Simmer Down Now
Answer: A
The US Department of Health and Human Services reports that approximately 4 million children (1 in 10) currently suffer from mental illness, but only 20% of those are receiving treatment. Adult patients with mental health
problems struggle with access to care; pediatric patients have additional obstacles, as pediatric practitioners and resources are even scarcer. The ED becomes the safety net for these patients and families.
The burden of psychiatric illness in children may involve aspects of depression, social maladjustment, bullying, or psychosis. Other behavioral reinforcers may prompt an ED visit: in the caregiver, it is a relief to turn to someone else to manage the child; in the child, a break from the often maladaptive environment is relief in itself, where he may seek the compassion, positive attention, and/or treats like television or video games which may be found in the ED.
The key to understanding the context of pediatric behavioral and psychiatric emergency department presentations is this: the child and/or the family is in some type of crisis. The emergency physician should seek out the internal risks (suicidal, homicidal/aggressive, intellectual delay) and the external risks (care providers, school, community, outpatient resources) in the pediatric patient.
When assessing the pediatric patient’s mental status, a mnemonic may be helpful:
“ABC STAMP LICKER”
Appearance, Behavior, Cooperation
Speech
Thought Process
Affect
Mood
Psychosis
Level of Consciousness
Insight/Judgment
Cognition
Fund of Knowledge
Endings: SI/HI
Risk Assessment
Recognition of an abnormal mental status and likely psychiatric problem is important (after addressing any organic disease). Interestingly, exact psychiatric diagnosis is not essential in the ED: disposition is the focu here
(diagnosis is often not feasible or reliable in this setting). Given this, the following questions are the most
high-yield:
How dangerous is the PATIENT?
How dangerous is his ENVIRONMENT?
How well is he CONNECTED TO CARE?
Care for the child and his family in a non-judgmental and caring manner, try to provide a safe and quiet environment, remove any weapons or drugs that might be used to hurt himself or others, keep him monitored with a sitter or other staff, and be ready to provide emergency medications as needed.
This child is experiencing a behavioral crisis that requires immediate attention. As with any patient, verbal de-escalation, distraction, and other non-pharmacologic techniques are important early modalities to use to address disruptive behavior in the ED. When that fails, the emergency physician must take over the situation to ensure the safety of the other patients in the department, the staff, and the patient himself.
The approach to chemical restraint in the pediatric patient differs from that of the adult. True and frank psychosis in children is rare; the majority of presentations involve some degree of behavioral crisis. As such, the goal in children is treating acute agitation or violent behavior with sedation, rather than attempting to diagnose and treat a psychosis.
Treatment will vary by institution, but many will agree to start with lower-risk medications such as anti-histamines (A) as a first-line agent (e.g. diphenhydramine at 1 mg/kg/dose IM up to 50 mg). Note that there is a chance
of paradoxical reaction, especially in younger children; if the patient is already taking an anti-histamine chronically, there will likely be little to no sedative effect.
In adult patients, atypical antipsychotic agents are often preferred over the older typical agents due to side effects, especially if given chronically. In children, typical antipsychotics (B) (e.g. haloperidol at 0.025-0.075 mg/kg/dose IM; max 2.5 if < 12 years, 2-5 mg if > 12 years) are second-line agents after antihistamines: they are used in this context for their excellent sedative properties (the antipsychotic/neuroleptic effects often require up to a week to have effect).
There are few data regarding the use of the newer atypical agents on children; for that reason (and the less sedative nature of these drugs), atypical antipsychotics (C) (which in adults are first-line) are third-line agents for children (e.g. risperidone at 0.01 mg/kg/dose IM, typically 0.25-4 mg/dose, depending on weight and prior
exposure).
Benzodiazepines (D) should be reserved for children who do not respond to the above 1st, 2nd, and 3rd line agents: they often cause a paradoxical disinhibition/agitation in these patients (especially those with developmental delay) and are overly sedating.
References
American Academy of Pediatrics. Technical Report: Pediatric and Adolescent Mental Health Emergencies in the Emergency Medical Services System. Pediatrics. 2011; 127(5):e1356-e1366.
American College of Emergency Physicians. Policy Statement: Pediatric Mental Health Emergencies in the Emergency Medical Services System. 2012.
Baren JM, Mace SE, Hendry PL, Dietrich AM, Goldman RD, Warden CR. Children’s Mental Health Emergencies-Part 2: Emergency Department Evaluation and Treatment of Children With Mental Health Disorders. Pediatr
Emerg Care. 2008; 24(7):485-498.
Kelly P. Lecture: “Initial Management of Pediatric Psychiatric Patients in the ER”. Emergency Departments Approved for Pediatrics (EDAP) Conference, Fort MacArthur, CA. 2013.
Special thanks to Cynthia Frankel, RN, MS.
The US Department of Health and Human Services reports that approximately 4 million children (1 in 10) currently suffer from mental illness, but only 20% of those are receiving treatment. Adult patients with mental health
problems struggle with access to care; pediatric patients have additional obstacles, as pediatric practitioners and resources are even scarcer. The ED becomes the safety net for these patients and families.
The burden of psychiatric illness in children may involve aspects of depression, social maladjustment, bullying, or psychosis. Other behavioral reinforcers may prompt an ED visit: in the caregiver, it is a relief to turn to someone else to manage the child; in the child, a break from the often maladaptive environment is relief in itself, where he may seek the compassion, positive attention, and/or treats like television or video games which may be found in the ED.
The key to understanding the context of pediatric behavioral and psychiatric emergency department presentations is this: the child and/or the family is in some type of crisis. The emergency physician should seek out the internal risks (suicidal, homicidal/aggressive, intellectual delay) and the external risks (care providers, school, community, outpatient resources) in the pediatric patient.
When assessing the pediatric patient’s mental status, a mnemonic may be helpful:
“ABC STAMP LICKER”
Appearance, Behavior, Cooperation
Speech
Thought Process
Affect
Mood
Psychosis
Level of Consciousness
Insight/Judgment
Cognition
Fund of Knowledge
Endings: SI/HI
Risk Assessment
Recognition of an abnormal mental status and likely psychiatric problem is important (after addressing any organic disease). Interestingly, exact psychiatric diagnosis is not essential in the ED: disposition is the focu here
(diagnosis is often not feasible or reliable in this setting). Given this, the following questions are the most
high-yield:
How dangerous is the PATIENT?
How dangerous is his ENVIRONMENT?
How well is he CONNECTED TO CARE?
Care for the child and his family in a non-judgmental and caring manner, try to provide a safe and quiet environment, remove any weapons or drugs that might be used to hurt himself or others, keep him monitored with a sitter or other staff, and be ready to provide emergency medications as needed.
This child is experiencing a behavioral crisis that requires immediate attention. As with any patient, verbal de-escalation, distraction, and other non-pharmacologic techniques are important early modalities to use to address disruptive behavior in the ED. When that fails, the emergency physician must take over the situation to ensure the safety of the other patients in the department, the staff, and the patient himself.
The approach to chemical restraint in the pediatric patient differs from that of the adult. True and frank psychosis in children is rare; the majority of presentations involve some degree of behavioral crisis. As such, the goal in children is treating acute agitation or violent behavior with sedation, rather than attempting to diagnose and treat a psychosis.
Treatment will vary by institution, but many will agree to start with lower-risk medications such as anti-histamines (A) as a first-line agent (e.g. diphenhydramine at 1 mg/kg/dose IM up to 50 mg). Note that there is a chance
of paradoxical reaction, especially in younger children; if the patient is already taking an anti-histamine chronically, there will likely be little to no sedative effect.
In adult patients, atypical antipsychotic agents are often preferred over the older typical agents due to side effects, especially if given chronically. In children, typical antipsychotics (B) (e.g. haloperidol at 0.025-0.075 mg/kg/dose IM; max 2.5 if < 12 years, 2-5 mg if > 12 years) are second-line agents after antihistamines: they are used in this context for their excellent sedative properties (the antipsychotic/neuroleptic effects often require up to a week to have effect).
There are few data regarding the use of the newer atypical agents on children; for that reason (and the less sedative nature of these drugs), atypical antipsychotics (C) (which in adults are first-line) are third-line agents for children (e.g. risperidone at 0.01 mg/kg/dose IM, typically 0.25-4 mg/dose, depending on weight and prior
exposure).
Benzodiazepines (D) should be reserved for children who do not respond to the above 1st, 2nd, and 3rd line agents: they often cause a paradoxical disinhibition/agitation in these patients (especially those with developmental delay) and are overly sedating.
References
American Academy of Pediatrics. Technical Report: Pediatric and Adolescent Mental Health Emergencies in the Emergency Medical Services System. Pediatrics. 2011; 127(5):e1356-e1366.
American College of Emergency Physicians. Policy Statement: Pediatric Mental Health Emergencies in the Emergency Medical Services System. 2012.
Baren JM, Mace SE, Hendry PL, Dietrich AM, Goldman RD, Warden CR. Children’s Mental Health Emergencies-Part 2: Emergency Department Evaluation and Treatment of Children With Mental Health Disorders. Pediatr
Emerg Care. 2008; 24(7):485-498.
Kelly P. Lecture: “Initial Management of Pediatric Psychiatric Patients in the ER”. Emergency Departments Approved for Pediatrics (EDAP) Conference, Fort MacArthur, CA. 2013.
Special thanks to Cynthia Frankel, RN, MS.