Initial assessment of a child or adolescent presenting with a behavioral emergency must include evaluation for an underlying medical illness or substance ingestion that may be life threatening. In the adult literature, 5% to 42% of individuals presenting with a psychiatric illness have an underlying medical illness that is producing the psychiatric symptoms (7). For example, psychotic symptoms or thought disorganization may result from any of the following: central nervous system lesions (tumors, congenital malformations, trauma), neurodegenerative disorders (Huntington chorea, lipid storage disorders), metabolic disorders (endocrinopathies, Wilson disease), developmental disorders (velocardiofacial syndrome), toxic encephalopathies (substances of abuse, medications, toxins), or infectious diseases (encephalitis, meningitis). Similarly, although violence may be associated with a number of psychiatric conditions present in children and adolescents (psychotic disorders, attention deficit hyperactivity disorder, oppositional defiant disorder, substance abuse, developmental delays, abuse or trauma), it may also result from neurologic conditions or other medical illnesses, delirium, medication side effects, alcohol or drug intoxications, or other toxic metabolic states.

A careful medical history is essential, including an assessment of recent childhood illness, pediatrician-prescribed and over-the-counter medications, and any recent substance abuse. Fluctua-ting levels of consciousness, impaired attention and memory, and disorientation, with or without visual, tactile, or olfactory hallucinations, may suggest a delirium or organic cause for the psychosis. A thorough physical examination that includes vital signs and neurologic examination must be performed. Routine laboratory testing must be completed, with specific testing obtained as warranted by clinical presentation (e.g., urine toxicology screen for suspected substance abuse, magnetic resonance imaging of the head for trauma) (8).

Guerrero (9) suggested an approach to the evaluation of child and adolescent emergencies that emphasizes careful deliberation of differential diagnoses, specific consideration of life-threatening conditions, advocacy for optimal general medical care, and effective communication and listening, as well as knowledge of child development and specific pediatric conditions.

Emergency management of a potentially violent pediatric patient must ensure safety for both the patient and staff. Children and adolescents may present to the PES in an agitated, threatening, or violent state. General management strategies should first involve providing a calm, quiet place for the interview that is devoid of sharp objects, cords, or hazardous equipment. The clinician should speak softly and clearly, move slowly, and set clear limits with the child or adolescent. Food or drink may be offered to engage the patient and signal concern for his or her well-being. Friends or family may be asked to stay with the child or teen if they produce a calming effect. If these interventions do not prove effective, oral medication may be offered.

If immediate intervention is required to maintain the safety of the child or staff, seclusion, restraint, or oral or intramuscular medication may be required. Literature on the use of seclusion or restraint in pediatric emergency settings is limited (10,11,12). Dorfman and Mehta (12) found that approximately 1 in 15 children undergoing psychiatric evaluation were restrained in a pediatric emergency service. Forty-nine percent were physically restrained, 24% were chemically re-strained, and 26% were physically and chemically restrained. Restraint use was associated with chief complaints of visual hallucinations, out-of-control behavior, hyperactivity, and admission to a psychiatric hospital.

Sorrentino (10) reviewed the definition, indications, and goals for chemical restraint, the classes of drugs used for behavioral control, and the legal implications associated with the practice. Chemical restraint was defined as “a medication used to control behavior or to restrict a patient’s freedom of movement [that] is not standard treatment for the patient’s medical or psychiatric condition,” and the emphasis was that it should be used only in instances in which danger to self or others is imminent. Dosages, side effects,
contraindications, and recommendations regarding benzodiazepines, neuroleptics, and atypical antipsychotics were reviewed.

Heyneman (13) noted the absence of specific acute pharmacologic treatment for pediatric aggressive behavior. She suggests that choice of medication should be based on severity of aggression, target symptoms, goals for intervention, underlying diagnosis, current medications, allergies, medical problems, and side effect profile. The medications most commonly used for acute agitation are listed in Table 27.1, together with recommended dosage, route of administration, onset of action, and side effects.

No single informant can provide a full description of a child or adolescent. Children, teachers, parents, other relatives, and clinicians observe distinct phenomena, and each may offer perspectives on the behavior of the child or adolescent. It should be remembered that differences in reports of parents and teachers or between two parents can result from genuine variations in the behavior of children in different settings.

Goldstein and Findling (14) discuss the approach to interviewing children and adolescents in an emergency setting. They address the idiosyncratic elements specific to the assessment, and discuss ways of establishing rapport with pediatric patients. They point out that the developmental stage of the child is critical. For example, young children may perceive the evaluation as a punishment for something done wrong, or may believe that being evaluated means they are “crazy.” Additionally, communication difficulties may be a feature of some childhood disorders, making assessment even more complicated. Practice parameters for interviewing children and adolescents have been published by the American Academy of Child and Adolescent Psychiatry (15).

The decision about who to talk to first may affect the ability to establish rapport with pediatric patients (14). If the child is younger than 12 years, Goldstein and Findling suggest interviewing the parent or guardian first, apart from the child. This allows the clinician to efficiently obtain information regarding the child’s history, changes in functioning and behaviors, past treatment history,
medications, possible risk factors, and the caregiver’s perception of risk level to self or others. When the actual interview occurs with a child younger than age 12, they advise beginning an interview with the adult in the room. The child perceives the interviewer as an adult he or she can trust because his or her parent or guardian is willing to speak with the interviewer. With older adolescents, it is recommended that they be interviewed prior to talking to the parent or caregiver. Thus, older adolescents receive a message that they will not be ignored and, if appropriate, will be a part of decision making. This also helps ameliorate the powerful initial belief in the adolescent age group that PES clinicians will accept the word of the parents and guardians as the only “true” version of the story.

Several strategies can be employed in interviewing uncooperative patients. If the child is uncooperative, the clinician may introduce himself or herself, explain the purpose of the evaluation process, proceed with all other aspects of the evaluation, and leave the patient interview until the end. Another strategy involves efforts to join with the child by acting as a patient advocate. For example, the clinician may say, “Given that you are here, could you help me figure out the best way to help you?” If the patient still refuses to cooperate, the various outcomes and disposition decisions available should be outlined for the child or adolescent should he or she refuse to cooperate. The interviewer may state, “The information that I got from your mother and the school leads me to believe that you are not safe or may hurt yourself or someone else. It is your choice whether or not you talk to me, but if you don’t, then I will have to make a decision based only on what your mom and teachers tell me happened at school today” (14).

Disposition from the PES can only be determined once the patient’s needs in terms of protec-tion, observation, supervision, and structure have been assessed using a biopsychosocial framework. Options may be influenced or limited by availability and insurance type, and include inpatient treatment, substance abuse rehabilitation, partial hospitalization or day treatment, respite care or emergency foster care placement, referral to child protective services, referral to outpatient mental health services, follow-up with existing services, and no referral due to definitive treatment.