Paediatric psychiatric emergencies

Published on 23/06/2015 by admin

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17.1 Paediatric psychiatric emergencies

Raymond Chin, Michael Fairley

Essentials

1 Children with psychological problems often present with somatic complaints and at times of family crisis. The treating emergency physician should be aware of this.
2 Early identification of psychological illness can reduce prolonged investigations and expedite specific psychiatric treatment.

Introduction

Paediatric patients and, at times, their parents can provide complex diagnostic and logistic challenges to staff in a busy emergency department (ED). They often present in a time of life crisis. However, the complaint may be primarily emotional. The majority of cases have no clear diagnosis and may be complicated by multiple visits to previous medical practitioners.

Assessment requires time and patience and unique clinical skills. Intent listening with directed questioning is required. It is important to avoid drawing premature conclusions, and emotional factors should be considered, even when the problem appears predominantly organic.

General approach

Assessment

In the case of children, parents generally initiate medical contact, so it is important to seek the child’s opinion early. If possible, a history from both the parent and the child should be obtained. Reassurance needs to be provided that the visit is not a punishment. Playing and drawing may put the child at ease.

In adolescents, self-referral for psychological problems is more likely, but is usually associated with reluctance to identify and discuss the problem. Physical complaint may point to a psychological issue, e.g. headache and panic attack. As the patient is usually unco-operative, reassurance should be provided about confidentiality.

History

A thorough medical history is imperative. In addition, the six Ps of collateral history should be explored.

Collateral history

Pre-existing psychological disorders, life experiences, medical conditions, family vulnerability.
Precipitants – trigger for presentation.
Presentation – why now, who is most troubled by the symptom.
Perpetuation – factors that operate to prevent recovery.
Positives – strengths and resources, coping with previous problems.
Preconceptions – belief system, expectations from medical consultation. What the child and parent really want.

Synthesis of assessment

It should be possible for the emergency physician to determine why the child is attending, who wants something done, and where the main pathology rests; in the patient, the parent or their relationship.

Examination

Examination includes obtaining vital signs, and a physical and mental state exam.

Investigations

Special tests should be confined to the differential diagnosis of assessment.

Common paediatric psychiatric presentations

The acutely disturbed child

See separate chapter dealing with this presentation.

Suicidal patients

It is important to establish:

Risk of suicide or repeat attempt.
Nature of current crisis and meaning of the event.
Presence of psychiatric disorder.
Background history, personality style, coping mechanisms.
Social supports.
Source of appropriate help.

Introduction

The presentation of a child or adolescent with self-directed harm or injury constitutes a medical and psychiatric emergency, even if the need for medical urgency appears low. The presentation of a child or adolescent with suicidal ideation but no apparent physical injury similarly constitutes a psychiatric emergency. More people die in Australia by suicide than by motor-vehicle accidents. The ratio of male to female suicides is currently approximately 4:1 and the figures representing ratios of male to female attempted suicides vary generally from being equal to up to 15:1 in favour of females.1

The rate of suicide in older teenagers has increased, especially over the past 30 years. Although rare in prepubertal children, it is always indicative of a severe disorder.

In young persons who commit suicide, up to 46% have made a prior threat or attempt, and of those who attempt suicide, some 10% eventually kill themselves, often within 2 years.

The most important contribution that can be made to the prevention of suicide is the recognition of the early signs of mental illness, in particular, depression and schizophrenia. Depression can present as school failure after normal achievement, hypochondriasis, social withdrawal and aggressive behaviour, more often than verbal complaints of depression and anxiety.

Energetic, persistent and effective treatment is required once a suicide attempt has been made.

Risk factors

Theories abound to explain these high suicide rates although many of the assumptions about causality are not proven but based only on occasions. Nevertheless, a thorough review of the literature2 leads to the conclusion that the risk of suicidal behaviour is increased among young people who:

• have previously attempted suicide;
• have a mood disorder or are involved in harmful use of drugs (including alcohol);
• have problems involving violence;
• are from a socially disadvantaged background characterised by low socioeconomic status, limited educational achievements, low income, poverty and associated factors;
• experience parental loss through separation and divorce;
• have experienced physical or sexual abuse;
• have experienced impaired parent–child relationships;
• have parents with a mental illness such as mood disorders, harmful drug use (including alcohol) or problems involving violence;
• experienced loss through suicide in their family or peer group;
• experience a greater number of life stresses than normal.

Evaluation of the suicidal crisis

Suicidal act

• Intent (wish to die).
• Lethality (danger to life).
• Mitigating circumstances (factors interfering with the person’s ability to assess the consequences of the act).

Specific enquiry into:

• Degree of isolation, probability of intervention, precautions against discovery.
• Actions to gain help during, or after, an attempt.
• Degree of planning, level of impulsivity.
• Communication of intent, suicide note.
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