IACAPAP Textbook of Child and Adolescent Mental Health

MISCELLANEOUS

Chapter

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CHILD AND ADOLESCENTPSYCHIATRIC EMERGENCIES
Ralph Parker Fader & Megan M. Mroczkowski

Ralph Parker Fader MD
Fellow, Child and Adolescent
Psychiatry, New YorkPresbyterian Hospital, USA
Conflict of interest: None
reported

Megan M Mroczkowski MD
Program Medical Director,
Pediatric Psychiatry Emergency
Service, Morgan StanleyChildren’s Hospital of New
York-Presbyterian Hospital;
Associate Professor of
Psychiatry at Columbia
University Medical Center, New
York, USA
Conflict of interest: nonereported

This publication is intended for professionals training or practising in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the editors or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the editors or IACAPAP endorse their content
or recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2020. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial.
Suggested citation: Fader RP, Mroczkowski MM. Child and adolescent psychiatric emergencies. In Rey JM & Martin A (eds),
JM Rey’s IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent
Psychiatry and Allied Professions 2020.

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Psychiatric complaints in youth are an increasingly common reason for
emergency department (ED) care (Kalb, 2019). Mood and anxiety disorders,
psychosis, behavior problems, and substance use all carry significant risk of
impairment and often emerge during childhood and adolescence. Additionally,
these conditions are often complicated by suicidality, aggression, and risky
impulsive behavior that require containment and de-escalation. Psychiatricemergency assessments are crucial to safely and effectively evaluating, diagnosing,and treating these disorders (Kalb, 2019; Merikangas, 2009). This chapter aims
to outline an standardized, efficient way of evaluating and managing psychiatricemergencies in children and adolescents.

GENERAL PRINCIPLES
Safety plays a crucial role in psychiatric evaluation in youth. The ED setting
often affords clinicians more resources to help manage psychiatric crises. Use ofquiet or seclusion rooms, continuous observation, medication for agitation, andphysical restraint are at times necessary to contain patients who pose an imminent
risk to themselves or others. Interventions like these should be used sparingly
and only when clinically appropriate as they come with their own risks (e.g.,
adverse drug effects, injury, emotional trauma, etc.). These interventions, thoughvital at times for the physical safety of the patient or others, can also decrease
the patient’s and the family’s sense of emotional safety. Working with emergency
medicine treatment providers to find private, quiet spaces will allow patients andtheir families to feel more at ease with the assessment and may facilitate disclosureof psychiatric symptoms or precipitating conflicts. In instances where private
spaces are not available, or the patient’s behavior poses too great a risk to assessalone, taking time at the beginning of the evaluation to inquire about ways toaddress patients’ comfort (e.g., food or drink, chairs, having caregivers nearby)
can also mitigate patients’ reticence. Simple measures to address both physical andemotional safety may obviate the need for more restrictive measures later in theevaluation and treatment process.
When psychiatric emergencies occur outside the emergency department,
assessing youth with psychiatric complaints can be more complicated. As in theED, safety of patient and staff should take priority. Techniques for maximizing
safety outside of the ED setting include decreasing ambient stimulation (e.g.,lights, noise, other people, etc.), removing dangerous objects (including sharps
and hard/heavy objects), and maintaining continuous observation of the young
person from at least two arm’s length away. Providers should introduce themselves
slowly and explain their role to the patient with simple language and a calm, nonjudgmental tone. As in the ED, asking about and addressing patient comfort may
help to both de-escalate the behavior and increase rapport. The goal, if there areconcerns about the child’s safety due to psychiatric symptoms, should be to calm
the young person enough for transport to the nearest emergency department forevaluation, if possible.
Obtaining collateral information is a mandatory component of every
evaluation. Children who are struggling are often unable to independently reachout for help. Additionally, they may not always be at a developmental level thatallows them to answer certain clinical questions. As such, caregivers’ reports are

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Goals of Evaluation•

Determine if the patient is at imminent risk of harm to self or others•

Clarify the psychiatric diagnoses (if any) that contributed to the presenting complaint•

Identify the biological, social, and psychological factors that contributed to thepresenting complaint•

Establish the patient’s level of functioning at baseline and changes from that baseline•

Identify the strengths, supports, and protective factors that may alleviate distress andmitigate risk of harm to self or others•

Clarify the problems and goals for treatment•

Determine the most appropriate level of care for treatment

crucial, particularly in emergencies. In addition to the psychiatric history, caregivers
will need to clarify who is responsible for medicolegal decision making for thechild, especially if consent for medication or inpatient hospitalization is required.
Caregivers can also identify other current care providers, school placement, and if
there is past or current involvement of child protection services. If caregivers are
not available, school staff and/or social services personnel may be able to provide
collateral information helpful for clinical evaluation.
Psychiatric assessment of children and teenagers also requires anunderstanding of cognitive, emotional, and physical development. Althoughdevelopment tends to follow a general trajectory, each child’s development is uniqueand may or may not match closely their chronological age or physical appearance.
Tailoring the interview and assessment to the child’s developmental level will help
providers build rapport with the patient and elicit clinical information that isboth accurate and helpful. A general rule of thumb is that younger school age
children require more direct questions, may need to use major life events (e.g.,birthdays, holidays, school starting or ending) as anchors to help constructtimelines, and may have little or no understanding of topics like death, trauma, orsex (Margaret & Hilt, 2018). Adolescents, conversely, may respond better to openended or exploratory questions, may be able to independently describe psychiatric
symptoms and construct timelines, and may withhold information about theirexperiences with death, trauma, sex, or substance use due to feelings of shameor fear of punishment (Margaret & Hilt, 2018). Clinicians should adjust theirinterview technique based on cues from the patient to foster rapport and to elicit
necessary clinical information.

Click on the picture to access“Child and Youth Emergency
Mental Health Care: A
National Problem”
by JL Cooper and R Masi.
The National Center forChildren in Poverty (2007)

Telepsychiatry
Telemedicine is a rapidly evolving field, particularly in the aftermath of the
COVID-19 pandemic. Telecommunication technology allows physicians to provide
clinical care across vast distances to those with limited access to medical resources.
Given the relative lack of reliance on complicated testing equipment, psychiatry
has flourished in this new clinical modality. Telepsychiatry allows patients to receive
expert psychiatric consultation that would otherwise be inaccessible. The benefitsof telepsychiatry, however, also come with significant questions of safety, privacy,
and system compatibility. Each of these are addressed through a combination ofstandards of practice, healthcare system protocols, and legal requirements (Deslich,

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IACAPAP Textbook of Child and Adolescent Mental Health2013). Providers interested in establishing a telepsychiatry practice should become
familiar with the rules and regulations specific to their jurisdiction.
For emergency psychiatric care, many of the same safety tenets that apply
generally also apply to telepsychiatry. Telepsychiatry providers should ensure thatthe patient and family are with care providers who can manage agitation or harm
to self or others should it occur during the evaluation. There should be clear lines
of communication between the telepsychiatry provider and the care providers
who are with the patient and family to determine when these interventions arenecessary. Providers should obtain formal consent for telepsychiatry assessment
from the patient and/or family. Performing a psychiatric assessment across
telecommunication devices can also affect the rapport-building process.
A variety of equipment and communication systems are used to facilitate
telemedicine encounters and each of these come with costs, logistic requirements,
and privacy concerns (Deslich et al, 2013).

Psychiatric versus Social Emergency
Clinicians must determine whether the presenting crisis is broadly of a
psychiatric nature or would be best characterized as a social emergency. Typically,
psychiatric emergencies in which patients are an acute risk to themselves or others
are best served by admission to an inpatient unit. Social emergencies may be best
addressed using community-based services such as home-based crisis intervention,family therapy, or individual therapy. However, many cases have features of both:patients presenting with “social” emergencies may also necessitate inpatient
psychiatric admission for diagnostic clarification and patient or family safety.
Furthermore, social emergencies usually are psychosocial stressors themselves andmay exacerbate underlying psychiatric illness. Some examples of psychiatric andsocial emergencies are listed in table J.1.1.

Click on the picture to watch
a video clip explaining whatparents, children and mental
health providers should
expect when a child istransported to the emergency
room for a mental healthevaluation (8:45)

Table J.1.1. Examples of psychiatric and social emergencies
Psychiatric Emergencies
•
•
•
•
•
•
•

Suicidal ideation, planning, attempts
Homicidal ideation
Acute psychosis
Mania
Depression
Anxiety
Agitation/aggression

Social Emergencies
•
•
•
•
•
•
•
•

Parent/child relationship issues
Homelessness
Death of family or friend
Military deployment of parent
Divorce of separation of parent/
caretaker
Immigration status concerns
Food insecurity
Disciplinary crisis

MEDICAL ASSESSMENT OF EMERGENCYPRESENTATIONS
Hickam’s dictum says that “patients can have as many diseases as they darnwell please.” Although it is meant to be humorous, this adage carries considerable
clinical and ethical weight when assessing patients with psychiatric emergencies.
According to the 2001-2003 National Comorbidity Survey Replication, almost
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two-thirds of people in the US with a psychiatric disorder have at least one nonpsychiatric medical condition (Alegria et al, 2016). Those who engage in destructive
behavior (i.e., suicide attempts, self-injury, and violence) as part of a psychiatricdecompensation can sometimes have serious medical sequelae. Furthermore,some medical conditions can present with psychiatric signs and symptoms (i.e.,delirium, intoxication, traumatic brain injury). Addressing both the psychiatricand medical components of a patient’s presentation to the ED is necessary for goodquality patient care.
The standard medical work-up should begin with a history of the presenting
illness (including a thorough review of systems), vital signs assessment, andphysical examination. Underlying medical complaints uncovered in these initialstages should inform laboratory and imaging studies. Laboratory tests may include
a metabolic panel (to assess electrolytes, glucose level, kidney function, and liverfunction), blood count (to assess for cytopenias and infection), urinalysis and urine
toxicology screen (to assess for infection and intoxication). If there are concerns
about head trauma or an intracranial mass, imaging may be warranted. In children
and adolescents, magnetic resonance imaging should be used whenever possible
over computed tomography to minimize radiation exposure. Further assessment,
work-up, and treatment should be specific to the patient’s presentation (see table
J.1.2).

COMMON PRESENTING PROBLEMS
Clinicians must determine whether patients in crisis require inpatientadmission or whether resources in the community would best address thepresenting complaints. We describe below common presenting problems and key
questions to consider during the evaluation. Further assessment, diagnostic, andmanagement issues are presented for each presenting problem.
Table J.1.2 Standard Medical Work-up
Investigations•

Vital signs and physicalexamination•

Purpose•Screen for medical stability

Metabolic panel•

Assess for electrolyte/glucose
derangements and renal dysfunction•

Liver function tests•

Assess for hepatic dysfunction andprotein deficiency•

Complete blood count•

Assess for cytopenias and infection•

Urinalysis•

Assess for infection•

Urine toxicology•

Assess for certain types of substanceuse•

Magnetic resonanceimaging or computed
tomography•

Assess for traumatic brain injury andintracranial mass (to be avoided unlesshigh suspicion for positive findings)

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Suicidal Ideation, Planning, and Attempts
Key Questions• Are you having thoughts of wanting to kill yourself?
•

Do you have a plan as to how you would kill yourself?

•

Have you taken steps or made preparations to carry out this plan?

•

Have you tried to kill yourself before? If so, when and how?

•Is there anything/anyone who would keep you from acting on these thoughts?

Suicide Risk Assessment
Issues about suicidal behavior are described in detail in chapter E.4of the eTextbook. Given the risk of suicide in youth, a comprehensive suicide
risk assessment is necessary to categorize the patient’s risk and recommend theappropriate level of care. There are many suicide screening instruments utilized
for this purpose including the Columbia Suicide Severity Rating Scale (C-SSRS),
SAFE-TP, and the ASQ Suicide Screening Questions. Bear in mind that thepredictive value of any of these aids is low and that preventing suicide in practiceis very difficult.
The Emergency Department Screen for Teens at Risk for Suicide (EDSTARS) is a multi-site study to identify latent class profiles of adolescents withelevated suicide risk and to study the association between these profiles and mental
health service utilization (King, 2019). This study found five profiles of elevatedsuicide risk with differing patterns of eight risk factors. Risk factors included:• History of multiple suicide attempts• Suicidal ideation during the previous month• Depression• Alcohol or drug use• Impulsive or aggressive behaviors, and• Physical or sexual abuse.
Adolescents with previous, but not recent suicidal thoughts, and those fromracial and ethnic minorities were least likely to utilize mental health treatment(King, 2019).

•

Elements of the Brown-Stanley Safety Plan
Warning signs (mood, behavior, thoughts, images, situation) suggesting that acrisis may be developing
Internal coping strategies – things I can do to take my mind off my problems
without contacting another person (relaxation techniques, physical activity, etc.)
People and social settings that provide distraction•••

People whom I can ask for help
Professionals or agencies I can contact during a crisis (e.g., Lifeline)
Making the environment safe.

••

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Safety Planning
The estimated level of risk of patients who present with suicidal ideation
is key to determine the correct level of care. Patients believed to be at the highest
risk typically require inpatient admission. Clinicians have often used the strategy
of “contracting for safety” as a verbal or written record of a patient’s commitment
to staying safe, although its effectiveness is unclear. Brown and Stanley expanded
upon, and sought to make this contract more practical and evidence-based—thesafety plan. The safety plan is a document whereby clinician and patient discuss
warning signs, internal coping strategies, people and social settings that provide
distraction, people the patient can ask for help, professionals and agencies thepatient can contact during a crisis, and steps to make the home environment safer(Stanley & Brown, 2012). Safety plans are recommended for every patient who
has suicidal ideation and is discharged with outpatient mental health treatment. A
template is available here.

Self-Injury
Key Questions•

Have you ever tried to hurt or harm yourself?

•

If yes, how many times?

•

What did you do to hurt yourself?

•

What were your thoughts when you were hurting yourself?

•

Was there any part of you that wanted to die or kill yourself when hurting
yourself?

Kathe Kollwitz: Woman with
Dead Child, 1903. Private
collection

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IACAPAP Textbook of Child and Adolescent Mental HealthSelf-inflicted injury is a common presentation in pediatric EDs. Selfinjury can range from deliberate self-harm with suicidal intent to involuntary or
stereotypic behavior, the latter is often observed in the developmentally disabled.
The most common forms of deliberate self-harm are cutting and burning, andpatients may use these behaviors as a way to cope with distressing emotions or topunish themselves. Stereotypic behaviors may include hitting, biting, headbanging
or scratching, and patients may use these behaviors to self-soothe, manipulate theenvironment, or express emotional distress.
The priority for treatment when patients present with self-injury is to assess,clean, suture, and dress the wound. Providers should obtain the patient’s historyof tetanus vaccination. If bite wounds are severe, prophylactic antibiotics may benecessary. Once the wounds have been properly treated, providers should explore
the context of the self-injury with the patient and family, with particular attention
to the possibility of suicidal intent. Those who pose an imminent risk of harm toself may require extended observation or inpatient admission. Those consideredsafe to be discharged should complete a safety plan (see above) with the family
present prior to discharge. The patient and family should also be educated on homesanitation, the process of examination (and removal) of objects that could be used
for self-harm within the home environment.

Photo: Fabrizio Canonico

Out-of-Control/Aggressive Behaviors
Key Questions•

What are the presenting behaviors?

•

What are the triggers for these behaviors?

•

How long has this been going on?

•

Have other people or objects been harmed?

•

Do the parents/caregivers feel safe at home with the patient?

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A 14 year old female
was brought to the ED forcrisis assessment. She
presented with superficial
cuttings on her arms (about
50 cuts) and had been
cutting herself for one year.
She had told her parents
about the cutting one monthearlier. She typically cut
herself when her mood was
low. She denied wanting todie. However, she persistedwith cutting herself. She
reported intrusive thoughtsof suicide with a recent
increase in frequency
and intensity and was
being bullied at school.
Despite these symptoms,
her functioning was not
impaired; she was insightful
for her age and stated she
cut herself to relieve tension
and to ward off feelings ofloneliness. She described“dips” in her mood triggeredby stressful situations anddid not sleep well. Family
history was significant for
depression. She denied
substance or alcohol use
and showed no signs ofintoxication. She had agood relationship with herparents, who described her
as a “good kid.”
She was assessed as
suffering from deliberate
self-harm and possibly amajor depression. Suicide
risk was assessed as low
and discharged home witha referral to outpatientmental health services.
She returned to the ED
six days later dissclosing
feeling suicidal, exhausted
and wanting to “give up.”
She denied having a plan.
Eventually she revealed
that a good friend had
died of suicide the day
before. The patient was
subsequently
admitted
voluntarily to the adolescentinpatient psychiatric unit
due to high suicide risk
Carandang et al (2012).

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IACAPAP Textbook of Child and Adolescent Mental Health

A myriad of causes may underlie aggressive outbursts; their characterization
can help clinicians determine the best management. Common examples include
parent/child conflict, substance use, mania or psychosis, and underlying medical
illness. Table J.1.3 outlines consensus guidelines for both the non-pharmacologic
and pharmacologic treatment of agitation based on etiology.
Table J.1.3. Management of Adolescent Agitation in the Emergency Department*
ETIOLOGY

Delirium

Substance
intoxication orwithdrawal

NON-PHARMACOLOGICINTERVENTIONS•Keep staff consistent•

Family by bedside to help orientation•

Clocks, calendars to orient•

Open window coverings in daytime•

Cluster care to minimize sleep
disturbanceUnknown
etiology

PO: quetiapine, risperidone, or clonidine•

IM: olanzapine or chlorpromazine•

IV: haloperidol or lorazepam•

Unknown substance: lorazepam +/- haloperidol•

Urine toxicology negative (suspect synthetic
cannabinoids or cathinones): lorazepam +/haloperidol or chlorpromazine•

PCP intoxication: lorazepam•

Alcohol/benzodiazepine withdrawal or stimulant
intoxication: lorazepam +/- haloperidol•

Opiate withdrawal: Clonidine or opiate
replacement (buprenorphine or methadone)•

Add symptomatic treatment

Tablet computer•

Fidget and sensory tools

Extra dose of current medication•

Weighted blankets

PO: clonidine•

Noise-cancelling headphones

PO/IM: diphenhydramine•

PO/IM: antipsychotic (risperidone,
chlorpromazine, olanzapine)•

Specific treatment of the psychiatric condition•

Moderate: diphenhydramine or lorazepam orolanzapine•

Severe: chlorpromazine or haloperidol +lorazepam or olanzapine

Offer food and/or beverages.

•

Ask parent/family to either stay orleave room, depending on current
relationship.

•
Developmental
disability or•
autism spectrum
disorder•Clear underlying
psychiatricdiagnosis•••

MEDICATION•

Storyboard about the ED visits•

Offer food and/or beverages.

•

Ask parent/family to either stay orleave room, depending on current
relationship.

•

Offer food and/or beverages.

•

Ask parent/family to either stay orleave room, depending on current
relationship.

•

Behavioral and environmental
strategies to deescalate

PO: oral; IM: intramuscular; IV: intravenous*Adapted from Gerson et al, 2019.

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9IACAPAP Textbook of Child and Adolescent Mental HealthDelusional/Psychotic
Key Questions•

What are the presenting symptoms?

•

How long have these symptoms been present?

•

Is there a family history of psychosis?

•

Is the patient experiencing command auditory hallucinations? If so, what are thehallucinations commanding the patient to do?

•

Has the patient acted on these commands?

•

What is the patient’s current level of functioning?

A systematic review showed that psychotic symptoms are relatively common
in young people (median 17% among 9 to 12-year-olds and 7.5% in 13- to
18-year-olds) (Kelleher et al, 2012). If these symptoms persist, impair functioning,or lead to acute risks to the patient or others, the young person may present to
the pediatric ED. Proper screening and work-up of psychosis in children andadolescents is of paramount importance for diagnostic clarification, safety, andtimely treatment.

First-Episode Psychosis
Work up of a first-episode psychosis should begin with a physical exam withfocus on neurological examination, vital signs, weight, height, body mass index(BMI), and waist circumference (see table J.1.4).

Commonly Used Psychosis Rating Scales•

Based on the clinician’s interview
with the patient and observationsof the patient’s behavior over theprevious 2-3 days•

Requires a 45-minute clinicalinterview during which the patientis rated from 1 to 7 on 30 different
symptoms based on the interview
as well as on reports of family
members and other informants.
It has three subscales:
positive, negative, and general
psychopathology symptoms.

Brief Psychiatric Rating Scale(BPRS) (Overall, 1962)

Positive and Negative Syndrome
Scale (PANSS) (Kay et al, 1987)•

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Table J.1.4. First-Episode Psychosis Work-Up*
DESIRABLEIF
INDICATEDTESTESSENTIALRATIONALECBCXElectrolytes

X

Renal function
tests

X

Liver function tests

X

ESR

X

Broadly screen for inflammatory andrheumatologic disorders

Antinuclear
antibody

X

Broadly screen for inflammatory andrheumatologic disorders

Fasting glucose

X

Lipid profile

X

Prolactin level

X

Hepatitis C

X

Pregnancy testX

Urine drug screen

X

TSH

X

FTA-ABSX

HIV test

X

CeruloplasminX

To rule out Wilson’s disease

Vitamin B12

X

To rule out pernicious anemia

X

If MRI not available

MRI headX

CT headEEGX

If documented history of: seizure, past head
injury, uncooperative patient with confusion,or suspicion of narcolepsy

Lumbar puncture

X

Only if infection is clinically considered andserum alone is inadequate to establish adiagnosis.

KaryotypeX

Only if physical presentation or family
history suggests presence of a genetic
syndrome.

Heavy metals

X

If home/work environment suggests
exposure to toxic substances

Eye examX

If concern about cataracts.

*adapted from Freudenreich et al (2009)

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Delirium

Common causes ofdelirium in children
and adolescents

Key Questions•

Does the patient have a waxing/waning level of consciousness? If so, for how
long?

•

Are there vital sign abnormalities?

•

Does the patient have signs of infection or illness?

•

Are there laboratory abnormalities?

Clarifying and then treating the underlying etiology is the crucial aspectof delirium treatment. However, complete resolution of delirium symptoms may
take anywhere from days to months after treating the underlying cause. Managing
the symptoms of delirium during the period of work-up and treatment can help
decrease the risk of avoidable complications. Environmental measures are a lowrisk and potentially high-yield intervention in addressing delirium in children andadolescents, as it may decrease the need for medication. Environmental measures
include:•••••Ensuring consistency in the staff working with the patient as much as
possible.
Opening windows for daylight exposure to help regulate the sleepwake cycle.
Clustering items of care (i.e., testing, blood extraction, medications) tominimize sleep disruption.
Ensuring that family or staff are frequently at bedside to reassure andre-orient the patient.
Keeping familiar toys, books, or games at bedside.

Medical
•
•
•
•
•

Fever
Nonconvulsive statusepilepticus
Childhood confusionalmigraine
Cerebral systemic
lupus erythematosus
End stage HIV/AIDS

Medication related•••

Anticholinergic
Antipsychotic
Benzodiazepine
withdrawal•

Drugs of abuse

If delirium symptoms persist after the implementation of environmental
measures, or are interfering with treatment, medication may be necessary. However,it should be noted that there are limited controlled data about effectiveness of
medications; recommendations are largely based on clinical experience and expert
opinion.
Using medication to control delirium symptoms should be based on thepatient’s current condition, the underlying etiology for the delirium, and thepotential risks and benefits associated with the medication in question. Medications
like melatonin and alpha-2-agonists may help with sleep disturbance. Alpha-2agonists may also help with agitation but carry risks of hypotension and should
be used with caution in youth with vital sign instability. Gabapentin may alleviate
anxiety in delirious patients, although it should be avoided in children with renal
dysfunction. Benzodiazepines and antipsychotics can help decrease acute agitation.
However, they both can cause a worsening of the delirium, potential dependence forbenzodiazepines, arrhythmias and seizures for antipsychotics, and excess sedation
for both. If antipsychotics are clinically indicated, second generation agents have amore favorable side effect profile as compared to first generation ones. Regardlessof what is used, patients who are started on a medication for the treatment of
delirium should be closely monitored for the impact on delirium symptoms as well
as for potential adverse effects.

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Intoxication and Overdose
Key Questions•

What are the patient’s vital signs?

•

Is the patient able to describe what substance taken?

•

When did the patient last use the substance(s)?

•Acute withdrawal from benzodiazepines or alcohol and alcohol intoxication
can be life-threatening and must be addressed immediately with medical
stabilization.

The initial step in any presentation of overdose or intoxication is emergency
medical evaluation and triage, with particular attention to circulation, airway, andbreathing. Depending on the severity of the patient’s presentation, electrolytes,
blood glucose level, complete blood count, liver function tests, electrocardiogram,
blood alcohol level, and urine toxicology may be indicated to identify medical
stability, the agent ingested, and potential adverse sequelae of ingestion. Oncethe ingested agent has been identified, providers should contact poison control
services (if available) for specific guidance on evaluation, monitoring, and medical
treatment. If the agent used can cause an intoxication or withdrawal syndrome,a psychiatric consultation may help the medical team with management ofagitation or distress. Tables J.1.5 and J.1.6 summarise the toxic syndromes forvarious ingestions as well as the intoxication and withdrawal symptom profiles forrecreational substances (Olsen et al, 2007, Radovanovic et al, 2000).
Table J.1.5. Common Substances in Overdose
SUBSTANCETOXIC SYNDROME

Salicylate•

Dizziness, nausea, vomiting, tinnitus, tachypnea, tachycardia, fever,lethargy, coma, seizures, cardiopulmonary failure, death•

Within 24 hours after ingestion: May initially be asymptomatic; nausea,
vomiting, diaphoresis
Between 24-72 hours after ingestion: right upper quadrant pain,transaminitis, elevated INR, renal damage
Longer than 72 hours after ingestion: fulminant liver failure, hepatic
encephalopathy, coagulopathy, hypoglycemia, renal failure, death

Acetaminophen/paracetamol•••

Diphenhydramine••

Selective Serotonin
Reuptake Inhibitors(SSRIs)Lithium

Psychiatric emergencies

Less than 0.3 grams: somnolence, tachycardia, nausea, vomiting,dizziness, blurry vision, urinary retention, constipation, xerostomia
Between 0.3 - 1 gram: agitation, confusion, hallucinations, QTC
prolongation
Greater than 1 gram: delirium, psychosis, seizure, cardiac arrhythmia,
coma, death

Serotonin syndrome:• Altered mental status (anxiety, agitation, disorientation)• Neuromuscular dysfunction (tremor, hyperreflexia, myoclonus, rigidity)• Autonomic instability (hypertension, tachycardia, tachypnea, hyperthermia,
diaphoresis, xerostomia, mydriasis, gastrointestinal distress, flushing,arrhythmia)•

Dizziness, vomiting, diarrhea, nystagmus, tremor, ataxia, tachycardia,
confusion, muscle weakness, arrhythmia, seizures, hypotension, death

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Table J.1.6. Intoxication and Withdrawal Symptoms of Common Recreational Substances
and Recommended Treatment
SUBSTANCEINTOXICATIONWITHDRAWAL

TREATMENT

0-12 hours after last use:
Shakiness, headache, anxiety,nausea, vomiting, tachycardia,
tachypnea, diaphoresis
AlcoholSedatives
Hypnotics

Sedation, dizziness, ataxia,
nystagmus, confusion, paradoxicalagitation, disinhibition, amnesia

12-24 hours after last use:
Confusion, hallucinations with
intact reality-testing, tremor,
agitation
24-48 hours after last use:
Seizures, death

Benzodiazepine taperusing the Clinical InstituteWithdrawal Assessment for
Alcohol (CIWA-A)
Referral to substance use
treatment

4-12 days after last use:
Delirium tremens

Opioids

Stimulants

CannabisHallucinogens(PCP,
MDMA, LSD,
psilocybin,
ketamine, GHB)

Sedation, euphoria, miosis,
nausea, constipation, urinary
retention, respiratory depression,
hypotension, bradycardia,
cardiopulmonary collapse,
respiratory arrest, coma, death

Flu-like symptoms, shaking,diaphoresis, gooseflesh,mydriasis, yawning, rhinorrhea,
nausea, vomiting, diarrhea,
anxiety, depression, akathisia,
crampsSupportive care using theClinical Opiate Withdrawal
Scale (COWS)
Buprenorphine induction,
Methadone, or clonidine
Referral to substance use
treatment
Supportive care

Tachycardia, hypertension,tachypnea, hyperthermia,
diaphoresis, mydriasis, anorexia,
euphoria, agitation, anxiety,decreased reality testing,hallucinations

Intense dysphoria, anxiety,fatigue, restlessness, increased
appetite, cognitive slowing, vivid
dreams, sexual dysfunction,suicidality

Conjunctival injection, impaired
short-term memory, impaired
attention, impaired motivation,
ataxia, perceptual disturbance,increased appetite, euphoria orrelaxation

Decreased appetite, difficulty
sleeping, irritability, anxiety,headaches, nausea, abdominal
pain

Altered level of consciousness,dissociation, perceptual
disturbance, euphoria, agitation,
aggression, tachycardia,
hypertension, diaphoresis

Variable

Cardiac monitoring
Benzodiazepines for acuteagitation
Referral to substance use
treatment
Supportive care
Benzodiazepines for acuteagitation
Referral to substance use
treatment
Supportive care
Referral to substance use
treatment

Intoxicated youth are increasingly
presenting to emergency services(photo: Daniel Neves)

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IACAPAP Textbook of Child and Adolescent Mental Health

Depressive Symptoms
Key Questions•

What are patient’s symptoms?

•

How long have these symptoms been present?

•

Is the patient in mental health treatment and if so, where?

•

What is the patient’s current level of functioning? How far is this from baseline?

•

Does the patient have suicidal ideation, intent, plan? If so, describe in detail.

•Has the patient done anything to try to end his/her life? If so, when and what.

In an emergency, psychiatric evaluation of a patient with known or suspected
depressive symptoms, in addition to understanding the depressive symptomology,
it is imperative to characterize suicidal ideation (intent, planning, previous
attempts) and the patient’s current and baseline level of functioning. These two
key areas of the history will largely dictate the level of care needed. How to deal
with suicidality is described above. Briefly, patients at high risk for suicide will
likely require a safe environment, typically, inpatient admission. In patients whose
depressive symptoms are so severe as to render them unable to function (eat, drink,attend to activities of daily living), inpatient admission may also be warranted.
There are many scales to measure depression severity (Zuckerbrot et al,2007). Examples include the Columbia Depression Scale and the Mood andFeelings Questionnaire (MFQ) (Angold et al, 1995). Both are free to use and thelatter is available in multiple languages.

Fearful/Mute
Key Questions•

How long has the patient been presenting this way?

•

Have there been any changes in the patient’s life—home, school, friends?

•

Does the patient feel safe at home? School? Outside of school? Is anyone in
the patient’s life threatening him/her?

•Is there a history of alleged or proven abuse or neglect? Has child protection
services ever been involved?

•

Has the patient ever had similar symptoms in the past?

The differential diagnosis for a patient who is fearful or mute is broad andincludes anxiety, acute trauma or abuse, oppositional behavior, selective mutism,and medical illness. History should focus on changes in the patient’s life athome or at school, past and current trauma, and history of similar presentations.
Consultation with specialists in pediatrics, neurology, and social work/child welfare
may be helpful.

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IACAPAP Textbook of Child and Adolescent Mental Health

Mistreatment
Key Questions•

What are the allegations of abuse or neglect?

•

Is there evidence suggesting mistreatment even if there are no explicit reports?

•

Who is the alleged perpetrator?

•

With whom does the patient reside? Names and ages of all people, includingchildren, in the domicile.

•

A full head-to-toe medical exam, documenting any marks and bruises, must becompleted.

•

Follow the requirements relating to child protection in your state or country.

Encountering evidence of child abuse and neglect is one of the mostemotionally-charged experiences in child emergency psychiatry. Abuse and neglect
can be both the response to and the cause of psychiatric symptoms in children.
Assessing for signs of abuse or neglect needs to be handled with care and empathy
and providers should adjust their approach so that screening questions aredevelopmentally appropriate for the patient. Whenever possible, providers shouldinterview children and adolescents without their caregiver present when assessing
for abuse as youth may not feel safe talking about abuse in front of their caregiver,particularly if their caregiver is the abuser.
Younger children may respond better to indirect questions like “What doyour parents do when you get in trouble?” or “Do other people ever touch yourprivate parts?” Older children and teenagers may respond to more direct questions
such as “Have you ever felt mistreated?” or “Has anyone ever touched you in a waythat made you feel uncomfortable?” Answers to these questions should guide more
direct questioning about physical, emotional, or sexual abuse or neglect. Even withdirect questioning, many children will not feel comfortable disclosing abuse andneglect. Open-ended exploration of what their lives are like at home may reveal
red flags. Additionally, if patients disclose abuse, it is important to only get the
information that you need for treatment and disposition for the patient. Delving
too deeply into the details of the abuse could cause the patient further distress andcould contaminate the evidence and potentially undermine legal proceedings lateron (see also chapters B.1 and J.14).

Trends in psychiatricemergency department visitsamong youth and young
adults in the US (3:26)

Photo: La Voz de Galicia

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IACAPAP Textbook of Child and Adolescent Mental HealthParent/Child/School Conflict
Key Questions•

What are the presenting behaviors and degree of harm to others/property?

•

What are the circumstances surrounding these behaviors?

•

Are these new behaviors or chronic?

•

Is the patient in psychiatric treatment?

•

What is the patient’s current educational status (e.g., special education)?

Parent/child conflict or conflict at school are common emergency
presentations. It is incumbent upon the clinician to obtain a history of the
behavior, circumstances surrounding it (antecedents and consequences), andwhether the behaviors are new or chronic in nature. Parents and caregivers areoften understandably frustrated or overwhelmed when seeking help. Clinicians
should focus on whether there is an underlying psychiatric disorder amenable totreatment or if it is a social crisis.
Children and adolescents also may present to the ED after conflict at
school, either with peers, teachers, or administrative staff. In these cases, apartfrom conducting an assessment, understanding the function of the behavior andits context is the key for management. Further, the patient’s educational status(e.g., regular vs. special education) is also crucial in understanding the resources
available to support the student. For every patient, clinicians should obtaincollateral information from at least one school official to ensure a complete
history. Because of the dearth of child and adolescent mental health clinicians,
this emergency assessment may be the first or only one the child will undergo andrecommendations can carry significant weight.

Homelessness
Key Questions•

Where has the patient been staying? Does the patient feel safe?

•

What are the risk factors for suicide and homicide?

•

What is the patient’s current physical health status?

•

Is there an underlying psychiatric diagnosis or substance use?

•

Would the patient be open to referral for housing, financial aid, vocational
support?

A study looking at the prevalence of psychiatric conditions among homelessadolescents found that 80% had a psychiatric disorder (Aichorn et al, 2008).
The most common was substance use disorder (65%). Other common diagnoses
included mood, eating and anxiety disorders. Over half had a history of self-harmand 25% reported at least one suicide attempt. This study also found that the longer
a youth was homeless, the more likely it was for the youth to have a psychiatricdisorder. Homeless youth engage in riskier behaviors than youth in the general
population (Milburn et al, 2006). These high-risk behaviors include shoplifting,Psychiatric emergencies

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After an extended trip
to Lebanon, a 15 year
old Canadian female ofLebanesebackgroundhad trouble readjusting.
Parents noticed a significant
change in her behavior, andconflict ensued. The youth
began to engage in highrisk behaviors – stayingout all night, not attending
school, became defiant anddisrespectful and, againstparents’ wishes, began
visiting another community
with a large number ofpeers of Lebanese origin.
This resulted in multiple
visits to the ED with her
overwhelmed
parents
insisting she was “mentallyill.” On one occasion the
youth had assaulted hermother, so much so thatcharges were laid and she
was asked to leave home.
Aggressive outbursts led
to more visits to the ED
involving grueling meetings
with the family and attempts
to improve the situation.
While waiting for an
outpatient appointment, thefamily doctor prescribed
risperidone
forher
impulsive
aggression.
Subsequently,
followinga fight with her mother,she got onto a bus andingested about 10 tabletsof risperidone. She thendeveloped
palpitations,became scared and called
her mother who took herback to the ED, where sheunderwent monitoring andovernight observation. She
told the crisis worker the
next morning that she had
not intended to kill herself.
Hospitalization was offered
but refused. However, shebecame more cooperative
and agreed to initiate safety
planning, which included
temporary placement withan extended family member(Carandang et al, 2012).

17

IACAPAP Textbook of Child and Adolescent Mental Healthprostitution, substance use, multiple sexual partners, and gang involvement(Carandang et al, 2012).
The evaluation must include a risk assessment for suicide and homicide
as well as an evaluation of physical health status. It is also necessary to explore
the patient’s living situation and to provide information about housing, financial
aid, educational, and vocational supports. Referral for social services support andoutpatient mental health follow-up may also be indicated; compliance with follow
up is usually low (Carandang et al, 2012).

Developmental Disability and Autism Spectrum Disorder(ASD)
Key Questions•

What are the behaviors noted in this current crisis?

•

Are these behaviors a change from the typical ASD symptoms?

•

How have these behaviors changed? Are they new or an escalation of existing
behaviors•

What are the typical antecedents to these behaviors?

•

What are the typical consequences or responses to these behaviors?

Youth ages 0-17 with autism spectrum disorder (ASD) are 30 times more
likely to present to the ED than youth without ASD (Lytle et al, 2018). One US
study showed that youth with ASD who presented to the ED were older, more
likely to have public insurance, and more likely to have non-urgent ED visits. Of
these visits, 13% were for behavioral or psychiatric problems; this is in contrast to
youth without ASD where less than 2% of visits were for psychiatric complaints.
Youth with ASD were more likely to have repeat visits and be admitted to a
psychiatric or medical unit compared to those without ASD (Lytle et al, 2018)

Management of Agitation in Patients with ASD in the ED
Acute agitation is one of the most frequent complaints for patients with
ASD or developmental disability presenting to the pediatric ED with a behavioral
health complaint (McGonigle et al, 2014). Given this presentation, it is imperative
to understand possible etiologies and swiftly manage agitation.
First and foremost, the clinician should conduct a rapid assessment of thepresenting behaviors. This can be conceptualized as a brief, focused, functional
behavioral analysis. Questions for parents/legal guardians should target thepresenting behavior and include the key questions above.
Clinicians should conceptualize agitation in ASD in a similar way todelirium. In other words, agitation in patients with ASD has a medical etiology until
proven otherwise. The differential diagnosis for agitation in patients with ASD isbroad and includes constipation related to poor nutrition or medications; seizures(25-35% risk of seizures in patients with ASD); head, eyes, ears, nose, throat
problems including ear infections, dental infections, pain from poor dental hygieneor care; sleep disturbances including obstructive sleep apnea; undetected injuries;
and urinary tract infections (McGonigle et al, 2014). After medical etiologies for

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IACAPAP Textbook of Child and Adolescent Mental Healthagitation have been ruled out, psychiatric issues should be considered. This patient
population has high rates of mood disorders in addition to the higher frequency of
sensory and communication issues.
A medical cause is more likely if the patient has abnormal vital signs,
memory loss, acute delirium, headache with focal neurologic deficits or seizures,increased muscle tone or weakness, temperature intolerance, or overt signs of
trauma. It is imperative that clinicians consider catatonia in this population. One
should inquire about loss of ability to perform activities of daily living, slowing ofspeech, or change in social interactions (McGonigle et al, 2014).
If psychotropic medication is indicated, this should be started at a low
dose and increased slowly. Both risperidone (starting daily dose 0.5mg-1mg)
and aripiprazole are FDA approved for irritability in ASD. The recommended
starting dose for olanzapine—less well studied—is 2.5mg-5.0mg. There is limited
data to support midazolam and lorazepam in this patient population in the ED(McGonigle 2014)

The ED Experience of Families of Children with Developmental
Disability
Parents’ surveys suggest that communication issues, insufficient staff
knowledge about developmental disability, and inadequate involvement of
parents impact negatively on their experience with the ED, while staff knowledge
about developmental disability, child- and family-centered care, and clarity ofcommunication impact positively (Nicholas et al, 2016). In this line, there has
been recent work to create evidence-based sensory-friendly pediatric emergency
departments. For example, the waiting room is often described as overwhelming,
loud, and bright. Providing families with noise-cancelling headphones, fidget andsensory tools, a storyboard about the ED visits, and staff education—including
learning specific techniques for distraction, communication, procedures, and deescalation—can help (Wood et al, 2019).

Deaf/Blind
Key Issues•

Hospitals ought to provide effective means of communication for patients who
are deaf or blind. This is mandated in the US (Americans with Disabilities Act
1990). Similar laws or expectations exist in other countries.

•

What is the patient’s preferred method of communication?

People who are deaf, hard-of-hearing, or blind rely on myriad ways tocommunicate. The Americans with Disabilities Act of 1990 mandates all hospital
programs and services to provide effective means of communication for patients,
families, and visitors for those who are deaf, hard-of-hearing or blind, and thisshould be the expectation everywhere. Examples of such means of communication
include Sign Language interpreters; oral interpreters (specially trained to articulate
speech silently and clearly, sometimes rephrasing words or sentences to give higher
visibility on lips); and computer assisted real-time transcription (CART), among
others.

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The patient is a 16-yearold, grade 9 girl who lives
with her mother. Overthe past two months, she
had exhibited depressive
symptoms characterized bytearfulness and disrupted
sleep. The patient and hermother had been evictedfrom their apartment fourmonths earlier and hadto spend several weeks
at a homeless shelter.
They have since found anapartment to rent, but thepatient is now worried that
her mother will kick her outof the house because she
recently turned 16, and hermother had been making
comments that the patient
should find a job because
she has to take care ofherself eventually. At times
they did not have money
to buy food. The patientand her mother fought
constantly; she dropped
out of school because herhome life was too stressful
to focus on schoolwork.
The mother brought thepatient to the ED becauseshewasconcerned
about her daughter being
depressed and droppingout of school, spending
most of her day isolated
in her room. The patientdenied suicidal ideations.
The patient was diagnosed
with adjustment disorderwith depressed mood andreferred for outpatientmental health follow-up(Carandang et al, 2012).

Click here to view the
US documents oncommunicating with people
who are deaf or hard ofhearing in hospital settings

19

IACAPAP Textbook of Child and Adolescent Mental HealthOut-of-Home Placement
Key Questions•

Where and with whom does the patient reside?

•

Who has legal guardianship?

•

Are there restrictions for the patient to communicate or see biological parents?

•

Are there active court cases?

Patients presenting with psychiatric emergencies who do not live at homepresent important legal considerations. Because laws and practices vary between
countries, clinicians need to be aware of the legal framework in their legislature.
It is paramount for the clinician to understand who has legal guardianship andmedical decision-making rights (see below). If the patient is in foster care, contact
with the foster care agency is crucial to understand these questions, as often the
biological parent retains legal rights and must consent to treatment.

Photo: Gunter Simon

Patients in Corrective Institutions
Key Questions•

Which corrective institution?

•

What is the patient’s past psychiatric history?

•

Does the patient have past suicide attempts? Inpatient psychiatric admissions?

•

Does the patient have substance use?

•

Is there a history of trauma?

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IACAPAP Textbook of Child and Adolescent Mental HealthStudies of adolescents in juvenile justice settings show that one-half tothree-quarters meet criteria for one or more psychiatric disorders. One-third to
one-half meet criteria for substance use disorder, and more than one-third for a
disruptive behavior disorder. It has also been shown that 80 to 90% of youths injuvenile justice experienced traumatic events (Wasserman et al, 2010). Therefore,
patients presenting with psychiatric emergencies in corrective institutions require
thorough psychiatric evaluation.

LGBTQIAKey Issues•

Clarify preferred name and pronouns.

•

Refrain from gendered language when possible.

•

Assess the patient’s level of support at home and in the community.

•

Respect confidentiality when discussing findings with family and treatment
providers.

Working with youth who are exploring gender and sexual identity—grouped under acronym LGBTQIA—complicates issues of confidentiality.
Although many cultures around the world are growing more accepting of genderand sexual minority groups, there is still significant stigmatization. The stress of thisstigmatization can play out both at a cultural level (risk of violence or oppression
in the community) as well as a familial level (risk of violence or conflict within thefamily unit). Youth who identify as LGBTQIA are at a higher risk for psychiatricdisorders (Coulter et al, 2019). Clinicians should provide culturally competentcare to LGBTQIA youth who present with psychiatric emergencies. This includes
clarifying their preferred name and pronouns, refraining from gendered language
wherever possible (e.g., rather than “Do you like boys or girls?”, ask “Do you
have a special someone?” or “Have you started having romantic interests yet?”),and assessing the level of support they have in their home and community. If thepatient indicates that they are not open about their identity at home, providers
should respect their confidentiality when discussing the findings of evaluation andrecommendations for treatment with caretakers. Additionally, given that caregivers
can request copy of medical records, providers should ask the youth if they would
like the information they share to be included in their medical record. In situations
where the details of a youth’s gender or sexual identity are pertinent to evaluation
or treatment, providers should take reasonable steps to ensure the youth’s safety athome and to support the youth in disclosing their identity to the family in orderto facilitate treatment.

SYSTEMS OF CARE
EthicsThe laws that inform clinical practice vary considerably from country tocountry or state to state. Parsing out the details of each particular government’s
guidelines would need a full academic volume on its own. This section summarizes

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IACAPAP Textbook of Child and Adolescent Mental Healthwidely accepted practices in child emergency psychiatry as well as pertinent
exceptions that providers should keep in mind (see also chapter A.1 of the eTextbook).
Despite differences across cultures, four ethical principles inform guidelines for
medical providers. Beneficence is the notion that clinicians should act in a patient’s
best interest. Non-maleficence holds that providers should refrain from harming
patients. Justice requires impartiality from physicians no matter the backgroundor identity of their patients. Autonomy is the tenet that providers must respect
the decision-making capabilities of the people whom they treat (Ostermeyer et al,2017). Although the first three of these ethical principles are broadly applicable
across the lifespan, the concept of autonomy has unique implications when working
with children. In general, physicians require informed consent from patients toprovide evaluation and treatment, and the validity of the consent depends on thedecision-making capacity of the patient. Adults, in general, are assumed to havedecision-making capacity while youth (i.e., younger than 16 or 18 years of age)
do not. When youth require medical treatment, their adult caregivers provide
consent (with some exceptions detailed later). Informed consent requires thatpatients and caregivers are made aware of the indications for, risks, and benefits of,and alternatives to the evaluation and treatment offered by the medical providers(Ostermeyer et al, 2017). Those with capacity to give consent should be able to:••••Understand the information given to them about the treatment
Remember the information relevant to the decision
Use or weigh the information relevant to the decision
Communicate their decision.

The weight given when assessing decision-making capacity should also be
applied along a sliding scale, such that higher risk decisions (e.g., neurosurgery,chemotherapy) would require a higher standard for assessing capacity thanlower risk decisions (e.g., drawing blood, intravenous fluids) (Appelbaum, 2007;
Ostermeyer et al, 2017). These issues can coalesce in variable and complicatedways when dealing with child psychiatric emergencies.

Consent Issues
When children present with psychiatric emergencies, the main clinicalquestions usually center around disposition. Can the child be discharged homewith outpatient follow-up? Do they require extended observation? Is inpatient
psychiatric admission necessary? Given that children in general lack decisionmaking capacity, caregivers must give informed consent for anything ranging
from release of information to third parties to inpatient admission. Additionally,clinicians must make a reasonable effort to obtain consent from caregivers, evenif certain aspects of the evaluation and treatment were necessarily initiated prior
to consent being obtained (Fortunati & Zonana, 2013). There are however
exceptions. Some jurisdictions may allow greater leniency in providing emergency
care without informed consent. For example, when contacting child protection
services if children present with a history or signs suggestive of abuse or neglect.
Emancipated minors may be another exception. In some areas of the world, youth
who are married, have children of their own, are members of the military, or liveon their own are considered emancipated, meaning that they are legally capableof making decisions for themselves (Fortunati & Zonana, 2013). Providers should
learn about local laws and practices around minor’s consent.

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IACAPAP Textbook of Child and Adolescent Mental HealthIn most countries, in a situation in which a youth needs to be psychiatrically
hospitalized, this can be accomplished voluntarily (with caregiver consent) or
involuntarily (without caregiver consent). Involuntary psychiatric hospitalization
is an option but it should be used sparingly. If a provider believes that psychiatrichospitalization is indicated and parents refuse, there may be grounds for reporting
to child protection services for medical neglect. This can cause ruptures in trust
within the family as well as between the family and the treatment team. Dependingon the country, involuntary hospitalization may require further procedures andreview to certify its need. Additionally, in some jurisdictions, although providers
can involuntarily hospitalize children, often cannot administer medication withouta court order if caregivers object. Thus, hospitalizing children involuntarily should
only be pursued if the risk to the safety of the child is high.

Reporting Abuse
The US Child Abuse Prevention and Treatment Act of 1974 establishes
mandatory reporting for “any act or failure to act on the part of a parent or
caretaker, which results in death, serious physical or emotional harm, sexual
abuse or exploitation, or an act or failure to act which presents an imminent
risk of serious harm.” Most countries have some kind of reporting laws. Many
nominate certain people as “mandated reporters,” typically including physicians
and mental health providers. In the course of an evaluation, when a clinician
uncovers evidence of abuse or neglect, they are required to report this evidence tothe local child protection services to determine if an investigation or intervention
is required. Providers may inform the family if a child protection report has been
made, although this is not obligatory. This conversation can be tense and difficult
to navigate. It may be helpful to highlight that your role is to report any evidenceof abuse or neglect and is mandated by law. Additionally, caregivers may benefit
from knowing what happens after a report is made. If there is doubt about whether
information disclosed requires reporting, it would be wise to discuss the situation
beforehand with a senior colleague.

Duty to Warn
Tarasoff v. Regents of the University of California (1968) is a landmark
case which established a new standard in mental health care in the US whereby
providers, when presented with evidence suggestive that their patient poses animminent risk of harm to another person, have a duty to protect (by ensuring thatthe patient is detained or treated) and a duty to warn (by informing the intended
target of the patient’s intent). Although the legal ramifications of this case vary
widely even within the boundaries of the US, the basic tenets of the case shouldstill inform clinical practice, particularly in psychiatric emergencies. This principle,
though not universal, is now widely accepted; providers should verify the standardsof duty to protect and duty to warn in the jurisdiction in which they practice. If
a patient makes a threat to the well-being of another, reasonable steps should betaken to address the patient’s risk of harm to others, which may need to include
hospitalization (if related to psychiatric symptoms) or communicating the patient’s
threat to the police. If the patient cannot be detained or treated, providers should
inform the intended targets of the patient’s threat. In situations in which the duty
to warn is unclear, providers should obtain advice from a senior colleague or a legal
consultation (Fortunati & Zonana, 2013).
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IACAPAP Textbook of Child and Adolescent Mental HealthConfidentiality
Information shared by the patient over the course of evaluation andtreatment is not to be shared with people outside of the treatment team.
Maintaining confidentiality with patients is a crucial component of fostering trustand encouraging adherence to treatment. Most jurisdictions codify the protectionof confidential information for adults, but children are not explicitly mentioned inmany of these laws. In spite of this, children should be afforded some measure ofconfidentiality commensurate with their developmental level and the circumstancesof their presentation. The limits of confidentiality should be discussed with theyouth and their caregivers from the start of the encounter (Fortunati & Zonana,2013). In general, topics like safety concerns or symptoms that are discussed aspart of treatment should not be kept from caregivers, as without this information
they cannot provide informed consent. Third parties outside the family unit may
also need to be contacted to obtain collateral details. Information should not beshared with these groups without explicit consent from caregivers unless there is an
imminent risk to the safety of the patient or others that warrants disclosure underemergency conditions.

Click on the image toaccess an excellent andcomprehensive guide formental health problems in
the ED (both adult and child)

REFERENCES
Aichorn W, Santeler S, Stelzig-Scholer R et al (2008) Prevalenceof psychiatric disorders among homeless adolescents.
Neuropsychiatrie, 22:180-188.

American Psychiatric Association (2013). Diagnostic andStatistical Manual of Mental Disorders, Fifth Edition.
Arlington, VA: American Psychiatric Association.

Alegria M, Jackson JS, Kessler RC et al (2016) Collaborative
Psychiatric Epidemiology Surveys (CPES), 2001-2003.
Ann Arbor, MI: Inter-university Consortium for
Political and Social Research, 2016-03-23. https://doi.
org/10.3886/ICPSR20240.v8

Appelbaum PS (2007). Assessment of patients’ competence
to consent to treatment. New England Journal of
Medicine 357(18), 1834-1840.

Angold A, Costello EJ, Messer SC et al (1995) The developmentof a short questionnaire for use in epidemiologicalstudies of depression in children and adolescents.
International Journal of Methods in Psychiatric Research
5:237–249.

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Carandang C, Gray C, Marval-Ospino H et al (2012) Child andadolescent psychiatric emergencies. In Rey JM (ed),
IACAPAP e-Textbook of Child and Adolescent Mental
Health. Geneva: IACAPAP

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IACAPAP Textbook of Child and Adolescent Mental HealthCoulter RWS, Egan JE, Kinsky S et al (2019). Mental health,drug, and violence interventions for sexual/genderminorities: a systematic review. Pediatrics 144(3):e20183367
Deslich S, Stec B, Tomblin S et al (2013). Telepsychiatry in the
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Freudenreich O, Charles Schulz S, Goff DC (2009). Initial
medical work‐up of first‐episode psychosis:
a conceptual review. Early Intervention in
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Gerson R, Malas N, Feuer V et al (2019). Best practices forevaluation and treatment of agitated children andadolescents (BETA) in the emergency department:
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Emergency Psychiatry. Western Journal of Emergency
Medicine 20(2), 409.
Kalb LG, Stapp EK, Ballard ED et al (2019) Trends inpsychiatric emergency department visits among
youth and young adults in the US. Pediatrics 143(4)e201829182; DOI: https://doin.org/10.1542/
peds.2018-2192
Kay SR, Fiszbein A, Opler LA (1987). The positive
and negative syndrome scale (PANSS) for
schizophrenia. Schizophrenia bulletin, 13(2), 261-276.
Kelleher I, Connor D, Clarke MC et al (2012). Prevalence of
psychotic symptoms in childhood and adolescence:a systematic review and meta-analysis of populationbased studies. Psychological Medicine 9:1-7.
King C (2019) 4.1 a computerized adaptive screen for suicidal
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national sample. Journal of the American Academy ofChild & Adolescent Psychiatry, 58(10), p.S305.
Lytle S, Hunt A, Moratschek S et al (2018). Youth with autism
spectrum disorder in the emergency department. The
Journal of clinical psychiatry, 79(3).
Margaret CP, Hilt R (2018). Evaluation and management of
psychiatric emergencies in children. Pediatric Annals
47(8): e328-e333.
McGonigle JJ, Venkat A, Beresford C et al (2014). Managementof agitation in individuals with autism spectrum
disorders in the emergency department. Child &Adolescent Psychiatric Clinics of North America 23:8395.

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