Paediatric psychiatric emergencies

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17.1 Paediatric psychiatric emergencies

Raymond Chin, Michael Fairley

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 literature ² 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

Circumstance of the act

• Precipitants – bereavement, separation, custody, disciplinary crisis.

• Immediate past history.

• Interpersonal relationships.

• Social support systems.

• Impact on others – e.g. rescue or rejection.

• Family diseases.

Hazards during assessment

• Use of denial by parents, doctors and nurses.

• Refusal to be interviewed.

• Lack of insight.

• Negative influence of relatives.

• Pressure and hostility from other staff.

Management following an attempt

Comprehensive medical assessment for extent of injury as soon as possible. This should occur prior to psychiatric examination.

Admission to a medical unit if outcome of assessment indicated that physical safety has been adversely affected.

If medical status is stable, referral to psychiatry for assessment is required in all cases.

Anxiety disorders

Anxiety is a complex feeling of apprehension, fear, and worry often accompanied by pulmonary, cardiac, and other physical sensations. It is a ubiquitous condition that varies from the physiological to the pathological in its presentation. Panic disorder has a lifetime prevalence of 1.5–3.5%.

In school refusal, the child often presents with a somatic complaint such as abdominal pain. Cases of syncopal collapse may manifest as a panic attack. Early identification can reduce the number of medical investigations and commence early psychiatric referral.

Acute anxiety can effectively be treated with a comprehensive approach utilising psychotherapy, counselling, and a wide spectrum of anxiolytics (e.g. benzodiazepines, buspirone, and antidepressants).

Autism

A syndrome of early childhood characterised by: abnormal social relationships; language disorder with impaired understanding, echolalia; rituals and compulsive phenomena; and uneven intellectual development with mental retardation in most cases.

Autism is two to four times more common in boys than girls.

Autism usually is manifest in the first year of life; its onset is not later than age 3 years.

Treatment

For the most severely impaired children, systematic application of behaviour therapy, a technique that can be taught to parents, helps manage the child in the home and at school. Butyrophenones provide limited benefit, mainly in controlling the most severe forms of aggressive and self-destructive behaviour – they do not resolve the psychosis. Fenfluramine, a serotonergic antagonist, is no longer available.

Speech therapy should begin early. For mute children, the value of learning sign language is not yet established. Children in the near-normal or higher IQ range often benefit from psychotherapy and special education.

Childhood schizophrenia

Psychotic states usually have onset after age 7 years and with behavioural similarities to adult schizophrenia. Evidence suggests that environmental stress precipitates manifest illness in children with a genetic predisposition.

The prevalence of this disorder increases with age. Whereas autism and pervasive developmental disorder are distinctly different from the adult schizophrenias, childhood schizophrenia forms a continuum with the adolescent and adult forms.

It is characterised by withdrawal, apathy, flat affect, thought disorder (blocking and perseveration), ideas of reference, hallucinations and delusions, and complaints of thought control. Diagnosis is based on descriptive clinical phenomena.

Treatment

Combined psychotropic and psychotherapeutic treatment is required. Phenothiazines (e.g. thiothixene 0.10–0.40 mg kg^–1 day^–1) and butyrophenones (e.g. haloperidol 0.05–0.15 mg kg^–1 day^–1) may be effective in controlling acute psychotic symptoms, but relapse is common. Hospitalisation is useful in managing acute exacerbations; some children require continuing inpatient psychiatric care.

Eating disorders

Anorexia nervosa occurs in approximately one out of 100 adolescent females and is most frequently found in middle-to-upper socioeconomic groups. Most recent studies have suggested no increased incidence of anorexia nervosa over the last four decades. A familial component appears to be present.

Mortality/morbidity

The mortality rate for anorexia nervosa ranges from 5–10% and is greater (5–40%) among bulimic patients.

Race

Anorexia nervosa is significantly more frequent in white populations than in people of other races. The co-existent effect of socioeconomic class, however, is difficult to isolate.

Sex

Female to male ratio is 10–50:1 in developed countries.

Age

Anorexia nervosa is primarily a phenomenon of puberty and early adulthood, although premorbid determinants and long-term outcomes are still being defined.

Anorexia nervosa is an eating disorder characterised by severe weight loss to the point of significant physiological consequences. Patients with anorexia nervosa generally fall into two categories: (1) those who practise extreme food restriction behaviours; and (2) those who display food binge/purge behaviour.

Complications

Complications of anorexia nervosa may result in ED presentation.

Cardiovascular effects include supraventricular and ventricular dysrhythmias, long QT syndrome, bradycardia, orthostatic hypotension, and shock due to congestive heart failure.

Renal disturbances include decreased glomerular filtration rate, elevated creatinine, oedema, acidosis with dehydration, hypokalaemia, hypochloraemic alkalosis with vomiting, and hyperaldosteronism.

Gastrointestinal findings include constipation, delayed gastric emptying, gastric dilation and rupture, dental enamel erosion, palatal trauma, enlarged parotids, oesophagitis, Mallory–Weiss lesions, diminished gag reflex, and elevated transaminases.

Finally, bone marrow suppression may occur, leading to platelet, erythrocyte, and leucocyte abnormalities.

History

• Patients may present to the ED with extreme weight loss, food refusal, dehydration, weakness, or shock.

• Affect may be flat or nearly catatonic.

• Patients may be depressed and should be questioned to gauge risk of suicide.

• Obtain a mental history because there is a strong association with depression and substance abuse.

• Often, the family will bring in the patient because many patients may refuse to seek help or may have no insight into their problem.

• Recurrent patients may recognise their problem and present spontaneously for therapy.

Physical

• Physical examination may reveal hypothermia, peripheral oedema, thinning hair, and obvious emaciation.

• Behaviourally these patients often have a flat affect and display psychomotor retardation.

Care

ED care may include rehydration, correction of electrolyte abnormalities (e.g. hypokalaemia), and institution of appropriate disposition for continuing medical and psychiatric treatment.

Consultations

As appropriate, consult with psychiatry and adolescent medicine specialists in order to optimise inpatient care and facilitate out-patient follow-up care.

Problem parents

Parents with a mental illness

Depression

Mothers with postnatal depression may present frequently in a ‘cry for help’.

Münchausen’s syndrome by proxy

In 1977, Englishman Roy Meadow published ³ the first report of a new form of child abuse. He coined the term Münchausen’s syndrome by proxy (MSBP) after the syndrome that first had been reported by Asher in 1951. This term is applied when an adult, usually the mother, presents a false history to the physician regarding a child who is not suffering from any of the fabricated symptoms. This history causes the physician to perform unnecessary diagnostic procedures that do not result in any specific diagnosis. (MSBP has also been called Polle syndrome, after Baron von Münchausen’s only child, who died when aged 1 year.)

In 1994, the DSM-IV ⁴^,⁵ included a definition for factitious disorder by proxy, which is now the accepted psychiatric category for MSBP. The definition includes the following:

Intentional production or feigning of physical or psychological signs or symptoms in another person who is under the individual’s care.

The motivation for the perpetrator’s behaviour is to assume the sick role by proxy.

External incentives for the behaviour, such as economic gain, avoiding legal responsibility, or improving physical well-being, are absent.

Children at risk for MSBP abuse are aged 15 months to 6 years. The emergency physician often is confronted with baffling symptoms. Frequently, the child has been taken to many care providers before the diagnosis is finally established. Warning signs that are suggestive of MSBP include the following:

• illness is multisystemic, prolonged, unusual, or rare;

• symptoms are inappropriate or incongruent;

• patient has multiple allergies;

• symptoms disappear when parent or caretaker is absent;

• in children, one parent, usually the father, is absent during hospitalisation;

• history of sudden infant death syndrome in siblings is noted;

• parent is overly attached to patient;

• patient has poor tolerance of treatment (e.g. frequent vomiting, rash, and problems with intravenous lines);

• general health of patient clashes with results of laboratory tests;

• parent shows inordinate concern for feelings of the medical staff;

• seizure activity is unresponsive to anticonvulsants and is witnessed only by parent or caretaker.

Tests that emergency physicians may consider include the following:

• urine toxicology screening;

• chemistry panels;

• electrocardiogram;

• drug levels for suspected poisoning agents (e.g. aspirin, paracetamol (acetaminophen), anticonvulsants);

• coagulation tests;

• head CT scan.

Parents with substance abuse

Parents with significant substance abuse, i.e. alcohol and other drugs have significant impact on the child’s presentation. The parental behaviour can be inappropriate, threatening and aggressive towards the practitioner. This makes the assessment of the child much more difficult and unreliable.

Miscellaneous

Night terrors

Sleep disruption is a parent’s most frequent concern during the first 2 years of a child’s life. Half of all infants develop a disrupted sleep pattern serious enough to warrant physician assistance. Night terror disorder is characterised by recurrent episodes of intense crying and fear, and by difficulty arousing the child. Children also can experience signs of autonomic arousal (e.g. tachycardia, tachypnoea, sweating) during episodes. Children do not recall a dream after a night terror and typically do not remember the episode the next morning. Night terrors are frightening episodes that disrupt family life and cause the child significant distress and impaired everyday function. Usually onset is in children aged 3–12 years; the disorder generally resolves during adolescence.

An estimated 1–6% of children experience night terror episodes. Recurrent night terror episodes accompanied by significant distress and impairment are less frequent.

Peak frequency in children younger than 3.5 years is at least one episode per week; among older children, peak frequency is 1–2 episodes per month.

History

The most important step toward diagnosing this disorder is to obtain a detailed history.

• Approximately 90 minutes after falling asleep, the child sits up in bed and screams. Prominent autonomic activity (e.g. tachycardia, tachypnoea, diaphoresis, flushing) occurs. The child appears awake but confused, disoriented, and unresponsive to stimuli.

• Most episodes last 1–2 minutes, but the child may remain inconsolable for 5–30 minutes before relaxing and returning to quiet sleep.

• If the child awakens during the night terror, only fragmented pieces of the episode may be recalled.

• In the morning, the child typically has no memory of the experience.

Management

This consists of educating the family about the disorder and reassuring them that episodes are not harmful.

1 Aghababian R.V., Allison E.J., Braen G.R., et al, editors. Emergency medicine: The core curriculum. Philadelphia, PA: Lippincott, Raven, 1998.

2 Baeutrias A. Risk factors for suicide and attempted suicide among young people. In: Setting the evidence-based research agenda for Australia: A literature review. Canberra: National Health and Medical Research Centre, Commonwealth Department of Health and Aged Care; 1999.

3 Meadow R. Munchausen syndrome by proxy. The hinterland of child abuse. Lancet. 1977;2(8033):343-345.

4 DSM-IV. Diagnostic and statistical manual of mental disorders, 4th ed. Washington, DC: American Psychiatric Association; 1994.

5 ICD-10-AM. The international statistical classification of diseases and related health problems, 10th revision, Australian modification, 2nd ed. Lidcombe, NSW: National Centre for Classification in Health; 2000.

Related

Textbook of Paediatric Emergency Medicine