism to ensure the safety of the minor patient, if such treatment is against the legal guardian's wishes, is to refer the legal guardian to CPS for neglect of the patient's psychiatric condition. It is important for emergency physicians to be familiar with local and state laws concerning involuntary treatment.

Mandatory Reporting Laws. The Child Abuse Prevention and Treatment Act of 1974 specifically defines child abuse and neglect to include completed acts or failure to act resulting in physical, sexual, or emotional harm or a risk of imminent harm. All physicians, psychologists and social workers are required to report abuse or neglect to CPS.13 Penalties for failure to report vary by state but may include fines and criminal charges.

Cultural Issues

As the United States population is becoming more culturally diverse, it is to be expected that more patients of ethnically diverse origin will be presenting in the emergency department. It is projected that by 2023, minorities will comprise more than half of all children.57 Ethnic minorities face many challenges in obtaining appropriate care due to language barriers, deficits in cultural competence of the clinician, underrepresentation of clinicians from an ethnic minority, and a health care system that is not set up to address the cultural needs of diverse populations.58 The challenge becomes even greater in the emergency setting because of the need for rapid assessment, diagnosis, and treatment. For example, children of Hispanic and African-American origin may show anger and disruptive behaviors from internalizing disorders like depression. Psychosis often goes undiagnosed in these groups.58 The subdued expressiveness found frequently in children of Asian and Native American origin can be misinterpreted as mood or affective disturbance.

Cultural issues of particular relevance to treating a pediatric patient of Muslim origin include dress code, abortion, and gender relations within the patient-doctor relationship. Some of these bioethical issues are grounded in the Islamic paradigm of medical ethics59 with which Western-trained physicians often are not familiar. In our institution, clinicians often encounter Somali-Muslim refugees who have high rates of PTSD with prominent symptoms, yet they tend to avoid mental health treatment due to the cultural stigma of mental illness and fear of being institutionalized and chained up, the way that mentally ill individuals often are treated in Somalia.60

Clearly, cultural diversity tends to add complexity and challenges to an already existing lengthy process of pediatric psychiatric care in ED. Culture can have a profound effect on the expression of psychiatric illness, so it is important for clinicians to recognize, understand, and respond to the cultural elements when treating pediatric patients.

Disposition

The nature of ED assessment is to arrive quickly at an accurate diagnosis and subsequently determine the most appropriate disposition. In pediatric patients, dispositions are determined based on the severity of the presenting symptoms and the strength of the safety plan, support system, and community follow-up. Options may be limited by insurance and systems issues, such the availability of inpatient treatment, partial hospitalization programs, substance use treatment programs, specialized crisis response teams, child protective services, and outpatient mental health services.

Hospitalization rates for pediatric patients after an ED mental health visit vary from 11% to 20%.1,61 Patients who typically require psychiatric hospitalization have the following characteristics:

• attempted suicide but are medically stable;

• abnormal mental state (confusional state);

• persistent wish to die, with clear plan, intent, and means;

• highly lethal, unusual, or painful method;

• agitated /violent patients who cannot be stabilized in the ED;

• clear danger to others;

• severe depression leading to withdrawal and refusal of food;

• acute, active psychotic symptoms;

• cannot be treated in less restrictive environment;

• safety cannot be maintained in less restrictive environment;

• require extended observation for differential diagnosis;

• require extended observation for stabilization on medication;

• inadequate supervision at home or family unresponsive to suicidal behavior.6,62

Despite the clinical rationale to hospitalize a suicidal patient, there has been no demonstrable impact on long-term outcome for suicidal adolescents.63

Involuntary hospitalization may need to be considered when less restrictive options, including a voluntary hospitalization, have been exhausted or when the parents (legal guardian) or child are in disagreement with the physician's recommendations for hospitalization.

Patients may be discharged safely if they are no longer suicidal, have solid family support with close supervision, if lethal means have been removed (no firearms, no pills), and outpatient mental health visits have been scheduled. In some states, specific Children Crisis Response Teams are available to follow up with the child and family at home to provide ongoing support until follow-up with outpatient treatment team is fully established. Also, they would be in a position to evaluate if the patient would need to return to ED for hospitalization. This option is particularly important because the data show that noncompliance with follow-up treatment is very high. Approximately 18-42% of suicidal patients discharged from ED don't show up for their first appointment and by the third appointment, the drop-out rate is more than 50%.61

Summary

The emergency department is becoming an ever more common setting for the assessment and management of children and adolescents with mental health issues. The evaluation of minors in psychiatric crisis presents challenges to busy physicians working in the ED. The evaluation may be a lengthy process requiring age-appropriate interviewing techniques, collateral sources of information, and ruling out the contribution of substances or medical causes. Attention to overarching guidelines increases the safety of patients, their parents, and ED staff.

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