Respond to  your  colleagues by recommending at least one additional way you would treat a  child or adolescent client differently than you would an adult and at  least one additional way you would address the legal and ethical issues  involved.   NOTE: Positive Comment                                                         Main Discussion Psychiatric  emergencies are severe behavioral changes that may result from  worsening mental illness. Psychiatric emergency is any disturbance in  thoughts, feelings, or actions that require immediate therapeutic  intervention (Stahl, S. M., 2014). The providers approach, attitudes and  work environment may escalate the situation and interfere with the  quality of care. Certain therapeutic measures can reduce the intensity  of the situation and provide a more dignified way for patients to  recover from the crisis. It is thus important that the PMHNP understand  how to assess patient’s emergency status and address their unique needs  while maintaining safety.   Case selected. Patient  is a 25-year-old AA male who presents to the emergency department with  psychotic behavior in believing he should kill his mother which led to  his attempt to stab his mother. Patient is admitted for inpatient  psychiatric stabilization. Patient has a history of schizoaffective  disorder and major depression that was managed with use of clozapine  150mg twice a day and Zoloft 100mg daily. Family reported that patient  has a history of medication non-compliant and had been on different  psychiatric medications in the past but were not working for him.  Additional reports by his parents shows that patient had missed several  doses of his medication, decompensated and they had notices some changes   recently including increase agitation, delusional believes that he is  the savior in the family and God had directed him to cast the demon in  his mother. Reports also that he had drawn a picture of himself with  knives cutting a woman he portrayed as a demon with blood flowing with a  man standing to the side, laughing. Patient currently stated that he  participates in a meeting with angels from which he gets directives on  how to attack his mother which led to his attempt to stab his mother.  Because of this, patient was considered dangerous to his mother per  admitting physician. Patients symptoms include psychosis, extreme  agitation, paranoia, verbal outburst, combative and very difficult to  redirect. Patient has no known drug allergies per parents.  Verbal  restraint was used including letting patient know what will happen if  he does not comply, respecting his autonomy, empathetic listening,  decrease environmental stimulation, reassure patient that they will be  safe, and maintain a safe environment. The patient was given emergency  medications including haloperidol lactate 5mg, lorazepam 2mg, and  diphenhydramine 50mg all IM for severe agitation and danger to others.  To prevent re-hospitalization within 12-24 hour.

1. Respond
to your colleagues by recommending at least one additional
way you would treat a child or adolescent client differently
than you would an adult and at least one additional way you
would address the legal and ethical issues involved.
NOTE: Positive Comment
Main Discussion
Psychiatric emergencies are severe behavioral changes that may
result from worsening mental illness. Psychiatric emergency is
any disturbance in thoughts, feelings, or actions that require
immediate therapeutic intervention (Stahl, S. M., 2014). The
providers approach, attitudes and work environment may
escalate the situation and interfere with the quality of care.
Certain therapeutic measures can reduce the intensity of the
situation and provide a more dignified way for patients to
recover from the crisis. It is thus important that the PMHNP
understand how to assess patient’s emergency status and
address their unique needs while maintaining safety.
Case selected.
Patient is a 25-year-old AA male who presents to the
emergency department with psychotic behavior in believing he
should kill his mother which led to his attempt to stab his
mother. Patient is admitted for inpatient psychiatric
stabilization. Patient has a history of schizoaffective disorder
and major depression that was managed with use of clozapine
150mg twice a day and Zoloft 100mg daily. Family reported

2. that patient has a history of medication non-compliant and had
been on different psychiatric medications in the past but were
not working for him. Additional reports by his parents shows
that patient had missed several doses of his medication,
decompensated and they had notices some changes recently
including increase agitation, delusional believes that he is the
savior in the family and God had directed him to cast the demon
in his mother. Reports also that he had drawn a picture of
himself with knives cutting a woman he portrayed as a demon
with blood flowing with a man standing to the side, laughing.
Patient currently stated that he participates in a meeting with
angels from which he gets directives on how to attack his
mother which led to his attempt to stab his mother. Because of
this, patient was considered dangerous to his mother per
admitting physician. Patients symptoms include psychosis,
extreme agitation, paranoia, verbal outburst, combative and
very difficult to redirect. Patient has no known drug allergies
per parents. Verbal restraint was used including letting patient
know what will happen if he does not comply, respecting his
autonomy, empathetic listening, decrease environmental
stimulation, reassure patient that they will be safe, and
maintain a safe environment. The patient was given emergency
medications including haloperidol lactate 5mg, lorazepam 2mg,
and diphenhydramine 50mg all IM for severe agitation and
danger to others. To prevent re-hospitalization within 12-24
hours of discharge, the physician ordered outpatient therapy
and continued use of clozapine and Zoloft along with necessary
lab work.
How I would treat the client differently if he or she were a
child or adolescent
Children and adolescent are usually brought for treatment when
their behavior or thoughts come to the attention of parents,
teachers, social workers, or school. For pediatric patients in a
mental health crisis, the typical chaotic nature of the situation

3. may easily further exacerbate an already traumatized state of
the patient. Just like in adults, as a PMHNP I would perform an
evaluation to determine the type of emergency and contributing
factors in child and adolescent emergency by assessing not just
the child but also the entire family. Additionally, safety and
protection are essential mandate in psychiatric emergency
evaluation especially when the patient pose imminent threat to
self or others. What I will do different when interviewing
children especially younger children is to assess the underlying
cause of the violent behavior and delusional symptoms within a
developmental context. Specifically, I would clarify that
"bizarre thinking " or accounts of seeing or hearing things that
others do not see or hear are different from developmentally
appropriate fantasy or difficulty while distinguishing inner
voices from distressing hallucinations. On like in adults where
they can provide information during the interview, when it
comes to younger children, I would need to obtain information
from parents or guardian. For adolescents, I would obtain
information from the patient first then talk to their parent or
guardian if the adolescent is able to tell most of their own
story. This may also help to give a sense of autonomy and
control to the adolescent which promote cooperation with the
interview process. However, information from family is very
crucial particularly for a child who is psychotic, frightened,
unable, or unwilling to corporate with the provider to help
understand how the situation occurred and the severity of the
behavior.
Same interviewing strategies used in adult may be used
including speaking in a soft voice respecting patients’
autonomy, assuring safety, validating feelings, offering
distractions (like video games) especially with very young
children, and clear limit-setting can be helpful. However,
children should be evaluated in a carefully planned setting with
doors closed for limiting access, and be sure appropriate
backup is available (Margret, C. P., & Hilt, R., 2018).

4. In violent situations children may require a different approach
in deescalating the situation than adults. Safety is the essential
mandate in an aggression evaluation, with the interviewer
specifically looking for imminent threats, plans, targeted
people, and access to means of harm (Margret, C. P., & Hilt,
R., 2018). Because adults are much stronger, they may require
physical restrain specially to administer medication to calm the
patient. Verbal restrain such as providing verbal directions in a
nonthreatening manner, setting limits, and assuring the child
that treatment may help them calm may be used for children
first. However, if the child is dangerously out of control and
aggressive, they may need medication to keep them calm and
safe.
Legal or ethical issues I would consider when working with a
child or adolescent emergency case
The ethical issue I will consider when working with children
and adolescent is respect for their autonomy, privacy, and
confidentiality. For very young children parents must consent
to treatment and the health care provider treating the child
should make every reasonable effort to obtain and document
informed consent. (American Academy of Pediatrics, 2015).
Just like adults, maintaining a patient’s confidentiality is an
important ethical consideration when providing care to children
and adolescents. However, when a PMHNP is concerned that
the patient may be at imminent risk for harm to self or others,
confidentiality requirements no longer apply (Chun, T. H.,
Katz, E. R., & Duffy, S. J., 2013). This means that the PMHNP
in this situation may disclose information collected from
patient to caregivers or others as needed and may obtain
information from others such as friends, family members,
school personnel, employers and other without obtaining
consent from the patient or guardians (Chun, T. H., Katz, E. R.,
& Duffy, S. J., 2013. Patient autonomy is a major principle in

5. making decisions about an individual’s health, and as a
PMHNP we are obligated to respect this right and allow
patients to practice their autonomy in the course of their
treatment (Parsapoor, A., Parsapoor, M. B., Rezaei, N., &
Asghari, F., 2014). However, a psychiatric emergency and age
may limit a child’s ability to make such decisions. Regardless,
it is always important to involve the child in informed decision
making even if the consent is signed by the parents or guardian.
References
Chun, T. H., Katz, E. R., & Duffy, S. J. (2013). Pediatric mental
health emergencies and special
health care needs. Pediatric clinics of North America, 60(5),
1185–1201. Retrieved from,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3792398/
Da Silva, A. G., Baldaçara, L., Cavalcante, D. A., Fasanella, N.
A., & Palha, A. P. (2020). The
Impact of Mental Illness Stigma on Psychiatric Emergencies.
Frontiers in psychiatry, 11,
573. https://doi.org/10.3389/fpsyt.2020.00573
Margret, C. P., & Hilt, R. (2018). Evaluation and Management
of Psychiatric Emergencies in
Children. Pediatric Annals, 47(8), e328–e333. https://doi-
org.ezp.waldenulibrary.org/10.3928/19382359-20180709-01
Parsapoor, A., Parsapoor, M. B., Rezaei, N., & Asghari, F.
(2014). Autonomy of children and

6. adolescents in consent to treatment: ethical, jurisprudential and
legal considerations.
Iranian journal of pediatrics,
24(3), 241–248. Retrieved from,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4276576/
Stahl, S. M. (2014). Prescriber’s Guide: Stahl’s Essential
Psychopharmacology (5th ed.). New
York, NY: Cambridge University Press.