In this chapter, we consider some aspects of mental health care in pediatrics and the medical care/hospital system. We begin with a short discussion of the role of primary care providers before turning to emergency care. As we discuss emergency mental health, referrals are of many types and some special issues, for example, suicidality and its assessment, as well as evaluation of aggressive behavior are of special importance. We also discuss when to consider hospitalization. In the final section of this chapter, we discuss the role of the mental health consultant within inpatient pediatric consultations. This includes consideration of the role of the consultant, the process of the consultation, and special areas of mental health services including conditions like pediatric oncology, delirium, pediatric transplants, epilepsy, and palliative care. Mental health consultation is an area of great and growing interest to many disciplines including not only psychiatry and child psychiatry but also psychology, social work, nursing, and child life support staff within larger hospital settings. As we note, the dearth of providers creates significant challenges in many settings.
MENTAL HEALTH ISSUES IN PRIMARY CARE
The integration of mental health resources and treatments into primary pediatric care settings presents many opportunities and challenges (Pumariega & Winters, 2018
). Most children in the United States have at least one visit with the primary care provider each year. The primary care provider may be required to interact with other systems, for example, school, child welfare, legal, as well as mental health. Although provision of medical care (including mental health care) has improved, mental health services remain lacking for many youth (Asarnow et al., 2005
; Pumariega & Winters, 2018
Typically, the primary care provider serves as a resource and potentially a gatekeeper in facilitating access to mental health services. The need for mental health providers is underscored by epidemiologic studies suggesting high rates of mental health problems in children, with probably one in five children having a significant problem (Pumariega & Winters, 2018
). These problems take a significant toll on school success and may impact peer and family relationships. The public health significance of these problems is underscored by work suggesting that about half of all mental health disorders have their onset by age 14 years and 75% by age 24 years.
Unfortunately, the historic divisions between medical and psychiatric service systems have tended to fragment service delivery and complicate provision of effective, integrated care. This unfortunate dichotomy is now greatly compounded by issues of insurance reimbursement and the organization (or lack thereof) of health care. These issues become further complicated for some disorders specifically covered within the mandates of schools for providing services. There are a few model programs, for example, that of Massachusetts, that aim to integrate care (Sarvet et al., 2010
Mental health conditions frequently present with physical problems, and patients with physical problems have associated psychiatric disabilities. Psychiatric conditions also have important associated medical risks, for example, for accidents and injuries, suicide, violence, substance abuse, and teen pregnancy, among others. Most chronic physical illnesses increase the risk for subsequent mental health problems. Conversely, the association of depression with a chronic condition like diabetes may be associated with significant risk for problems. It is important to be aware of medical conditions that increase the risk for mental health disturbances in the child (see Table 27.1
Sadly, despite the awareness of the effective mental health interventions, most children and adolescents do not receive treatments they need and even those who do do not necessarily receive treatments considered best practice, evidence-based interventions. Primary care providers can offer clinical management for most psychosocial problems and account for the majority of prescriptions of psychoactive medications. This is true for various conditions ranging from depression, anxiety, and mood problems to attention-deficit disorder (see Havens et al., 2018
). Fortunately, there have now been some attempts on the part of the American Academy of Pediatrics to produce guidelines for management of mental health care issues in primary pediatric care. The field of Developmental-Behavioral Pediatrics arose from concerns about the need for more sustained and effective training of pediatricians in behavioral health. This approach has focused on common behavioral and developmental problems, and the subspecialty has been officially recognized and now includes a period of fellowship training. The medical home model (Sheldrick & Perrin, 2010
) has now been used with good results in a range of conditions, for example, autism, to provide better integrated care.
Primary care providers may feel more comfortable in the management of some disorders, like ADHD, but not others, for example, depression (Asarnow et al., 2005
; Schonfeld & Campo, 2018
). There are many obstacles to providing mental health services including lack of
access, social stigma, the shortage of child and adolescent psychiatrists, reimbursement, and administrative issues. Clearly, priorities in this area include better training, new models of care like the medical home, and new methods of service delivery, for example, school-based clinics. Communities in rural and impoverished areas may have the least access to good models of care, and telemedicine has some important potential advantages in these situations.
TABLE 27.1 Common Medical Causes of Psychiatric Disturbance in Children and Adolescents
Nonconvulsive status epilepticus
Temporal lobe seizures
Cerebral systemic lupus erythematosus
Childhood confusional migraine
Head trauma or post-concussive syndrome
Sickle cell disease
Withdrawal from illicit substances
Steroid psychosis or steroid-induced mania
Central nervous system neoplasm or other occult malignancy
Medication adverse effects such as akathisia from risperidone or irritability from levetiracetam
Reprinted with permission from J. F. Havens, R. S. Gerson, and M. March. (2018). Designing emergency psychiatry services for children and adolescents. In A. Martin, M. Bloch, & F. R. Volkmar (Eds.), Lewis’s child and adolescent psychiatry, (5th ed., p. 349). Wolters Kluwer.
Although they can occur at any age, child mental health emergencies become more common as children enter school and high school. The urgency of the situation depends on the nature of the psychiatric symptoms, available supports, and issues of safety for the child and others. Unfortunately, as with other aspects of medical care, psychiatric emergency services are frequently, but inappropriately, used to deal with problems more appropriate to less urgent settings, but, given an absence of community resources, such problems may present on an emergent basis or directly in the emergency department. Sometimes, issues have been simmering for a long time and something finally tips the situation over the edge (Havens et al., 2018
). At other times, there may be rapid emergence of difficulties. Referrals may come from many sources including parents and family, schools, juvenile justice, community agencies, and so forth. Referrals from junior high and high schools are frequent except in the summer. Heightened sensitivities to violence have often led schools to adopt a policy of zero tolerance; these policies may require some sort of psychiatric assessment before the child returns to the school.
Mental health emergency referral of all kinds has become more common in recent years. Kalb and colleagues (2019)
reported a nearly 30% overall increase with a 2.5-fold increase in visits related to suicidal thoughts/actions. Sadly, only about 16% of youth were actually evaluated in the emergency department (ED) by a mental health professional. The reasons for the increased number of referrals remain unclear but include higher rates of suicidal thinking and increased rates of violent behavior. Dwindling options for community-based care force more children and adolescents to emergency settings when crises occur. Many mental health professionals in private practice are willing to see patients on an urgent basis but if issues of hospitalization or suicidality or violence arise, they typically will refer the patient and their family to the ED. Insurance coverage pressures have also forced shorter lengths of stay when mental health hospitalization is indicated. Finally, of course, the ED remains the place of last resort for the many uninsured children and adolescents who need acute mental health care.
CONSULTATION IN THE EMERGENCY DEPARTMENT
Child psychiatric emergencies are characteristically times of great stress for all concerned. The sense of urgency is often complicated by anxiety about the outcome and/or the ongoing issues or conflicts. Typically, many different factors are involved in precipitating the trip to the ED and often a relevant place to begin is with the question “why now” (Havens et al., 2018
Clarifying the relationships of the various individuals centrally involved is another important priority. Children function in several different contexts: home and family, school, and community. A crisis can occur with any number of changes to these overlapping systems—for example, school failure, parental discord, violence, bullying, and victimization. Sometimes a sudden upsurge in the level of severity of an ongoing problem can precipitate the crisis. Often clarifying the questions of why now and who is involved become the first steps in thinking about a resolution of the crisis.
In understanding the nature of the emergency, the evaluator typically has several important goals:
understanding the factor(s) that led to the referral (including interviewing all the relevant participants),
developing a shared or working alliance with the child and family about goals for evaluation,
obtaining a history of the child’s current difficulties as well as long-standing issues and problems and relevant support systems, and
conducting a mental status examination focused not only on issues of differential diagnosis and treatment but also with attention to the presence of suicidal or homicidal ideation, symptoms of psychosis or delirium, and so forth.
It is important to develop an emergency treatment plan and arrive at a disposition, with due consideration for the safety of the child (and others) with follow-up and collaboration with other clinicians involved in the child’s care, including the primary care provider.
Given the intense pressures on a busy hospital ED, it is not surprising that often the focus in an emergency is the question of dangerousness and potential needs for hospitalization. This approach misses the potential therapeutic value, that is, using a crisis to stimulate change, of the ED visit and the opportunity it presents for significant benefit. In contrast to the somewhat more leisurely pace of typical assessments, the urgency of the ED situation typically leads to rapid clinical decisions and treatment formulation. This process can be severely hampered, for example, by the absence of key adults who can provide information or by limited community resources for treatment after discharge from the ED. The latter can be even more of a problem when, as is often the case, the evaluation is conducted at night or on the weekend rather than during regular business hours. Given the pressures involved, the clinician must be efficient and well organized. With experience, clinicians rapidly develop a clear sense of the priority of problems and often begin to formulate their ideas about diagnosis and treatment planning as soon as the evaluation has begun.
The typical ED is a busy place with little privacy and many distractions. Depending on the situation, it can be very helpful if the clinician can locate a quieter and less stimulating area to use for interviewing the child and others. This area must, however, be safe and the clinician should feel that help is at hand should the need arise. Typically, an adult, rather than the child, will have been the source of the referral to the ED. Similar to other situations that require mental health evaluation (see Chapter 4
), assessment often requires eliciting information from multiple sources, but in contrast to the usual outpatient situation, the adult bringing the child may not necessarily be the parent but a police officer, social service worker, or a teacher who might be involved in the crisis. A lack of relevant information and/or conflicting sources of information can complicate the task of assessment. Practically speaking, the examiner often ends up collecting information in a piecemeal fashion but with an overall understanding of the most critically important issues to address. Whoever is present becomes a legitimate source of information, that is, the child and whoever has transported them, for example, police or schoolteachers and resource officer or parents. It may be important to touch base with all concerned; in emergency situations, the clinician has considerable leeway in gathering information but parental contact is indicated as quickly as possible if parents do not come with the child. In many states, adolescents may be able to give consent when parents are not available and the clinician should be aware of applicable state laws and guidelines to mental health emergencies, consent issues, and involuntary hospitalization.
The chief complaint may vary, sometimes markedly, depending on who serves as the informant. These discrepant views (also termed informant variance
) simultaneously complicate the task of the clinician but also provide helpful information about the factors that led to the emergency evaluation. They also can serve as a starting point for intervention because they reflect major areas of discrepancy between the views of the child and important adults. Other variations arise depending on the setting or context within which the child or adolescent is observed and levels of demands/expectations placed on them. The complaint, for example, that “Becky needs medication because of her behavior on the bus” suggests an important initial area of inquiry (“Only on the bus?”) that can tremendously streamline subsequent discussion! Benarous and colleagues (2019)
examined data on ED use by children. Overall, there was a 3.85 times increase in the annual number of ED visits, with a sharp rise in primary complaints of anxiety or depression rising from 5% in 1981 to 34% in 2017.
A simple way to view mental health emergencies is to realize that children and adolescents can be disturbed or disturbing or both. It is the child who is disturbing or exhibiting “externalizing” problems who frequently is the focus of parental or school concern and complaint. On the other hand, the child who is disturbed (anxious, depressed, or quietly suicidal—that is, exhibiting “internalizing” problems) but does NOT exhibit high levels of behavior problems may be less likely to present for emergent evaluation. Parents may have a selective bias in their recognition of family or personal factors contributing to difficulties in the child, for example, marital conflict or violence in the home. The examiner should be alert
to the child who is vague or minimizes problems because often this results from an attempt on the child’s part to protect the parent(s) and/or to maintain some family secret within the family, for example, parental violence, illegal behavior, mental illness, substance abuse, or physical or sexual abuse. Evaluation in these cases is particularly difficult.
The Interview of the Child or Adolescent
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 or the social worker has arrived to conduct an evaluation, the child often has been sufficiently stressed that they are angry, withdrawn, or overtly oppositional and antagonistic. In situations like this, the clinician can invoke the “constructive use of ignorance”: for example, “I don’t know much about why you are here. Can you help me out?” and thus invite the child to provide a view of the events leading to the current situation (Havens et al., 2018
The attitudes of the child and their parents and their ability to work with each other provide important information relative to the safety of potential discharge home with follow-up in outpatient settings. The child or adolescent’s ability to reflect on their 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/family who acknowledge the realities of the difficulties and seem motivated to change have a much greater likelihood to use outpatient treatment successfully. The next sections of this chapter will review three of the more important topics: aggressive behavior, suicidal thoughts and behavior, and the decision on whether to hospitalize.
Aggressive Behavior as a Mental Health Emergency
Aggressive and/or uncooperative patients present special problems for assessment in the ED. 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, 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/resolution, the clinician should approach the aggressive child/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 themselves with whatever capacity the child or adolescent has to remain in control. Unfortunately, the stressors of being in 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 different psychiatric conditions. To complicate the situation further, frequently oppositional defiant and more overtly aggressive/violent behaviors have multiple origins and determinants and often a long history antedating a specific event. 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, cognitive delays, and associated coping difficulties may also contribute to such behaviors. Exposure through observation or direct experience of aggression in violent families is another risk factor. Substance use/abuse can impair judgment, increase irritability, and contribute to disinhibited, impulsive behaviors. Psychotic conditions of various types can similarly present
with overt aggression, for example, 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, post-concussive states as discussed later in the chapter. Careful medical history is important, and the clinician should be particularly alert to the presence of such conditions (Havens et al. 2018
). Treatments vary with associated conditions (see Table 27.2
The history should focus both on recent and on past aggressive behavior: for example, 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. The perspective of the patients and the various relevant adults often provides important information on these issues. In situations where the child is involved as a victim, the child’s account, the setting of the event, and 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/factors that contributed to the child’s response. Areas to be assessed are summarized in Table 27.3
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 even when dealing with the most challenging patients. The clinician should not place themselves in a situation of danger where backup is not available, and sensible precautions, for example, sitting between the patient and the door, should occur as a matter of course. As in other areas of mental health, one’s own inner sense will provide important clues, for example, if a patient makes the clinician very anxious, there probably is a good reason. The waiting area and examination room should be one free of safety hazards and objects that might be used in an aggressive outburst; as much as is reasonable, it should provide minimal stimulation (certainly as compared to 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/procedures for alerting staff if necessary. The possibility of seclusion and/or restraining should also be available if needed.
TABLE 27.2 Psychiatric Disorders and Treatment of Acute Aggression
Set clear limits, reinforce positive behaviors
Treat command hallucinations/paranoia that are triggering aggression
Stabilize mania to address impulsivity/irritability
Anxiety or OCD
Identify and address triggers (such as being blocked from completing compulsions)
Identify trauma reminders, promote safe coping behaviors
Promote verbal problem solving and other coping behaviors
Set clear consequences for antisocial behaviors and reinforce positive behaviors
Increase supervision, motivation enhancement techniques to reduce use
Reprinted with permission from J. F. Havens, R. S. Gerson, and M. March. (2018). Designing emergency psychiatry services for children and adolescents. In A. Martin, M. Bloch, & F. R. Volkmar (Eds.), Lewis’s child and adolescent psychiatry (5th ed., p. 849). Wolters Kluwer.
TABLE 27.3 Components of a Comprehensive Assessment
History of present illness
Past psychiatric history
Current medications and medication history
Past medical history
Substance use history
Social history including trauma and child welfare involvement
Developmental and educational history
Mental status examination including cognitive examination when indicated
Medical clearance including physical examination if indicated
Reprinted with permission from J. F. Havens, R. S. Gerson, and M. March. (2018). Designing emergency psychiatry services for children and adolescents. In A. Martin, M. Bloch, & F. R. Volkmar (Eds.), Lewis’s child and adolescent psychiatry (5th ed., p. 850). Wolters Kluwer.
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 overstimulating, disorganizing environment is important as is the presence of another person, for example, a family member, who can provide reassurance and orientating/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, for example, observing the patient for signs of other medical conditions, changes in levels of consciousness, and so forth (see next section).
Pharmacologic 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 behavioral difficulties as well as the patient’s medical status, history, and goals of the sedation. Careful medical monitoring is indicated. Various agents, but particularly the neuroleptics and/or benzodiazepines, are frequently used. The shorter acting benzodiazepines can be used for both sedative and anxiolytic properties. Unfortunately, at times, the benzodiazepines can also result in a seemingly paradoxical disinhibition; this seems particularly likely in children and adolescents. Sometimes, higher potency neuroleptics are used for more aggressive and agitated patients (but only after careful assessment). For younger children, the antihistamine diphenhydramine (Benadryl®) can be given. If medications are used, understanding their potential side effects and any interactions with medications the individual is receiving is important.
Only gold members can continue reading. Log In