 In approaching the patient, the clinician needs to keep in mind that a

child or adolescent is by definition a minor and should not be

unaccompanied.
 Often, especially during standard working hours, collateral
information must also be obtained from agencies or institutions that
are stakeholders in the welfare of the child.
 Ideally, any child age 12 years or younger should be seen by or
referred to a child and adolescent psychiatrist who would be better
prepared than an adult psychiatrist to address developmental issues.
 1. The psychiatrist acts as the patient’s advocate.
 2. The assessment of safety is the chief goal of emergency evaluation.
 3. Any intervention considered should be appropriate to establish and
maintain the safety of the patient and of those in the immediate
surroundings of the patient.
 4. Assessment tests, procedures, and interventions should be
efficient, practical, and useful in contributing to establishment of the
etiology of the patient’s presentation, and in helping to establish the
primacy of medical versus psychiatric conditions.
 1. The population to which this patient belongs
 2. Specific risk factors associated with this population
 3. The appropriate level of intervention required to maintain both
temporary and long-term safety
 4. Resources available to the specific population served
 5. State, federal, and regulatory agency mandates
 6. Standard level of care
 Three spheres of functioning
◦ Home
◦ School
◦ Social
Table 10–1. Three spheres of functioning for child and adolescent assessment

Spheres of functioning Assessment considerations

Home Nature of the patient’s relationship with family/caretakers

1. Parents
a. Are they married? Recently separated?
b. Do they have socioeconomic issues or stressors?
c. Do they have psychiatric issues? Drug or alcohol abuse/
dependence?
d. Is there a history of domestic violence? Has the patient witnessed
this?
e. Is the patient afraid something bad will happen to his or her
parents?
f. What is the family’s source of income?
g. What is the nature of the patient’s relationship with parents?
Table 10–1. Three spheres of functioning for child and adolescent assessment

Spheres of functioning Assessment considerations

Home Nature of the patient’s relationship with family/caretakers

2. Siblings
a. Are the siblings biological? Half-siblings? Foster or adopted
siblings?
b. What are the age differences?
c. Where does the patient fall in the sibling hierarchy?
d. What is the nature of the patient’s relationship with siblings?

3. Caretakers
a. If the parents are not the primary caretakers, who are?
b. Are the caretakers relatives? Foster family? Adoptive?
c. Is the child being cared for in an institutional setting? Residential
home? Group home?
Table 10–1. Three spheres of functioning for child and adolescent assessment
Spheres of functioning Assessment considerations
Home Patient’s enjoyment and place within the family
1. Is there any aspect of the family system that antagonizes the
patient?
2. Is the family system supportive of the patient? How?
3. Is the patient happy at home? Scared to be home? How does the
family spend time together?
4. Is the patient allowed to have friends outside the family circle?
Table 10–1. Three spheres of functioning for child and adolescent assessment

Spheres of functioning Assessment considerations

Home Supervision
Is there adequate supervision of the minors, including the patient, in
this home?

Social supports for the family

1. Is the family system strict? Unsupervised?
2. If there is more than one caretaker/parent, are the caretakers/
parents in agreement about issues of child rearing?

Bedtime/curfew
1. When is bedtime/curfew for the patient? Is it enforced?
2. How often does the patient use the computer, especially the
Internet?
3. Does the patient stay up all night playing on the computer and
Table 10–1. Three spheres of functioning for child and adolescent assessment

Spheres of functioning Assessment considerations

School Academic performance

1. Has there been a decline in functioning?
2. Have the patient’s grades deteriorated?
3. Has the patient had excessive school absences?
4. Have there been phone calls home from teachers?

Friends
1. Does the patient have friends at school?
2. Is he or she a bully or the victim of bullies?
3. Does the patient isolate himself or herself? Does the patient
belong to a group? A gang?
Table 10–1. Three spheres of functioning for child and adolescent assessment
Spheres of functioning Assessment considerations
School Teachers
1. Was a psychoeducational evaluation performed on the child?
2. Does the child have any learning disabilities or speech language
difficulties?
3. Is the child in an appropriate classroom setting?
4. Does the child require more structure or supervision? Further
testing?

Caretakers
1. Are caretakers supportive of the patient’s academic work?
2. Do caretakers help the patient with assignments? With
remembering to do homework?
3. Are the caretakers involved in the patient’s school?
4. What method(s) do the caretakers use to help the patient perform
to his or her academic level or behave appropriately in school? Do
Table 10–1. Three spheres of functioning for child and adolescent assessment
Spheres of functioning Assessment considerations
School Enjoyment/sense of achievement
1. Does the patient enjoy school?
2. Does the patient feel adequately challenged?
3. Is the patient struggling to keep up with schoolwork?
Table 10–1. Three spheres of functioning for child and adolescent assessment

Spheres of functioning Assessment considerations

Social Friends
1. Does the patient have friends outside of school?
2. Does the patient limit himself or herself to “virtual” friends (i.e.,
friends made through the Internet on video games, chat rooms,
etc.)?

Hobbies
1. Is the patient involved in after-school or extracurricular activities?
Sports? Clubs?
2. Does the patient have particular interests? Computer or video
games? Playing a musical instrument? Singing? Dancing?
Table 10–1. Three spheres of functioning for child and adolescent assessment

Spheres of functioning Assessment considerations

Social Enjoyment/frequency
1. Does the patient enjoy social interaction with peers?
2. How often does the patient see friends? Engage in social
activities?
3. Does the patient have a sense of mastery?
4. What is this patient’s self-image?
5. What is this patient’s future outlook?
 The patient should be triaged to the most appropriate setting, and if
that means to a medical emergency room rather than the psychiatric
emergency room, this quick evaluation is potentially life saving,
especially with certain conditions
◦ nonobvious head trauma
◦ hypoglycemia, or
◦ other potentially reversible causes of mental status changes
 Clear and tactful communication is essential.
 The clinician must be very clear about communicating the
process of the psychiatric evaluation and potential
interventions before, during, and after they occur.
Table 10–2. Key laboratory studies
Basic labs To help rule out potentially reversible causes of delirium or mental status
changes, or for baseline assessment before the initiation of medications:
• Complete blood count with differential
• Blood glucose
• General chemistry screen
• Liver function tests
• Thyroid function tests
• Urinalysis
• Urine toxicology screen
• Alcohol level (if indicated)
• Pregnancy screen (if applicable)
• Electrocardiogram
Table 10–2. Key laboratory studies
New-onset psychosis labs If at risk, or for new-onset psychosis and
atypical psychosis, all the above plus:
• Infectious disease screens: Lyme titers (endemic areas), human
immunodeficiency virus, rapid plasma reagin (if at risk, such as
runaways, delinquents, children of substance abusers)
• Rheumatoid factor
• Anti-nuclear antibodies
• Erythrocyte sedimentation rate
• Vitamin B12/folate (if at risk, such as patients who have anorexia, are
strict vegetarian, or have malnutrition)
• Computed tomography, magnetic resonance imaging (if evidence of
neurological dysfunction or new-onset psychosis)
• Electroencephalogram (if history is suggestive of seizures or seizure-
like events)
• Lumbar puncture (if history is suggestive of central nervous system
involvement)
Table 10–2. Key laboratory studies
Special labs If patient is taking valproic acid:
Amylase Lipase Valproic acid—to rule out toxicity; to establish
therapeutic levels, obtain trough level in the morning before A.M. dose
of valproic acid

If patient is taking lithium: Lithium—to rule out toxicity; to establish

therapeutic levels, obtain trough level in the morning before A.M. dose
of lithium

If patient is taking antipsychotics: Hemoglobin A1c (if weight has

increased) Fasting blood glucose (if weight has increased) Lipid profile (if
already taking or if starting antipsychotics)
 Ensure that the patient is not a danger to self or others
 Provide a safe and nonthreatening environment to avoid escalation of
potentially dangerous behaviors
 The interaction between the patient and his or her caretakers must be
quickly evaluated to determine if their physical proximity is likely to
hinder, worsen, or improve the ability of the patient to remain safe.
 History is frequently obtained from others and the mental status
examination is based on observations of the child and his or her
interactions with the evaluator.
 1. Chief complaint and history of present illness:
◦ Elicit the specific reasons why the patient is in the emergency room.
◦ Obtain details about acute and chronic stressors and their temporal
relationship to the onset of acute or chronic symptoms.
◦ Explore patient’s strengths and weaknesses.
 2. Psychiatric history
 3. Family history
◦ a. Current stressors
◦ b. Intrafamilial stressors
◦ c. Familial coping abilities and strategies
 4. Developmental history (as relevant)
 5. Medical history (as relevant) 6. Social history (as relevant)
 7. Mental status examination
 Assessment
◦ Risk factors for suicidality in children and adolescents are often comorbid with
other psychiatric disorders
 Depressive
 Disruptive
 Anxiety
 Substance abuse disorders
 Other risk factors: adverse family circumstances
 the caretaker’s low satisfaction with the family environment, low parental
monitoring, and parental history of psychiatric disorder.
◦ Evaluation of the child’s home environment and the parents’ or caretakers’
capacity to support an at-risk child must be considered, especially as the
evaluation moves toward a disposition.
 Although completed suicide is known to be a rare event in
preteen children, the risk begins to increase at age 13
years, and by the end of adolescence, the rates are similar
to those of young adults.
 Girls make more frequent attempts than boys
 Boys are more likely to successfully complete suicide.
Table 10–3. Elements of the suicide assessment
Suicide component Evaluation questions
considerations
Wish to die What does the patient expect will happen if he or she dies?
How lethal are the means by which the patient chose to end his or
her life?
Preparations Was the attempt planned beforehand or impulsive?
Did the patient write a note or make attempts to say good-bye?
Concealment Did the patient plan the attempt in a manner by which he or she
would not be found? (Investigate the timing of the attempt or
selection of the location in terms of discovery by others.)
Communication Did the patient make attempts to tell others, either directly or
indirectly?
Precipitants What led to the event or the wish to die?
What degree of stress or anxiety preceded the event?
Was there any relief of symptoms after the event?
Was any degree of reconciliation between the patient and
significant others achieved by the event?
In the context of similar stressors or exacerbation of stressors,
does the patient now deny suicidality?
 The clinician needs to spend time educating the family and the
patient about suicide, suicide prevention, and mental illness.
 close follow-up with an outpatient clinician (OPD)
◦ individual case
◦ the resources available
◦ the willingness of the family to engage in treatment
 Youngster who has made an apparent nonlethal suicide attempt or who has passive
suicidal ideation
◦ further exploration of the home environment
 Alternative placements if parents are
◦ unable to adequately monitor the youngster
◦ are known to be dangerous or to abuse alcohol or substances
◦ do not fully comprehend the discharge instructions
◦ are considered by the youngster to be significant enough stressors that his or her
safety at home cannot be guaranteed
 If the patient’s safety at home is in any way in doubt
◦ the first option is to find other family members who may
be willing and able to take the child temporarily.
 Admit
◦ If this is not possible, the child should be admitted until
appropriate placement can be arranged in a residential
crisis center, with a foster care agency, or with a similar
social service agency.
 If the patient’s legal guardians refuse to cooperate
and the child is in danger of harming self or others,
the clinician may be required to report the case
 inpatient hospitalization
 hospital emergency room–based services (crisis intervention)
 stepdown programs such as a day treatment program
 home-based crisis intervention
 intensive case management intervention
 standard outpatient care
 no follow-up at all
 1. Does the patient have accompanying symptoms suggestive of a
psychiatric disorder or of a medical or neurological disorder?
 2. Is the behavior volitional or done for secondary gain?
 3. Is the behavior secondary to fear or anxiety, or is it in anticipation
of hospitalization?
 4. What is the patient’s cognitive level?
 5. Does the patient have hallucinations?
 Aug and Ables (1971) listed five factors that may predispose a child
to experience so-called primary hallucinations in the absence of any
diagnosable disease or disorder:
 Age and limited intelligence
 Emotional deprivation
 Emphasis on a particular mode of perception
 Family religious and/or cultural beliefs
 Strong emotional states at times of stress
 Primary hallucinations include the following:
◦ Hypnagogic hallucinations (transient, occur between true sleep and
waking)
◦ Eidetic imagery
◦ Imaginary playmate
◦ Dreams, nightmares
◦ Isolated hallucinations
◦ Hallucinosis
 Primary mood or psychotic disorders
◦ severe mood symptoms, either depressed or manic
◦ affect is incongruent, flattened, blunted, or grandiose
◦ impaired memory, agitation, restlessness, a disturbed sleep-
wake cycle
◦ disturbances of memory, attention, or concentration
 Primary neurological condition when hallucinations are accompanied
by
 perceptual distortions
 automatic and repetitive movements
 partial loss of consciousness
 periods of confusion
 if they are preceded by a visual aura
 Familiar persons should remain nearby
 The child should be provided with food, fluids, and diversionary
activities
 When working with a cognitively limited patient who is verbally and
physically aggressive, the clinician should try to ignore the patient
(e.g., by avoiding eye contact, verbal responses, and touching).
Table 10–4. Commonly used psychotropic medications for pediatric population
Name Dose Onset of Action Elimination half-life
(hours)
Lorazepam 0.25–2 mg po or im q im: 20–30 minutes Children: 11 Adults:
6–8 hours prn po: 30–60 minutes 13
(maximum 2–3 doses
in 24 hours)
Chlorpromazine 10–50 po or 12.5–25 im: 15 minutes 30
im q 2–4 hours prn po: 30–60 minutes
(maximum 2–3 doses
in 24 hours)
Haloperidol 0.25–5 mg po or im q im: 20–30 minutes 18–40
2–4 hours prn po: 2–3 hours
(maximum 2–3 doses
in 24 hours)
Table 10–4. Commonly used psychotropic medications for pediatric population
Name Dose Onset of Action Elimination half-life
(hours)
Risperidone 0.125–2 mg po q 4–6 po: 1–3 hours 20
hours prn (maximum
2–3 doses in 24 hours)

Benztropine 0.25–2 mg po or im q im: ≤15 minutes 6–48

6–8 hours prn po: ≤1 hour
(maximum 2–3 doses
in 24 hours)

Diphenhydramine 12.5–50 mg po or im q im: <2 hours po: 2–4 2–8

4–6 hours prn hours
(maximum 2–3 doses
in 24 hours)
 The following important guidelines should also be followed:
◦ Do not order prn medications without physician reevaluation
◦ Do not mix different types or classes of antipsychotic medications.
◦ Do not mix different types of benzodiazepines.
 Restraints
◦ cases in which all interventions have failed
◦ temporary
 Medicolegal Concerns
◦ All interventions that require sedation or restraints should follow
regulatory guidelines specific to the hospital and state.
◦ Additionally, parents must be included in all decisions.
 Disposition
◦ Hospitalization
 symptoms suggestive of a prodromal psychotic state
 first-break psychosis
 exacerbation of psychotic symptoms that were previously well controlled
 Home/outpatient
◦ If the family is able to provide appropriate supervision and outpatient follow-up
◦ Patients with developmental disabilities
 Inpatient hospitalization should be used only as a last resort unless a unit with
specialized interventions for children with disabilities is available.
 Any behavior that harms the physical or psychological well-being or
the normal growth and development of a child by an adult.
 Establish rapport
◦ A strong alliance will help the child to reveal sensitive information
◦ maintaining a professional stance will help if the intervention
requires removal of the child from the family to the protective
environment of an inpatient unit or other social service until details
are evaluated
Table 10–5. Risk factors for child abuse
Parent or Personality characteristics/mental health
caregiver History of abuse
factors Substance abuse
Child-rearing approaches
Teen parents
Family factors Family structure
Domestic violence
Stressful life events
Child factors Birth to age 3 years
Disabilities
Low birth weight
Environmental Poverty and unemployment
factors Social isolation and social support
Violence in communities
Types of Child Abuse
Child neglect generally characterized by omissions in care that result in significant harm or
risk of significant harm
3 types: physical, educational, and emotional neglect
Sexual abuse Includes both
- touching offenses (fondling or sexual intercourse) and nontouching offenses
(exposing a child to pornographic materials)
- can involve varying degrees of violence and emotional trauma
Physical abuse The injury may have resulted from severe discipline or physical punishment
that is inappropriate to the child’s age or condition.
Psychological a repeated pattern of caregiver behavior or extreme incident(s) that convey to
maltreatment children that they are worthless, flawed, unloved, unwanted, endangered, or
only of value in meeting another’s needs (the Child Welfare Information
Gateway, 2009)
 Evaluation
◦ Being overly responsible
◦ being impulsive
◦ displaying extreme mood swings
◦ misunderstanding personal boundaries
◦ being shy or withdrawn
◦ Younger patient: nightmares or night terrors
 Older children
◦ More withdrawn
◦ Change their clothing style (more sexually provocative)
◦ Make efforts to hide their sexual development and attractiveness
 Suspected victim of abuse
◦ Laboratories
◦ Cultures
◦ Swabs
◦ Imaging studies
 As always, in working with potential abuse victims, the clinician should maintain a
professional stance,
◦ being sensitive
◦ Thoughtful
◦ Empathetic
◦ Objective
◦ goal and action oriented
 Countertransference
◦ MUST: maintain a sense of calm and safety within the emergency department
 The clinician should learn from both the patient and the
patient’s parents or caretakers the details of the alleged
abuse.
 Consult with other members of the psychosocial team,
hospital child abuse assessment team, or other supervisors
to determine appropriate disposition.
 Two reports must be filed:
◦ 1. a written legal form documenting the examination findings and
◦ 2. a telephone report to the child abuse agency to begin the disposition process
and treatment plan for the child and family
 Admission
◦ In cases where suspected abuse is substantiated by physical findings (sexual or
physical)
◦ the appropriate investigative authorities immediately involved
 hospital-based child abuse assessment team
 the local social services office
 at the very least, law enforcement
 Hospitalization
◦ If the child’s safety is of primary concern
 More common presentations of anorexia nervosa
◦ recent dizziness or fainting spells in school or at home or seizures
◦ when the parent or caregiver is highly suspicious of an eating
disorder after the patient is observed vomiting
◦ when the parent or caregiver notes that the patient is dangerously
restricting intake
 Inpatient medical hospitalization
◦ ≤75% of ideal body weight (patient in gown after voiding)
◦ Heart rate < 45 bpm, resting by lying down for at least 5 minutes
◦ Hypokalemia
◦ Hyponatremia
 Admission
◦ Severe suicidality with high lethality or intention
◦ Worsening ability to control self-induced vomiting, increased binge
eating, use of diuretics, and use of cathartics that may be
considered life threatening
◦ Weight changes related to altered or changed mental status due to
worsening symptoms of mood disorder, suicidality, or psychotic
decompensation.
◦ Preoccupation with weight and/or body image, accompanied by food
refusal, or obsessive thoughts about body image or weight that
cause the patient to be uncooperative with treatment and require a
highly structured setting for rehabilitation