description of common common childhood behavioral emergencies with stress on the importance of child psychiatry specialty

2. By Dr: Samir M Al-Minshawy
Lecturer of Neuropediatrics
Minia University

3. Underestimation& Under appreciation

4. Documentation

5.  Psychiatric illness profile in Egyptian
children(emotional, behavioural
disorders and learning difficulties)
 Egypt has few psychiatrists
specialising in childhood problems.
 Few general psychiatrists have an
interest in child psychiatry and their
knowledge and skills are based on
expertise and education acquired
abroad.
 Egyptian universities do not offer a
degree in child psychiatry in spite of
the magnitude and severity of mental
health problems in childhood.
Focus on psychiatry in Egypt
(A. Okasha; 2004)

6. Terminology
Behavior
 Anything that an organism does in response to
stimulation
 The response of an individual, group, or species to its
environment
May be internal or external, conscious or subconscious
, overt or covert and voluntary or involuntary.
Overt behavior is generally understood by those around
the person.
Covert behavior has hidden meanings or intentions.

8.  Psychology Vs Psychiatry
 Psychology is the study of people:
how they think, act, react and
interact. Psychology is concerned
with all aspects of behavior,
thoughts, feelings and motivation
underlying such behavior.
 Psychiatry is the study of mental
disorders and their diagnosis,
management and prevention.
 Child and adolescent psychiatry:
the study, diagnosis, treatment,
and prevention of
psychopathological disorders of
children, adolescents, & their
families (Kaplan & Saddock)
 The term "psychiatry" was first
coined by the German physician J.
Christian Reil in 1808

9. History talk
Emil Kreapelin
 1883: Emil Kreapelin: recognition
of childhood as a special phase of life.
ignored disorders in children
 1930: 1st academic child psychiatry
department in the world was founded by
Leo Kanner in Baltimore
 1933: Moritz Tramer: Swiss psychiatrist.
the first to define the parameters of child
psychiatry in terms of diagnosis,
treatment, and prognosis within the
discipline of medicine
 1934: 1st Journal: Zeitschrift für
Kinderpsychiatrie = Acta
Paedopsychiatria
 1959: Board certified speciality

10. History Talk
 Mental disorders have been recognised in Egypt for
millennia; 5000 years ago and described in the Ebers
and Kahun papyri. These disorders carried no stigma,
as there was no demarcation then between psyche and
soma.
 In the 14th century – 600 years before similar
institutions were founded in Europe – the first
psychiatric unit was established, in Kalaoon Hospital
in Cairo.

11. Epidemiology
 Less studied than in adults.
 The incidence has dramatically increased (nationwide)for the past decade and
predicted to rise in the next 15 years by 50%, becoming a major cause of
morbidity, mortality and disability.
 Between 3% and 18% of children have a psychiatric disorder with median
prevalence of 12% depending on diagnostic methodology (e.g. clinical
interview, self-report or parent-report questionnaire and DSM-IV). Less than
20% of them receive treatment.
 Risk factors: positive family history ( genetics), poverty, single parenthood or
parental dysfunction, abuse, neglect, domestic violence , poor social
relationships, peer disacceptance and substance abuse

12. Developmental disorders
Autistic spectrum disorders including Asperger's disorder
Learning disorders
Disorders of attention and behaviour
Attention deficit hyperactivity disorder
Oppositional defiant disorder
Conduct disorder
Psychotic disorders
Childhood onset schizophrenia
Mood disorders
Depression
Bipolar disorder
Anxiety disorders
Panic disorder
Phobias
Obsessive Compulsive Disorder
Eating disorders
Anorexia nervosa
Bulimia nervosa
Gender identity disorder
Gender identity disorder in children

13. Psychiatric Signs and Symptoms

14. Similarities and differences between
pediatric and adult mental health issues
 Children: more vulnerable and more resistant.
 Their existence and development depends on others
(care givers) who give information building diagnosis
 The developmental stages are very important in
assessment
 The child who suffers by psychiatric problems in
childhood can be an emotionally stable in adulthood
(diagnosis will be aged out)
 Psychopharmacotherapy use is less common

15. Behavioral Emergencies

16. Behavioral and psychiatric emergencies
 Pediatric behavioral emergency exist when:
 disorder of thought or behavior is dangerous or disturbing to the
child or to others
 behavior likely to deviate from social norm and interfere with child’s
well-being or ability to function.
Result from different etiologies: psychiatric illness, medical,
metabolic, psychosocial/situational, infectious, intracranial and drug
abuse
 Psychiatric emergencies are a subset of behavioral emergencies.
 True psychiatric emergencies in children are rare: they
 do not always stem from mental illness
 are more likely to stem from situational problems
 may be due to other medical problems or injury
 Medical conditions: diabetes, hypoglycemia, brain injury, meningitis,
encephalitis, seizure disorders, hypoxia, and toxic ingestions-can
manifest with signs and symptoms that suggest psychiatric illness like
altered mental status, hallucinations, delusions, incoherent speech,
and aggressive behavior

17. Childhood behavioral emergencies
challenges.
 Muddled picture, anxious parents, and an acting-out
child
 Impression of abuse or neglect may be misleading.
 Inadequate social support.
 Inadequate coverage by health insurance.
 Few specialists
 Stigmatization
 Multiple suspected etiologies

18. Assessment
 Part of treatment.
 Clinical stabilization (ABC) has the 1st priority
 Directed to patient and family (Rapport building is
crucial)
 In a quiet and safe environment (Scene Size-Up )
 Chemical or physical restraints as necessary

19.  Attention: signs requiring immediate intervention,
such as psychomotor agitation, aggressiveness,
alterations in the level of consciousness, and suicidal
behavior
 Physical and neurological exam: complications and
exclusion of conditions provoke psychiatric
manifestations
 Mental status of the patient
 Ancillary tests might be required in these cases, such
as drug screening, blood count, electrolyte analysis,
cardiac monitoring, and computed tomography

20. Treatment
 Goals: relief of symptoms, implementation of the
treatment and investigation of the triggering factors to
reducing the risk of future episodes
 In crisis, isolation to reduce anxiety gain self-control
 If excessive impulsivity, sedation may be done.
 In the absence of adequate family or social support,
maintain the patient under hospital supervision .
 The psychopharmacological treatment must take with
special concern to pharmacodynamics and
pharmacokinetics, adverse effects in children

21. SOME ACUTE PSYCHIATRIC
DISORDERS PRESENTING TO THE ED

22. Mnemonics for acute psychiatric disorders in children
and adolescents (IACAPAP Textbook of Child and Adolescent Mental Health)

24. Psychosis
 Disorder of thinking (delusions) and perception (hallucinations)
with impairment in reality testing
 Because of the overlapping symptoms, it can be difficult to
differentiate between schizophrenia and bipolar disorder in manic
phase or depression with psychotic symptoms.
 Severe episodes of sudden onset are more indicative of organic
conditions or intoxication which should be ruled out .
 Treatment: with acute episodes, neuroleptics with a sedative
profile are used in cases of insomnia or agitation, severe
agitation may require intramuscular drug injections.

26. Depression
 Presented with somatic symptoms or behavioral
problems
 Adolescent experience more irritability or depressed
mood, which persists for more than 2 weeks and is
associated with deterioration in functioning also,
social withdrawal, declining school performance,
disrupted sleep patterns, changes in appetite or
weight, and fatigue. A negative self-appraisal, low self-
esteem and cognitive distortions,,,,,,,,,,,
 Up to 60% also have suicidal ideation and 30% attempt
suicide

28. Anxiety and somatoform disorders
 Acute stress disorder, posttraumatic stress disorder, panic disorder and social
phobia may require ED
 Strong association with mood disorders and traumatic events.
 Typical anxiety crises are uncommon in children and usually manifest through
somatic symptoms (e.g., headaches or abdominal pain).
 Organic etiology considered in long duration and persistent neurological
symptoms.
 Conversion and anxiety disorders may overlap with other clinical pathologies.
Dissociative episodes with loss of consciousness, syncope, and motor or sensory
dysfunctions can resemble epileptic seizures.
 Acute crises should be properly medicated to permit immediate relief and
reassessment. Low dose of short half-life benzodiazepines to prevent
excessive somnolence, which would hamper the clinical reassessment.
 Referral for psychiatric and psychological treatment after discharge.

30. Disruptive behavior disorders
Attention deficit hyperactivity disorder
 Core symptoms are inattention, hyperactivity and impulsivity,
before the age of 7 years and lead to functional impairment in at
least two settings
Oppositional defiant disorder:
 Has defiant, noncompliant, and hostile behavior towards
authority figures for at least six months and lead to academic,
social or occupational impairment. Children are argumentative
and refuse to follow rules,
Conduct disorder
 Inability to appreciate the importance of others’ welfare and
show little guilt about harming others.
 Lies and stealing is frequent.
 The four main clusters of symptoms are: aggression or threats of
harm to people or animals; repeated violation of household or
school rules or breaking the law; and persistent lying to avoid
consequences


31. Suicidal behavior
 Suicide is already: 4th leading cause of death between ages 10-14y
 Associated with mood disorders, eating disorders, psychosis, and
conduct disorders
 Related to family disturbances and chronic physical conditions
 The concept of death changes with development: The intention to die
can be explicit and strong or ambiguous and vague so assessment of
these intentions may be difficult
 The underlying cause(s): determined and treated
 Long-term drug treatment may be needed
 Sedation may be required when the patient is agitated and resistant to
restraining measures. Neuroleptics with sedative properties like
chlorpromazine are first choices. benzodiazepines should be avoided,
especially in children, due to the risk of paradoxical effects and other
adverse reactions.
 Discharged only with the full remission of suicidal ideation, and once
the clinical and psychosocial treatment of the triggering condition has
been implemented

32. Parameters to asses the suicidal
behavior
(Scivoletto et al. 2010)

33. Eating disorders
 The highest mortality rates among psychiatric disorders – 5.6%
per decade. The peak of incidence, in girls aged 15-19 years.
 Emergency situations due to severe behavioral alterations and
clinical complications associated with malnutrition which
appear late and suddenly and are potentially lethal.
 Psychiatric emergencies include the risk of suicide associated
with dissatisfaction with the body image or with a concomitant
mood disorder; intense irritability and aggression directed
towards self and others; complete and fixed refusal to eat; and
uncontrollable vomiting or purging symptoms.
 DD: anorexia nervosa with other causes of anorexia and
malnutrition , bulimia nervosa with disorders of the digestive
tract that can cause vomiting and psychogenic vomiting
 Control and monitoring of clinical complications.
 Gradual refeeding.

36. Intoxications and confusional states
 More in adolescence.
 The most common presentation is intoxication, since severe withdrawal
syndrome is rare.
 Acute intoxication episodes can be manifested through psychomotor
agitation, aggression, acute psychosis and, in more severe instances, mental
confusion, coma, and cardiocirculatory alterations.
 In children, acute intoxications usually occur accidently. In adolescents,
intentional ingestion is more likely, even in cases of products that are not
considered to be drugs of abuse, such as cleaning products, solvents, and
insecticides. In these cases, it is fundamental to differentiate the episode from a
suicide attempt.
 Clinical stability is he priority before detailed assessment.
 Some clinical signs can indicate a higher probability of the use of one specific
substance.

37.  Patients are afraid of being punished or getting involved with the police
so they deny. Symptoms may resemble a panic attack (including
tachycardia, sweating, and feeling of imminent death)
 Acute intoxication episodes might be associated with other primary
psychiatric conditions such as mood disorders and psychosis.
 Treatment based on the symptoms presented.
 Cardiorespiratory stabilization and consciousness monitoring in a
quiet place Medications aimed at stabilizing the clinical alterations,
but should be restricted to reduce the drug interactions.
 In severe agitation low dose antipsychotics can be used with special
attention to excessive sedation. Acute intoxication symptoms usually
disappear within a few hours, reassuring and referral to follow-up and
treatment

40. Maltreatment and abuse
 Physical or psychological violence, sexual abuse or
serious neglect.
 Building rapport is fundamental to provide comfort
and safety, diminishing the defensive reactions.
 Patients may deny clear signs due to the fear of being
responsible for a family crisis or for future aggressions.
It is important to watch the patient’s reactions in the
presence of different family members
 Suspicion is based on clinical history, physical
examination, and diagnostic imaging exams

41. The absence of these indicators does not exclude the possibility of abuse, in the same
way that isolated findings cannot be taken as a positive indication of victimization

42.  The child may appear frightened, evasive, and aggressive, as well as
take a defensive position. Apathy, somnolence, and sadness are
common features.
 Once suspected, the patient should be protected.
 Chronic abuse provokes more manifestations, especially depression,
post-traumatic stress disorder, dissociative and somatoform symptoms,
difficulties to manage anger and to control impulsivity, problems in
getting sexually involved, aggressiveness, and substance abuse.
The management targets:
 Avoidance of subsequent abuse:
 Relief of the effects of the past event
 Assessment of emotional, social, and educational needs following the
event.
 A team of social worker, medical, psychological.

44. Aggression
 Although unspecific sign, it is the main cause of psychiatric emergencies
in childhood and adolescence, Aggressive behaviors can be
manifestations of nearly any psychiatric diagnosis.
 Diagnosis may be determined by associated symptoms and previous
history, which should be assessed after the behavior alterations are
under control
 The acute behavior disturbance is generally manifested through
aggression and can result from a new episode of a pre-existing
condition.
 Triggering factors must be investigated even in the absence of
psychiatric disorders, the child or adolescent may present aggressive
behavior as a reaction to family, social, or personal crises, in these cases,
the episodes are isolated, infrequent, and less severe.
 The psychopharmacological approach will depend on the diagnosis.
Aggressive behavior can be controlled with neuroleptics
(extrapyramidal symptoms and tardive dyskinesia in up to 41% of
children ) Benzodiazepines can be used but avoided in case of use
other drugs, especially depressors of the CNS. With intense agitation
injections.

45. Screening and prevention
 Avoidance of high-risk situations.
 Early detection
 Screening is difficult and time consuming
 Effective ED screening must meet 2 criteria: (1) the
screening instrument must be accurate, efficient, and
acceptable; and (2) the screening must be linked to
effective intervention.
 Clinician training

46. Risk of Suicide Questionnaire (Horowitz et al)

47. Medicolegal Considerations
1-Consideration to patient rights
2-In case of abuse the physician is obliged to report the
fact and even his suspicions to child protection services.
3-the patient should be protected until the situation is
clarified
4-Obtain consent when possible.
5-Documentation is a necessity

48. Take-home message(s)
 Estimation & Appreciation : Values
 Documentation: Half of Knowledge
 Mind and body: Inseparable
 Child psychiatry : A must
 Childhood behavioral emergencies : Need a clear
research agenda
 Childhood mental health : Need “out-of-the-box”
decision making.
 Street children: Pomp