Emergency Evaluation of Children and Adolescents

Questions

• 1.

  Where is the patient?

• 2.

  What is the age of the patient?

• 3.

  Who brought the patient to the hospital, and why? Will they be available to speak in person at the time of evaluation? If not, can their contact information be recorded and provided to the on-call psychiatrist?

• 4.

  Has the patient had a physical examination and/or laboratory tests done? If so, what specific tests were performed, and are there any abnormalities?

• 5.

  Does the patient take medications? If so, which ones and at what dosages?

• 6.

  Has the patient abused drugs or alcohol? Was a toxicology screening done?

• 7.

  Does the patient require one-to-one observation, seclusion, or restraint?

Requests for Staff Before Consultant Arrives

• 1.

  Have the patient placed in a room in which he or she will be safe. One-to-one observation may be required if the patient is assaultive, aggressive, suicidal, or an elopement risk. Consider the layout of the area in which the patient will be waiting for evaluation to ensure that it is adequate for the safety of the patient and appropriate for the patient’s age.

• 2.

  Request that the patient be searched for weapons and other instruments that may cause injury. However, it is important to ensure that the search be done with sensitivity to the age of the patient.

Safety

To complete a comprehensive evaluation, both the evaluating physician and the patient must be in an environment that is free of distractions and dangerous furnishings or medical equipment. A safe setting is necessary to protect the physician, the patient, anyone accompanying the patient, and others in the area. Restraint is sometimes necessary to prevent aggression or elopement. Chemical and physical restraint should only be used if less restrictive means, including verbal deescalation, have failed. Although several first- and second-generation antipsychotics have been approved for children with autistic, mood, psychotic, and tic disorders, none have been approved for the use of chemical restraint in children. Because physical restraint has the potential to be traumatic to a child or adolescent, its use must be considered carefully. Finally, the evaluating physician must assess immediately for primary medical emergencies including medical illness, medication side effect, head trauma, overdose, and alcohol or drug intoxication or withdrawal.

Suicidality

Suicide is the second leading cause of death in American youth aged 10 to 19 ( Box 8.2 ). A psychiatric evaluation of a child or adolescent is incomplete without an assessment of suicide risk, even if suicidality is not the chief complaint. Some examples of pediatric screening tools that have been used in emergency psychiatric settings include the Reynolds Suicide Ideation Questionnaire, the Columbia Suicide Severity Rating Scale, and the Ask Suicide-Screening Questions.

In determining a young patient’s risk of suicide, the evaluating psychiatrist should consider both chronic and acute risk factors, as well as collateral information. An individual’s chronic risk of suicide is elevated by a family history of suicide, personal history of physical or sexual abuse, and prior suicide attempts. Acute risk factors include substance abuse or intoxication, mania, depression, psychosis, impulsivity, and severe psychosocial stressors. In the case of recent suicide attempts or current suicidal ideation, lethality of the method and intent to die should be considered. Access to firearms and other weapons should always be investigated. However, attention-seeking or manipulative self-harming behavior should not be discounted because individuals without true suicidal ideation may inadvertently endanger their lives in an effort to have their distress taken seriously.

Homicidality and Aggression

The psychiatrist who is called to evaluate aggression or violence in a young person should consider biologic, psychological, and social contributions to the patient’s presentation, as well as collateral information. These risks are elevated in young patients with a history of aggressive behavior toward people or animals, fire-setting, truancy or serious rule violation, running away from home, and use and access to firearms and other weapons. Children and adolescents with poor frustration tolerance, behavioral dysregulation, and impulsivity are at increased risk for violence and aggression. Acute elevations in risk can also be caused by undiagnosed medical conditions, such as altered mental status due to a neurologic condition or toxic metabolic state, intoxication or withdrawal, or acute psychiatric states of mania and psychosis. The evaluating physician should attempt to identify stressors or triggers for violence or increased aggression. Finally, collateral information from parents or legal guardians, school officials, or residential facility staff is essential to fully assess the risk of violence.