Assessment and Evaluation of Child and Adolescent Psychiatric Emergencies

The incidence of child and adolescent psychiatric emergencies has increased over the past 20 years.^1,2 This rise in emergency department (ED) mental health visits coincides with an overall increase in ED use-from 89.8 million visits in 1992 to 107.5 million visits in 2001.³ Psychiatric presentations by children and adolescents (often in the absence of medical complaints) account for up to 5% of the total visits to an ED in a given year^2,4 and, in some reports, such presentations account for as many as 16% of ED visits.⁵

Analysis of the National Hospital Ambulatory Medical Care Survey database for utilization patterns of emergency department pediatric mental health (EDPMH) visits from 1993 to 1999 showed an overall increase in population-based rates of EDPMH visits by year but without an increase in diagnoses commonly thought to be emergent, such as suicide attempt, self-injury, or psychosis.¹ Instead, the most prevalent diagnoses were substance use disorders, anxiety disorders, and disruptive behavior disorders.

The study of psychiatric emergencies among children and adolescents is a new field, and little is known about who these patients are (demographics, adolesinsurance status, level of mental health involvement) (A.B.G. and S. Horwitz, unpublished data, 2005). The issues with which patients present are varied, and there are no universally accepted practice parameters or models of best practice in the assessment of these issues, nor are there clear guidelines for making decisions regarding disposition. Although the American Academy of Child and Adolescent Psychiatry (AACAP) has published practice parameters for the assessment and emergency management of suicidal behavior, this document does not address the assessment or disposition of emergent presentations that do not involve suicide or suicidal ideation.⁶

This leads to multiple challenges for clinicians who have to evaluate or consult on emergent cases. Since the increase in the number of patients seen in the ED is not caused by a rise in suicide attempts, physicians may be required to conduct more general psychiatric interviews. Evaluation is further complicated by the fact that assessment of child and adolescent psychopathology differs significantly from emergency evaluation of adults. Presentation of symptoms differs and, in the case of children, a greater emphasis should be placed on social and environmental factors.

There are several published reviews that describe common psychiatric emergencies among child and adoles-cent populations.^7,8 Table 1 summarizes the key areas of concern and the aspects of each that are specific to children and adolescents. The focus of this article is to provide a broad framework for assessment that may be applied to any child or adolescent psychiatric ED presentation.

OVERVIEW

Assessment of a child or adolescent psychiatric emergency involves conducting a concise yet detailed clinical interview and the ability to differentiate a true emergency from a familydefined “crisis.” In this context, an emergency is “a relatively abrupt, sudden situation in which there is an imminent risk of harm: (1) risk of suicide; (2) risk of physical harm to others; (3) states of seriously impaired judgment in which the individual is endangered; or (4) situations of risk to a defenseless victim.”⁹

A crisis, on the other hand, is often defined as a “loss of psychological equilibrium.” Crises tend to be longer-lasting than emergencies, are less specific, and involve no or a decreased risk of danger to self or others.⁹ Emergencies can and do occur in the context of a crisis. Rates of crises versus emergencies among children and adolescents presenting to EDs have not yet been established. Most families who present to the ED, however, report that the patient is a clear danger to himself or herself or others.

Five key points of emergency assessment of children and adolescents will be reviewed in this article:

• Safety measures.

• Strategies for interviewing.

• Role of collateral contacts.

• Legal issues.

• Options for disposition.

By the end of the evaluation, the consulting clinician should be able to answer the questions of “Why is the patient presenting now?” and “Can the situation be managed effectively in an outpatient setting?”

The discussion that follows assumes that the patient has been medically evaluated and that general medical conditions have been ruled out as underlying the patient's current psychiatric symptoms. Medical illnesses that present with psychiatric symptoms¹⁰ or the medical complications that result from substance use¹¹ must always be kept in mind, but these have been reviewed elsewhere.

The Figure presents a flowchart outlining the steps required in the emergent psychiatric evaluation of children and adolescents: triage and establish the patient's safety; evaluate him medically; obtain necessary consents for evaluation and possible hospitalization; conduct a clinical interview (see Table 1 for content areas); establish collateral contacts; and make disposition decisions and facilitate referrals as necessary. Few studies have evaluated the average length of stay in the ED for psychiatric consultations. Those who have examined this topic have found the length of consultations for adolescents to be significantly longer than that for adults,¹² probably because of the increased number of contacts necessary to complete the evaluation.

ESTABLISHING SAFETY: ED-BASED INTERVENTIONS

As with adult evaluations, the child or adolescent's safety should be established and ensured before proceeding with a psychiatric interview. Children presenting to the ED may be violent, agitated, and difficult to engage, particularly if they are brought to the ED against their will, or if they do not agree that they are experiencing a crisis. A first-level intervention for these patients should be behavior management, with an emphasis on a calm, nonthreatening approach.

Chemical restraint

In cases of severely agitated or psychotic patients, medication in the ED may be necessary. A chemical “restraint” has been defined by the Centers for Medicare & Medicaid Services (CMS) as “a medication used to control behavior or to restrict a patient's freedom of movement and [that] is not standard treatment for the patient's medical or psychiatric condition.”¹³ The drugs used may help decrease the patient's anxiety or discomfort, minimize disruptive behavior, prevent escalation of the patient's behavior, and/or reverse the underlying cause of the behavior.¹⁴ Guidelines and practice parameters for physical and chemical restraint have been published by the AACAP,¹⁵ the Joint Commission on Accreditation of Healthcare Organizations, and the CMS.

There is sparse literature regarding effective agents for restraint in child and adolescent populations.^14,16 The safety and efficacy of various medications in emergent child and adolescent situations have not been established. In considering the route of administration, patients should be offered the option of taking a medication orally; keep in mind that the presentation of a needle for an injection may result in a significant escalation of the crisis rather than de-escalation.

Given the lack of empiric support for the use of chemical restraints in children and adolescents and the potential for escalation of a crisis, their use should be avoided if possible. The majority of children and adolescents will respond to a quick implementation of behavioral interventions and a calm, nonthreatening approach to evaluation.

A DEVELOPMENTALLY APPROPRIATE INTERVIEW Approaching the interview

There are several reasons why interviewing children, in general, is different from interviewing adults: children's cognitive and language skills are less well developed; children do not often request the evaluation, so they are not present of their own will; children may perceive the evaluation as a punishment for something done wrong; children may have misinformation about the clinician's role-they may believe that the clinician is there to lecture them about what they did wrong, or that their having to be interviewed by a clinician means they are “crazy.”¹⁷ Difficulty in communication is a feature of some childhood disorders, which further complicates the interview.¹⁷ All of these reasons must be addressed both directly and indirectly if an interview with a child is to be successful. For more detailed information on interviewing children and adolescents, practice parameters are available through the AACAP.¹⁸

Often in emergency settings, a patient is interviewed several times during the course of his visit (by the triage nurse, medical student/resident, intern, attending physician, social worker). In establishing rapport, it may be helpful to acknowledge that information is shared among providers and that you, the consultant/ clinician, have received information about why the patient is in the ED. Emphasis should be placed on the importance of hearing what happened directly from the patient.

Children and adolescents may vary with regard to their feelings about a consultant having to speak with them and their parents. Some do not want to answer questions to which they know the clinician already has the answers, while others do not like clinicians' speaking with others about “their business.” It is best to follow the lead of the patient. For example, if an adolescent is upset about being asked questions that he has already answered for others, ask him the bare minimum that you need to hear directly from him to adequately conduct the interview (such as questions about mental status, including possible suicidal and/or homicidal ideation).

Ways of establishing rapport: whom to talk to first

There is generally little time to establish rapport in an emergency evaluation. As a result, small gestures on the part of the clinician can contribute to larger gains in rapport with a child or adolescent. Before initiating the interview, consider the age of the patient, the nature of the presenting complaint, and how those 2 factors may interact or independently contribute to the course and direction of the interview.

Regardless of the patient's age, he will likely be in an examination room with a parent, guardian, or other adult who brought him to the ED. If the child is younger than 12 years, interview the parent/guardian first, ideally in a separate location. This will allow an opportunity to gather information regarding the patient's history, changes in functioning and behaviors of clinical concern, past treatment history, medications, possible risk factors, and the caregiver's perception of risk level to self or others. Speaking with the guardian first may also help direct the subsequent interview with the child.

With children younger than 12 years, it is advisable to begin an interview with the adult in the room. This may allow the child to perceive the interviewer as an adult he can trust because his parent/guardian is willing to speak with the interviewer.

With older preadolescents and adolescents, it is recommended that they be addressed first so that they do not feel ignored. This communicates the message that they will be included in the evaluation and, if appropriate, the decision making. Interview the patient before interviewing the parent. There will be opportunity after the interview with the parent to speak with the adolescent again should there be a conflict in information provided.

Regarding the order of the interview, it is informative for disposition and treatment planners to witness the interaction between the child and parent/guardian, although it may result in conflict if the child was brought to the ED against his will or because of an earlier disagreement with the caregiver. A recommended approach is to do an initial introduction with both parties present, followed by a brief interview focused solely on establishing what brought them to the ED.

Extensive interviewing of an adolescent in front of his parent is likely to result in his minimization of his symptoms and/or his risk-taking behavior (such as sexual activity, drug use, suicidal thoughts) and therefore, should be avoided. Adolescents may be hesitant to disclose drug use, even with a parent absent, out of concern for possible legal ramifications. Confidentiality restrictions should always be reviewed with patients (see “Limits of confidentiality,” below). Explain to the patient that not providing all of the information will influence disposition decisions and treatment planning.

Interviewing uncooperative patients

There are several strategies to use in approaching children who are uncooperative in the evaluation process. One is for the clinician to introduce himself or herself to the patient, explain the purpose of the evaluation process, and then proceed with all other aspects of the consultation, leaving the patient interview for the end. This may give the patient time to calm down before being interviewed. Another strategy would be for the consultant to “join” with the patient by acting as a patient advocate. (“What can I do to help make things better for you?” Or “I would like to hear your side of the story so I can figure out the best way to help you.”)

Children/adolescents who are hostile and who refuse to cooperate with the interviewer but are not violent may respond to a consultant who clearly outlines the various outcomes and disposition decisions available should the patient refuse to cooperate. (“The information provided by your parent/guardian leads me to believe that you are not safe or may hurt yourself or someone else. It is your choice not to speak to me, but if you don't, then I will have to make a decision based only on what your parent/guardian tells me.”) Should the patient continue to refuse to cooperate with the interview, the clinician at least should attempt to do a safety assessment and mental status examination and rely on collateral contacts to provide any additional information required for treatment planning.

Symptom presentation

A developmental approach to psychopathology not only accounts for differences between children and adults but also considers differences among children at various developmental stages. Using such an approach to psychopathology and symptom assessment is critically important; merely applying adult diagnostic criteria to children's presenting complaints without accounting for changes in mood expression and cognition across their life span may result in inaccurate assessments and erroneous decisions.

Interviewing children and adolescents about suicide

In assessing suicidal ideation among children, it is important to consider the child's level of cognitive development, which may be especially variable among prepubertal children.¹⁹ Children's level of verbal skills and understanding of time, causality, and death will not only affect their concept of suicide but also what information they communicate to the clinician.¹⁹ While young children may have suicidal intent, some children may not fully appreciate the finality of death and may use a phrase such as “I want to die” to say that they want negative feelings to end, not their life. Children who are sad and possibly depressed but not actively suicidal may acknowledge that they do not want to die but have no other way of expressing their feelings of sadness. Younger children may also believe that if they hurt themselves, it will improve their relationship with their parents-the parents would miss them or realize how much they love them.

Focused areas of assessment for suicidal ideation or behavior should include intent, lethality of means/feasibility of plan, concepts of death, mood, degree of hopelessness, and extent of future orientation. When dealing with younger children, ask concrete questions that use specific examples of time (for example, “Do you think that every day?” vs “Do you have that thought often?”).¹⁹ Sample questions to use in an interview are provided in Table 2, while examples of standard rating scales are reviewed elsewhere.^20,21

With children, in addition to asking specific questions of the child and parent regarding past suicidal thoughts and gestures, an assessment of past behavior in general may provide useful information for determining past suicidal ideation and behavior. For example, does the child have a history of placing himself in potentially dangerous situations (running out into the middle of the street without looking; engaging in dangerous sports and recreational activities without appropriate safety equipment; playing games such as trying to fly from a tree or the roof of a house)? These behaviors may indicate impulsivity and poor judgment, or they may represent past suicide attempts.

A key difference between children and adults is the finding that among children and adolescents, there is no clear relationship between medical lethality of attempt and intent.^22,23 Young children may lack the knowledge of what may hurt them, but that does not mean that they lack intent to die. When considering disposition for patients reporting suicidality, access to means of self-harm (such as knives, firearms, medications) should be restricted if the patient is being discharged. In the case of child and adolescent evaluations for suicide, parents should always be counseled regarding the importance of limiting access to means and should be encouraged to remove any potentially lethal objects from the home.

MULTIPLE INFORMANTS: WHO DEFINES “EMERGENCY”?
Unlike adult emergencies, in child and adolescent mental health it is often the child's parent/guardian who labels a situation as a “crisis” or identifies a need for emergency care. An adult with whom the child interacts may feel overwhelmed in his or her own capacity to manage a child's behavior or may interpret a child's behavior as dangerous or inappropriate. ⁸ Thus, it may not be the child's behavior, per se, that is significant but its interpretation by the child's caregiver. For example, a behavior that is acceptable to, or managed by, the parent in the home may not be tolerated in a school setting. While the child is usually able to answer concretely the question of “Why did your mother bring you to the ED today?” (“Because I got into a fight with my little brother”), he is unlikely to label his own behavior as problematic or emergent.

It is the role of the consultant/physician to decide whether the child's behavior is a true emergency. The consultant determines whether the child's behavior represents a change in usual day-to-day functioning; is clinically meaningful, diagnostically relevant, and out of the realm of “normal” development; or is a reaction to a specific environment or caregiver (in which case, altering the environment may alleviate the problematic behavior).

When the parent is not the primary referral source, the consultant should seek out collateral contacts and, ideally, speak to the person who labeled the child's behavior as emergent. For example, since the events in Columbine, Colo, and other national tragedies, schools have increasingly implemented zerotolerance policies for violence or threatening behavior.²⁴ This may lead to increased ED presentations for children who violate school policy by making threats and who require evaluation before being allowed back into school. The parents typically lack a clear understanding of what transpired at school, because the patient is likely to report a “he said/she said” interaction with another student. In addition, the child may be unwilling to accept responsibility for any of his actions and out of anger, frustration, or discomfort, may be difficult to engage in an interview.

If the parent did not bring written documentation from the school, the consultant should call the school principal, teacher, or counselor to determine the exact nature and context of the offense. This type of information is essential if hospitalization is an option for disposition, because it may be difficult to justify an admission without a first-person account of the dangerous behavior. If the parents do not have documentation from the school describing what happened or if the clinician is unable to contact school personnel, a general assessment of dangerousness may be conducted. Not having an accurate description of the current precipitating factor may curtail options for disposition. The same principles apply if a patient is referred to the ED by a treating therapist or psychiatrist.

LEGAL ISSUES
Consent to treat

Although obtaining consent for medical treatment is typically waived in situations of life-threatening emergencies, the majority of patients presenting to a psychiatric emergency service do not typically require life-sustaining treatment. This results in the need to obtain consent before initiating assessment/ treatment.²⁵ Obtaining consent becomes complicated if the parents are divorced, the child is a ward of the county or state, or the adult bringing the child to the emergency setting is not his legal guardian. Reasonable attempts should be made to obtain consent before treatment, and such efforts should be documented. Clinicians should consider consulting with hospital attorneys in cases of married parents who disagree about evaluation and treatment.²⁵

States have begun to acknowledge a minor's right to consent to certain medical, mental health, and substance use treatments without parental knowledge. There are 5 types of consent laws for minors: emancipated minor, mature minor, age of consent to medical treatment, age of consent to voluntary commitment, and age of consent to outpatient treatment.²⁵ State laws vary with regard to the age at which a minor may consent to mental health treatment. It is important to be familiar with your specific state's law. In some states, children as young as 14 years can consent to mental health treatment without parental consent or knowledge.

Limits of confidentiality

Before starting an evaluation, clinicians should review limits of confidentiality with patients. Clinicians should use discretion when deciding what to reveal to a third party-for example, contacting school personnel who initiated a referral necessitates revealing that the patient is being evaluated, but does not warrant disclosure of diagnostic formulation, treatment recommendations, or family issues.²⁵ In the case of a parent's refusing the release of information, the identification of the situation as emergent would permit the breach of confidentiality. ²⁵ The individual state's law should be reviewed to determine specific practices with respect to confidentiality (for example, whether minors can prevent disclosure of confidential information to parents).

Reporting child abuse and neglect

All physicians, psychologists, and social workers are required to report abuse and neglect. States vary regarding whether there must be knowledge of abuse or merely suspected abuse to initiate a report, and many states impose penalties (fines, misdemeanor charges) on providers for failure to report abuse. Methods for reporting suspected abuse are available online through the US Department of Health and Human Services at: http://www.childwelfare.gov/responding/reporting.cfm

The federal Child Abuse Prevention and Treatment Act (CAPTA) (42 United States Code Annotated §5106g), amended by the Keeping Children and Families Safe Act of 2003, sets forth broad guidelines for defining child abuse and neglect: “Any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse, or exploitation; or an act or failure to act which presents an imminent risk of serious harm.”²⁶ CAPTA establishes a minimum standard of abuse, with each state creating its own statute defining abuse and neglect. A searchable database of state statutes is available online through the National Clearinghouse on Child Abuse and Neglect Information: http://www.childwelfare.gov/systemwide/laws_policies/search/index.cfm.

DISPOSITION DECISION MAKING

The most difficult aspect of the evaluation process is clinical decision making regarding the most appropriate disposition for a child or adolescent who may be a danger to himself or others.²⁷ There are 2 primary decisions to be made in this type of evaluation: whether the patient presents a clear danger to himself or others, and what is the most appropriate level of care for the patient. Decision making in the ED has been further complicated by the role of managed care in mental health service delivery and the necessity for treatment decisions to be cost-effective and clinically appropriate.²⁸

In making a disposition decision, the clinician must consider the constraints of the mental health service delivery system. Although the emphasis in the clinical literature is typically placed on treating young persons in the least restrictive and most clinically appropriate setting,²⁹ there are continued financial incentives for inpatient hospitalization over the development of communitybased programs.³⁰ Despite the need, there may not be sufficient numbers of community- based mental health programs; indeed, lack of access to care in the community setting is often hypothesized as the reason for the increase in ED visits for mental health concerns.^1,2,31

In general, there has also been a decrease in available psychiatric inpatient beds³² and fewer days of inpatient care among child and adolescent populations. ³³ It is possible that children needing a high level of care are presenting to and receiving treatment from outpatient settings because of a lack of inpatient beds. This may prompt overflow patients seeking mental health care (those in crisis, but not emergent) to visit EDs. Efforts to refer these nonemergent patients back to community mental health centers may be difficult because of long waiting lists for appointments.

In deciding disposition for children, the consultant must also assess the parents' ability to supervise when the patient is expressing suicidal thoughts, their ability to follow through with recommended appointments, and their attitudes toward the patient. For example, a frustrated parent who is angry with his child may be limited in his ability to carefully monitor the child. Using a continuum of care model (from least to most restrictive), Table 3 provides possible dispositions for children and adolescents.

Psychopharmacology in the ED

Given the variability in who conducts emergency evaluations of psychiatric patients,³⁴ prescribing medication in the ED may not always be an option (for example, if the consultant is a social worker or psychologist). Because there are often limited means of ensuring that the patient will engage in follow-up care after discharge from the ED, it may not be advisable to initiate a medication intervention that requires observation and monitoring by a physician.

Hospitalization

While attention has been paid to risk factors for presenting to an ED35,³⁶ and for committing suicide,^37,38 there has been less empiric research examining decision making and, more specifically, factors to weigh when deciding whether to hospitalize a young patient. Factors to consider when evaluating the benefits of hospitalization for children and adolescents have been published by the AACAP.³⁹

A review of the research found certain variables to be key determinants in disposition decision making for adults: severity of symptoms (particularly psychotic symptoms), suicidal and/or homicidal ideation, and previous hospitalization. ⁴⁰ Because this research was conducted on adult patients, it is not clear whether the findings transfer to a child and adolescent population. Recent studies, however, examined this issue in child populations. One such study identified at least 3 factors that could predict psychiatric hospitalization: cooccurrence of suicidal and assaultive behaviors as presenting problems, substance use in a child, and a family member (typically a parent) with a substance use problem.⁴¹

There is also some debate regarding the relevance of diagnosis to decision making about disposition.^41,42 While specific diagnoses are associated with dangerous behaviors, a patient can be dangerous even without a strict DSMIV- TR diagnosis. In addition, the reliability of diagnoses made in the ED is questionable,⁴³ which raises concern about their use in determining patient disposition.

The use of rating scales

Psychiatric emergency settings vary with regard to whether they use standardized instruments in emergent evaluations and what measures they use. Possible domains of assessment include factors related to suicidality (risk, intent, lethality), specific psychopathology, and admission criteria for hospitalization. Reviews and examples of such measures have been published elsewhere, ^20,21,44-47 but few of the published measures have been developed or evaluated in ED settings.

CONCLUSION

The emergency assessment of children and adolescents is a challenging task. A successful evaluation necessitates not only a thorough assessment of the patient's emergent symptoms but also his social environment. Also required is an understanding of how symptom presentation in children/adolescents might differ from that in adults, as well as across age groups (see “Take-home points,” below). If the trend of children and adolescents presenting to EDs for emergency complaints continues, research and advanced training for providers in this specialty are likely to follow.

Take-home points

• The assessment of any child or adolescent with a psychiatric emergency has 2 components: review of psychiatric symptoms and risk factors for suicide and/or violence toward others and assessment of social factors influencing the patient’s functioning.

• The length of child and adolescent psychiatric consultations will be greater than those of adults, given the necessity of establishing collateral contacts. It is rare that the patient will identify a situation as a crisis. As a result, a complete assessment necessitates interviews of adult figures in the child’s life who are defining the situation as emergent.

• Keys to successful interviewing of children/adolescents are to establish rapport, speak to the child and ask questions on a level that matches developmentally, include the child/adolescent in the process, and follow the child’s lead regarding willingness to talk.

• In the emergency department, where time is limited, small efforts to gain rapport (such as talking to the child first) go a long way, but an evaluation and disposition can be based solely on collateral contacts if the patient is not cooperative or is an “unreliable” reporter of events.

• In case of child and adolescent evaluations, issues of consent and confidentiality may be complicated by the patient’s status as a minor. Unlike adult evaluations, there are multiple levels of consent (patient, parent, county, and state) and confidentiality to be considered. This necessitates familiarity with the age of consent in the jurisdiction within which one practices, laws of confidentiality, and careful attention to who has custody of the patient.

• When considering disposition options for children and adolescents, in addition to assessing the patient, the clinician must conduct an assessment of the parents/ guardians. In some instances, a child may have to be placed in a more restrictive setting than medically indicated if the caregiver cannot or will not supervise the child, will not follow up with recommendations, or is threatening toward the child. The goal is always to place the child in the least restrictive setting that can still maintain his or her safety.

When this article was written, Dr Goldstein was a senior instructor in child and adolescent psychiatry at Case Western Reserve University School of Medicine and a clinical psychologist at University Hospitals of Cleveland. She is currently a postdoctoral fellow at the Johns Hopkins Bloomberg School of Public Health in Baltimore. Dr Findling is professor of psychiatry and pediatrics at Case Western Reserve University School of Medicine and director, division of child and adolescent psychiatry, at University Hospitals of Cleveland. The authors report no conflicts of interest regarding the subject matter of this article. This article first appeared in Psychiatric Issues in Emergency Care Settings (2005;4(1):7-18).

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