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Psychiatric emergencies in children and adolescents can be similar to or different from those in adults. For instance, suicide, violent behavior, and drug and alcohol abuse are seen in persons of all ages, whereas runaway behavior is unique to children and adolescents because they are physically, emotionally, and legally dependent on a parent or adult guardian.
When evaluating the child in the emergency service, the clinician must ensure the child's physical safety, assess and intervene with the parent or caregiver, and adhere to any legal requirements applicable to minors. A complete emergency psychiatric evaluation includes the chief complaint, the present illness and precipitating stress, the family history and composition, the child's developmental and medical history as relevant, a detailed interview with the child and family, and a mental status examination of the child (Robinson. 1986).
This chapter reviews suicidal, violent, abusive, and addictive behavioral emergencies in children and adolescents and outlines specific treatment considerations for these problems.
Suicidal behavior is the most common psychiatric emergency in children and adolescents. Suicide is the third most common cause of death in this age-group, and the suicide rate among children and adolescents is rapidly increasing. Girls contemplate suicide three times more frequently than boys, yet boys kill themselves almost three times more often than girls (Khan, 1979; Pfeffer, 1981).
The clinician must take seriously any suicidal behavior, regardless of the patient's age. Although younger children may not understand the finality of death, their consideration of death as a solution to an unbearable situation is as dangerous as an older child planning a suicide, and the clinician must help the patient realize that alternatives to suicide exist. Suicidal behavior can be acute or chronic, intentional or unintentional, planned or impulsive, and more or less ambivalently executed.
The suicidal child or adolescent is usually brought to the emergency department (ED) by a parent, guardian, relative, friend, school nurse or counselor, or religious advisor, and the accompanying person may describe the chief complaint (accident, overdose, or self-mutilation). Only after the clinician inquires about the details of the event does the patient usually admit to having suicidal thoughts, wishes, or plans or to being angry or depressed. Even more investigation is needed for the patient to reveal a relationship between external events or stressors and the feelings, thoughts, and actions that resulted in the psychiatric emergency.
The patient who is admitted with a serious injury or overdose should be medically treated first, then referred for psychiatric evaluation only when out of immediate danger. Depending on the severity of the medical condition, the patient may not be able to speak about the event for hours or days. In all cases, assess the probability of future suicidal behavior and have a skilled staff available if the patient tries to harm himself while receiving medical care. Medical management and psychiatric evaluation can occur simultaneously if the patient is conscious and cooperative. If the patient does not cooperate, use any means necessary, including restraints, to prevent further self-destructive behavior.
To assess the patient's motivation and likelihood of immediate suicidal risk, establish a relationship with the patient and his parents. Speak with the child first, then the parents, and then the family together, if possible. Parents can provide information about family stressors, previous suicidal gestures or attempts, and family history of suicidal behavior. In this way, you can construct a complete picture of the situation and discuss the urgency of intervention with the patient and the parents.
To determine the risk of future suicidal behavior, document all indicators of high suicide risk. Future suicide attempts are more likely if the patient:
Determine whether the patient is aware of the seriousness of his behavior and the finality of death, whether the patient is experiencing command hallucinations that order suicidal behavior, and whether the patient exhibits signs of a psychosis (bizarre thoughts. delusions, loose associations, and other noncommand hallucinations). For the mental status examination, evaluate the patient's impulse control (ability to control anger, anxiety, or other powerful emotions that may result in dangerous behavior) and mood and affect (feelings of anger, depression, fear, guilt, hopelessness, help lessness, or worthlessness). Document signs of drug or alcohol intoxication or withdrawal-slurred and incoherent speech, disorientation, memory deficits, and lowered or heightened level of consciousness.
Note any abnormalities that may pertain to the suicidal behavior. For example, depression may be caused by an underlying medical illness, such as chronic infection, endocrine disorders (hypothyroidism, hyperparathyroidism, Addison's disease, diabetes mellitus), neoplasia, intoxication (from alcohol, sedatives, marijuana, stimulants), or withdrawal (from stimulants, especially cocaine). Physical findings can also indicate an underlying illness or handicap that causes the patient to feel hopeless, ashamed, or frightened enough to contemplate and carry out suicide. For instance, patients who are blind, deaf, or mentally impaired and those with learning disabilities (such as dyslexia) or a condition that requires frequent or regular medication (insulin-dependent diabetes) are more likely to become depressed. Because children, especially adolescents, respond to peer pressure and because adolescents are preoccupied with their body shape, size, and function, any physical handicap can have a profound impact. Fear of rejection by the peer group may trigger depression and suicidal behavior.
Suicidal behavior in a child or adolescent is a family problem. The clinician must assess the parents' role in the behavior as well as their response to it and their ability and willingness to safeguard the child. Suicidal behavior in a nonpsychotic patient represents the patient's maladaptive attempt to rectify a breakdown in childparent communication. Such behavior demands a prompt, nonjudgmental, and caring response from the parents. Whether the parents can respond in this manner depends on how the family as a whole behaves in the crisis.
The most important differential diagnosis is "accidental" behavior. Some psychiatrists believe that most serious accidents are the result of unconscious suicidal or homicidal impulses. The patient's emotional response to an accident may be the first and only clue to more serious ramifications. Even with very young children who accidentally ingest poisons, a certain amount of parental negligence may be present.
The clinician must also differentiate between a suicidal gesture (parasuicide) and an attempt. To make this clinical judgment, consider that a gesture is typically less serious than an attempt and more likely a planned effort to manipulate another person rather than an attempt to die; that a person making a suicide gesture is more ambivalent about living and dying and more likely to want help; that a gesture is more likely to represent a plea for help; and that persons may make repeated gestures, which can ultimately result in their death.
Intervention and treatment start with the initial evaluation and are primarily interpersonal and family-based. Begin to establish a rapport with the child by speaking his language, paying attention to the direction he takes during the interview, attending to objects or toys he brings to the hospital, maintaining a nonjudgmental attitude, and allowing enough time to listen to him.
To assess the severity of the situation, ask direct questions about the patient's behavior; that is, whether the attempt was planned or impulsive, whether the patient was alone, whether the patient requested help for a problem, and whether the patient left a note. Also consider the seriousness of the injury, even when the patient reports no earnest intent to commit suicide or claims accidental ingestion. Adolescents and children do commit suicide by accident: they may misjudge the depth of a cut, the placement of a gun, the number of pills to take, or the potential response of another person.
Obtain as many details as possible about the suicide attempt to evaluate the patient's motives and ongoing risk (Fauman and Fauman, 1981). Possible motivations include manipulation, revenge, a desire to join a dead relative, or response to a command hallucination. Because patients who have attempted suicide are likely to try again, ascertain whether the patient has had previous suicidal thoughts and the duration of these thoughts. The patient's attitude toward surviving the attempt is also important. The patient may be relieved or angry, fearful of retaliation by parents or relatives, or frightened or complacent about the attempt.
Also explore factors in the patient's life that may have led to the suicide attempt. Common stressors associated with self-destructive behavior include relationships, especially with parents or caregivers; changes within the family; illness; school problems; peer pressure; trouble with the law; trauma, such as incest, rape, or physical abuse; and substance abuse.
Unless the patient is acutely psychotic or agitated, pharmacologic intervention is not needed. However, if the patient suffers from an acute organic psychosis (such as toxic, metabolic, or infectious encephalopathy), the clinician must take specific measures to treat the underlying medical illness. A psychotic patient may require haloperidol (Haldol) 0.05 to 0.15 mg/kg/day in two or three divided doses or chlorpromazine (Thorazine) 0.1 mg/kg every 4 to 6 hours. A nonpsychotic but agitated patient can be given hydroxyzine (Vistaril) 0.2 mg/kg or diphenhydramine (Benadryl) 5 mg/kg/day in four divided doses. Benzodiazepines should not be given because of the possible adverse effect of these drugs on attention deficit disorder and because of the potential for addiction. Some evidence indicates that lorazepam (Ativan) is safe to use in children and adolescents. Lorazepam may be appropriate for managing nonpsychotic agitation even when antihistamines are contraindicated because of their anticholinergic properties.
Never blame family members for the patient's self destructive behavior. Instead, support their attempts to cope with and listen to the child. Share with them any information obtained from the patient, including possible reasons for his behavior, so that a dialogue can develop between the child and the parents. Additionally, work closely with the parents to suggest ways of ensuring the child's safety at home, such as removing drugs and weapons from easily accessible locations, providing more supervision, and devoting more uninterrupted time to the child.
The disposition varies, depending on the parents' responsiveness to your requests. If the parents appear genuinely willing to comply, you can discharge the patient to their care, although you should ensure that the patient continues to receive help by giving the parents phone numbers to call in case of an emergency and by arranging a follow-up appointment with an outpatient therapist for the next day.
If the parents have difficulty responding to the instructions or if the safety of the patient is in doubt, consider hospitalizing the patient, finding another family member with whom the patient can temporarily reside, or, in extreme cases, placing the patient in emergency foster care.
Safety is the overriding consideration in the disposition of the suicidal child or adolescent. Hospitalize a patient with a psychosis, drug or alcohol addiction, organic mental syndrome, or any serious condition resulting in depression. Those who have no will to live or who refuse to accept or comply with an outpatient appointment should also be hospitalized. In addition, whenever the patient demonstrates suicidal intent, either hospitalize the patient or refer him to a residential crisis intervention center.
In many states, the standard for civil commitment is whether the minor is "in need of psychiatric care that cannot be provided in a less restrictive setting," which is less stringent than the adult standard of "dangerousness."
Children younger than the age of consent can be signed into a hospital without the need for commitment procedures. However, parents or guardians may want the child released against medical advice. In such cases, determine if state laws permit the detention of the patient via commitment. If the patient was injured "accidentally" (for instance, by ingesting drugs or alcohol or by using a firearm), the parents may be liable for child neglect. Keep in mind that a clinician has a duty to report instances of neglect to the state child protective agency and to take necessary precautions to ensure the child's safety.
Juvenile violence is increasing at nearly twice the rate of adult violence. Suicide and homicide account for the greatest number of deaths in adolescents and for the greatest number of emergency psychiatric visits in this population (Rosenn, 1984). Violent behavior in children and adolescents ranges from behavioral dyscontrol to premeditated homicide. In some cases, violent youth have little if any psychopathology; in other cases, they may be profoundly mentally disturbed. Violence in young persons, except in self-defense, should be considered pathological until proven otherwise. Very young children may be unaware of the seriousness of their attack on another person. Yet all homicidal behavior signifies a breakdown in communication and the containment of thoughts and feelings. The younger the child, the more likely that he has a serious personality disorder or is the victim of parental abuse or neglect.
Thoroughly examine any child or adolescent who has an immediate history of harming or threatening to harm someone or destroy property. The evaluation may be complicated by the need to control the patient while establishing sufficient trust to enable the patient to reveal the details of the event and his attendant feelings and thoughts. Because the patient may not be fully aware of the events that just occurred or may deliberately withhold or distort information, interview those who accompanied the patient to the ED to obtain a complete picture of the episode. Depending on the perceived seriousness and awareness of the act, the patient's emotions can be intense. An increasingly frequent contributing factor in youthful violence is drug and alcohol intoxication or withdrawal.
Examine the patient to assess his recall of and emotional reaction to the event, use of drugs or alcohol, level of intellectual functioning, possible stressors (such as loss of a significant relationship), history of psychiatric illness or psychosis, and history of child abuse. Furthermore, you must ascertain the parents' reaction to the violent behavior. Although violence in children usually represents a communication failure among family members, a newly violent child or adolescent requires careful screening for medical and acute psychiatric causes. Aggressively homicidal youth may insist that the act was an accident or done in self defense.
Conduct a physical examination to rule out underlying medical problems that result in violent behavior. In particular, be alert for impaired consciousness, orientation, and intellectual functioning; physical handicaps; signs of physical or sexual abuse; specific neurologic impairment; symptoms of intoxication or withdrawal: and any other signs of acute medical illness, such as infection.
You must rule out depression and look for signs of physical or sexual abuse (see Signs of physical and sexual abuse). Violent behavior may also be associated with alcohol or drug intoxication or withdrawal and organic mental states, which can impair reality testing, impulse control, and judgment.
| Signs of Physical and Sexual Abuse | |
| Physical Abuse | |
| · | Multiple injuries at various stages of healing |
| · | Bruises in the pattern of finger marks or strap marks |
| · | Burns from cigarettes |
| · | Scalding injuries |
| · | Bite marks |
| · | Bald spots (from hair pulling) |
| · | Injuries of the long bones, especially dislocated metaphyses or epiphyses, spiral fractures, or subperiosteal thickening |
| · | Rupture of viscera |
| Sexual Abuse | |
| · | Genital or anal tears, bruises or irritations, discharge, and sexually transmitted disease |
| · | Encopresis (associated with anal rape) |
| · | Enuresis (from regression, over excitation, or fears related to sexual abuse) |
| · | Psychosomatic symptoms., such as headaches or stomachaches |
| Source: Robinson, 1986. Adapted with the permission of the publisher. | |
An acutely agitated, angry, and violent patient must be prevented from harming himself or others. Although the patient may be out of control and frightened, the clinician must maintain a nonjudg-mental, calm, and firm attitude and treat the patient with respect. Sometimes patients can be controlled by removing them from the family, placing them in a quiet room, attending to their basic needs, or providing food and support. In other cases, mild physical or four-point restraint (restraining the arms and legs with padded leather straps) or the presence of many staff members may be needed to convince the patient that he is in a protected setting. Until a diagnosis is established, physically restraining a violent youth is safer than using sedation; drugs may contribute to an inaccurate diagnosis or worsen an underlying organic condition.
When physical restraint fails to calm an agitated patient and medical causes of the anxiety are ruled out, the clinician can quiet the patient by administering hydroxyzine 0.2 mg/kg I.M. or orally or diphenhydramine 5 mg/kg for 24 hours in four divided doses. For a more acutely agitated patient in whom no medical causes can be found, the physician can safely use either chlorpromazine 0.1 mg/ kg every 4 to 6 hours or haloperidol 0.05 to 0.15 mg/kg/day in two or three divided doses.
In almost no case should the clinician use benzodiazepines or other secondary and tertiary anti aggressive drugs, such as lithium (Eskalith), carbamazepine (Tegretol), or propranolol (Inderal), during emergency management of violent behavior. Benzodiazepines carry the risk of further disinhibiting aggressive behavior, especially when the patient has a coexistent attention deficit disorder, such as hyperactivity (although benzodiazepines may be indicated for alcohol or sedative withdrawal syndromes). The other drugs have a long onset of action, and they could not be administered safely without further baseline medical studies and a more precise diagnosis.
After assessing the seriousness of the violence, arriving at a diagnosis, and judging the appropriateness and potential success of the parental response, evaluate the risk of continued violent behavior. Potentially homicidal children and adolescents considered at high risk for violence share one or more of the following characteristics: neurologic impairment, schizophrenia, underlying psychiatric illness, limited intellectual functioning, school failure, poor family situation, personal experience with brutality, history of fire setting or cruelty to animals, conduct-disordered behavior at an early age, labile and highly anxious or angry affect, and action-oriented personality. They may also believe that killing is an acceptable way to express anger, have access to a weapon, or have a homicidal plan (Rosenn, 1984).
If a primary medical or psychiatric condition is causing the violent behavior, initiate treatment, which probably entails hospitalizing the patient. When multiple causes are involved, intervene with a combination of medical treatment, psychological support.containment of dangerous behavior, and immediate crisis intervention. If protective pharmacologic or physical restraint is needed to ensure that no harm comes to the patient or staff, a short term inpatient evaluation is probably necessary.
If the patient is discharged in parental custody, the clinician should provide emergency phone numbers and schedule an outpatient appointment for the following day. Because a homicidal child can quickly become a suicidal one, parents should be familiar with the signs of depression and remorse, which may indicate a possible suicide attempt.
The clinician can legally commit a minor patient who is menially disturbed or dangerous to persons or property. However, voluntary hospitalization or parental consent can often be obtained instead.
Most youths run away to escape a destructive home life. They do not run away simply to join another person or family or to have a different life-style. Before puberty, boys run away twice as often as girls, but after puberty, girls leave home two to three times more frequently than boys (Rosenn, 1984). Most adolescents who run away are never seen for psychiatric evaluation. Yet running away is not necessarily evidence of psychopathology; the child may be reacting to a pathological family situation (Stierlin and Ravenscroft, 1972; Stierlin, 1973).
Some runaway children or adolescents come to the ED alone; others are brought by their parents after they have returned home or are suspected of planning to leave home. Sometimes parents come alone to the emergency service for help a day or several days after the child has left. The parents may be angry, guilty, grief stricken, or fearful and may need advice on coping with the event.
Abortive runaways (those who have unsuccessfully escaped from home) usually return through their own efforts. For example, they may feign an illness that results in an ED visit or may turn themselves into the police. Schizoidal runaways are the most psychiatrically disturbed and usually break down away from home. Their psychotic symptoms or depression may bring them to the ED in a crisis. Casual runaways separate easily from the home and rarely come to the ED unless they want to manipulate their parents or guardians. Because they are socially and sexually precocious, casual runaways survive the runaway culture well. In contrast, crisis runaways remain preoccupied with the family even after being away for days or weeks. These runaways may come to the ED as a result of aggressive, sexual, or antisocial behavior they have displayed to carry out some unconscious "mission" of the parents (such as fighting with someone whom the parents intensely dislike).
When conducting the mental status examination, look for signs of psychosis or idiosyncratic and bizarre thinking, panic, depression or suicidal ideas, remorse, guilt, ambivalence about returning home, and fear of reprisal. In taking the patient's history, note whether the patient exhibits endangering behavior, which increases the likelihood of exploitation by others, and assess his use of alcohol or drugs, promiscuity, or antisocial activity. In addition, gather details about the runaway event itself: the patient's motivation for leaving: contact with parents while away; living arrangements and survival tactics; length of time away; reason for coming to the ED; whether the runaway was planned or impulsive; whether the patient remained alone or with a group; and whether this event was an isolated incident or part of a chronic problem.
The physical examination supports or refutes data from the patienthistory. Look for injuries (bruises, lacerations, welts, scratches, malnutrition, signs of assault (both physical and sexual), and alcohol or drug abuse.
Findings may warrant a chest X-ray, complete blood count and differential, urine drug screen, and a hepatic and renal profile. including electrolytes, glucose, and blood urea nitrogen.
Begin to establish a rapport with the patient while assessing his physical health. A nonjudgmental and concerned approach facilitates the development of a relationship. Rapport is essential for gaining the youth's trust in order to learn more about the family problems that caused the runaway behavior.
The primary goal is to determine whether to send the patient home immediately. If the patient is psychotic, suicidal, medically ill, or physically or sexually abused, hospitalization is necessary. If the patient is ambivalent about returning home and has no indications for hospitalization, the clinician becomes the key to reuniting the parents and child. To prevent the patient from leaving the emergency setting, carefully assess the patient's fears, ambivalence, and possible negative consequences of returning home before contacting the parents.
Before discharging the patient, arrange a meeting between the parents and the youth in the ED. If the patient's health or safety is at stake, hospitalize the patient and then notify the parents.
Never discharge a minor without informing the parents of the youth s whereabouts and condition and without obtaining their consent. If you determine that the patient should be placed outside the home, the parents must be involved in this decision, even if only temporary placement is necessary. States laws delineate in loco parentis responsibilities for caregivers of youths under age 18.
The term emancipated minor describes an adolescent who has obtained the legal right to live independently from parents or guardians. Emancipated minors do not usually have other adult rights and responsibilities. Be alert for adolescents who declare themselves emancipated out of desire rather than because of legal status. An adolescent who lives alone or has a child is more likely to be legally emancipated. If you cannot determine the patient's status, you must notify the parents or other concerned relatives of the disposition plans.
Child abuse comprises all forms of adult behavior that are physically or psychologically destructive to a child's well-being and normal growth and development. Up to 4 million cases of child abuse occur in the United States every year, and as many as 2,000 children die each year as a result of abuse (Ludwig, 1983). Abuse may recur within families and is seen in all socioeconomic and ethnic groups. (See Risk factors for child abuse, page 208.) Because child abuse is always a family crisis, any childhood emergency should arouse the examiner's suspicion. Become familiar with child abuse laws and reporting practices and with hospital and community resources. The clinician must intervene in a sensitive and professional manner in this highly complex and intense family emergency.
| Risk Factors for Child Abuse | |
| The Child | |
| · | Infants and preschoolers |
| · | Medical problems |
| · | Mental retardation |
| · | Physical handicap |
| · | Neurological impairment |
| · | Hyperactivity |
| · | Prolonged hospitalization during infancy |
| The families | |
| · | Lack of preparation for parenting |
| · | Poor role models |
| · | Use of corporal punishment |
| · | Unrealistic expectations for the child |
| · | Severe social isolation |
| · | Critical extended family |
| · | Severe parental conflict |
| Parent-Child interaction | |
| · | Economic problems |
| · | Unemployment |
| · | Crowding and poor housing |
| · | Parental illness |
| The parents | |
| · | • Impulse disorders |
| · | Drug or alcohol abuse |
| · | Psychiatric illness |
| · | Abused as a child |
| Source: Sargent et al., 1984. Robinson, 1986. | |
The clinician should be familiar with the four types of child abuse (Sargent et al., 1984):
Physical abuse. Abuse that results in physical injury, including fractures, burns, bruises, or internal damage. Physical abuse may be disguised as discipline or punishment and accounts for about 65% of reported child abuse cases.
Sexual abuse. Any contact or interaction between a child and an adult when the child is used for the sexual stimulation of the abuser. Sexual abuse may also be committed by a minor who is older than or in a position of power over the child. This type of abuse accounts for about 20% of all reported cases.
Child neglect. Acts of omission, such as the failure of a parent to provide for a child's welfare, basic needs, and proper level of care with respect to food, clothing, shelter, hygiene, medical attention. or supervision. Child neglect is seen in about 10% of all reported cases.
Emotional abuse. Abuse that results in impaired psychological growth and development of the child. Verbal abuse and excessive demands on a child's performance are forms of emotional persecution that can result in a negative self-image and disturbed behavior. Emotional abuse accounts for about 5% of all reported cases, although it almost always accompanies other forms of abuse.
Because child abuse is rarely the chief complaint, be alert to evidence of abuse when examining the child. For example, physical abuse is likely if the injured child was not brought to the ED promptly or if the history is inconsistent; includes repeated injury or hospitalization, family stress, or preexisting illness in the child: or does not adequately explain the circumstances of the injury.
Sexual abuse is a possibility when a prepubertal girl has gynecological symptoms or when the patient is sexually preoccupied, reveals stories with a sexual content, or has a history of abrupt changes in behavior or school performance. The patient may reveal incidents of sexual abuse purposely or accidentally. Disclosure always precipitates a crisis for the family.
Child neglect becomes apparent when examining the child for other problems. Parents who neglect their children may underestimate or overestimate their child's physical and emotional needs. Children with "failure to thrive" or developmental delay, if non-organically based, are products of neglect. The feeding, growth, and developmental history provide clues to neglect.
Mental status findings
A younger child may be fearful, have unreasonable expectations (such as a reunion with a perfect family or an undoing of the abuse), be overly responsible, have a difficult temperament with impulsivity and mood swings, or be shy and withdrawn. The younger patient may have nightmares or night terrors, cling and whine, and refuse to stay with a particular person. An older child may be hypersexual and promiscuous, exhibit deviant sexual behavior, run away, abuse alcohol or drugs, or attempt suicide.
Physical findings
Signs of abuse can be seen in the skin, hair, eyes, ears, bones, central nervous system, gastrointestinal system, and genitourinary system.
Laboratory studies
Laboratory studies to evaluate abuse include a bone survey; urethral, vaginal, oral, and anal cultures and wet mounts; pregnancy test; clotting factors; computed tomography scan or magnetic resonance imaging; abdominal flatplate X-ray; and urinalysis.
Intervention begins during the first contact with the child and family. The clinician must be thoughtful, sensitive, goal-directed, and action-oriented. The clinician's objective is to protect the health and well-being of the child and to provide as much consistency in the child's life as possible.
A clinician who suspects child abuse may have strong feelings of anger for the abuser and sympathy for the victim. Even so, the clinician must attempt to form a satisfactory relationship with the child and parents. A confrontational and accusatory approach is inappropriate and will frighten both the patient and family members. The child's fear and concerns for his parents should be respected. The clinician should convey to the parents an understanding of their emotional state and reaction to their child without condoning or sanctioning the abusive behavior. Management of child abuse should include a consultation with other members of the psychosocial team to validate suspicions and determine the disposition.
The use of medication for a victim of child abuse should be avoided unless absolutely necessary. Pharmacologic intervention further confirms the child's fear that he is sick, bad, or out of control and can increase the child's sense of victimization.
Once a diagnosis of abuse is made, the clinician must inform the parents and, without equivocation, describe the follow-up plans. Their response to this information may supply additional corroborating or refuting data. Families who cooperate early in the evaluation are more easily helped.
The disposition should be guided by a concern for the child's safety and by legal constraints (see “Medicolegal considerations” below). Hospitalization is necessary when the child's physical or mental status warrants it or when the clinician is concerned about the child's safety at home.
The clinician must file two child abuse reports-by telephone to the child abuse hotline and on a legal form documenting the detailed findings of the examination. The child abuse agency should be contacted immediately to provide further assistance in implementing a treatment plan for the child and family. Ultimate disposition of the child outside the hospital is the legal domain of the child abuse agency.
In most cases, if the child remains at risk, the agency must complete a full evaluation of the situation within 24 hours. Sometimes the examining physician must provide courtroom testimony. In other cases, the clinician may need to involve the hospital administration or legal authorities to protect the child, hospitalize the child, or remove threatening and violent family members.
In all cases, family members should be informed of their rights and responsibilities, which include a full court hearing with legal representation and a continued duty to protect the child's well-being. The clinician should explain that, if the parents cooperate with medical, legal, and psychiatric authorities, the child can be returned to their custody.
Alcohol and drug abuse are prevalent among younger persons and increasingly part of all adolescent emergencies. The clinician should suspect drug intoxication or withdrawal in all cases of acute changes in the patient's mental state. Substance abuse should be part of the differential diagnosis in every emergency evaluation of children and adolescents.
Drugs and alcohol alter perceptions; alter the speed, content, and coherence of thought; diminish insight; and impair judgment. Indeed, these substances can have a substantial impact on youthful behavior and can cause psychiatric emergencies that might not otherwise occur. In assessing an adolescent, the clinician must obtain a detailed drug history, including the duration of drug abuse, the type and quantity of drugs used, and the perceived effects on the patient.
The clinician should not be misled by a history of substance abuse into erroneously assuming that alcohol or drug abuse is the predominant problem. Many adolescents with major psychiatric disorders, such as schizophrenia, mania, or depression, self-medicate with drugs and alcohol. Consequently, the clinician must conduct a comprehensive medical, neurologic, and psychiatric evaluation before making a final diagnosis and treatment decision.
See Chapter 4, Alcohol Emergencies, and Chapter 5, Drug Abuse Emergencies, for more detailed information on relevant interventions, dispositions, and medicolegal considerations.