Child and Adolescent Psychiatric Emergencies

Lynelle E. Thomas

Robert A. King

Nature and Scope

The emergency nature of a child or adolescent psychiatric problem is defined both by the severity and urgency of the potential threat to the child’s and family’s safety and wellbeing and by the community and clinical resources the family is able to access and use to address it. Thus some situations, such as intense aggressive or homicidal threats or outbursts, acute psychotic or anxiety states, serious suicide attempts, ingestions or intoxications, or acute toxic metabolic states, usually require immediate psychiatric attention in a setting that can muster the full range of immediate medical and psychiatric diagnostic and therapeutic interventions. Conversely, the presentation of many other more chronic or less urgent cases to the pediatric psychiatry emergency service (PES) reflects the absence of adequate mental health resources in the community or the family’s relative inability to access or use clinical and social resources that could have prevented the crisis or permitted its management in a less acute outpatient setting. Although it is usually clear that these latter cases require prompt intervention, the perception that the case is an emergency and should be seen in a tertiary emergency service setting is more relative. For example, under what circumstances does an unhappy, neglected child’s suicidal ruminations or threats indicate an imminent risk and need for crisis intervention? When does normative adolescent oppositionality or risk-taking evolve to illicit substance use, unprotected sexual activity, and other antisocial and high-risk behaviors, and at what point do these become so severe that emergency psychiatric intervention becomes urgently imperative?

The judgment that a given child’s thoughts, feelings, or actions constitute a psychiatric emergency reflects some adult’s perception that the child’s condition is serious, urgent, or unmanageable in the current environment. As a corollary, a multiplicity of adults or agencies may potentially initiate the referral to a child psychiatric emergency service. These include parents, extended family members, teachers, police, mental health clinicians in the community, and child welfare workers (1). In addition, many facilities such as youth shelters, residential treatment centers, and juvenile detention use the hospital-based child psychiatric emergency service in the absence of adequate on-site emergency psychiatric capacities. During the academic year, middle and high schools are primary emergency department (ED) referral sources. Local and nationally publicized violence within school settings has sensitized communities and administrators to problematic behaviors. Many schools have, in turn, adopted a “zero tolerance policy” whereby youngsters must obtain “psychiatric clearance” before returning to school after having behaved in a way that was perceived as being threatening or dangerous to themselves or others (2).

Psychiatric emergencies were once considered uncommon in childhood. In recent years, however, the number of child and adolescent emergency patients has been on the rise. For example, between October 1, 1963 and July 31, 1964, the number of psychiatric consultations in the Yale–New Haven Hospital emergency department (ED) in New Haven, Connecticut, for children less than 15 years of age represented only 0.6% of the pediatric ED population (3). In contrast, the annual number of child psychiatry-related visits to the same ED was 2.5% of all pediatric visits in 1995 and 3.9% of those in 1999. Thus, by 1999, as a percentage of all ED cases, the proportion of child psychiatric emergency cases increased almost 60% over 1995 and more than five-fold compared with 1963 (4). In May 2006, psychiatry-related visits to the Yale–New Haven Hospital pediatric ED reached an all-time high of 6.6% of visits to the pediatric ED [unpublished data]. The magnitude of this clinical burden is apparent if this referral rate is extrapolated to the more than 31 million annual child and adolescent ED visits occurring nationally (5).

The root causes of these dramatic changes are unclear given the relative paucity of national data on child psychiatric ED use.

One contributing factor, the high prevalence of youth behaviors likely to result in an ED visit involving psychiatric evaluation or consultation, is amply documented by epidemiologic data. According to the national Youth Risk Behavior Survey (6), 16.9% of high school students have seriously considered suicide in the past 12 months, 13% made a suicide plan, 8.4% attempted suicide once or more, and 2.3% made a suicide attempt that resulted in an injury, poisoning, or overdose that had to be treated by a doctor or nurse. Furthermore, during the prior 12 months, 7.9% of students had been threatened or injured at least once with a weapon on school property; 3.6% of students had been in a physical fight in which they were injured and had to receive medical treatment; and 7.5% of students had ever been physically forced to have sexual intercourse when they did not want to.

In addition, dwindling funds and efforts at cost containment in mental health and community-based social service systems in many states have transformed hospital-based emergency services into a major provider of mental health services. Low Medicaid provider reimbursement rates and managed care–driven strictures have further eroded the availability of mental health resources in the community and have dramatically shortened lengths of hospital stay, thus denying many children and families adequate outpatient treatment in the community and effective inpatient treatment when that becomes necessary. Indeed, in many communities, the crisis in child PES parallels the overall crisis in ED care, as the ED becomes the primary care provider of last resort, particularly for Medicaid beneficiaries and the 45 million uninsured Americans (7).

This dearth of adequate child mental health facilities not only results in increased PES utilization, but also impacts the disposition of cases from the PES. The changing ecology of emergency psychiatric care for youth can be seen in recent trends in ED utilization and dispositions for self-injury. During
the period 1997–2002, the annual rate of emergency visits for self-harm among young people aged 7 to 24 years of age was 225.3 per 100,000 (8). Approximately half of these visits (56.1%) resulted in an inpatient admission. Reflecting managed care restrictions, however, the length of stays of youngsters psychiatrically hospitalized after deliberate self-harm decreased significantly from 1990 to 2000, despite a dramatic increase in the severity of diagnoses (9,10). (This trend of increased severity and decreased length of hospital stay for self-injury parallels that seen in overall admissions to child inpatient psychiatric services (11,12)).

Because of a shortage of outpatient and inpatient child psychiatric services, a log jam or bottle neck crisis often prevails in hospital PES, where timely, appropriate dispositions cannot be found for many of the youngsters seen (2,13). As a result, youngsters who cannot be discharged may end up being “boarded” on pediatric wards or in the ER itself pending the availability of an inpatient psychiatric bed. Additionally, the PES is burdened by frequent “bounceback” visits, as partially treated youngsters are discharged from inpatient services, but shortly return to the ED because they cannot be maintained at home by available outpatient resources.

Indeed, this log jam or gridlock too often prevails along the entire length of the child mental health care system, with a shortage of resources and pileup of untreated, undertreated, or inappropriately placed children at each level of care. Some children wait months for outpatient therapy and case management. Other youngsters ready for discharge from psychiatric hospitals cannot be discharged for lack of suitable subacute, residential, or community-based treatment resources. And, as always, when the predictable crises occur, the PES remains the access point of least resistance and resource of last resort.

With this background in mind, this chapter discusses the complexities of child and adolescent psychiatric emergencies and hospital-based assessment, and examines the problems confronting ED-based child and adolescent psychiatrists. We also discuss approaches to assessment, treatment, and disposition planning that are unique to this population, with a special focus on the uncooperative patient. (For the broader topics of the psychiatric evaluation of the child and the assessment of the suicidal child, see Chapter 4.2.2; Chapter 5.3.3; King et al. (14) For emergency psychiatric evaluation in the inpatient pediatric setting see King and Lewis (15).

Hospital-Based Child Psychiatric Emergency Evaluation

Adaptive Context of Child Psychiatric Emergencies

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. Despite this acuity, child psychiatric emergencies are usually the outcome of complex, ongoing processes rather than sudden, discrete events. 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. More often, however, the acute emotional or behavioral symptom that bring the youngster to the attention of the emergency service have been preceded by a longer history of emotional or behavioral difficulties. Thus, a key element of the emergency child psychiatric assessment is to answer the questions: “Who is concerned about the child?” and “Why now?”

A child’s functioning and psychological wellbeing are highly dependent on the family, school, and community setting in which he or she lives and studies. Anything that adversely affects this system has the potential to precipitate a crisis. A child psychiatric emergency usually represents some perturbation or pathology in one or several of the elements in this delicately balanced ecosystem. Either an efflorescence of the child’s psychopathology has overwhelmed the caretaking system and/or the caretaking system has, in some fashion, become less sufficient or less adequate. From this perspective, many child psychiatric emergencies can be conceptualized as a mismatch between needs and resources (16). The corresponding 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, psychopharmacotherapy, outpatient therapist, family support services) to restore equilibrium. Systematically clarifying the details of the precipitants to the crisis is thus paramount in determining the needed interventions and disposition.

Goals and Aims of the Hospital-Based Child Psychiatric Emergency Assessment

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

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

General Considerations

The hospital ED is designed to contain and resolve urgent or life-threatening situations. The “triage model”— rapid determination of imminent dangerousness, containment, and referral— typifies the process of most hospital-based psychiatric emergency consultation and care. Some beleaguered psychiatric emergency services confine themselves to addressing only two questions: a) Is the child a danger to himself or others? b) Does the child need to be hospitalized or can he or she be discharged back home? Although these dispositional questions must remain at the forefront of the busy emergency
clinician’s mind, circumscribing the evaluation too narrowly to these areas both precludes an accurate understanding of the clinical situation and renders the ED visit of little ongoing value to the child, family, or treatment effort. Given that most crisis referrals arise out of multiple factors in the child’s life, it is important that, no matter how expeditiously the evaluation is conducted, it provides the child, family, and clinicians with some useful perspective on how the crisis came about and how it fits into the overall trajectory of the child’s life and clinical care.

The assessment and management of child psychiatric emergencies differ from the routine office evaluation in several important ways. The severity, dangerousness, or urgency of the symptoms usually requires rapid clinical decision-making and treatment implementation. Furthermore, the emergency assessment must often proceed under unpropitious circumstances constrained by time pressures, in the relative absence of trained support personnel or optimal physical arrangements, with unfamiliarity with the patient and family, the unavailability of key informants, and the lack of timely, appropriate alternatives for disposition.

Yet another constraint on emergency evaluations is the inconvenient hours at which they often occur— late at night or on weekends, when important informants, such as primary clinicians, teachers, or social welfare agency workers may be unavailable. The already difficult task of arranging an appropriate disposition at such hours is further complicated by the frequent unavailability of insurance reviewers needed for precertification, psychiatric hospital admissions staff members who can provide prompt information regarding bed availability, or outpatient clinicians who can undertake the responsibility of seeing the patient promptly for follow-up. The availability of sufficient social work, psychiatric nursing, or other professional staff members to assist in these information-gathering and coordinating tasks is essential to prevent burnout of clinicians faced with large volumes of child emergency evaluations.

Time constraints and the urgency of the situation do, of course, require that the clinician be active in eliciting the most relevant data in a time-efficient manner. Right from the onset of the interview process, the experienced emergency clinician begins to prioritize symptoms and to formulate and test tentative etiologic and diagnostic hypotheses that guide further questions. At the same time, the clinician also begins to ponder what interventions and dispositions these diagnostic hypotheses imply. Unlike less urgent settings, the emphasis is on clarifying the child’s current symptoms and functioning, the factors in the child’s living situation that have served to stabilize or exacerbate difficulties, and the resources and competencies available to the patient and the family.

Physical Setting

It is important to find a quiet evaluation area, where the clinician, adults, and child will not be frequently distracted by the sights and sounds of physically ill and upset children and their families. The area needs to be free enough of dangerous or delicate medical equipment or furnishings so the clinician need not be preoccupied with keeping the room and the patient safe. The spot needs to be secluded enough that the belligerent or uncooperative psychiatric patient will not disturb other families in the ED, yet near enough to other staff that reinforcements can be called on if needed for safety or calming or to prevent elopement.

Informants

The clinician’s first task is to identify why this particular child has been brought to the ED at this particular time. The impetus for child psychiatric emergency referrals, with few exceptions, comes from adults in the child’s life, rather than from the child. Obtaining a full and accurate diagnostic picture for any child psychiatric assessment requires gathering information from diverse sources, including the family, school staff, clinicians, and the child himself. In the emergency situation, however, the initial or primary informant may be an adult other than the primary caretaker, for example, police or corrections officers, school personnel, or representatives of various social service agencies. The wide array of potential referents and perspectives complicates the task of the evaluator, who must efficiently interview multiple informants and, like a detective, rapidly consolidate and reconcile sparse, often conflicting data.

From a practical standpoint, data are collected as they become available. At a minimum, the emergency assessment entails direct interviews with the child and all adults who accompany the child to the hospital setting, as well as any caretakers, clinicians, or caseworkers who are accessible by telephone. On a practical level, if the child is brought in by nonparental parties (friends, police, correctional officers, or child welfare workers) who may not want to remain in the ED for the evaluation, it is essential to speak with them directly and to obtain immediate contact information for those persons with direct knowledge of the precipitating crisis and the child’s recent circumstances and responsibility for the child’s care and disposition. Even when the child is not accompanied by a custodial parent or legal guardian, most states give the emergency clinicians the latitude to initiate emergency treatment of a child, including contacting of collateral informants, without parental consent. In such cases, it is always clinically desirable to contact and to involve the parents as soon as possible. Many states also permit adolescents to seek mental health services without a parent’s involvement. These patients should also be encouraged to involve parents and other adult supports.

The presenting complaint and reasons for the referral are often described very differently, depending on the informant. These discrepancies, referred to in the research literature as informant variance, arise for a variety of reasons (17). Although these discrepancies complicate the diagnostician’s task, when markedly differing accounts or divergences of perspective do occur, they provide potentially important clues to the nature of the child’s crisis. At the very least, they point to troublesome lacks of continuity in the child’s holding environment and a lack of shared consensus between the child and important adults.

Differences may stem from the different contexts in which the child is observed, the standard of judgment employed, and variations in the demands or stressors impinging on the child in each setting. This is particularly the case when children’s symptoms are situation specific (occurring only at school, only at home, or only at one parent’s house, but not the other’s).

Informants may differ in their access to information concerning the child’s feelings and behavior. Parents may be quick to report a behavior of the child that they find disturbing or annoying, especially externalizing behavior, but they may be less aware of internalizing problems (18) and may fail to recognize how discord within the family system (domestic violence, separation, divorce) may directly precipitate crisis symptoms within the child.

The child, in contrast, even if aware of and able to describe the problematic behavior verbally, may refrain from doing so out of defensiveness, shame, or fear of reproach. The interviewer must also be aware that vagueness and minimization of problems can sometimes indicate an attempt to maintain some secret within the family system, such as a parental mental illness, illegal activity, child or parental substance abuse, domestic violence, or physical or sexual abuse. In these cases, the evaluation can be extremely difficult,
because the events surrounding the crisis may never be completely clarified.

Child Interview

In traditional office-based child psychiatric assessment, several hours and more than one interview with the child are usually desirable to place the child at ease with the interviewer and to obtain a full picture of the child. In contrast, the emergency assessment must be completed within the confines of a single interview. The emergency child interview and mental status examination must also reckon with the characteristic lability of children and their propensity to fall back to more immature or oppositional ways of coping, especially when they are confronted with the anxiety and distress associated with a hospital ED setting. Although it may not accurately reveal the child’s optimal or characteristic level of functioning, this “snapshot” of the child in the ED often provides a valid picture of the child’s vulnerability to regress under stress and how such regression may have led to the emergency referral.

Although every effort must be made to place the child at ease and to obtain his or her cooperation in understanding what has brought about the crisis, this is often difficult. The high levels of expressed emotion in the events leading up to ED referrals and the coercive processes required to bring the child to the ED often stimulate the child’s oppositionality. As a result, the child in the ED is often sullen, mute, withdrawn, or antagonistic.

To the child who is aggrieved or sullenly refusing to talk, the clinician can validly invoke what has been termed the “constructive use of ignorance” by observing that, because they have never met before, the clinician really does not know what has led up to the ED visit and would genuinely like to hear the child’s view of what has been happening.

Child Mental Status Examination

The mental status examination is of particular importance in the emergency evaluation (see Chapter 4.2.2) (19). In trying to understand the nature of the crisis and the interventions needed, the clinician will be especially attentive to evidence of psychosis, delirium, or other organic process, intoxication, dissociation, or extreme anxiety, depression, or elation. The presence of any of these factors is likely to render the patient more labile and vulnerable and points to the need for more intensive interventions and diagnostic studies. Hence, the clinician must be alert to and explicitly note the presence of the following: