Psychiatric Emergencies in Child and Adolescent Psychiatry

Clinical Description

The suffering of children and youth in the throes of a psychiatric emergency is palpable. They frequently feel desperate and hopeless. Suicidal ideation, suicide attempt, or seriously out of control behavior are the most common child and adolescent psychiatric emergencies and will be the focus of the chapter (Table 21.1).

In assessing children and youth in crisis, you are faced with the difficult decision regarding the management of these patients, such as when to recommend (or require) hospitalization, how to facilitate acute outpatient treatment, dealing with recurrent suicide attempts, and ameliorating the social chaos that often surrounds these youth. These decisions are taxing even for experienced physicians. Assessing and providing stabilization for youth in psychiatric crisis are critical skills for all child and adolescent psychiatrists (Table 21.2).

Table 21.1. Types of Psychiatric Emergencies for Children and Adolescents

Suicidal ideation, intent, gesture, or attempt
Serious aggression toward others or threats of violence (including firesetting or sexual perpetration)
Psychosis or mania
Acute anxiety or panic
Conversion symptoms
Anorexia nervosa or bulimia nervosa
Running away or high-risk behaviors
Delirium or acute mental status change
Substance abuse
Victim of physical or sexual assault or abuse
Acute school refusal

Table 21.2. Essential Emergency Child and Adolescent Psychiatric Assessment

Rule out an acute medical issue (such as overdose, intoxication, head trauma, or other).
Demographics—age, residence, caretakers.
Presenting complaint—details of the events that precipitated the crisis assessment.
History of present illness—symptoms have presented for how long? How severe? Acute stressors. Get information from multiple sources (youth, parent/guardian, teachers or others, as appropriate).
Psychiatric history—prior treatment, taking medications, psychiatric symptoms (depression, suicide attempts, psychosis, aggression, substance abuse).
Risk assessment—suicidal thoughts, prior attempts, intent, what means, physical or sexual abuse, recent stressors, access to means (firearms, medication, etc.), homicidal thoughts, revenge fantasies, level of impulse control.
Developmental history—learning issues, friends, regression in functioning.
Family situation—living situation, communication in the family, abuse, neglect, or substance use in the family, family support, supervision, firearms or other dangers in the home.
Family genetic history of psychiatric illness, suicide, incarceration, learning issues.
Medical history—current or prior acute or chronic illness, medication.
Mental status exam—with focus on thought process, psychosis, organicity, hopelessness, insight and judgment, motivation for help, ability to form alliance, acute psychiatric status (review of psychiatric symptoms, including neurovegetative symptoms, psychosis, mania, obsessive thoughts, etc.), suicidal thoughts, and thoughts of revenge.