The treatment of the behaviourally disturbed adolescent

17.2 The treatment of the behaviourally disturbed adolescent

1 Emergency psychiatry is treating the underlying neurobehavioural processes NOT the cognitive content or psychiatric diagnosis.

2 When thinking about management it is worthwhile to move back through the ABCC from the most disrupted young people, through to the early levels of distress and dysfunction.

C – If cognitive processes are very disrupted, hospital admission will be necessary irrespective of the eventual diagnosis.

C – If containment is threatened – offer co-operative sedation early and put security on notice. If it is actually being breached, all other treatment must wait until containment is addressed voluntarily or involuntarily.

B – If behaviour is extreme, actively offer relief with calm reassurance, nursing presence and medication while consciously preparing for escalation to a containment breach.

A – If arousal is high, establish whether this can be readily managed by calmness and co-operative use of medication. If calm is not forthcoming, be prepared for behavioural escalation.

Introduction

Emergencies fragment clinician thought, unless they are transformed into routine. No area of medicine is more difficult to conform to routine without practice than psychiatry and no area of psychiatry is more ‘inconvenient’ in this regard than adolescent psychiatry.

Just as in paediatrics, the first question is not ‘which illness?’ but ‘how sick are they?’ There is currently too much emphasis on whether or not there are signs of a particular mental illness, not whether there are the crucial elements of neurobehavioual disorder and the disruption of basic neurobehavioural systems. Despite this, once the essentials are understood and applied, the emergency physician can provide consistent, high quality care in triage, initial stabilisation and management of immediate risks before preparing for transfer for definitive management and ongoing treatment where needed.

This chapter is written with the underlying premise that psychiatrists will be in short supply, sometimes not trained in Emergency Psychiatry, or unaccustomed to adolescent psychiatry. For the present, emergency adolescent psychiatry largely falls to emergency physicians.

The principles of psychiatric triage

Purpose of triage

Triage aims to enable the earliest possible identification and treatment of factors that may threaten the immediate safety and well-being of the patient, others and staff in triage and the emergency department (ED). The aim is to put safety first, management of distress and behaviour second, and diagnosis third. It is critical that the task of definitive diagnosis does not delay acute management. Whether or not a young person has a particular psychiatric disorder is of secondary importance. Accurately identifying the components of threat, the complexity of the threat (that is the number of domains of risk), the level of the threat, the emotional and behavioural identifiers of risk and the performance indicators for risk management, all within a rapid time frame, requires training, skill and experience.

Time is risk

The time taken before treatment begins in psychiatric triage is related to increasing risk, as impulsivity, agitation and lack of relief of distress converge with the sensory overstimulation of most ED waiting areas. Time passing constitutes an escalating risk of a loss-of-control, or loss-of-containment, event. Where agitation is present, motor activity increased and cognitive processes clearly altered, the risk rises dramatically after even short periods of waiting. The commonly encountered slide down the spectrum of distress to disruption – anxiety, agitation, anger, together with demanding, impatient, impulsive and explosive behaviour – leaves few options once in full progress. On the other hand, the rapid initiation of triage and the commencement of an altogether less disruptive process – seen, relieved, treated, monitored, transitioned – are each associated with a reduced risk of loss-of-control.

Pre-triage

Early warning signs – subjective

• Identifying a safety threat to staff and others.

• Questions such as ‘Do I feel unsafe?’ ‘Am I anxious for their welfare?’ ‘Is there a sense of threat?’ may all provide useful clues, if considered (Table 17.2.1). It is worthwhile acting on this as a given until reassured otherwise.

Table 17.2.1 A triad of subjective early warning signs
Threats to safety	Syndromes of distress	Organic flags
If you feel unsafe or moved to protect others	If you feel distressed at watching	If you can’t make sense and the child looks unwell

Early warning signs – observed

Some behaviour stands out as ‘out of control’, unusual, potentially dangerous, conflicting, or distressing, before the patient and those attending them sit down and you begin to listen. Sitting down is a helpful first step to reducing arousal and activation. A louder than usual voice, an argument between parent and child, a surly withdrawn father, a seemingly drunken teenager, may all catch our attention.

An immediate threat to others, an immediate threat of patients to themselves or an immediate threat to medical safety, all require immediate action analogous to a cardiac arrest. Practising commonly encountered scenarios with acceptance of ‘error and inefficiency’ is essential.

The hierarchy of needs

All triage involves addressing a hierarchy of needs (Table 17.2.2).

Table 17.2.2 The hierarchy of patient needs
Threat	Need	Sign for observation
Danger	Safety	Signs of threats to safety
Distress	Relief	Signs of intense distress
Disease	Treatment	Signs of organic cerebral, and long-term psychiatric dysfunction

Safety, symptom relief and initial investigation (SSRI) and working or provisional diagnosis (PD) form the underpinnings of emergency psychological care. The establishment of mental state monitoring and the active exclusion of medical contributors commence immediately upon completing the initial stabilisation.

Signs of intense distress

By way of analogy with the provision of acute life support, it is helpful to employ the ABCC mnemonic.

The ABCC of rapid psychiatric assessment

Arousal – autonomic and cortical arousal

Behaviour – behavioural activation

Containment – behavioural control within a social setting

Cognitive processes – the coherent communication of reality-based thinking and feeling.

Identifying the triad of early changes, rate of change and the extremity of change to each component of assessment will be used throughout.

Arousal

The triad of early signs of change in arousal, volatility of arousal and extremes of arousal are our focus. Thus, early autonomic signs of either sympathetic or parasympathetic shift include pallor, flushing, tachycardia, bradycardia, tremulousness, mydriasis and tachypnoea. Marked hypervigilance and clouding of consciousness or rapid excursions between the two are very helpful in identifying the need to intervene rapidly. Anxieties may be more difficult to assuage with lack of fine social and emotional tuning with either unresponsiveness, or exquisite responsiveness, to the environment, or a rapidly changing mixture of both. If the arousal is sufficiently disruptive, the child or young person may have a functional overflow of their arousal into their behaviour.

Behaviour

Again, early signs of change in behaviour, volatility of behaviour and extremes of behaviour are our focus. Sitting with one leg constantly shaking, wringing of hands or stroking of hair as part of anguish or anger all portend an imminent deterioration in behaviour. Constant pacing or refusal to move, a loud voice or speaking very quietly, swearing excessively and particularly offensively, or refusing to talk as part of a broader picture of social disinhibition or extreme inhibition, reflect extremes of response and lack of fine social and emotional tuning. If these are sustained, they may overflow and have an impact on the other patients, staff and the functioning of the ED. If this impact is sufficiently disruptive, they may constitute a containment threat or demand for containment.

Containment

Behavioural control within a social setting so as to reduce major threat and disruption, that is in an acute medical setting, is termed containment. While containment is usually a physical process, which reduces the capacity of a patient to disrupt the ED, it is primarily aimed at reducing risk to others, risk to self and risk to the environment in the ED. The acute and open nature of the ED means that any disruptive threat may constitute a broader threat to the provision of urgent medical treatment to the young person in question or to others.

It follows that, since changes in arousal normally precede changes in behaviour, which precede changes in the likelihood of containment, the early warning signs of a loss of containment event have already been covered under the headings of arousal and behaviour. However, frequently these early features will have happened prior to being seen in the ED and the demand for containment is the presenting request.

Running away, disrupting the ED, damaging property and creating an atmosphere of threat and menace would all constitute a containment threat or a containment failure event. In extreme cases this may involve weapons, the police and the clearing of the ED, with cessation of medical activities while a local Disaster Response is put into place. In most cases, some form of containment was in place before being brought to the ED and it is important that this containment is not lost in the transition process into the ED or in transfer from the ED. If containment failure is the external manifestation of maximal disruption to the individual, the fragmentation of thought processes or pathological coalescence of thinking into paranoid or self-destructive ideation is the inner manifestation shown in arousal, behaviour, including speech, and containment.

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Tags: Textbook of Paediatric Emergency Medicine

Sep 7, 2016 | Posted by admin in EMERGENCY MEDICINE | Comments Off

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