Pediatric mental health emergencies encompass a range of conditions, including psychological disorders such as mood and anxiety disorders (depression, bipolar disorder, suicidal ideation, obsessive compulsive disorders, posttraumatic stress syndrome), exacerbations of behavioral disorders (attention-deficit/hyperactivity disorder, aggressive outbursts, conduct disorders), deteriorating neurodevelopmental disorders (autistic spectrum disorders, tic disorders, intellectual disabilities), addictive disorders, and eating disorders. The psychological and sometimes physical aftermath of child maltreatment, mass casualty incidents and disasters, and exposure to violence and unexpected deaths are also likely causes of mental health emergencies.^1,2,3,4

The role of the emergency physician includes medical stabilization, differentiating physical from mental health issues, performing a psychosocial assessment, and directing patients and families toward appropriate resources for acute and long-term needs. Initial management may include pharmacologic therapy, physical restraint, and referral for inpatient admission.^2,5

The mental health crisis involves all socioeconomic and ethnic groups and is not unique to any one geographic area, state, or region. The cause of the dramatic rise in pediatric mental health emergencies is multifactorial and complex. A Centers for Disease Control and Prevention report of a 5-year (2005 to 2011) mental health surveillance among children in the United States cited a prevalence of mental health disorders of 13% to 20% and suicide as the second most common cause of mortality among children 12 to 17 years old in 2010.⁶ The National Comorbidity Survey–Adolescent Supplement data found the lifetime a prevalence of any one Diagnostic and Statistical Manual of Mental Disorders class disorder among adolescents of 51%.⁷ In Canada, 14% to 25% of children and youth are affected by at least one diagnosable mental disorder.^8,9 Factors contributing to high prevalence of mental illnesses among children and youths include family instability or dysfunction, economic crisis or financial hardship, inadequate numbers of mental health professionals (especially those with pediatric expertise), lack of access to care, shortage of funding for mental health services, and failure to seek care due to cultural stigma.¹ In addition, social networking exposes youths to cyberbullying, online harassment, social isolation, and “Facebook depression,” adding further risks for developing mental health illnesses.¹⁰

Multiple economic forces negatively impact the availability and delivery of mental health services^1,4,5,11,12 and have transformed EDs into the safety net for a fragmented mental health infrastructure.⁵ Mental health follow-up or aftercare is also a problem. Of patients discharged from psychiatric emergency facilities, 40% to 60% do not receive aftercare, which increases the risk of repeat ED visits.¹¹

It is therefore not surprising that ED use for mental health care by children and youth is increasing. In the United States, both the absolute number (from 565,000 to 823,000) and proportion of all ED visits (from 2.0% to 2.8%) by children and youth for a mental health problem are on the rise.¹³ The Pediatric Emergency Care Applied Research Network reported that 3.3% of all participating pediatric ED visits were made for psychiatric-related visits. These visits are more frequently arriving by ambulance, are associated with longer length of stays, and result in admission to the hospital more commonly than other causes for ED visits.¹⁴ Pediatric psychiatric emergencies show seasonal variation and are more common during the school year, peaking in May and November, while reaching a nadir in July and August. While the visit distribution over days of the week appears to be even, visits occur more frequently in the evening, coinciding with a time period when most outpatient community mental health resources are not easily reachable.¹⁵

GENERAL GOALS

The first goal in the assessment of children with mental health emergencies is to identify and treat acute life-threatening medical emergencies. The second goal is to determine whether the child in a medically stable condition poses an imminent threat to his or her own life or the life of others, because this determines the need for hospitalization. Next, exclude organic causes. The general approach to making this determination is outlined here, and individual psychiatric conditions are further detailed below in “Management of Psychiatric Presentations.” Table 147-1 lists medical and psychiatric conditions that may present with agitation, psychosis, or obtundation. Table 147-2 enumerates some general characteristics that may distinguish organic from psychiatric causes of psychosis.

HISTORY

Focus the history on the chief complaint and details of the presenting symptoms, circumstances, and precipitating events (e.g., social stressors). The timing and sequence of events and associated symptoms may help to distinguish organic from psychiatric conditions, and a thorough review of systems aids in this regard. Auditory hallucinations are associated with psychosis, whereas visual hallucinations may indicate intoxication or organic causes. A history of head injury, chronic or progressive headaches, visual changes, vomiting (especially morning vomiting), and deterioration of motor skills or gait suggests an intracranial process such as a brain tumor or subdural hematoma. Constitutional symptoms that may provide clues to an organic etiology include temperature instability, palpitations, and changes in appetite, stool patterns, hair, or skin.

The past medical history and family history will help identify the pattern and chronicity of the presenting symptoms. Similarly, a review of medications, including adherence to prescribed medication regimens, and their efficacy will guide the treatment plan and disposition. A family history of psychiatric or organic disease may indicate a potential genetic predisposition.

In addition to noting these standard components of history, pay particular attention to the social history. Many psychosocial screening tools exist, and some have been validated, such as the HEADS-ED (Table 147-3). The HEADS-ED assesses the degree of acute distress in domains pertaining to the home, education, activities and peers, drugs and alcohol, suicidality, emotions and behavior, and discharge resources.¹⁶ In addition to facilitating the assessment, this tool also guides management decisions.

PHYSICAL EXAMINATION

Assess vital signs and the airway, breathing, and circulation status, and perform a detailed neurologic examination. Alterations in vital signs may provide clues to potential intoxication, ingestions, or organic pathology (endocrinologic and metabolic). Tachycardia, hypertension, pyrexia, and tachypnea may suggest intoxication with stimulants such as amphetamines, cocaine, and “ecstasy” (3,4-methylenedioxymethamphetamine). Assessment for toxidromes may help identify anticholinergic symptoms or salicylate toxicity. The pupillary responses, presence or absence of nystagmus, skin temperature and moisture, and condition of the mucous membranes are all helpful in identifying toxidromes.

Focus the neurologic examination on level of consciousness, gait and coordination, and reflexes, and administer the Mini-Mental State Examination. Note the child’s affect and general appearance, content and organization of thought, and articulation and expression of speech. Pressured speech with flight of ideas may signal acute mania, whereas echolalia, “word salad,” and other disordered thought may indicate acute psychosis.

LABORATORY TESTING AND IMAGING

Laboratory tests and imaging are dictated by the history and physical examination. Pubertal girls should have a urine pregnancy test, because many psychiatric medications can affect the fetus. Urine drug screening can be helpful when intoxication from drugs of abuse is suspected. Obtain serum acetaminophen (Tylenol) and aspirin levels in children who have ingested drugs or attempted suicide. Hyperglycemia, hypoglycemia, and hyperammonemia can cause alterations in mental status, and measurement of glucose and ammonia levels may be useful in obtunded patients. A 12-lead ECG is useful in cases of potential ingestion or intoxication to identify interval prolongation or conduction abnormalities. Document normal sinus rhythms at baseline, before initiating psychotropic medications that may accentuate long QT disorders. Screening laboratory tests performed in psychiatric emergencies vary by institution. Many inpatient psychiatric facilities require basic chemistry panels and screening for thyroid disorders. See chapter 137, “Altered Mental Status in Children” for further discussion of altered mental status.

Imaging studies are rarely indicated or helpful except as dictated by the findings of the history and physical examination. Chest radiographs may identify aspiration in the obtunded vomiting patient. Abdominal radiographs may identify radiopaque foreign objects or ingestions. Neuroimaging can exclude intracranial mass lesions in those with suggestive clinical signs and symptoms.

A detailed summary of child and youth mental health issues is beyond the scope of this book. Formal diagnoses of mental health conditions usually occur after the ED presentation. Therefore, this section will focus on the approach to, and treatment of, psychiatric presentations. Many care environments use social workers, youth care workers, nurses, and other clinicians to conduct significant portions of the mental health assessment in the ED.

SUICIDAL IDEATION AND ATTEMPTS

Suicide is complex. Although it is one of the most common causes of death in youth (4.9 per 100,000 per year between the ages of 10 and 19, more than neoplasm, respiratory, and cardiovascular deaths combined),¹⁷ the vast majority of youth who have suicidal thinking or behaviors do not go on to complete suicide (Table 147-4).^18,19,20 Risk prediction is currently not possible.²¹ Therefore, the standard of care in an approach to suicide is not risk prediction; rather the focus should be on risk/protective factor identification and acuity assessment, collateral history, clinical synthesis, and safety management.