Common Pediatric Psychiatric
Presentations to the Emergency
Room.
Zaid B. Malik, MD
Asst. Professor
Director C&L
Asst. Residency Program
Director.
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Child psychiatric emergencies presenting
in the hospital setting are most often
characterized by intense symptoms,
perceived danger, and a sense of urgency
complicated by the perception of
imminent catastrophic outcome and
frequent conflict among the parties
involved.
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Despite this acuity, child psychiatric
emergencies are usually the outcome of
complex, ongoing processes rather than sudden,
discrete events. (this is true most of the times)
Occasionally, a previously well functioning child
with some underlying vulnerabilities may
abruptly decompensate and display psychiatric
symptoms in the presence of some critical or
traumatic event or organic process.
The goal of child psychiatric emergency
services evaluation is then to clarify the
nature and the cause of the imbalance
that has arisen and to identify the
resources needed (safe environment,
psychoeducation,
psychopharmacotherapy, outpatient
therapist, family support services) to
restore equilibrium.
The primary goals of the child psychiatric
emergency evaluation are, as
expeditiously as possible:
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To obtain each informant's account of the
reason for referral
To develop a working alliance, if possible,
with the patient and other involved parties
around the assessment and disposition
planning
 To obtain a focused developmental
history of the child's current difficulties
and prior functioning against the
backdrop of the child's family, current
living situation, and any involved
clinicians or agencies, with particular
attention to the possible precipitants of
the current crisis
 To perform a mental status examination,
with particular attention to evidence of
suicidal or homicidal ideation,
hallucinations, delusions, or thought
disorder; evidence of confusion,
disorientation, or other signs of delirium;
and intense anxiety
 To develop a differential diagnosis,
including a formulation of what changing
factors have precipitated the need for
emergency evaluation at the present time
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To arrive at a judgment regarding the
degree of probable risk to the patient's
safety or that of others
To identify interventions that will help to
contain and ameliorate the patient's
difficulties
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To plan and implement a disposition
To collaborate effectively with other
clinicians and care providers involved in
the case, both within and beyond the
hospital setting
The clinician must be alert to and
explicitly note the presence of the
following:
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Disorientation, confusion, and fluctuating
levels of consciousness
Incoherence of thought or speech
Evidence of hallucinations or delusions
Impaired memory
Slurred speech, ataxia, or apraxia
Assessment of safety additionally
requires explicit attention to the
following:
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The presence of suicidal or homicidal ideation
Aggressive threats or ideation
Impulsivity
Proneness to regression or agitation during the
interview
Poor judgment and insight and limited
intelligence
Mood lability
Case 1
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CJ was a 5 year old who had just started KG. He had no
experience with preschool and had never been away from
home in a group situation. He presented to an outpatient
psychiatry clinic after hitting his teacher and biting the principal.
No history of previous evaluation or treatment of
developmental, behavioral, or emotional disorder. He was
healthy and active. His mother had moderately severe anxiety
disorder and stayed mostly at home. He lived with his father,
mother and older brothers. On MSE he was a small, compliant
child with poor eye contact. He responded to questions with
monosyllables that were hard to hear.
Case 2
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ST was a very bright 12 yr old twin. He presented to a residential
treatment unit with a history of severe aggression and rages at home
and school when he did not get his way. His ability to tolerate
frustration varied considerably; at times he was able to accept limits
and consequences; at other times he would become explosive,
hyperactive, and destructive. His family was not able to go into public
spaces for fear that he would become angry. He had been treated for
ADHD and ODD since early childhood. He was healthy, without
chronic illness and although a twin his pregnancy and perinatal history
was unremarkable. On MSE, he was a well developed 12 yr old with
poor eye contact. He was sulky and irritable with angry affect. Family
history was positive for bipolar disorder. His parents were divorced
due to his father’s mood instability. He was being reared in a single
mother household. His mother was genuinely frightened of his rages.
Case 3
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HJ was a developmentally delayed 7 year old with
an IQ of 60 and a diagnosis of autism. When
frustrated he had a history of aggression with peers,
caregivers and himself (head banging and biting his
forearm until it bled). He was rigid with poor
tolerance of over stimulating environments and
transitions. He lived with his mother and father in an
intact home and attended a behavioral classroom in
a public school.
Case 4
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LC was a 10 yr old boy in a single mother household presenting
at the insistence of the school. His academic and behavioral
problems at school started in KG. Behaviors included fighting,
talking back, vandalism, lying, truancy, and stealing from other
students. He was diagnosed with ADHD in KG and had been
treated with psycho stimulants off and on since then. He did
not know his father. Throughout his childhood his mother’s
boyfriends moved in and out of the house. He had little
supervision or monitoring. Discipline at times was excessively
harsh. The family had had involvement in the Department of
Children and Family Services before following a substantiated
case of physical abuse. Family history was positive for
substance abuse, depression, and poor anger management.
Differential Diagnosis of Aggression
Symptoms of Aggression are common in a wide range
of psychiatric conditions.
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Conduct Disorder
Oppositional Defiant Disorder
Mood Disorder
ADHD
Anxiety Disorder
Psychotic disorders (especially those including paranoia)
Developmental Disorders
Anxiety
Treatment Options
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Medications
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Antipsychotics
Mood stabilizers
Serotonin Reuptake Inhibitors
Stimulants
Case 5
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A. 16 yr girl, considered generally well adjusted, without psychiatric
history presents to the ED at 11p. She is drowsy and nauseated. Her
mother says that her daughter has been seeing a boy for the past 2
years. He broke up with her last week. Since then she has been sad
and tearful, uninterested in her usual activities. Tonight, after seeing
her ex-BF at a restaurant with another girl. She came home and took
a bottle of aspirin. An hour later she came to her mother and told her
what she had done. Family history is negative for psychiatric illness
and completed suicide. On MSE she is sleepy and feeling sick. She
denies longstanding depressive symptoms and says that she does not
want to die now. She says that she never wanted to die but wanted
people to understand how sad she is. She also said that she hoped
her BF would come back to her.
Case 6
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MH A seventeen year old boy, who recently graduated from HS, is found barely
conscious in his bedroom by his mother when she goes in to wake him up. She
takes him to the ED where a tox screen reveals that he has taken an overdose
of Depakote. The Depakote was his mother’s. On the floor he is extremely
quiet and uncommunicative. He says that he wants to go home. There is no
previous psychiatric history but his mother says that he has been “acting
different for the past year”. He has been staying in his room with less and less
interest in doing things with friends. She is not aware of any traumatic events.
There is a family history of schizophrenia. This patient has no past psychiatric
history. On interview he is quiet with a blunt affect. He denies any problems,
cannot explain his overdose, but feels that he has to get out of the hospital b/c
the people there are getting on his nerves. He denies AH but is suspicious and
guarded when questioned about them. He does talk about his graduation
ceremony and says that when he walked across the stage the other students
laughed at him. When asked about that his mother says that that did not occur
and he has always been well-liked at school.
Leading Causes of Death in
15-19 Year-Olds
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Accidents
Homicide
Suicide
Cancer/Leukemia
Heart Disease
Congenital Anomalies
(NCHS 2001)
12-Month Prevalence of Suicidal Ideation
and Behavior
U.S. High School Students- Youth Risk Behavior Surveillance CDC 2000
Ideation
17-19%
 Ideation w/ plan 11-14%
 Attempt
5-8%
 Attempt requiring 1-3%
medical attention
 Suicide (age 15-19) .008%
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2.7 million
1.9 million
1.0 million
296,000
1,600
Ratio of Teen Attempts to Teen
Suicides
Deaths* Attempts* Ratio
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Males
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Females
YRBS CDC 2000
14
all numbers/100,000
3
5,700
10,900
1:400
1:3,900
Suicide Methods
United States 1999, 15-19 Year-olds
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Firearms
Hanging/Suffocation
Ingestions
CO poisoning
Jumping
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In 1998 suicide rates were highest among
white males of all ages, followed by nonwhite males, white females, and non-white
females.
Biological factors
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Low Serotonin levels
Genetic Predisposition
Types of Stress Events Preceding
A Suicide
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Disciplinary Crises
48%
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Relationship Problem
36%
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Humiliation
16%
Most Common Teen Suicide
Diagnoses
ANY
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Mood Disorder
Antisocial Disorder
Substance Abuse
Anxiety Disorder
Shaffer et al 1996, Brent et al 1999
MALE
50%
43%
38%
19%
FEMALE
69%
24%
17%
48%
Imminent Risk in Suicide Attempters
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Agitation
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Intense Anxiety
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Recent Discontinuation of Medications
High-Risk Attempters
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Male
Abnormal mental state
Previous attempt
Family history of suicidality
History of aggressive outbursts and
substance and alcohol abuse
Method other than ingestion
Clinical Risk Factors
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1/3 of Teenage suicide victims have made a
previous attempt
½ have persistent thoughts of hopelessness
Aggressive/impulsive behavior is increased
in both sexes
½ of teenagers who commit suicide have had
contact with a PCP or MHP
Clinical risk factors (continued)
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Alcohol and cocaine abuse are present in 2/3 of 1819 year old males but uncommon in younger males
and females
Schizophrenia and bipolar illness each represent
fewer than 10 % of suicides but are relatively
infrequent conditions
Increased Frequency of suicide attempts and
completions in relatives of suicide victims
Decreased family support
Emergency Room Management of the
Suicidal Adolescent
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Medical Care
To Admit or not to admit
Sedation
?? Contract for Safety
Hospitalizing a Teen Attempter
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Sufficient
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Medical Necessity
Abnormal Mental State
Persistent Wish to Die
Highly Lethal or Unusual Method
Hospitalization (continued)
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Adds weight but not Sufficient
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Prior Attempt(s)
Male gender
Family history of suicide
Inadequate care and supervision at home
Over age sixteen
Contract for Safety
Thought to improve compliance
 Thought to reduce likelihood of further
suicidal behavior
 A probe to assess patients willingness to
assist in treatment efforts
No evidence for any of the above.
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Etiology
Suicidal Behavior is complex. The factors
involved are outlined in accordance with five
axis.
 Primary psychiatric disorders
 Developmental and personality disorders
 Biological factors
 Stress
 Social functioning
It is important to assess and document
the following in the child or
adolescent:
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The degree of premeditation and planning
versus impulsiveness (22)
Ego syntonicity or dystonicity
Consistency with the patient's past
behaviors or style (including chronic
bullying)
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Extraordinary or uncontrolled rage and
use of weapons
The validity of perceived self-defense
Evidence of grossly impaired judgment or
consciousness
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Bizarre or delusional behavior or thought
content
Risk of self-injury during the violent
episode
The extent to which the child can
remember the details of the episode
(including his actions and their
consequence), accept responsibility, or
express remorse
Conclusion: