Children with mental health problems are increasingly being evaluated and treated by both pediatric primary care and pediatric emergency physicians. This article focuses on the epidemiology, evaluation, and management of the 2 most common pediatric mental health emergencies, suicidal and homicidal/aggressive patients, as well as the equally challenging population of children with autism or other developmental disabilities.
Key points
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Patients with suicidal and homicidal ideation, as well as autism and/or developmental disability are commonly cared for in the emergency department.
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Evaluation for underlying medical condition, as well as a thorough risk and safety assessment should be performed for all these patients.
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A number of calming and distraction techniques may facilitate the care of children with autism and/or developmental disabilities.
Introduction
Visits for mental health problems to both pediatric primary care settings and pediatric emergency departments have increased markedly in recent decades, and now account for up to 25% to 50% of primary care and 5% of pediatric emergency department visits. Both pediatricians and pediatric emergency physicians identify lack of training in and lack of confidence in their ability to care for mental health problems as barriers to caring for these patients. The focus of this article is the 2 most common pediatric mental health emergencies, both of which involve threats to safety: suicide, whereby there is risk of harm to the patient, and homicide or aggression, whereby there is risk of harm to others. In addition, the challenges of caring for children with autism or other developmental disabilities are discussed.
Introduction
Visits for mental health problems to both pediatric primary care settings and pediatric emergency departments have increased markedly in recent decades, and now account for up to 25% to 50% of primary care and 5% of pediatric emergency department visits. Both pediatricians and pediatric emergency physicians identify lack of training in and lack of confidence in their ability to care for mental health problems as barriers to caring for these patients. The focus of this article is the 2 most common pediatric mental health emergencies, both of which involve threats to safety: suicide, whereby there is risk of harm to the patient, and homicide or aggression, whereby there is risk of harm to others. In addition, the challenges of caring for children with autism or other developmental disabilities are discussed.
Suicidal ideation and suicide attempts
Key Points
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Suicide is one of the leading causes of death in pediatric patients.
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Constant observation is necessary to ensure patient safety during suicide evaluation and crisis stabilization.
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Evaluation includes assessment for potential underlying or associated medical conditions.
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Laboratory and/or imaging should be obtained on an as-needed basis.
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High-risk patients should be referred directly for inpatient psychiatric admission.
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Less intensive treatment options may be considered for patients who are able to maintain their safety in outpatient settings.
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Although there are no medications with which to directly treat suicidality, there are safe and effective treatments for the majority of the associated psychiatric conditions.
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All evaluations of patients in the setting of suicidal ideation or suicide attempts should include a thorough discussion of safety planning, including means restriction and indications for seeking emergency care.
Introduction
Suicide is the third leading cause of death among persons aged 10 to 24 years in the United States, accounting for more than 4000 deaths per year. Approximately 16% of teenagers report having seriously considered suicide in the past year, 12.8% report having planned a suicide attempt, and 7.8% report having attempted suicide in the past year. Although only a small percentage of suicide attempts lead to medical attention, suicide attempts still account for a significant number of emergency visits.
Risk factors
Females are more likely to consider and attempt suicide, but males are more than 5 times more likely to complete suicide. This difference is primarily accounted for by the use of more lethal means: males are more likely to attempt suicide using firearms and hanging, whereas females are more likely to attempt suicide via a drug overdose.
Other risk factors for attempting and/or completing suicide include :
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History of previous suicide attempts
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Impulsivity, mood, or behavior disorders
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Recent psychiatric hospitalizations
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Substance abuse
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Family history of suicide
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History of physical or sexual abuse
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Homelessness/runaways
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Identification as lesbian, gay, bisexual, or transsexual
Evaluation
Identifying at-risk patients
Some patients will identify themselves as being suicidal, with suicidal ideation or suicide attempt as their chief complaint. However, many may not proactively report their suicidality to providers. Given the prevalence of suicidal ideation and attempts as well as the morbidity and mortality associated with attempts, pediatric providers are encouraged to screen all of their teen patients for suicidality. Screens may be brief and focused directly on suicide risk or a more extensive part of a broader mental health screening tool, such as the Pediatric Symptom Checklist. Another clinical resource is the TeenScreen National Center for Mental Health Checkups. All patients presenting with mood symptoms, substance abuse, ingestions, acute intoxication, single-car motor vehicle crashes, self-inflicted or accidental gunshot wounds, and falls from significant heights should be screened for the presence of suicidal ideation.
Ensuring safety
First and foremost, providers must ensure the safety of the patients, their family, and health care staff during the course of the evaluation. Whenever concern for suicidal ideation or attempt is present, patients should be constantly monitored. Patients should not be left unobserved, as they are at risk for further injuring themselves or eloping. Patients should undergo a search of their person and belongings, be asked to change into hospital attire or an examination gown, and be placed in as safe a setting as possible, ideally one without access to medical equipment that could be used for self-harm.
Confidentiality
When a physician is concerned that the patient may be at imminent risk for harm to self or others, confidentiality requirements no longer apply. Physicians may disclose information gathered by patients to caregivers and may obtain information from others (including friends, family members, school personnel, and other caregivers) without obtaining consent from the patient or guardians.
Interview
Patients and caregivers should be interviewed both together and alone. It is essential that providers obtain collateral information from caregivers, as patients frequently minimize the severity of their symptoms or the intention behind their acts. It is paramount to ask patients directly about suicidality. Asking patients about suicidal ideation and attempts does not increase suicidal behaviors. In fact, it may have the opposite effect, as having an open, honest conversation about their suicidal thoughts may provide patients with a sense of safety and relief. In turn, this may enable them to fully disclose their suicidality and engage in treatment.
In addition to obtaining routine historical data (both medical and mental health histories), clinicians should obtain thorough details of the events and symptoms leading up to presentation of patients. Specific attention should be paid to:
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Recent psychosocial stressors, for example:
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Family conflict
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Breakup of a romantic relationship
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Bullying
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Academic difficulties
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Disciplinary actions/legal troubles
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Depression
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Mania
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Anxiety
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Psychosis
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Impulsivity
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Aggression
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Substance abuse
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Access to lethal means
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Firearms
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Knives
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Medications
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Access to a responsible, supportive adult to whom they could turn if they had suicidal thoughts
Younger patients tend to be triggered more often by family conflict, whereas older adolescents are more likely to cite peer or romantic conflicts.
When discussing suicidal ideation, clinicians should inquire about patients’ reasons for considering/attempting suicide, and what, if any, are their reasons for living. Where were they, and what was happening immediately before the attempt? Was the attempt planned or impulsive? Did they do anything to avoid discovery? What was their expectation of the outcome would be? It should be noted that adolescents are typically poor judges of the dangerousness of their acts. Although patients with low-lethality attempts may not be at significant medical risk, patients’ understanding of the potential lethality of their actions should form the basis of the suicide risk assessment.
Patients may deny that their behaviors constituted a suicide attempt and instead report that they “did it without thinking” or that they were just trying to go to sleep or get high, or get a break from their feelings. Clinicians should be wary of accepting these explanations at face value, and should probe for any signs of ambiguity or ambivalence. For example, in the setting of an overdose it may be useful to ask patients if they questioned the safety of the ingestion beforehand. Was there any part of them that thought it might endanger their life? If so, it may be helpful to wonder out loud whether there was part of them that would not have cared if they did not wake up from the ingestion. If the patient acknowledges any ambivalence, the clinician should follow up by exploring what parts of the patient would not have cared. The clinician should also assess how, given the patient’s awareness of the ingestion’s potential lethality, he or she arrived at the decision to carry it out.
If patients respond by steadfastly denying any suicidal thoughts and/or maintaining that they did not consider the consequences of their actions, it may be that there truly was no intent for self-harm. However, there are some circumstances in which there is enough evidence supporting suicidal intent (such as statements to family and friends or postings on social media) that is concerning enough to overcome any potential reassurance from patients’ denial of intent for self-harm. There may also be circumstances in which patients may not have had any intent to harm themselves, but their lack of judgment about the dangerousness of their actions could be considered life-threatening and still necessitate intensive psychiatric treatment.
Family interview
Parents should be questioned about recent signs, symptoms, and stressors as well as the details of the any events that may have led to their presentation. In addition, pediatricians should inquire about the patient’s access to lethal means, the level of caregivers’ knowledge of/concern for the patient’s safety and well-being, their willingness/ability to monitor the patient, their level of openness to psychiatric treatment, and any barriers that might impede engagement in care. Clinicians should also work to identify areas of competence in both the patient and the family. These areas of strength form the basis for a successful treatment plan that enables the family to respond effectively to the crisis at hand.
Physical Examination
There are several purposes to the medical examination in suicidal patients. Clinicians should evaluate the patient for any evidence of injury or ingestion. Specific attention should be paid to the skin examination to look for evidence of cutting and also for signs suggestive of a toxidrome. Clinicians should examine the patient for any signs suggestive of an underlying medical cause for the patient’s psychiatric symptoms or for any medical conditions that would require treatment beyond the initial medical evaluation.
Laboratory Testing
Many patients, particularly those with preexisting psychiatric diagnoses and who have normal vital signs, a normal physical examination, and no “red flags” for medical illness on history and review of systems, do not require routine laboratory or radiologic testing. Decisions to obtain laboratory testing should be based on the patient’s presenting medical and mental health condition. Clinicians should have a low threshold, however, for obtaining toxicology screens and pregnancy screening. In addition, patients with an acute change in psychiatric symptoms typically require at least some laboratory evaluation.
Pharmacologic Considerations
There are no medications whose primary indication is the prevention or treatment of suicide. Pediatricians may consider starting a selective serotonin reuptake inhibitor (SSRI) for patients with a significant depressive episode or an anxiety disorder. If SSRIs are initiated, these patients and their caregivers should receive extensive education about and be closely monitored for worsening suicidal ideation. Pediatricians should be wary of prescribing disinhibiting medications such as benzodiazepines to suicidal patients, and use extreme caution in prescribing medications that could be lethal in overdose (eg, tricyclic antidepressants or narcotics). If such medications are necessary, special care should be taken to ensure the safety of their administration, such as dispensing a week’s worth of medicine at a time and/or having a responsible caregiver lock up and directly administer the medication.
Nonpharmacologic Strategies
One of the primary roles of a pediatrician managing a suicidal patient and their family is to provide psychoeducation about the need and support for engaging in adequate treatment. Caregivers may need help in recognizing the seriousness of the child’s symptoms, and may also harbor negative feelings and/or misunderstandings about mental health diagnoses and their management options. Pediatricians should try to impress on patients and families the many dangers of untreated mental illness and/or unaddressed psychological stressors (including family discord) and that there are safe, confidential, and effective treatments available. It may be useful to inform caregivers that patients are at the highest risk of reattempting suicide in the months following the initial attempt and that, while treatment may take time to help, they should do everything they can to help support the patient in adhering to recommended care.
Determining the Level of Care
There are no validated criteria available to guide a pediatrician in assessing the level of risk for subsequent suicide and determining the level of care needs. However, it is generally agreed that criteria for immediate referral for an inpatient psychiatric admission include any the following:
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Continued desire to die
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Severe hopelessness
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Ongoing agitation
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Inability to engage in a discussion around safety planning
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Inadequate support system/ability to adequate monitoring and follow-up
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High lethality attempt or an attempt with clear expectation of death
Under certain circumstances, pediatricians must insist on admission to a psychiatric inpatient unit over the objections of patients and/or their guardians. Every state in the United States has laws governing involuntary admission (ie, a “psychiatric hold”) for inpatient psychiatric hospitalization. Laws vary from state to state, but in most cases physicians are able to admit a patient against his or her will for a brief period. Pediatricians should familiarize themselves with the relevant statutes and involuntary commitment procedures in the states where they practice.
Patients who do not meet criteria for inpatient psychiatric hospitalization should be referred for subsequent mental health intervention. Partial hospital programs, intensive outpatient services, or in-home treatment/crisis stabilization interventions should be considered when a patient needs treatment more intensive or urgent than weekly counseling. It should be noted that even patients who are deemed to be at relatively low risk of future suicidal or self-injurious acts still warrant at least some outpatient follow-up. Unfortunately, outpatient mental health providers are not always readily accessible. In such circumstances, primary care providers may need to play an ongoing treatment role, by providing frequent follow-up, bridging care, and/or in-office counseling.
Safety Planning
Although having a patient sign a no-suicide contract has not been shown to prevent subsequent suicides, pediatricians should still engage in a safety-planning discussion. Safety plans typically include elements such as identification of: (1) warning signs and potential triggers for recurrence of suicidal ideation; (2) coping strategies the patient could use; (3) healthy activities that could provide distraction or suppression of suicidal thoughts; (4) responsible social supports to which the patient could turn should suicidal urges return; (5) contact information for professional support, including instructions on how and when to reaccess emergency services; and (6) means restriction.
Means restriction refers to counseling families about restricting access to potentially lethal methods. Because a large percentage of suicide attempts are impulsive in nature, educating caregivers about “suicide-proofing” their home is critical. One study of patients aged 13 to 34 years who had near-lethal attempts found that 24% of patients went from deciding to attempt suicide to implementing their plan within 0 to 5 minutes, and another 47% took between 6 minutes and1 hour. Several studies have demonstrated that patients usually misjudge the lethality of their attempts. There is also a wide variation in the case-fatality rates of common methods of suicide attempt, ranging from 85% for gunshot wounds to 2% for ingestions and 1% for cutting. It thus follows that interventions that decrease access to more lethal means and/or increase the amount of time and effort it would take for someone to carry out their suicidal plan are likely to have a positive effect.
Means restriction education should include recommendations for securing knives, locking up medicines, and removing firearms. Of importance is that parents often underestimate their children’s abilities to locate and access firearms, and that a gun in the home has been shown to double the risk of youth suicide. Families who are reluctant to permanently remove firearms from the home may be open to temporarily relocating them until the child is in a better emotional state. If families insist on keeping firearms in the home, they should be counseled to secure them with trigger locks, to store them unloaded in a specialized or tamper-proof safe, to separately lock or temporarily remove ammunition, and ensure that minors do not have access to keys or lock combinations. Given the rates of drug and alcohol intoxication among attempters and completers, physicians may also want to recommend restricting access to alcohol and drugs, as well as referral for substance-abuse treatment.
Instill Hope
At the conclusion of the visit, pediatricians should review with patients their reasons for living. Many patients may need help in generating this list. Pediatricians should highlight any of the patient’s stated goals for the future and the ways in which the recommended treatment plan is designed to help the patient to not only survive but thrive.
Homicidal ideation, aggression, and restraint
Key Points
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Aggression is the final common pathway for a variety of medical and mental health conditions.
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Similar to the approach to the suicidal patient, careful evaluation for potential medical causes that may be the underlying cause and/or may complicate treatment of the aggression is vital.
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Mandatory federal and regulatory standards should guide the use of restraints with children and adolescents, including using the least restrictive methods possible, frequent reassessment of the need for continued versus discontinuing restraint, and offering food, drink, and bathroom facilities.
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Physical and chemical restraint may have significant adverse effects, and require careful planning, administration, and monitoring.
Introduction
Aggressive, violent behavior is not a diagnosis unto itself but is the result of an underlying medical, toxicologic, or mental problem(s), or a combination of these conditions. Symptoms vary widely, depending on the patient’s age, developmental level, and physical condition, and may include restlessness, hyperactivity, confusion, disorientation, and verbal threats to frank violence toward property, others, or oneself. It is a frequent cause of injury to both patients and medical staff. As the evaluation of homicidal ideation and aggression share many of the priorities and strategies of the evaluation of the suicidal patient, this section focuses primarily on the management of aggressive patients.
Risk factors
Risk factors associated with aggression and violence are listed in Box 1 .
