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Best Practices in Managing Child and Adolescent Behavioral Health Emergencies

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Table of Contents
About This Issue

It is often assumed that a behavioral health issue is solely due to a psychiatric cause. However, many medical pathologies may present with behavior problems and must be ruled out. In this issue, you will learn:

Risk factors for suicide, aggression, and violence

The common presentations of behavioral health emergencies, including depression, anxiety, suicidal behavior, aggression, and severe disorganization, as well as potential underlying medical causes of these behaviors

Steps to ensure a safe environment for the patient and ED staff

Key aspects of evaluating and examining patients with suicidal behaviors, psychosis, and disorganized behaviors

When screening laboratory tests and radiologic studies are warranted

Environmental, verbal, pharmacologic, and physical de-escalation interventions

Which patients require inpatient psychiatric or medical admission, as well as various options for outpatient care

Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Etiological Considerations
    1. Suicide and Suicidal Behaviors
      1. Suicide Risk Assessment
      2. Suicide Risks Among Prepubertal Children
    2. Aggression and Violence
    3. Severe Disorganization
  6. Differential Diagnosis
    1. Neuroleptic Malignant Syndrome
    2. Serotonin Syndrome
    3. Extrapyramidal Symptoms and Akathisia
  7. Prehospital Care
  8. Emergency Department Evaluation
    1. Immediate Assessment of Safety
    2. Evaluation of Aggression and Violence
    3. Medical Evaluation
    4. Evaluation of Suicidal Behaviors
    5. Evaluation of the Patient With Psychosis and Disorganized Behaviors
    6. Physical Examination
  9. Diagnostic Studies
    1. Screening Laboratory Testing
    2. Radiologic Evaluation
  10. Treatment
    1. Environmental Interventions
    2. Verbal Interventions
    3. Pharmacologic Interventions
    4. Physical Interventions
  11. Special Populations/Circumstances
    1. Lesbian, Gay, Bisexual, and Transgender Youth
    2. Autism Spectrum Disorder
    3. Legal and Forensic Issues
    4. Substance Use
  12. Controversies and Cutting Edge
    1. Ketamine for Treatment of Agitation and Depression
    2. Telepsychiatry
  13. Disposition
    1. Discharge and Outpatient Care
    2. Multidisciplinary Teams
  14. Summary
  15. Risk Management Pitfalls in the Management of Patients With Behavioral Health Emergencies
  16. Time- and Cost-Effective Strategies
  17. Case Conclusions
  18. Clinical Pathway for Management of Pediatric Patients Presenting With Behavioral Health Emergencies
  19. Tables and Figures
    1. Table 1. Most Common Categories of Psychiatric Diseases in Children and Adolescents
    2. Table 2. Suicide Risk Factors
    3. Table 3. Risk Factors for Aggression and Violence in Youth
    4. Table 4. Differential Diagnosis of Behavioral Emergencies
    5. Table 5. Medical and Behavioral Side Effects Related to Psychotropic Medications
    6. Table 6. Comparison of Neuroleptic Malignant Syndrome and Serotonin Syndrome
    7. Table 7. Informants for Assessment and Issues to be Reviewed During Assessment
    8. Table 8. Summary of Psychiatric Medications for Management of Acute Agitation
    9. Table 9. Strategies to Facilitate Interactions Between Emergency Clinicians and Patients With Autism
    10. Figure 1. Distribution of the Most Common Methods of Completed Suicide in Adolescents, 2004-2012
  20. References


Behavioral health emergencies most commonly present as depression, suicidal behavior, aggression, and severe disorganization. Emergency clinicians should avoid relying solely on past medical history or previous psychiatric diagnoses that might prematurely rule out medical pathologies. Treatments for behavioral health emergencies consist of de-escalation interventions aimed at preventing agitation, aggression, and harm. This issue reviews medical pathologies and underlying causes that can result in psychiatric presentations and summarizes evidence-based practices to evaluate, manage, and refer patients with behavioral health emergencies.


Case Presentations

A 16-year-old adolescent girl presents to the ED after ingesting an entire bottle of ibuprofen 4 hours prior. The patient vomited a few times before arrival to the ED. Her initial vital signs are: temperature, 37°C (98.7°F); heart rate, 90 beats/min; blood pressure, 100/70 mm Hg; respiratory rate, 15 breaths/min; and oxygen saturation, 100% on room air. The girl is alert and oriented. Her physical examination is significant for mild epigastric tenderness and numerous well-healed bilateral cut marks on her wrists and thighs. A quick neurological examination reveals no abnormalities. The patient is a high school student who had excelled academically, but has had poor examination results recently. Her long-term boyfriend ended their relationship 1 week prior. The girl denies any substance use. She states that when she took the pills, she had wanted to kill herself because, “everything is horrible and overwhelming.” While you evaluate her privately, she does not make eye contact and remains silent when you ask about her current intent for suicide. You begin to think about the precautions you should take to keep this patient safe and what the next steps in the management should be...

A 15-year-old adolescent boy is brought to the ED by police because he threatened his mother with a knife. The police report states that he “trashed the house.” The patient’s mother arrives in the ED and states that their argument started because she would not allow her son to go out with a group of older friends whom she believes are a bad influence. She reports that her son has been abusing “oxy” that was initially prescribed following a football-related back injury. Since the injury, depression and truancy have been significant problems. The patient’s family history is concerning for both depression and substance abuse. When you evaluate the patient, he is diaphoretic and his pupils are dilated. Initially, he is cooperative and admits that he wants to “stop using the pills.” He adds that he has had transient thoughts of suicide but has never made a plan or attempted suicide. As you continue questioning the patient, his behavior begins to escalate and, despite redirection, he starts yelling. What should you do to ensure the safety of this patient and the ED staff? How should you respond if the patient’s aggressive behavior escalates further?

A 16-year-old adolescent girl presents to your ED. She has had 4 previous psychiatric hospitalizations for depression and, most recently, 1 for psychosis. Her medical workup for the new-onset psychosis at her last ED visit was negative. She was admitted to a psychiatric facility for 15 days and discharged on risperidone. Her parents called 911 because they state she has been acting very strangely, moving stiffly, and burning up with a fever. She is sweating, pale, and does not answer any questions. She appears to be disoriented, only responds to her name by looking at you briefly, is drooling, and appears tremulous. Her vital signs are: temperature, 41.5°C (106.7°F); heart rate, 132 beats/min; blood pressure, 144/88 mm Hg; respiratory rate, 26 breaths/min; and oxygen saturation, 100% on room air. As her evaluating physician, what would be your immediate concerns? What lab tests should you order? What consultations do you obtain in the ED?



Pediatric emergency department (ED) visits for behavioral health problems continue to rise, with rates doubling in the last decade. Recent reports confirm that this trend continues, with an increase of more than 40% from 2008 to 2013, from an initial rate of 9.3 behavioral health visits per 1000 ED visits to a peak of 13.7 behavioral health visits per 1000 ED visits in 2013.1,2 United States Department of Health and Human Services data indicate that 11.2% of children and adolescents aged between 2 and 17 years have a behavioral health or developmental condition.3 The prevalence of behavioral health problems leading to impairment peaks at 22.2% in the adolescent population, with up to 40% of these youth meeting criteria for more than 1 mental health condition.4 Recently published national trends in adolescent depression have also revealed a sharp increase, from 8.7% in 2005 to 11.3% in 2014.5 This is further complicated by the fact that, in the United States, about 2.3 million adolescents (9.4%) aged 12 to 17 years are involved in illicit substance use.6 Additionally, violence and suicide remain major problems in the adolescent population. Suicide is the second leading cause of death for persons aged between 10 and 24 years, resulting in 5491 lives lost in 2015. Homicide is the third leading cause of death for a similar age range, with 4733 victims reported in 2015.7

Despite the overwhelming healthcare needs of these children and adolescents, a serious shortage of community resources continues to lead to increasing ED visits for behavioral health–related causes.8 In a study of children and adolescents with serious mental illness and impairment, only 20% utilized specialty behavioral healthcare services in community settings.9 Additionally, despite American Association of Pediatrics (AAP) recommendations that pediatricians should identify risk factors for suicide, only approximately 10% of youth discuss these with their pediatrician, and this percentage has not changed in over a decade.10 For all of these reasons, the ED often becomes the first contact for many children and adolescents who present in a crisis and may require unique psychiatric evaluation, intervention, and coordination of after-care needs.11

After the first contact with triage, the emergency clinician is expected to gather the appropriate history, identify immediate medical needs, assess safety-related issues, obtain relevant laboratory work, arrange for appropriate consultations, and establish disposition planning.12 Additionally, different healthcare organizations/settings have different resources ranging from no available psychiatric care to telepsychiatry, an in-person psychiatric consultant, a dedicated behavioral health emergency team integrated within the ED, or a stand-alone psychiatric emergency service.13 This issue of Pediatric Emergency Medicine Practice reviews common clinical presentations of behavioral health emergencies, and provides a practical approach for best practices based on current evidence and established consensus guidelines.


Critical Appraisal of the Literature

A systematic search strategy was conducted in PubMed for a comprehensive review of the literature, using the following keywords in a Boolean search: childchildrenadolescentschild and adolescentpediatricyouthbehavioralbehaviormentalmental healthpsychiatricaltereddeliriumaggressionviolencesuicideemergency, and emergencies. After reviewing the titles and abstracts of 9068 records, 161 articles were selected for full text review. Criteria for inclusion were: (1) the study was conducted in a child or adolescent population, (2) there was presentation to an ED or management in an ED setting, and (3) there was a focus on violence, aggression, suicide, or delirium. Several review papers and retrospective studies were identified with a focus on epidemiology, presentations, disparities in access, etiology, comorbidity, investigations, management strategies, practice gaps, and policy guidelines. Very few randomized controlled trials comparing interventions were identified despite a broad-based search strategy and supplemental searches related to the population of interest in ED settings.


Risk Management Pitfalls in the Management of Patients With Behavioral Health Emergencies

2. “I thought the patient’s tachycardia was due to his anxiety and odd behavior. I did not even notice his fever.”

Evaluating all of the patient’s vital signs in the ED is important. With behavioral health patients, tachycardia and fever may be a sign of NMS or serotonin syndrome, which are potentially lifethreatening conditions and cannot be missed.

9. “The kid’s mom says he does not like to do the things he used to do and now he won’t go to school. He clearly has depression.”

This patient is presenting with classic depression symptoms, but it is important to also rule out other potential issues, including drug use. Opioid misuse and addiction has become a national epidemic. Not identifying this cause of depression is a missed opportunity for potentially effective interventions. Initiating referral and connecting the patient to other resources may prevent the downward spiral of addiction and/or a life-threatening overdose in the future.

10. “This kid is out of control. Restrain him!”

Restraints are a high-risk procedure for patients and staff and should never be the first line of treatment. Environmental, verbal, and pharmacological interventions should always be attempted first; physical restraints should be utilized only in cases of imminent danger and failed interventions. When physical restraints are needed for severe agitation threatening the patient or staff, chemical restraint should be used with physical restraint to prevent selfinjury.


Tables and Figures

Behavioral Health - mental health - psychiatric emergency - Table 1. Most Common Categories of Psychiatric Diseases in Children and Adolescents



Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study, such as the type of study and the number of patients in the study is included in bold type following the references, where available. The most informative references cited in this paper, as determined by the author, are noted by an asterisk (*) next to the number of the reference:

  1. Simon AE, Schoendorf KC. Emergency department visits for mental health conditions among US children, 2001—2011. Clin Pediatr (Phila). 2014;53(14):1359-1366. (Retrospective; 65,400 patients)
  2. Rogers SC, Mulvey CH, Divietro S, et al. Escalating mental health care in pediatric emergency departments. Clin Pediatr (Phila). 2017;56(5):488-491. (Retrospective descriptive study; 13,204,293 patients)
  3. U.S. Department of Health and Human Services, Health Resources and Services Administration Maternal and Child Health Bureau. The National Survey of Children's Health 2007. Rockville, MD: U.S. Department of Health and Human Services; 2010. (National survey; 91,000 subjects)
  4. Merikangas KR, He JP, Burstein M, et al. Lifetime prevalence of mental disorders in U.S. adolescents: results from the National Comorbidity Survey Replication--Adolescent Supplement (NCS-A). J Am Acad Child Adolesc Psychiatry. 2010;49(10):980-989. (National survey; 127,605 subjects)
  5. Mojtabai R, Olfson M, Han B. National trends in the prevalence and treatment of depression in adolescents and young adults. Pediatrics. 2016;138(6):e20161878. (National survey; 180,459 subjects)
  6. Center for Behavioral Health Statistics and Quality. Behavioral health trends in the United States: results from the 2014 National Survey on Drug Use and Health (HHS Publication No. SMA 15-4927, NSDUH Series H-50). Available at: Accessed December 11, 2017. (National survey; 127,605 subjects)
  7. Centers for Disease Control and Prevention. 10 leading causes of death by age group, United States -- 2015. Available at: Accessed December 11, 2017. (Pooled national data)
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  12. * Baren JM, Mace SE, Hendry PL, et al. Children’s mental health emergencies--part 2: emergency department evaluation and treatment of children with mental health disorders. Pediatr Emerg Care. 2008;24(7):485-498. (Review)
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  43. Loh K, Walton MA, Harrison SR, et al. Prevalence and correlates of handgun access among adolescents seeking care in an urban emergency department. Accid Anal Prev. 2010;42(2):347-353. (Survey; 3050 subjects)
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  51. Martini DR. Delirium in the pediatric emergency department. Clin Pediatr Emerg Med.5(3):173-180. (Review)
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Publication Information

Vera Feuer, MD; Babar M. Saggu, MD; Jason M. Andrus, MD; Joshua Rocker, MD

Peer Reviewed By

Steven Rogers, MD, MS; Genevieve Santillanes, MD

Publication Date

January 8, 2018

CME Expiration Date

February 2, 2021

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