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Faculty of Medicine

Department of Psychiatry

Unit of Children’s and Adolescents’ Psychiatry

Author: Vikas Sharma

Psychiatric Emergencies in the Pediatric Patient and ethical issues

concerning those

Master of Medicine program

Supervisor: Professor Darius Leskauskas Ph.D., MD, associate professor

at Lithuanian University of Health Sciences




1. SUMMARY ... 3










11. CONCLUSIONS ... 16





This master thesis written by Vikas Sharma, with the title “Psychiatric emergencies in the pediatric patient and the ethical issues concerning those”

The purpose of the thesis was to look at psychiatric emergencies in the pediatric patient as it has been an increasing concern because of an increasing prevalence of young patients being seen due to psychological issues. I have looked at statistical data e.g. a study made by the University of Pittsburgh about increase of psychosocial problems seen in children. I looked at qualitative studies done in children about the prevalence of emergent disorders, to find which disorders are common, during this process I became familiar with what is

considered emergency psychiatry and the most common acute psychiatric disorders which are seen in children and adolescents, such as: major depression, anxiety, psychosis, PTSD, intentional self-harm, suicide attempt, substance abuse with its comorbidities and eating disorders such as anorexia which may present as somatic patients but are considered patients in need of psychiatric intervention , In which ages the different conditions are seen and if there was a gender which was more often presenting with said conditions .

I have also included the ethical issues related to the treatment of a child and adolescent in regard to confidentiality, parental involvement, the use of involuntary commitment in a pediatric patient.

The considerations and issues appearing when there is cause for concern about the child’s wellbeing and the doctor’s ethical responsibilities to the child. The ethical portion has been based on the Norwegian healthcare system and the related laws as this is the system I am most familiar with and have worked in during my student time.




Foremost I would like to express my sincere gratitude to my supervising Professor

D.Leskauskas MD, Ph.D. for his patience and understanding, during the process of writing this thesis. Last but not the least, I would like to thank God almighty and my family for their support and blessings throughout my life and studies


The author has no conflicts of interest to declare as per the extent of his knowledge.


The presented Master thesis does not raise any ethical issues, like any identifiable patient details or data and therefore an ethical clearance is not required.


1. EM: Emergency Medicine

2. PEM: Pediatric Emergency Medicine 3. LOS: Length of Stay

4. CARES: Child and Adolescent Rapid Emergency Stabilization 5. ED: Emergency Department

6. PSY.EM: Psychiatric Emergency Medicine 7. PTSD: Post Traumatic Stress Disorder 8. FAED: Food avoidance emotional disorder




In today’s society there are increasing concerns regarding pediatric psychiatric emergencies. The prevalence of emergency department visits for psychiatric illnesses has increased in the last years. [1] The World Health Organization has estimated that by the year 2020,

neuropsychiatric disorders will become 1 of the 5 most common causes of morbidity, mortality, and disability for children. [2]

The University of Pittsburgh have in studies shown an increase from 7-18 % in identified psychosocial problems in primary care visits of children of age 4-15 years. [3] Despite the increasing prevalence, the risk of suicidal behavior among children is often undetected. A study shows about 83 % of adolescent patients, who had attempted suicide were not recognized as possible suicidal patients by their primary physicians. [4] The emergency department is the initial source of physical care for child victims of disasters or trauma. Studies of child survivors of trauma and disasters have shown a increased development of depression and post-traumatic stress disorder (PTSD)[5]. Untreated and unrecognized, acute and posttraumatic stress symptoms may cause lifelong mental and behavioral problems, as a result of changes in brain neurodevelopment and function. These changes can create a risk of depression, suicidal ideation, aggression and poor school performance. [6]

The most prevalent group is anxiety disorders of psychiatric disorders in the US. One in a third youths of age 13 and 18 years will go through an anxiety disorder in his/hers lifetime, suggesting to common conditions as ADHD and mood disorders.[7]

Although ADHD in itself cannot be classified as a pediatric emergency some of the

symptoms related can lead to EM contact. Often symptoms as impulsive behavior related to violence against oneself or others and long standing depressive and anxiety symptoms.[8]

Evaluation of emergency pediatric patient after thorough psychiatric follow-up can increase the probability of early detections of psychiatric problem in children.

In infants they will appear in the emergency department due to sleep problems, eating issues, neglect, and under-stimulated child.

When the parent brings the child with sleep issues it is often because the parent is exhausted that the child is not sleeping properly [9,10]


6 The data regarding occurrence of psychosis in children is limited. But what we do know is that many children develop psychosis before they are 18 and is not discovered on time. Several studies show that untreated psychosis occurs more often in children and

adolescents than in adults, in addition to the burden of suffering from untreated psychosis, additional issues develop as a consequence that the normal development is interrupted. Psychotic disorders in children are often associated with a higher effect of neurobiological and developmental deviation. Suicidal thoughts and behavior is common in the time before diagnosis [11].

At the same time as we take psychotic symptoms seriously, it is also important to keep in mind that psychosis-like symptoms and single psychotic symptoms often occurs in children without it being related to psychopathology. Sometimes symptoms like these will disappear on their own, while other times they develop into psychiatric conditions and not psychotic conditions.

The knowledge about normal occurrence, normal child development is crucial to distinguish worrisome symptoms from the more normal ones.

Children and adolescent can develop psychosis and when these occur in very young age it is often associated with a higher grade of complexity than what it would be in adult.

Something which makes it a challenge in children is that symptoms are often

undifferentiated, and that differential diagnostics can be a challenge. This especially concerns the differential to affective disorder, traumatic condition, developmental

disturbances and personality disorders. It is also very common that there is comorbidity present, which makes the process of assessment challenging. Structured assessment is vital in these cases. Children will not by themselves tell about psychosis like experiences, if there is suspicion about psychosis it is important that one ask direct questions about psychotic symptoms, preferably based in a structured interview. The child’s inner world needs to be assessed and the child might need help to put in words their experiences. Symptoms vary in intensity and content, depending on experienced level of stress and other factors. That symptoms are not present continuously does not mean we can exclude a psychosis disorder. An assessment should always, along with a thorough diagnostically interview, including anamnesis, somatic status and assessment of capability. This assessment it is recommended that a specialist in pediatric psychiatry performs [12]




Aim is to study the first line psychiatric evaluation and management of pediatric patients in emergency department and raise some of the ethical issues one has to keep in mind.


1. Epidemiological and Etiological factors causing psychiatric emergencies in pediatric patients in emergency department.

2. To study frequent psychiatric disorder presenting in pediatric or adolescents in emergency department

3. To study steps for management taken for evaluation and management of pediatric and adolescent psychiatric patient presenting to the emergency department and the ethical issues in regard to management and further referral


Children presenting in emergency department often come with co-symptoms of Depression, Distress, Anxiety and Aggression[13]. Teenage girls also come to emergency department may have signs and symptoms of Bulimia, Anorexia, Anemia or Severe nutritional

deficiencies. One of the most common reasons for contact among adolescents and in girls in particular.

Frequent visitors may have been affected from domestic violence or depression. Aggressive children may have history of multiple injuries and scars along with other unhealed old

fractures in X-ray, laboratory findings of substance abuse [14].

Psychiatric signs presented by pediatric patients in the primary health care visit or emergency department which frequently is missed by primary health care giver that can be dangerous in psychological growth and development of the patient, it can also further develop into serious psychological disorder that may let them harm society or themselves[15].


8 Correct and step by step psychological assessment of children presenting in emergency department may increase the incidence of non-diagnosed psychiatric disorders which further help in decrease incidence of severe psychiatric disorders that means early detection can also decrease the patient's stay in psychiatric patient department[16]

The majority of the children in need of psychiatric help presenting to the Emergency Department were those who present following indications: Aggressive Behavior, Suicidal Ideation, Psychotic features, Depression, Anxiety[17][18]. Now taken into consideration that worldwide 10-20% of children and adolescents experience mental disorders [19] we can see that it is crucial that the health care provider needs to have at least some basis and training to adequately manage the patient. Mental health care for children on a global scale spans in several mental disorders;

Table 1: Prevalence of Mental disorders in children and adolescents based on population studies in Europe and the United states

(Remschmidt H, Belfer M.[19])

Taken into consideration that the patient may have a somatic presentation and sometimes not typically be recognized by the examining physician as a psychiatric patient, a study performed to investigate the reported differences after an implementation of intervention, reported an increased number from 83 encounters in June 2012-June 2013 to 129 Encounters in October 2013-October 2014 [20] this signifies the importance of proper

training not only to handle but also to recognize the presenting patients as being one in need of proper psychiatric help, an alternative have been implementations of screening tools


9 which could be utilized by emergency department staff and web-based assessment which could be self-administered by the adolescents visiting the Emergency Department to assess themselves [20,21] in both cases the implementation resulted in an increase of identification of possible unrecognized psychiatric problems. Now data have shown that an increase in the psychiatric visits to the emergency department by a young or adolescent patient in the

previous year’s and the implementation of various programs, tools and training has shown improvement in accordance with Length of Stay (LOS) and cost of pediatric patient in the emergency departments (ED) [23] amongst implementations which were attempted and studied we have the Child and Adolescent Rapid Emergency Stabilization program (CARES) “which was a retrospective review of ED patients, presenting a year before the CARES and compared to patients presenting a year after the implementation. Before the implementation there were 1719 visits and 1867 after, with 1190 and 1273 unique patient visits respectively” in this we see that pre-CARES, mean LOS was 19,7 hours while post-CARES was a mean of 10.8 and comparing only the unique visits the average total cost of patient had a decrease of $56.[24]

Another study made on physicians preparedness in handling a pediatric patient in need of psychiatric help seen in the ED, concluded that the physicians did not fully feel that they were properly equipped or had the adequate time needed for properly giving the patient the proper care when it came to treating them after the basic management.[25] Amongst others anxiety disorders were more efficiently isolated after implementation of tool developed specifically for the ED, the efficiency showed an increase of 26-33% in not previously identified anxiety patients.[26] When it comes to suicide and the risk of suicide in the pediatric patient, it is very important that it is adequately recognized and if needed the

patient is hospitalized. The physician is a crucial point in this matter as not only will he or she need to be able to distinguish the severity of the case in front of him but also if an more extensive process needs to be pursued [27,28] The decision to hospitalize a child after an suicide attempt, depends on a multitude of factors, not only will the physician have to

establish trust with the patient to be able to learn of the cause of attempt but also the means that the patient has chosen to perform the attempt.[29] Lastly in the emergency department, children and adolescents will sometimes appear for matters that present themselves somatic in nature but it is important that the EM physician seeing the child is aware of and able to recognize cases that may be the cause of abuse, especially if the child appears on several occasions, but also with presentations which are psychiatric in nature[30,31,32]




The organization of the study was undertaken by first determining what the author would require to have an appropriate basis to undergo the thesis; this was established by doing an critical analysis of published research and academic texts.

In this thesis the author chose to use a qualitative method. One of the main reasons to choose qualitative was to understand the relation between the matters and it’s structures. The reason it was chosen instead of quantitative is because it gives the liberty to look at the current comprehension and standpoints and the interventions which are utilized currently, this is reached in a more precise manner by using a qualitative study.

By using the qualitative methodology it was possible to be more discrepant and selective when it came to selecting which literature to include and exclude.

The author’s selection followed pre-determined, by author, criteria for inclusion or exclusion: • The scope of the research in regards to distribution of patient group should preferably

be wide

• It contains data about pediatric and adolescent psychiatric emergency • Texts relate to pediatric patients with emergent psychiatry in the emergency


• Illustrate gender distribution

Some articles containing statistical data, regarding gender distribution and age ranges have also been implemented in the writing of the thesis



In total 36 sources related to pediatric and adolescent psychiatric emergency were reviewed, of these 15 had U.S origin, 7 were Canadian, 1 German, 2 Italian, 1 Turkish,4 Norwegian 1 Swedish and 5 were collaborative by authors from different parts of the world. For finding these articles I have used PubMed, BioMed Central and ClinicalKey.

Using among others the terms: emergencies, emergency, crisis, acute, gender, male,



treatment, suicide, overdose, disorder, age, psychosis, violent. With the appropriate

BOOLEAN operators (AND and OR)

For the ethical and legislative portion I have used native Norwegian resources located at; www.nhi.no, www.helsebiblioteket.no and lovdata.no

From these the relevant data was collected, the gathered data regarding psychiatric emergencies in the pediatric and adolescent patient and their ethical issues.

The Domestic situation of the child has a major impact on the child’s mental health, situations such as Child abuse, child negligence and domestic violence. A parent with an untreated psychiatric disorder does also plays role in the child psychology with long term exposure and leads to developmental anomalies and mental health regression, and later in life that leads into depression, anxiety and behavioral issues. Another and crucial risk factor for the child would be parents with substance abuse.

Other factors which lead to the child presenting to the emergency department with

psychiatric ailments are alienation and bullying by peers, relationship breakups is a common trigger among adolescents for suicidal thoughts.

Peer pressure may lead to substance abuse at particular among adolescents, criminal behavior and other aggressive behavior, which in itself may cause the underlying psychiatric disorders to be hidden due to intoxication as the symptoms and presentation of intoxication may differ from the patient’s actual pre-existing condition.

Of articles pertaining to patient gender and distribution of age we saw that the pediatric patients with psychiatric indications were almost equally divided by gender (mean calculated from the literature utilized: 51,9 % Male v/s 48.1% Female), but with different indications and the different age groups also had different presentations for appearing in the emergency department. The mean age of children appearing in the ED was 14 years of age with range from 5-17 years. The following table gives the distribution of presenting cases ranged by age but cause such as suicide attempts, spanned between the classifications from late school age to young adulthood

Table 2. Reason for patient’s appearance in the Emergency Department divided by age:

Age group Reason for appearance in ED



• Reactive attachment disorder • Pervasive developmental

disorders(ADHD,Autism and Aspergers)

Adolescence 13-17 • Major depressive disorder

• Oppositional defiant disorders

• Conduct disorder

• Borderline Personality disorder

• Substance abuse/addiction

Young adult <18 • Substance abuse/addiction • Anxiety disorder

• Bipolar disorder • Schizophrenia

As illustrated in the table the patients were presenting with acute re-debut of psychiatric ailments, with regards to their age group. And most of the patients were triaged as emergent or urgent on arrival, consultation with specialist and physical or chemical restraints were required in the cases were patient displayed aggressive behavior, now in some cases the aggressive behavior may be a direct cause of the patient being in the ED as it is a high stimulus environment where the physician does not have enough time to direct the required attention in a timely manner towards the patient leading to increase in stress and anxiety The most common psychosis disorders are conditions from the schizophrenic and affective specter. Recent research and clinical experience suggests that it can be appropriate to deal with this kind of diagnosis as a spectrum and not categorical group of diagnosis. Differential diagnostics into subcategories is more important in consideration to prognosis.

It is important to separate psychotic and near-psychotic symptoms from dissociative conditions. Patients with PTSD may experience hallucinations, but these bare a flashback-nature, where the hallucination is linked to the trauma. Treatment of these conditions is very different. We can although not forget that dissociative symptoms and traumas during life are common in the schizophrenic and affective spectrum and can occur alongside psychotic symptoms. Patients with Asperger’s syndrome may have a symptomatic image similar to psychosis. Time of debut and familial anamnesis is important to differentiate the conditions during the differential. It is not uncommon that very early onset (VEOS) and early onset (EOS) schizophrenia have Asperger like symptoms such as neurologic late development and reduced interactive abilities.


13 Anxiety and compulsive behavior can mimic psychosis symptoms. Diagnostic clarification can be made by observing the patients level of function, their self-insight into their own symptoms. But, anxiety and compulsions may be pre-ceding symptoms of psychosis. Conditions with increased level of confusion with visual hallucinations and reduced orientation should lead to suspicion of somatic reasons, such as substance abuse. A

somatic assessment is a prerequisite for all treatment of psychosis-related conditions, also in the acute phase.

Comorbid condition is also very common in patients with early debut of psychosis. Common conditions are behavior disorders, depression, separation anxiety, compulsions, social difficulties and language difficulties. In the texts it was also noted that.

Other causes of the patient arriving in the emergency department instead of primary health care or specialized facility is due to the lack of resources in these facilities, such as less inpatient beds, primary care physician not adequately trained and the And the stigma

associated with suffering from a mental disorder, which leads to the patient not seeking help in time leading to re-debut of the disorder.

Lastly it is also important to note that many children with psychiatric illness will not present to the Emergency Department with clear psychiatric symptoms, and several will have somatic symptoms such as headache and abdominal pain, which also require the proper psychiatric evaluation, but in many instances will not be done. The most common presenting complaints were:

• Depression

• Intentional self-harm • Suicide attempt

• Mental and behavioral disorder secondary to substance abuse • Schizophrenia or other psychotic disorder

• Violent behavior

• Anxiety/situational crisis • Disruptive behavior • Bizarre behavior

• Agitation with paranoia • Overdose


14 Suicidality/ Self-harm: The term deliberate self-harm is used in ICD 10 which covers all kind of self-harm, from serious suicide attempts to injuries such as cutting, where the goal is to get a temporary relief from a mental pain. By looking at the intention of the self-harm it is divided into self-harm without suicidal intention, self-harm with some intent of suicide and also self-harm where the intention is unknown. Clinically such a division has its purpose, even if all the intents may be present in one patient at different times. The assessment is the same, everyone who self-harm should be assessed properly considering suicidal intentions. But the treatment will not be the same. To predict suicide is difficult but some risk factors are well documented, Most important are psychiatric disorders, previous suicide attempts and substance abuse. Of psychiatric disorders depression is especially important to note, but all disorders increase the risk for suicide. It is important to look for accumulation of risk factors. Depression combined with aggressive behavior and substance abuse is especially a noted risk patient. Other risk factors can be exposure to suicide in family or social circle

Eating disorders: Defines disorders with symptoms such as compulsion about being thin, an extreme fear of being overweight, a negative body image and abnormal eating habits. Anorexia nervosa is one of the most common serious disorders in teenage girls.

Amenorrhea is a central symptom, therefore it makes it difficult to diagnose in prepubescents and boys. Anorexia may present itself due to other predisposing psychiatric disorders such as obsessive disorders, anxiety disorders and autism specter disturbances, or it can be triggered due to traumas and sexual abuse. It is of note that even though the acute treatment of anorexia is considered somatic, the follow up treatment is considered psychiatric.

All children and adolescents have the right to be protected from abuse and neglect; it is a doctor’s duty to take appropriate actions when they have concerns about a child’s wellbeing. This is a complicated area where the doctor works with uncertainty and in some cases against the parents. There are situations where the doctor cannot share everything with the parents that he or she has learned regarding the situation in order to not put the child in more danger, such as when the parents are violently abusive or molesting the child. Even if the doctor is uncertain if he or she suspects abuse or neglect they must take action even if it after further investigation turn out that the child is not at risk or suffering from it. But as an accepted norm the parents should be included in the process of their child’s treatment, also


15 so that they may continue adequately caring for the child so they can get the care and

support they need to be healthy.

When it comes to confidentiality it is a foundation for trust between physician and patient and it is important that the patient trusts the doctor, so the child or adolescent feel comfortable in sharing and giving information that the doctor needs to properly treat them during their visit, but the doctor must always put the child’s wellbeing first, as law upholds it is required to ask for consent before sharing information, but when there is a concern that obtaining consent may do more harm it is important that the doctor do not delay contacting appropriate

authorities even when one does not have consent. The doctor also has an ethical obligation to keep proper documentation regarding the patient, entering information such as time of event, if there are any concerns no matter if it is small, it needs to be documented. Clinical findings, course of action taken and any information which is given or received, although it is often neglected a doctor has an obligation to also document conversations they have had with the child, adolescent, their parents or other family members in regards to the patient themselves, here we go back in regards to confidentiality, if there has been shared any information without consent this needs to be documented, along with the reason for doing so and if any steps were made in an attempt to obtain consent beforehand. Lastly if any

previous concerns regarding the safety of the child or adolescent have not been correct this needs to also be documented.

The following regarding involuntary commitment is based on Norwegian laws as the author is properly familiar with their legislations:

Involuntary commitment of a patient on psychiatric basis may be deemed necessary in patients above the age of 16. In individuals below 16 years the patient is committed

voluntarily in accordance with Norwegian Psychiatric Health Care Legislations (N.PHVL) with the consent of parents or child welfare services.

There are some considerations to take note of; one is that a voluntary committed patient may not be placed under restrictions of an involuntary commitment as they are protected by N.PHVL due to them voluntarily submitting themselves to treatment. Although the following assessed exceptions are present:

- The patient’s condition or prognosis is drastically reduced if they are discharged, or - If a patient is a potential threat to their own or another’s life or health after discharge.


16 The law, under these circumstances, gives the physician the right to keep the patient back, in such case the state appointed control committee needs to be notified in writing that an exception has been made. In a child or adolescents case the parents needs to also be included and properly informed in regards to the patients current mental state and the

assessment which has made the basis for the conversion of the voluntary committed patient to involuntary commitment in accordance to N.PHVL[32-36]



I. Epidemiological and etiological factors

Emergency child psychiatry is defined as the treatment or examination of acute psychiatric symptoms or re-debut of an underlying psychiatric disorder or an event which requires immediate attention for a child or adolescent in psychiatric crisis at the time of presentation. The reason children and adolescents may develop these kind of disorders was observed to be due to amongst others the domestic situation as it affects the well-being of the child not only physically but also mentally. The patients appearing in the emergency department it was commonly observed that they came from a home environment affecting them and potentially had triggered the predispositions some of the children had for developing mental disorders. Substance abuse, violent home environment and/or parents with mental disorders themselves, in some cases untreated, were reported. The children seen were in cases victims of abuse and neglect. But alienation and bullying by peers were also noted to be the underlying cause of the patients appearing in the emergency department with an ailment defined as psychiatric. Disorders seen in the emergency department had a variance according to gender and age, in which boys were more often seen due to violent or

aggressive behavior and depression while girls had the majority representation of patients seen due to eating disorders. But of note is that in suicide attempts there was next to equal distribution (51,9% males vs 48,1% females) suicide is uncommon among children before puberty and increases in adolescent age, where females were seen more due to attempts, males had a higher rate of completion of suicide, meaning the patient either was dead on arrival or died during intervention in the emergency department.



II. Frequent psychiatric disorders presenting in pediatric or adolescents in ED

Dependent on the age of the patient, in conclusion the most common seen psychiatric disorders in the Emergency Department were: Developmental disorders predisposing ADHD, early signs of autism, intermittent explosive disorders, major depressive disorder, which were associated with school problems, chronic illness and/or genetic

predisposition.But most often the children seen in the emergency department were

prepubescent or adolescents, presenting with conduct disorders, substance abuse with the acute presentations of the effects of some substances, such as drug induced psychosis, paranoia, aggressive behavior. Suicidal attempts and onset of Schizophrenia

III. Steps of management and evaluation of the pediatric patient presenting to

the emergency department and the ethical issues in regard to management and further referral

The emergency department has a modified narrowed training, tools and interventions in place to handle the acute onsets of some of the disorders which the pediatric and adolescent patients present with but in several cases there is a discrepancy between what is normative treatment and what is possible with the current protocols in place. A psychiatric pediatric emergency were met and in some cases handled as a somatic presentation or managed as it would have been in an adult patient. The intervention when it comes to children under the age of 16 needs to include the network of the child in much larger extent than with adults.

One must seek the consent of the parents and where the situation is pressing and such consent cannot be obtained the doctor must give priority for the interest of the patient rather than the family. In most European countries it is possible to involve the child services and seek consent from them. However the doctor should only seek this option as a last resort as the implications of this can be severe considering the autonomy of the family. It should only be done in cases where there are immediate threat to the patient`s life or there is a danger for permanent serious harm to the child’s health.

However it cannot be stressed enough that the child should feel as a part of any decision made regarding its health. The doctor is obliged to inform the child to such extent that seems


18 necessary, and in a way that the child can understand. As a minimum the doctor should inform the child about what’s going to happen next but while giving this information one must keep in mind that the information should be presented in such a way that it does not give unnecessary mental stress to the child.



• Initiatives to train emergency department staff to be able to properly screen,

intervene and further recommend children and adolescents with mental health and substance use disorders to specialized facilities

• Prepare standardized tools for screening to accurately detect suicidal risks in the youth who are seen in emergency departments.

• Implement plans to handle the unique requirements of children and adolescents with psychiatric disorders and substance abuse, also for their families.

• Introduce some basic training for school staff and other adults who interact with children as a means of preliminary intervention before the children and young adults will need emergency help for their issues

• For statistical gain and future assessment of efficacy register and follow up for children and adolescents who have been in contact with Emergency department for mental health problems.



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