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Evaluation and Management of Children and Adolescents with Acute Mental Health Or Behavioral Problems

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Evaluation and Management of Children and Adolescents with Acute Mental Health Or Behavioral Problems CLINICAL REPORT Guidance for the Clinician in Rendering Pediatric Care Evaluation and Management of Children and Adolescents With Acute Mental Health or Behavioral Problems. Part I: Common Clinical Challenges of Patients With Mental Health and/or Behavioral Emergencies Thomas H. Chun, MD, MPH, FAAP, Sharon E. Mace, MD, FAAP, FACEP, Emily R. Katz, MD, FAAP, AMERICAN ACADEMY OF PEDIATRICS, COMMITTEE ON PEDIATRIC EMERGENCY MEDICINE, AND AMERICAN COLLEGE OF EMERGENCY PHYSICIANS, PEDIATRIC EMERGENCY MEDICINE COMMITTEE INTRODUCTION This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have Mental health problems are among the leading contributors to the global fi led confl ict of interest statements with the American Academy of Pediatrics. Any confl icts have been resolved through a process 1 burden of disease. Unfortunately, pediatric populations are not spared of approved by the Board of Directors. The American Academy of mental health problems. In the United States, 21% to 23% of children and Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication. 2, 3 adolescents have a diagnosable mental health or substance use disorder. Clinical reports from the American Academy of Pediatrics benefi t from Among patients of emergency departments (EDs), 70% screen positive for expertise and resources of liaisons and internal (AAP) and external 4 reviewers. However, clinical reports from the American Academy of at least 1 mental health disorder, 23% meet criteria for 2 or more mental Pediatrics may not refl ect the views of the liaisons or the organizations health concerns, 5 45% have a mental health problem resulting in impaired or government agencies that they represent. psychosocial functioning, 5 and 10% of adolescents endorse significant The guidance in this report does not indicate an exclusive course of 6 treatment or serve as a standard of medical care. Variations, taking levels of psychiatric distress at the time of their ED visit. In pediatric into account individual circumstances, may be appropriate. primary care settings, the reported prevalence of mental health and All clinical reports from the American Academy of Pediatrics behavioral disorders is between 12% to 22% of children and adolescents.7 automatically expire 5 years after publication unless reaffi rmed, revised, or retired at or before that time. Although the American Academy of Pediatrics (AAP) has published a policy DOI: 10.1542/peds.2016-1570 statement on mental health competencies and a Mental Health Toolkit for PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). pediatric primary care providers, no such guidelines or resources exist Copyright © 2016 by the American Academy of Pediatrics 8, 9 for clinicians who care for pediatric mental health emergencies. This FINANCIAL DISCLOSURE: The authors have indicated they do clinical report supports the 2006 joint policy statement of the AAP and not have a fi nancial relationship relevant to this article to disclose. American College of Emergency Physicians (ACEP) on pediatric mental FUNDING: No external funding. health emergencies, with the goal of addressing the knowledge gaps in POTENTIAL CONFLICT OF INTEREST: The authors have indicated 10, 11 this area. The report is written primarily from the perspective of ED they have no potential confl icts of interest to disclose. clinicians, but it is intended for all clinicians who care for children and adolescents with acute mental health and behavioral problems. To cite: Chun TH, Mace SE, AAP FACEP, Katz ER. Evaluation and Management of Children and Adolescents With Acute Recent epidemiologic studies of mental health visits have revealed a Mental Health or Behavioral Problems. Part I: Common rapid burgeoning of both ED and primary care visits. 12 – 20 An especially Clinical Challenges of Patients With Mental Health and/or Behavioral Emergencies. Pediatrics. 2016;138(3):e20161570 problematic trend is the increase in “boarding” of psychiatric patients in Downloaded from www.aappublications.org/news by guest on September 28, 2021 PEDIATRICS Volume 138 , number 3 , September 2016 :e 20161570 FROM THE AMERICAN ACADEMY OF PEDIATRICS the ED and inpatient pediatric beds barriers to caring for their patients medical illnesses or injuries in (ie, extended stays lasting days or with mental health problems. 46, 47 patients presenting with psychiatric even weeks). Although investigation Part I of this clinical report focuses complaints. Concern that medical of boarding practices is still in its on the issues relevant to patients illness may be the underlying cause 21 infancy, the ACEP and the American presenting to the ED with a mental of a psychiatric problem has led 22 Medical Association have both health chief complaint and covers the some to suggest “that emergency expressed concern about it, because following topics: patients with psychiatric complaints it significantly taxes the functioning receive a full medical evaluation.” 48 and efficiency of both the ED and • Medical clearance of pediatric Medical clearance originates from hospital, and mental health services psychiatric patients the perspective that an ED evaluation may not be available in the ED. 23 –26 • Suicidal ideation and suicide of a psychiatric patient may be the only opportunity to diagnose In addition, compared with attempts underlying illnesses or injuries that other pediatric care settings, ED • Involuntary hospitalization could result in morbidity or mortality patients are known to be at higher • Restraint of the agitated patient because resources for diagnosing risk of mental health disorders, and treating medical conditions including depression,27, 28 anxiety, 29 o Verbal restraint may not be readily available in some posttraumatic stress disorder,30 o Chemical restraint psychiatric facilities. In addition, and substance abuse.31 These many psychiatric complaints and mental health conditions may o Physical restraint disorders can be exacerbated or be unrecognized not only by • Coordination with the medical precipitated by medical illness, 49 and treating clinicians but also by the home some psychiatric patients may have child/adolescent and his or her Part II discusses challenging unmet medical needs. 50 –52 parents. 32 –36 A similar phenomenon patients with primarily medical has been described with suicidal or indeterminate presentations, Medical Diseases in ED Psychiatric patients. Individuals who have in which the contribution of an Patients committed suicide frequently underlying mental health condition Previous studies of medical visited a health care provider in the may be unclear or a complicating conditions in ED psychiatric patients months preceding their death.37, 38 factor, including: have been almost exclusively Although a minority of suicidal conducted with adults and have patients present with some form • Somatic symptom and related had highly variable findings. Past of self-harm, many have vague disorders reports have found underlying somatic complaints (eg, headache, • Adverse effects to psychiatric medical problems in 19% to 63% of gastrointestinal tract distress, medications ED psychiatric patients. 53 – 55 Studies back pain, concern for a sexually o Antipsychotic adverse effects of adults admitted to psychiatric transmitted infection) masking units after an ED medical evaluation their underlying mental health o Neuroleptic malignant syndrome have had similarly disparate results. condition. 34 –36 o Serotonin syndrome Some have reported missed medical Despite studies demonstrating • Children with special needs in conditions in up to half of patients, 53, 56 moderate agreement between the ED (autism spectrum and including diabetes, uremic and emergency physicians and developmental disorders) hepatic encephalopathy, pneumonia, psychiatrists in the assessment and urinary tract infections, and sepsis, 57 • Mental health screening in the ED management of patients with mental but another found that only 4% health problems, 39, 40 ED clinicians An executive summary of this (12 of 298) needed treatment of a frequently cite lack of training clinical report can be found at www. medical condition within 24 hours and confidence in their abilities as pediatrics. org/ cgi/ doi/ 10. 1542/ of admission to the psychiatric barriers to caring for patients with peds. 2016- 1571. unit. 58 To address these concerns, mental health emergencies. 41 – 44 some have suggested a standardized Another study of emergency evaluation and documentation of medicine and pediatric emergency MEDICAL CLEARANCE OF PEDIATRIC the ED medical evaluation. 59 Major medicine training programs found PSYCHIATRIC PATIENTS limitations of these studies are that formal training in psychiatric that they are from older literature, Background problems is not required nor offered and they did not include children. by most programs. 45 Pediatric Medical clearance can be defined More recent adult and pediatric primary care providers report similar as the process of excluding acute studies, discussed later, suggest that Downloaded from www.aappublications.org/news by guest on September 28, 2021 e2 FROM THE AMERICAN ACADEMY OF PEDIATRICS significant rates of medical morbidity a comprehensive list of such electrocardiogram (18%). 66 Other in psychiatric patients may be less conditions is beyond the scope of this commonly obtained laboratory likely. article. Table 1 focuses on medical evaluations for medical clearance
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