Best Practices in Managing Child and Adolescent Behavioral Health Emergencies

Table of Contents

 

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

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

Abstract

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?

Introduction

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: child, children, adolescents, child and adolescent, pediatric, youth, behavioral, behavior, mental, mental health, psychiatric, altered, delirium, aggression, violence, suicide, emergency, 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

References

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: https://www.samhsa.gov/data/sites/default/files/NSDUH-FRR1-2014/NSDUH-FRR1-2014.htm. 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: https://www.cdc.gov/injury/images/lc-charts/leading_causes_of_death_age_group_2015_1050w740h.gif. Accessed December 11, 2017. (Pooled national data)
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9. Burns BJ, Costello EJ, Angold A, et al. Children’s mental health service use across service sectors. Health Aff (Millwood). 1995;14(3):147-159. (Longitudinal study; 4500 subjects)
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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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27. Horwitz AG, Czyz EK, King CA. Predicting future suicide attempts among adolescent and emerging adult psychiatric emergency patients. J Clin Child Adolesc Psychol. 2015;44(5):751-761. (Retrospective longitudinal; 473 patients)
28. Stanley IH, Snyder D, Westen S, et al. Self-reported recent life stressors and risk of suicide in pediatric emergency department patients. Clin Pediatr Emerg Med. 2013;14(1):35-40. (Self-reported study; 524 patients)
29. Tishler CL, Reiss NS, Rhodes AR. Suicidal behavior in children younger than twelve: a diagnostic challenge for emergency department personnel. Acad Emerg Med. 2007;14(9):810-818. (Review)
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37. Herrenkohl TI, Maguin E, Hill KG, et al. Developmental risk factors for youth violence. J Adolesc Health. 2000;26(3):176-186. (Prospective; 808 patients)
38. Swahn MH, Bossarte RM, Palmier JB, et al. Psychosocial characteristics associated with frequent physical fighting: findings from the 2009 National Youth Risk Behavior Survey. Inj Prev. 2013;19(2):143-146. (National survey; 16,410 subjects)
39. Espelage DL, Low S, Rao MA, et al. Family violence, bullying, fighting, and substance use among adolescents: a longitudinal mediational model. J Res Adolesc. 2014;24(2):337-349. (Survey; 1232 subjects)
40. Cunningham R, Walton M, Trowbridge M, et al. Correlates of violent behavior among adolescents presenting to an urban emergency department. J Pediatr. 2006;149(6):770-776. (Survey; 1128 subjects)
41. Woolfenden S, Dossetor D, Nunn K, et al. The presentation of aggressive children and adolescents to emergency departments in Western Sydney. J Paediatr Child Health. 2003;39(9):651-653. (Retrospective; 279 patients)
42. Denninghoff KR, Knox L, Cunningham R, et al. Emergency medicine: competencies for youth violence prevention and control. Acad Emerg Med. 2002;9(9):947-956. (Review)
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)
44. Sorland TO, Kjelsberg E. Mental health among teenage boys remanded to prisoner. Tidsskr Nor Laegeforen. 2009;129(23):2472-2475. (Prospective; 40 patients)
45. Wood DB, Donofrio JJ, Santillanes G, et al. Treating psychiatric emergencies in incarcerated minors in the emergency department: what is the cost and what is their disposition? Pediatr Emerg Care. 2014;30(6):403-408. (Retrospective cross-sectional descriptive; 180 patients)
46. Constantine RJ, Andel R, Robst J, et al. The impact of emotional disturbances on the arrest trajectories of youth as they transition into young adulthood. J Youth Adolesc. 2013;42(8):1286-1298. (Retrospective; 10,360 subjects)
47. Breslow RE, Klinger BI, Erickson BJ. The disruptive behavior disorders in the psychiatric emergency service. Gen Hosp Psychiatry. 1999;21(3):214-219. (Retrospective; 1939 patients)
48. McKechnie MD, Beattie TF. Assessment of the child with altered level of consciousness. Eur J Emerg Med. 2001;8(4):251-252. (Review)
49. Dulcan MK. Dulcan’s Textbook of Child and Adolescent Psychiatry. 2nd ed. Arlington, VA: American Psychiatric Association Publishing; 2015. (Textbook)
50. Ghaziuddin N, Dhossche D, Marcotte K. Retrospective chart review of catatonia in child and adolescent psychiatric patients. Acta Psychiatr Scand. 2012;125(1):33-38. (Retrospective; 101 patients)
51. Martini DR. Delirium in the pediatric emergency department. Clin Pediatr Emerg Med.5(3):173-180. (Review)
52. Halamandaris PV, Anderson TR. Children and adolescents in the psychiatric emergency setting. Psychiatr Clin North Am. 1999;22(4):865-874. (Review)
53. Zayac A, Grewal S, Hegazy H. Anchors aweigh: the dangers of anchoring bias in a case of serotonin syndrome. Crit Care Med. 2016;44(12):541. (Case review)
54. Croskerry P. From mindless to mindful practice--cognitive bias and clinical decision making. N Engl J Med. 2013;368(26):2445-2448. (Case review)
55. Mahajan P, Alpern ER, Grupp-Phelan J, et al. Epidemiology of psychiatric-related visits to emergency departments in a multicenter collaborative research pediatric network. Pediatr Emerg Care. 2009;25(11):715-720. (Retrospective; 84,793 visits)
56. Goldstein AB, Horwitz SM. Child and adolescent psychiatric emergencies in nonsuicide-specific samples: the state of the research literature. Pediatr Emerg Care. 2006;22(5):379-384. (Literature review)
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70. Kaplan T. Emergency Department Handbook: Children and Adolescents With Mental Health Problems. London: RCPsych Publications; 2009. (Textbook)
71. Correll CU, Carlson HE. Endocrine and metabolic adverse effects of psychotropic medications in children and adolescents. J Am Acad Child Adolesc Psychiatry. 2006;45(7):771-791. (Review)
72. Lee CS, Williamson LR, Martin SE, et al. Adverse events in very young children prescribed psychotropic medications: preliminary findings from an acute clinical sample. J Child Adolesc Psychopharmacol. 2015;25(6):509-513. (Prospective; 158 patients)
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76. Kuehn BM. FDA panel seeks to balance risks in warnings for antidepressants. JAMA. 2007;297(6):573-574. (Review)
77. Nischal A, Tripathi A, Nischal A, et al. Suicide and antidepressants: what current evidence indicates. Mens Sana Monogr. 2012;10(1):33-44. (Review)
78. Goodman WK, Murphy TK, Storch EA. Risk of adverse behavioral effects with pediatric use of antidepressants. Psychopharmacology (Berl). 2007;191(1):87-96. (Retrospective; 4000 subjects)
79. Amitai M, Chen A, Weizman A, et al. SSRI-induced activation syndrome in children and adolescents—what is next? Curr Treat Options Psychiatry. 2015;2(1):28-37. (Review)
80. Hagino OR, Weller EB, Weller RA, et al. Untoward effects of lithium treatment in children aged four through six years. J Am Acad Child Adolesc Psychiatry. 1995;34(12):1584-1590. (Retrospective; 20 patients)
81. Groleau G. Lithium toxicity. Emerg Med Clin North Am. 1994;12(2):511-531. (Review)
82. McKnight RF, Adida M, Budge K, et al. Lithium toxicity profile: a systematic review and meta-analysis. Lancet. 2012;379(9817):721-728. (Meta-analysis; 385 studies)
83. Speirs J, Hirsch SR. Severe lithium toxicity with “normal” serum concentrations. Br Med J. 1978;1(6116):815-816. (Case report; 1 patient)
84. Ortinski P, Meador KJ. Cognitive side effects of antiepileptic drugs. Epilepsy Behav. 2004;5 Suppl 1:S60-S65. (Review)
85. Besag FM. Behavioural effects of the new anticonvulsants. Drug Saf. 2001;24(7):513-536. (Review)
86. Mancuso CE, Tanzi MG, Gabay M. Paradoxical reactions to benzodiazepines: literature review and treatment options. Pharmacotherapy. 2004;24(9):1177-1185. (Review)
87. Kandemir H, Yumru M, Kul M, et al. Behavioral disinhibition, suicidal ideation, and self-mutilation related to clonazepam. J Child Adolesc Psychopharmacol. 2008;18(4):409. (Letter to editor)
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