The child interview in emergency situations requires considerable focus. Given the nature of the setting, the examiner must cope (and help the patient cope) with intrinsic distress associated with the ED setting. Although not easy to do, every effort should be made to help the child feel as comfortable as possible. Unfortunately, by the time the child psychiatrist has arrived, the child often has been sufficiently stressed that he or she is angry, withdrawn, or overtly oppositional and antagonistic. In situations like this, the clinician can invoke the “constructive use of ignorance” and invite the child to provide a view of the events leading to the current situation.

The attitudes of the child and his or her parents and their ability to work with each other provide important information relative to potential discharge home with follow-up in outpatient settings. The child or adolescent’s ability to reflect on his or her contributions to the current situation and the events leading up to the ED visit also become important in terms of disposition planning. Difficulties arise when children refuse to acknowledge their contributions to problems or when parents attempt to minimize the problem and attribute it to external sources and unreasonable expectations. On the other hand, the child or family who acknowledge the realities of the difficulties and seem motivated to change has a much greater likelihood to use outpatient treatment successfully.

The next sections of this chapter review three of the more important general areas of difficulty presenting in the ED: aggressive behavior, suicidal thoughts and behavior, and delirium and confusional states.

Aggressive and uncooperative patients present special problems for assessment in the ED. Oppositional and aggressive outbursts are a frequent cause of ED referrals, and the patient may be transported to the ED by law enforcement or emergency medical services. The child or adolescent, sometimes in physical restraints, may be agitated and belligerent and prone to act out. The child’s threats and yelling may understandably disturb other patients and staff. Despite the pressure for a rapid solution or resolution (e.g., “shut him up”), the clinician should approach the aggressive child or adolescent patient in a thoughtful, calm, and deliberate fashion. Both in terms of doing an adequate assessment and contributing to the resolution of the crisis, the clinician should try, as much as possible, not to be caught up in the maelstrom but ally him- or herself with whatever capacity the child or adolescent has to remain in control. Unfortunately, the ED environment can contribute to irritability, anger, aggression, or defiant behaviors.

The clinician should be aware of the many causes of aggressive behavior and its association with many different conditions. To complicate the situation further, frequently oppositional defiant and more overly aggressive or violent behaviors have multiple origins and determinants and often a long history. In evaluating such behavior and developing a differential diagnosis, the clinician should be aware of the many factors that may contribute. Impulsive behavior and poor impulse control are frequent in various conditions, including attention-deficit disorders, hypomania, autism, and conduct disorder. Learning difficulties and cognitive delays and associated coping difficulties may also contribute to such behaviors. Exposure through observation or direct experience of aggression in violent families is as another risk as is psychosocial adversity more generally. Substance use or abuse can impair judgment; increase irritability; and
contribute to disinhibited, impulsive behaviors. Psychotic conditions of various types can similarly present with overt aggression (e.g., as the child or adolescent responds to a state of considerable confusion with paranoia or auditory [command] hallucinations). Aggression and apparent psychosis may also be seen as a feature of various medical conditions, including delirium, encephalitis, seizure disorder, and postconcussive states, as discussed later in the chapter. Taking a careful medical history is important, and the clinician should be particularly alert to the presence of such conditions.

The history should focus both on recent as well as past aggressive behavior (e.g., is this a new problem or one that emerges in the context of years of increasing difficulty?). A thorough history of the events leading up to the present problem is critical with attention to the precipitants of the aggressive outburst as well as the steps leading up to it. The perspectives of the patient and the various relevant adults often provide important information on these issues. When another person is involved as a victim, the actions of the victim, the setting of the event, and the broader context should be identified. Often, problems will have come about as an adult attempted to set a limit. In such cases, the context may clarify issues or factors that contributed to the child’s response. Areas to be assessed are summarized in Table 24.1.

The safety of the child and others (including the clinician) is the first consideration in management. The clinician should feel comfortable in the setting with adequate support. In the absence of this, the clinician cannot be nearly as effective or helpful. Several steps can be taken to ensure that the patient is in sufficient control for a thorough assessment to be conducted. In approaching the patient and family, the clinician should be professional and respectful and avoid becoming angry or irritable. A stance of concern and professionalism is important. The clinician should not place her or himself in a situation in which backup is not available, and sensible precautions (e.g., sitting between the patient and the door) should occur as a matter of course. As in other areas of psychiatry, one’s own inner sense will provide important clues (e.g., if a patient makes the clinician very anxious, there probably is a good reason). The waiting area and examination room should be free of safety hazards and objects that might be used in an aggressive outburst; as much as is reasonable, these areas should provide minimal stimulation (certainly compared with other parts of the ED) and have some privacy. At the same time, it should also be an area close enough to have help at hand, and there should be some potential for visual contact with other staff with use of appropriate codes or procedures for alerting staff if necessary. The possibility of seclusion and restraint should also be available if needed.

Clear expectations and firm but nonconfrontational limit setting may help de-escalate violent or potentially violent behavior. Communication of rules and expectations can be done to clarify what behavior is and is not considered acceptable. This should be provided both to the patient and family. Agitation and aggression related to confusion and disorganization make it particularly important that patients be monitored carefully. For such patients, avoiding an
over-stimulating, disorganizing environment is important as is provision of another person (e.g., a family member) who can provide reassurance and orientating or organizing information. Although there is often a temptation to proceed directly to medication and sedation, it is important to have a clear sense of the nature of the difficulty (e.g., observing the patient for signs of other medical conditions, changes in levels of consciousness, and so forth; see below).

Pharmacological intervention may be needed if behavioral approaches are not successful; in such situations, consideration of sedation should involve an awareness of the severity of the symptoms; potential underlying causes of the difficulties; and the patient’s medical status, history, and goals of the sedation. Various agents, but particularly the neuroleptics and benzodiazepines, are frequently used. The benzodiazepine lorazepam has a relatively short half-life (10 to 20 hours) and can be given orally (PO) or intramuscularly (IM). This agent has both sedative and anxiolytic properties, and as with other benzodiazepines, its effects can be reversed with the benzodiazepine antagonist flumazenil. In children, typical doses range from 1 to 2 mg (either PO or IM) hourly until the desired degree of sedation is achieved (see Thomas & King, 2007). Unfortunately, at times, the benzodiazepines can also result in a seemingly paradoxical disinhibition; this seems particularly likely in children and adolescents and can occur at a low dose. Haloperidol (Haldol^TM) is another frequently used agent. This high-potency neuroleptic has been shown to be more efficacious than lorazepam in addressing violent behavior in adults. Typically, doses are 2 to 5 mg either IM or PO with doses repeated hourly until the desired degree of sedation is achieved. Other neuroleptics can also be used, but the lower potency neuroleptics (e.g., chlorpromazine) may cause hypotension, may increase the seizure threshold, and have more anticholinergic side effects.

Occasionally, the antihistamine diphenhydramine (Benadryl^TM) is used in pediatric settings; this agent, which has soporific effects, is readily available and safely given either PO or IM, but as with the benzodiazepines, some children, particularly those with developmental difficulties or brain injuries, may be prone to behavioral disinhibition or increased agitation. Potential behavioral and medical effects of combinations of medication should also be considered (e.g., the combination of chlorpromazine and diphenhydramine can result in significant anticholinergic side effects, leading to further confusion and agitation and, occasionally, frank delirium).

The choice of a drug for rapid tranquilization should also be guided by the patient’s medical history, current medications, and potential contraindications or drug interactions. For example, use of a neuroleptic might also prompt consideration of prophylactic administration of an agent such as diphenhydramine or benztropine (Cogentin^TM) to avoid acute dystonic side effects. The ED staff should monitor vital signs as well levels of consciousness and sedation and be alert for possible side effects. Newer atypical neuroleptics are now available, but experience with them has been limited, partly because of the lack of an injectable preparation. If possible, the child or adolescent can be given a choice of PO or IM administration; the latter may be needed for children who are less cooperative and has the advantage of a somewhat more active onset. As at any time in using a medication, the balance of risks versus benefits should be carefully considered.

The use of physical restraints is regulated by several sets of standards and should be reserved for situations when there is immediate danger to the patient or others. Restraints should be used only in such situations and only for as long as they are needed. Institutional policies for seclusion and restraint should be in place. These typically clarify indications for use, the role of key personnel, guidance on monitoring (e.g., to be sure vital signs are stable, that the airway is not restricted), and on periodic reassessment and removal. Such policies provide guidance on the ways orders can be written and the child monitored.

Along with aggressive behavior, one of the most recent sources of ED referral is suicidal ideation and behavior. Prevention of suicide in children and adolescents has been increasingly recognized as an important public health problem in the United States and internationally (Pfeffer, 2007).

This awareness has been fostered by a number of well-publicized cases as well as recognition of the problem at the national level (e.g., the Surgeon General’s Report). The sensitivity of parents, teachers, and primary care providers to this important topic has been substantially increased as a result. The Surgeon General’s Report was built on a large body of work on suicide risk assessment and prevention that began the 1980s and then increased in the past 2 decades. This work has encompassed a range of topics, including suicidal behaviors (i.e., suicidal thoughts and acts) and important psychiatric and psychosocial correlates (e.g., with depression and general psychopathology). Researchers have identified a continuum of behaviors ranging in severity from nonsuicidal behavior to suicidal ideas, attempts, and actual suicide. As in other areas of child psychiatry, age and developmental factors are relevant, and sometimes complicating, considerations. Historically, the publication of Goethe’s The Sorrows of Young Werther precipitated a wave of youth suicide. The topic was the focus on much interest, including to the Vienna Psychoanalytic Society in the first decade of the 20th century, when Freud emphasized the importance of conflict with significant others in suicide. Starting in the late 1960s and peaking in 1977, a rapid increase in rates of suicide in teenage and young men drew increased attention to the issue as did reports of “cluster cases.” The result was increased demand for new and better approaches to suicide prevention. This effort stimulated further research as well as important attempts to achieve a consensus on the need for more consistent approaches to definition; database development; research approaches and work on education, treatment, and prevention of suicidal behavior.

In 2006, suicide was a leading cause of death for adolescents and young adults. Data from the National Institutes of Mental Health suggest rates of suicide ranging from 1.3 per 100,000 in children (10 to 14 years of age), 8.2 per 100,000 in adolescents (15 to 19 years of age), and 12.5 per 100,000 in young adults (20 to 24 years of age). Historically, suicide risk has been highest in white males of all ages followed by nonwhite males, white females, and nonwhite females. Over time, rates of suicide among black youths have increased, possibly related to greater degrees of assimilation into U.S. society. Native Americans have particularly high rates of suicide; loss of traditional cultural values, unemployment, and alcohol problems likely contribute to this risk. Firearms are a frequent means of suicide followed by hanging and poisoning.

Data on suicide attempts are based on the results of a nationally representative sample of high school students (no national registry exists). In this sample, about 20% of the students reported suicidal ideation, with higher rates (25%) in young women compared with (14%) young males. Young women were more likely than young men to attempt suicide, and about 3% of those who attempted suicide experienced a serious injury as a result. Males are more likely to use potentially more lethal means (accounting for higher rates in males). In preadolescents, about 1% of children had attempted suicide, and one-third of adolescents who had a psychiatric inpatient admission had a recent suicide attempt. A history of psychiatric hospitalization is associated with a substantially (ninefold) risk of suicide compared with a community-based sample.

Unfortunately, suicidal intent may be either very clear or very ambiguous. As a result, the attempt to evaluate the degree of intentionality is difficult, particularly in prepubertal children, who may exhibit overt suicidal behavior without clear-cut suicidal ideation or intent. In this group, changing conceptions of the meaning of life and death (see Chapter 2) pose a further complication (e.g., the child may not see death as an irreversible event). Conversely, some adolescents may make serious attempts (e.g., with ingestion of a potentially lethal dose of a medication) but not understand the seriousness of their attempts. As a result, clinicians should carefully consider the potential suicidality of any self-injurious act in children and adolescents; thus, both the overt seriousness of the act and the intent are important to understand.