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Clinical assessment of child and adolescent psychiatric emergencies

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Clinical assessment of child and adolescent psychiatric emergencies

  1. 1. Clinical Assessment of Child and Adolescent Psychiatric Emergencies Carlo Carandang, MD, FAPA
  2. 2. Goals of Acute Assessment • To determine if the patient is at imminent risk of harm to self and/or others • To determine if the young person presenting with crisis is suffering from an acute psychiatric disorder versus a mental health problem • Acute medical complications emanating from the acute mental health problem need to be ruled out • Ultimately, urgent mental health assessment is needed to determine if a higher level of care is needed, such as referral to a psychiatric inpatient unit, crisis unit/step-up unit, or urgent mental health outpatient clinic.
  3. 3. Psychiatric Diagnosis versus a Mental Health Problem • Important to determine if the patient has a psychiatric diagnosis versus a mental health problem • Presenting with an acute psychiatric disorder has a different treatment plan than for a youth presenting with adjustment problems after a break-up with their girlfriend/boyfriend
  4. 4. Acute Mental Health Problems Presenting to the ED
  5. 5. Suicide • Suicide is a major public health concern around the world • Third leading cause of death in the US among 15 to 24 y/o accounting for 12.2% of all deaths in this age group • Youth Risk Behaviour Surveillance Survey ’09- In a 1-yr period, 13.8%of students grades 9-12 had S.I. 10.9% made a plan, 6.6 made at least one attempt, 1.9% made an attempt requiring medical attention
  6. 6. Assessing For Risk of Suicide When assessing a suicidal youth, ED clinicians gather info. regarding risk factors. Risk factors are not necessarily causes but rather associated characteristics. • Gender • Psychiatric Illness • Previous Suicide Attempt (s) • Family History of Suicide • Access to Firearms • Sexual Orientation • Stressful Life Events
  7. 7. SADPERSONS Scale • Sex (male) • Age less than 19 or greater than 45 years • Depression (patient admits to depression or decreased concentration, sleep) • Previous suicide attempt • Excessive alcohol or drug use • Rational thinking loss: psychosis, organic brain syndrome • Social supports lacking • Organized plan or serious attempt • No spouse • Sickness, chronic disease
  8. 8. The SADPERSONS Scale and Clinical Decision Making Note: Some patients can have many risk factors for suicide; however are not at risk. Others can have few risk factors but be at risk for suicide. Total Points Proposed Clinical Action 0 to 2 Discharge with follow-up 3 to 4 Discharge if able to arrange close follow-up; otherwise consider hospitalization 5 to 6 Likely to admit to hospital unless immediate reliable follow-up is available 7 to 10 Admit to hospital, either voluntarily or involuntarily
  9. 9. Case Example 14 y/o female seen for Crisis Ax on a Friday. Shy, quiet and not attention seeking. Disturbing (superficial) pattern of cutting on arm x 1 year (50 cuts). Told parents about the cutting one month ago. Typically cuts when mood is low. Denies a strong intent to die, however; insists on persisting with cutting, possibly deeper. Reports intrusive thoughts of suicide with recent increase in frequency and intensity. Functioning well in other areas (doing well in school in spite of being bullied last year). For her age, + insightful and stating she cuts to relieve tension and to battle loneliness. Poor coping skills. Describes “dips” in her mood that seem situationaly driven. Hx of insomnia. Hx of significant depression on maternal side. Not using Any substance / alcohol. Good relationship with parents, by all accounts “good kid.” **Prescribed meds for sleep, and d/c home with a priority referral (within 7 days) to IWK outpatient mental health. ** Returned to the ED 6 days later following an outpatient mental health session. Sent to the ED by the Clinician as she disclosed feeing suicidal, exhausted, wanting to “give up.” Vague about the S.I., no plan. Arrives in the ED. Won’t talk to the Crisis Worker. Reports she does not talk to anyone, including her boyfriend. We work our magic… she tells us her good friend completed suicide and died yesterday. Still vague about the S.I. and no concrete plan; however, states, “my friend was always smiling and no one knew because she never talked to anyone. That is how I am.” ADMITTED.
  10. 10. Understanding the Patient’s Thinking and Planning To complete a risk assessment, it is crucial to assess the patient’s current thinking with regard to suicide. • Establish positive therapeutic alliance (empathic, not appear rushed, eye contact, non-judgemental) • Introduce topic gradually (gently). Move to direct questioning • Open-ended questions to direct questions • Scale of 1 to 10 • Degree of Hopelessness • Future Orientation (immediate and distant) • Careful History • Availability of help and potential to abort attempt
  11. 11. Management of the Suicidal Patient • Imminent Risk (hopeless, lack of future orientation, persistent suicidal ideation and plan with intent to commit suicide, access to means, little social support) = Admission • Uncooperative Patients at imminent risk refusing admission = Admitted involuntarily • Low to Moderate Risk patients will require a well-organized, comprehensive discharge plan
  12. 12. Management of the Suicidal Patient Con’t • Each d/c plan will vary and will need to be developed in consultation with the patient and the family • D/C plans include: discussion with the patient / family about creating a safe environment by removing access to means (firearms, medications), information about follow-up plans (who, where, when), return to the ED if necessary
  13. 13. Contracting for Safety • Developed in collaboration with the patient and the family • Lists what a patient agrees to do should their S.I. return or worsen • Key Components: listing triggers, coping skills (exercise, music, reading), friends and family the patient can call, contact numbers (crisis lines, peer support), creating a safe home environment and listing reasons for returning to the ED
  14. 14. Aggression Treating and containing the aggressive patient is one of the most CHALLENGING situations in the ED. Needed: skilled empathic staff, adequate facilities, security, collaboration with law enforcement / justice / and / or child welfare, verbal de-escalating techniques, NVCI. Chemical and / or physical restraint may be required.
  15. 15. Most Common Psychiatric Diagnoses Associated with Aggressive Behaviours • Disruptive Behaviour disorders (ADHD, ODD, Conduct Disorder) • Mood Disorders (irritability with depression and mania) • Substance Abuse (intoxication) • Developmental Disabilities (cognitive, autism) • Psychosis and general medical conditions (head injuries)
  16. 16. Case Example • 14 y/o female born in Lebanon, grew up in N.S. After an extended trip to Lebanon, patient has trouble readjusting upon her return home (current school is not diverse, patient feels “out of place”). Parents noticed a significant change in behaviour at this time. Extreme parent-adolescent conflict ensues. Patient engages in high risk behaviour (staying out all night, school refusal, defiant, disrespectful, and visiting another community against parent’s wishes where there is a large representation of Lebanese peers). Multiple ED visits with overwhelmed parents insisting patient is “mentally ill.” Patient assaulted mother (violent). Charges laid and patient asked to leave the home (placed with a neighbour). Patient unable to follow rules in neighbour’s home. Patient continues to feel isolated in her home and community. • Repeated visits to the ED involving grueling family conflict resolution and attempts to help improve patient’s situation. On wait list for outpatient mental health. Will be waiting another 6 months to 1 year. • Family doctor prescribes Risperidone. Patient has a fight with mom, gets on a bus, ingests roughly 10 or more tablets. Heart races, she gets scared, calls mom from a payphone. Admitted to the ED, EKG, and overnight observation. Tells Crisis Worker the next morning that she never meant to kill / harm herself. Just wanted attention. • Priority Referral to outpatient mental health
  17. 17. Parent-Child Relational Conflict • ED visits as a result of lack of timely, accessible and available community resources • High conflict situations that require a comprehensive d/c plan involving temporary solutions between parent and child • Take up a lot of time in the ED • Emerge at any age • Goal in the ED is to Defuse the situation via brief family mediation / conflict resolution / building communication skills
  18. 18. Adjustment Issues • DSM1V-TR definition: Reactions to a specific stressor that are beyond the normal expected reaction or that cause significant impairment in functioning. • Symptoms onset within 3 months of the stressor and usually resolve within 6 months. Chronic AD if symptoms last beyond 6 months • AD develops when the stressor overwhelms the coping skills (death of a loved one, move to a new school / city, bullying, relationship break-up, poor grades • Can be at SIGNIFICANT RISK for suicide • Diminished stressor can = improved symptoms • Treatment – Ongoing outpatient therapy
  19. 19. Borderline Traits • Maladaptive Coping • Shifts in mood, uncontrollable and intense anger • Self-damaging behaviour (substance abuse, gambling, compulsive spending, eating disorder, shoplifting, reckless driving, compulsive sexual behaviour, defying curfew, self-mutilation, etc.) • Identity issues, chronic feelings of emptiness, boredom, heavy need for affection, reassurance • Unstable chaotic relationships (splitting), alternating between “clingy” and distancing • Effort to avoid real or imagined abandonment • Lack of trust in others • Can be at risk for suicide due to impulsive, risk taking behaviour • Intervention – long-term therapy (DBT)
  20. 20. Case Example • 16 y/o female. “Outrageous” personality, funny, bright and creative. Piercings, brightly coloured hair (pink, purple). Multiple presentations to the ED for behavioural outbursts, parent-adolescent conflict, cutting and ongoing threats of self-harm and / or complete suicide. Several admissions to inpatient mental health unit. Patient recently texted her boyfriend to say she was going to a cliff to kill herself. Patient smoked marijuana, drank 2 Vodka coolers, drove to the beach, stood on the cliff for 2 hours waiting for him to come get her. When he did not show, she felt rejected, cold and angry. Patient called police to come get her. Police took too long, so patient walked through the woods in search of them. Previous admissions to mental health unit not helpful; in fact, patient’s mental state worsens when admitted on the unit. • The intervention? Long-term outpatient therapy (DBT – Dialectical Behaviour Therapy). • The risks? Impulsive and risk taking behaviour can lead to accidental death / completed suicide.
  21. 21. Child Abuse / Homeless Youth • Many forms: physical, verbal, sexual, emotional and chronic neglect (most common) • The impact of child maltreatment on mental health is significant • Collaboration with Child Welfare authorities is essential in the ED • Homeless youth are often brought to the ED by police for risky / dangerous behaviours as well as mental health difficulties • Tenuous support systems, poor compliance with follow-up services • The longer a youth is homeless, the more likely it is for the youth to have a mental health problem • Assessment must include risk assessment for suicide / homicide and basic info. on housing / shelter, financial aid, clothing, educational and vocational support, food banks / soup kitchens, etc…
  22. 22. Confidentiality – Case Example • 16 year old woman who discloses she has a loaded gun at home and plans to shoot her stepfather if he comes near her or her 10 year old brother again, as he has before, when he is drinking and violent. She also states that sometimes she thinks about turning the gun on herself because she is miserable at home. • Safety of the young woman (self harm; abused by stepfather) • Safety of the stepfather • Brother’s safety (Child Welfare) • Ethical dilemma / duty to protect and warn? Confidentiality vs. safety • Warning police, stepfather while preserving daughter’s safety • Explore alternative living arrangement • Outpatient follow up if not admitted
  23. 23. Confidentiality • Key component of the physician-patient / clinician-patient relationship • The limits of confidentiality should be clearly established at the beginning of the assessment • Confidentiality must be maintained unless the patient is at risk for harming himself / herself (risk of suicide) or others (risk of homicide), if someone is harming them (child maltreatment) or if the Health Centre is served with a court order (Order for Production) • If the patient understands the importance of maintaining confidentiality and the limits to confidentiality, he / she may be more likely to open up • Clinicians can receive unlimited information from parents / collaterals (school personnel, police, caregivers) without requiring consent from the patient. Clinicians should not share information with parents / collaterals and nonclinical staff without the patient’s consent. • Information can be shared among the patient’s treatment team involved in the patient’s direct care at the Health Centre. Assessment results can be sent to the family doctor (with permission) • Privacy legislation varies among countries and within countries. There are also variations in the age at which patients can give consent for the release of medical information. • It is crucial that clinicians be up to date in terms of their local privacy legislation governing their practice
  24. 24. Acute Psychiatric Disorders Presenting to the ED
  25. 25. Psychosis • Psychosis is a disorder of thinking (delusions) and perception (hallucinations) in which there is a gross impairment in reality testing • Positive symptoms- excess or distortion of normal functions- delusions, hallucinations, disorganized speech or disorganized or catatonic behaviour • Negative symptoms- diminution or loss of a normal function- affective flattening, alogia or avolition • Look for decline in their social and cognitive functioning: social withdrawal, worsening of school performance, bizarre or eccentric thoughts and behaviours, self-neglect, suspiciousness, anxiety, irritability, hostility, or aggression • Patients might not come for medical care, and they are often brought by their relatives • The youth in the emergency department might be fearful, apprehensive, irritable, or agitated
  26. 26. Psychosis • Mnemonic for psychosis is THREAD: Thinking may become disordered, Hallucinations may occur, Reduced contact with reality, Emotional control affected (incongruent affect, affective fattening), Arousal may lead to worsening of symptoms, and Delusions might occur
  27. 27. Mania • Irritable, elevated or expansible mood state, which represents a significant change from the youth’s usual mood state and persists for at least a week • Change in mood state accompanied by grandiosity • Youth with mania often think highly of themselves and also think that everyone shares or welcomes their bright ideas; this leads to over confidence • Also have decreased need for sleep, racing thoughts, increased interest in multiple activities, hypersexuality, impulsivity, poor judgment, pressured speech, provocative change in clothing style, distractibility • More than half of the adolescents with mania might develop psychotic symptoms • The mnemonic for mania is DIGFAST
  28. 28. Depression • Youth with depression often present as irritable rather than depressed or sad • Up to 60% of youth with depression also have suicidal ideation and 30% attempt suicide • The mnemonic for depression is SIGECAPS
  29. 29. Anxiety Disorders • For ED, focus on acute stress disorder, post traumatic stress disorder, panic disorder, and social phobia
  30. 30. Post Traumatic Stress Disorder • This disorder occurs after a traumatic event, in which the youth experiences extreme fear, hopelessness or horror • In younger children the experience could be expressed through agitated or disorganized behaviour • Re-experiencing symptoms associated with the trauma • avoidance of stimuli associated with the trauma and symptoms of hyperarousal; which causes significant distress and/or functional impairment • When these symptoms last more than a month, then the diagnosis of PTSD is given • The parents might not always know about their child’s exposure to trauma (or they may be the perpetrator) • The mnemonic for PTSD is TRAUMA: Traumatic event, Re- experience, Avoidance, Unable to function, Month or more of symptoms, and Arousal increased
  31. 31. Acute Stress Disorder • Acute stress disorder is similar to that of PTSD with respect to symptom occurrence • ASD is limited to one month following the traumatic event • Youth’s subjective report of symptoms are more focused on the trauma than the re-experience of it • When youth discuss the traumatic event, they will often describe having experienced it in a dissociative manner (eg youth may describe watching the event happen to themselves, lacking an emotional response to the event, or have incomplete recollection of the event)
  32. 32. Panic Disorder • Panic attack is the sudden emergence of intense fear and associated symptoms peaking within ten minutes: palpitations, shortness of breath, paresthesias, dizziness, sweatiness, shaking and the perception of choking • Youth could be considered to have a panic disorder when panic attacks are repetitive and happen with or without stimuli • They also worry about having future panic attacks and make behaviour changes in attempts to avoid them • Onset of panic disorder usually occurs in late adolescence
  33. 33. Social Phobia • Marked distress and fear of social situations • Pattern of avoidance and anticipatory anxiety of these situations • Younger children might not be able to recognize anxiety-provoking situations; thus, their anxiety may be expressed in tantrums or crying spells • Older children and adolescents might have somatic symptoms such as nausea, abdominal pain or headaches related to social situations • For youth presenting to ED, often the problem is refusing to attend school or gatherings
  34. 34. Disruptive Behavioural Disorders and Substance Abuse • ADHD, ODD, Conduct D/O • Substance Abuse – WILD: Work, school and home failure, Interpersonal or social consequences, Legal problems, and Dangerous use • Substance Dependence – ADDICTeD: Activities are given up or reduced, Dependence - physical – Tolerance, Dependence - physical – Withdrawal, Intrapersonal (internal) consequences: physical or psychological, Can’t cut down use or control use, Time-consuming, Duration of use is greater than intended
  35. 35. Acute Medical Assessment for the Mental Health Patient • Overdose • Self mutilation • Intoxication • Serotonin Syndrome • Acute EPS • Neuroleptic malignant syndrome (NMS) • Serious adverse drug events • Lithium toxicity • Traumatic Brain Injury • Delirium
  36. 36. Summary • Clinical assessment of child and adolescent psychiatric emergencies requires systematic, yet concise and prompt evaluation of acute psychiatric illness, acute mental health problems, and the acute medical complications • Assessment and treatment of acute psychiatric emergencies in children and adolescents in the ED require a team approach consisting ideally of a child psychiatrist, crisis worker/ social worker, nursing staff, and ED physician
  37. 37. Summary- continued • Once the medical complications are addressed, then the next step is to determine the safety risk, specifically the risk of harm to self and/or others. This risk is determined by a number of factors in a variety of presentations, spanning from a youth with acute psychiatric illness (ie psychosis) to a youth who presents with cutting behaviours who has emotional dysregulation and parent-child relational conflict • The primary goal of an urgent psychiatric assessment in the ED is to determine the safety risk of the patient, and if there is imminent risk of harm to self and/or others due to psychiatric illness and/or acute mental health problems, then admission to a psychiatric inpatient unit is warranted, and at times this is done against the will of the patient and/or their family, to ensure the safety of the mental health patient
  38. 38. To Learn More Carandang CG, Gray C, Marval H, MacPhee S (in press) “Clinical Assessment of Child and Adolescent Psychiatric Emergencies.” IACAPAP Textbook of Child and Adolescent Mental Health, Editor Joseph Rey