Are a child's symptoms psychiatric, or something else? Rule out medical causes

Don't "block out" other diagnoses

A young girl experiencing hallucinations presents to an ED after being evaluated at another hospital, and twice referred for psychiatric care. "Her diagnosis was, in fact, a potentially life-threatening underlying cardiac disorder. Unfortunately, that missed diagnosis is not uncommon," says Deena Brecher, MSN, RN, ACNS-BC, CEN, CPEN, a clinical nurse specialist in the ED at Alfred I. duPont Hospital for Children in Wilmington, DE.

Psychiatric diagnoses come only after medical diagnoses are excluded, warns Brecher. "Encephalitis, meningitis, brain tumors, ingestions of toxic substances — all of those things can mimic psychiatric symptoms," she says. "Even if the patient has been seen by psychiatry and is being medicated, we still need to rule out medical causes for their symptoms."

Wendy Pittman, LBSW, intake team coordinator in the ED at Cook Children's Health Care System in Fort Worth, TX, says her ED has seen a 60% increase in pediatric psychiatric patients since 2000. "We have also seen a 253% increase in the number of preschool-aged children presenting to the ED for psychiatric concerns," she reports.

To avoid missing an underlying medical condition, Pittman recommends obtaining a thorough medication history along with the presenting problem. "Asthma or other breathing difficulties can look like anxiety attacks. Migraines can cause depression or hallucinatory symptoms," adds Pittman. "Substance ingestion can cause all types of psychiatric symptoms."

Exclude seizures if a child is agitated or hallucinating, says Pittman, and remember that ear infections and urinary tract infections can cause agitation in autistic children.

"You may be thinking with good reason, 'this is a psychiatric problem.' But don't stop considering medical issues, or disregard possible medical signs and symptoms if they emerge," says Colleen Robinson, RNC, BSN, MA, unit-based educator for the ED at Maine Medical Center in Portland.

Keep an open mind

Sheryl Bloomer, MA, BSN, BA, RN, CPN, clinical manager of the ED at Cincinnati (OH) Children's Hospital Medical Center, gives these reasons why a medical condition may be missed in an ED when dealing with a child with a mental health issue:

1. Mechanical or medical restraints might be needed.

If a child presents with violent or aggressive behavior, says Bloomer, "there isn't time to do an appropriate assessment."

2. Assumptions may be made based on the patient's presenting complaints.

If an adolescent girl presented with slightly altered mental status and no one was available to give any history, for instance, ED nurses could wrongly assume that she had a psychiatric diagnosis or was attention-seeking, while she might actually have a head bleed.

"Always take the time to dive a little bit deeper, to find out what the causes are," says Bloomer.

3. Intentional overdoses or drug abuse can cause behavior changes that mimic psychiatric disorders.

"If further differential diagnosis isn't considered, a drug screen isn't ordered," says Bloomer. Another possibility is that a known patient with a psychiatric disorder tells ED nurses he or she hasn't taken anything, so a drug screen isn't ordered, she adds.

4. Glucose changes can manifest as behavioral changes that could be mistaken for a psychiatric diagnosis.

"It is fairly easy to get caught up in patient presentations that follow a certain pathway, and block out other diagnoses," says Bloomer.

5. A patient with unknown head trauma may present.

Bloomer says to ask about history of abuse, neglect, or domestic violence, all of which could lead you down the pathway of possible head trauma.

"If they are uncontrollable, then the psychiatric pathway may seem the most logical," says Bloomer. "Keep an open mind to potential diagnoses that may not be obvious, even if the environment is busy and chaotic." (See related stories on obtaining a history and identifying medical comorbidities, below.)

Sources

For more information on caring for pediatric psychiatric patients, contact:

  • Sheryl Bloomer, MA, BSN, BA, RN, CPN, Clinical Manager, Emergency Department, Cincinnati (OH) Children's Hospital Medical Center. Phone: (513) 803-2153. E-mail: Sheryl.Bloomer@cchmc.org.
  • Deena Brecher, MSN, RN, ACNS-BC, CEN, CPEN, Emergency Department, Alfred I. duPont Hospital for Children, Wilmington, DE. Phone: (302) 651-6282. Fax: (302) 651-6133. E-mail: dbrecher@nemours.org.
  • Colleen Robinson, RNC, BSN, MA, Unit-Based Educator, Emergency Department, Maine Medical Center, Portland. Phone: (207) 662-4141. E-mail: robinco@mmc.org.

Get a thorough history from peds psych patient

If you are obtaining a history from a pediatric psychiatric patient, you'll need to "slow down and be less task-oriented," according to Colleen Robinson, RNC, BSN, MA, unit-based educator for the ED at Maine Medical Center in Portland. Here are steps taken by ED nurses to get more information about the patient's baseline and current condition:

• ED nurses exchange information with area community providers.

Obtaining information from other sources is particularly important when there is a question of suicidality, says Robinson. You may learn whether the patient's symptoms were gradual or came on suddenly, she notes, whether there is any previous history of psychiatric issues, or whether drugs or alcohol are involved.

• Local law enforcement utilize ambulance triage instead of walk-in triage with patients they bring to the ED for psychiatric complaints.

"The patient gets rapidly triaged, and the officers escort the patient to the treatment area," says Robinson. "They give direct report to the psychiatric clinicians regarding who placed the 911 call, what the officers noted at the scene, how the patient behaved with them, and so on."

• Nurses contact the Assertive Community Treatment team or residential home staff to learn the patient's medications, when appropriate.

"Obtaining the patient's medication and drug allergy list can be really important," says Robinson. "It often gives many clues as to what illness the patient has."


Child with mental illness? ID medical comorbidities

Are you triaging a child who presents for a medical problem, when you learn there is also a psychiatric history? "Children with mental health issues also get broken bones or appendicitis. You are then caring for their medical issues while treating their psychiatric issues," says Deena Brecher, MSN, RN, ACNS-BC, CEN, CPEN, clinical nurse specialist in the ED at Alfred I. duPont Hospital for Children in Wilmington, DE.

Patients with major mental illnesses have higher rates of medical comorbidities than the general population, notes Colleen Robinson, RNC, BSN, MA, unit-based educator for the ED at Maine Medical Center in Portland. "Some of the medications they take can contribute to development of movement disorders and metabolic syndromes," she adds.

Children with a psychiatric history who present with medical complaints should be assessed and treated as any other patient would be, says Robinson, and not sent to a separate psychiatric area for evaluation.

"Use your knowledge of their psychiatric illness to help you strategize your communication with the patient," says Robinson. "Involve family, residential staff, or other supports, if possible."