Common Pediatric Psychiatric Presentations to the Emergency Room.

1
Common Pediatric Psychiatric Presentations to the
Emergency Room.

• Zaid B. Malik, MD
• Asst. Professor
• Director CL
• Asst. Residency Program Director.

2

• Child psychiatric emergencies presenting in the
  hospital setting are most often characterized by
  intense symptoms, perceived danger, and a sense
  of urgency complicated by the perception of
  imminent catastrophic outcome and frequent
  conflict among the parties involved.

3

• Despite this acuity, child psychiatric
  emergencies are usually the outcome of complex,
  ongoing processes rather than sudden, discrete
  events. (this is true most of the times)
• Occasionally, a previously well functioning child
  with some underlying vulnerabilities may abruptly
  decompensate and display psychiatric symptoms in
  the presence of some critical or traumatic event
  or organic process.

4

• The goal of child psychiatric emergency
  services evaluation is then to clarify the nature
  and the cause of the imbalance that has arisen
  and to identify the resources needed (safe
  environment, psychoeducation, psychopharmacotherap
  y, outpatient therapist, family support services)
  to restore equilibrium.

5

• The primary goals of the child psychiatric
  emergency evaluation are, as expeditiously as
  possible

6

• To obtain each informant's account of the reason
  for referral
• To develop a working alliance, if possible, with
  the patient and other involved parties around the
  assessment and disposition planning

7

• To obtain a focused developmental history of the
  child's current difficulties and prior
  functioning against the backdrop of the child's
  family, current living situation, and any
  involved clinicians or agencies, with particular
  attention to the possible precipitants of the
  current crisis

8

• To perform a mental status examination, with
  particular attention to evidence of suicidal or
  homicidal ideation, hallucinations, delusions, or
  thought disorder evidence of confusion,
  disorientation, or other signs of delirium and
  intense anxiety

9

• To develop a differential diagnosis, including a
  formulation of what changing factors have
  precipitated the need for emergency evaluation at
  the present time

10

• To arrive at a judgment regarding the degree of
  probable risk to the patient's safety or that of
  others
• To identify interventions that will help to
  contain and ameliorate the patient's difficulties

11

• To plan and implement a disposition
• To collaborate effectively with other clinicians
  and care providers involved in the case, both
  within and beyond the hospital setting

12
The clinician must be alert to and explicitly
note the presence of the following

• Disorientation, confusion, and fluctuating levels
  of consciousness
• Incoherence of thought or speech
• Evidence of hallucinations or delusions
• Impaired memory
• Slurred speech, ataxia, or apraxia

13
Assessment of safety additionally requires
explicit attention to the following

• The presence of suicidal or homicidal ideation
• Aggressive threats or ideation
• Impulsivity
• Proneness to regression or agitation during the
  interview
• Poor judgment and insight and limited
  intelligence
• Mood lability

14
Case 1

• CJ was a 5 year old who had just started KG. He
  had no experience with preschool and had never
  been away from home in a group situation. He
  presented to an outpatient psychiatry clinic
  after hitting his teacher and biting the
  principal. No history of previous evaluation or
  treatment of developmental, behavioral, or
  emotional disorder. He was healthy and active.
  His mother had moderately severe anxiety disorder
  and stayed mostly at home. He lived with his
  father, mother and older brothers. On MSE he was
  a small, compliant child with poor eye contact.
  He responded to questions with monosyllables that
  were hard to hear.

15
Case 2

• ST was a very bright 12 yr old twin. He
  presented to a residential treatment unit with a
  history of severe aggression and rages at home
  and school when he did not get his way. His
  ability to tolerate frustration varied
  considerably at times he was able to accept
  limits and consequences at other times he would
  become explosive, hyperactive, and destructive.
  His family was not able to go into public spaces
  for fear that he would become angry. He had been
  treated for ADHD and ODD since early childhood.
  He was healthy, without chronic illness and
  although a twin his pregnancy and perinatal
  history was unremarkable. On MSE, he was a well
  developed 12 yr old with poor eye contact. He
  was sulky and irritable with angry affect.
  Family history was positive for bipolar disorder.
  His parents were divorced due to his fathers
  mood instability. He was being reared in a
  single mother household. His mother was
  genuinely frightened of his rages.

16
Case 3

• HJ was a developmentally delayed 7 year old with
  an IQ of 60 and a diagnosis of autism. When
  frustrated he had a history of aggression with
  peers, caregivers and himself (head banging and
  biting his forearm until it bled). He was rigid
  with poor tolerance of over stimulating
  environments and transitions. He lived with his
  mother and father in an intact home and attended
  a behavioral classroom in a public school.

17
Case 4

• LC was a 10 yr old boy in a single mother
  household presenting at the insistence of the
  school. His academic and behavioral problems at
  school started in KG. Behaviors included
  fighting, talking back, vandalism, lying,
  truancy, and stealing from other students. He
  was diagnosed with ADHD in KG and had been
  treated with psycho stimulants off and on since
  then. He did not know his father. Throughout
  his childhood his mothers boyfriends moved in
  and out of the house. He had little supervision
  or monitoring. Discipline at times was
  excessively harsh. The family had had
  involvement in the Department of Children and
  Family Services before following a substantiated
  case of physical abuse. Family history was
  positive for substance abuse, depression, and
  poor anger management.

18
Differential Diagnosis of Aggression

• Symptoms of Aggression are common in a wide range
  of psychiatric conditions.
• Conduct Disorder
• Oppositional Defiant Disorder
• Mood Disorder
• ADHD
• Anxiety Disorder
• Psychotic disorders (especially those including
  paranoia)
• Developmental Disorders
• Anxiety

19
Treatment Options

• Medications
• Antipsychotics
• Mood stabilizers
• Serotonin Reuptake Inhibitors
• Stimulants

20
Case 5

• A. 16 yr girl, considered generally well
  adjusted, without psychiatric history presents to
  the ED at 11p. She is drowsy and nauseated. Her
  mother says that her daughter has been seeing a
  boy for the past 2 years. He broke up with her
  last week. Since then she has been sad and
  tearful, uninterested in her usual activities.
  Tonight, after seeing her ex-BF at a restaurant
  with another girl. She came home and took a
  bottle of aspirin. An hour later she came to her
  mother and told her what she had done. Family
  history is negative for psychiatric illness and
  completed suicide. On MSE she is sleepy and
  feeling sick. She denies longstanding depressive
  symptoms and says that she does not want to die
  now. She says that she never wanted to die but
  wanted people to understand how sad she is. She
  also said that she hoped her BF would come back
  to her.

21
Case 6

• MH A seventeen year old boy, who recently
  graduated from HS, is found barely conscious in
  his bedroom by his mother when she goes in to
  wake him up. She takes him to the ED where a tox
  screen reveals that he has taken an overdose of
  Depakote. The Depakote was his mothers. On the
  floor he is extremely quiet and uncommunicative.
  He says that he wants to go home. There is no
  previous psychiatric history but his mother says
  that he has been acting different for the past
  year. He has been staying in his room with less
  and less interest in doing things with friends.
  She is not aware of any traumatic events. There
  is a family history of schizophrenia. This
  patient has no past psychiatric history. On
  interview he is quiet with a blunt affect. He
  denies any problems, cannot explain his overdose,
  but feels that he has to get out of the hospital
  b/c the people there are getting on his nerves.
  He denies AH but is suspicious and guarded when
  questioned about them. He does talk about his
  graduation ceremony and says that when he walked
  across the stage the other students laughed at
  him. When asked about that his mother says that
  that did not occur and he has always been
  well-liked at school.

22
Leading Causes of Death in 15-19
Year-Olds

• Accidents
• Homicide
• Suicide
• Cancer/Leukemia
• Heart Disease
• Congenital Anomalies (NCHS 2001)

23
12-Month Prevalence of Suicidal Ideation and
BehaviorU.S. High School Students- Youth Risk
Behavior Surveillance CDC 2000

• Ideation 17-19 2.7 million
• Ideation w/ plan 11-14 1.9 million
• Attempt 5-8 1.0
  million
• Attempt requiring 1-3 296,000
• medical attention
• Suicide (age 15-19) .008 1,600

24
Ratio of Teen Attempts to Teen Suicides

• Deaths Attempts
  Ratio
• Males 14 5,700 1400
• Females 3 10,900 13,900
• YRBS CDC 2000 all numbers/100,000

25
Suicide Methods

• United States 1999, 15-19 Year-olds
• Firearms
• Hanging/Suffocation
• Ingestions
• CO poisoning
• Jumping

26

• In 1998 suicide rates were highest among white
  males of all ages, followed by non-white males,
  white females, and non-white females.

27
Biological factors

• Low Serotonin levels
• Genetic Predisposition

28
Types of Stress Events Preceding
A Suicide

• Disciplinary Crises 48
• Relationship Problem 36
• Humiliation 16

29
Most Common Teen Suicide
Diagnoses

• ANY
  MALE FEMALE
• Mood Disorder 50 69
• Antisocial Disorder 43 24
• Substance Abuse 38 17
• Anxiety Disorder 19 48
• Shaffer et al 1996, Brent et al 1999

30
Imminent Risk in Suicide Attempters

• Agitation
• Intense Anxiety
• Recent Discontinuation of Medications

31
High-Risk Attempters

• Male
• Abnormal mental state
• Previous attempt
• Family history of suicidality
• History of aggressive outbursts and substance and
  alcohol abuse
• Method other than ingestion

32
Clinical Risk Factors

• 1/3 of Teenage suicide victims have made a
  previous attempt
• ½ have persistent thoughts of hopelessness
• Aggressive/impulsive behavior is increased in
  both sexes
• ½ of teenagers who commit suicide have had
  contact with a PCP or MHP

33
Clinical risk factors (continued)

• Alcohol and cocaine abuse are present in 2/3 of
  18-19 year old males but uncommon in younger
  males and females
• Schizophrenia and bipolar illness each represent
  fewer than 10 of suicides but are relatively
  infrequent conditions
• Increased Frequency of suicide attempts and
  completions in relatives of suicide victims
• Decreased family support

34
Emergency Room Management of the Suicidal
Adolescent

• Medical Care
• To Admit or not to admit
• Sedation
• ?? Contract for Safety

35
Hospitalizing a Teen Attempter

• Sufficient
• Medical Necessity
• Abnormal Mental State
• Persistent Wish to Die
• Highly Lethal or Unusual Method

36
Hospitalization (continued)

• Adds weight but not Sufficient
• Prior Attempt(s)
• Male gender
• Family history of suicide
• Inadequate care and supervision at home
• Over age sixteen

37
Contract for Safety

• Thought to improve compliance
• Thought to reduce likelihood of further suicidal
  behavior
• A probe to assess patients willingness to assist
  in treatment efforts
• No evidence for any of the above.

38
Etiology

• Suicidal Behavior is complex. The factors
  involved are outlined in accordance with five
  axis.
• Primary psychiatric disorders
• Developmental and personality disorders
• Biological factors
• Stress
• Social functioning

39
It is important to assess and document the
following in the child or adolescent

• The degree of premeditation and planning versus
  impulsiveness (22)
• Ego syntonicity or dystonicity
• Consistency with the patient's past behaviors or
  style (including chronic bullying)

40

• Extraordinary or uncontrolled rage and use of
  weapons
• The validity of perceived self-defense
• Evidence of grossly impaired judgment or
  consciousness

41

• Bizarre or delusional behavior or thought content
• Risk of self-injury during the violent episode
• The extent to which the child can remember the
  details of the episode (including his actions and
  their consequence), accept responsibility, or
  express remorse

42
Conclusion