Clinical Practice Guidelines for Assessment and Management of Children and Adolescents Presenting with Psychiatric Emergencies

Abstract

INTRODUCTION India ranks second in being the most populous country. Every fifth person is an adolescent between 10 and 19 years, and every third person is aged between 10 and 24 years. We have a record of the highest number of children and adolescents, more than 434 million. There is wide variation in reporting of psychiatry disorders in CAMH (Child and Adolescent Mental health), and the recent national mental health survey reported a prevalence of 7.3% of morbidity among adolescents. There is no national data on the prevalence of psychiatric emergencies. Overall, there is a trend for increased utilization of psychiatry emergency services by children and adolescents.[1] An American study reports a 60% increase in mental health disorder is the reason to visit emergency services.[2] Literature reports that the most frequent emergencies are suicidal behavior, depression, aggressiveness, substance abuse, and violence-related situations. The emergency may be related to an underlying mental health condition, which has relapsed or may be the first episode of an illness. Repeat visits to the emergency services have been reported from 20 to 47%.[3,4] A psychiatric emergency is an acute disturbance of either behavior, thought, or mood of a person and has the potential for a negative impact. This emergency if unattended can cause harm to the patient or other community members. The clinical presentation of psychiatric emergencies in CAMH is usually different from that seen in adults. Assessment warrants identifying symptoms, assessment of underlying disorder, the impact of the emergency on the child and family, the protective factors, and the resources for management. Besides a good history, a thorough examination to rule out medical comorbid or etiological disorders is important. It is imperative to quickly triage and pinpoint symptoms requiring immediate attention. These could be psychomotor agitation, aggressiveness, violence, delirium, and suicidal behavior. Investigations such as drug screening, blood count, electrolyte analysis, cardiac monitoring, and computed tomography may be required in some cases. Early and prompt identification and treatment would yield positive results. An important competency required is the ability to assess risk and manage it effectively. With this large child and adolescent population, coupled with a paucity of child mental health professionals to serve the psychiatry disorders in CAMH, it is important to have standard guidelines for managing psychiatric emergencies in CAMH. A guideline on assessment and management of psychiatric emergencies in children and adolescents encompasses identifying at-risk patients, ensuring safety, interviewing the child and parent, developing a therapeutic alliance, examination, and management of both pharmacological and nonpharmacological approaches strategies. EPIDEMIOLOGY Children and adolescents visit the emergency for a variety of reasons. A western study reported that nearly three-fourths of the patients had a primary psychiatric diagnosis. The most frequent diagnoses reported were anxiety states/panic disorder (14%), depression (13%), drug abuse (11%), and conduct disorders (8%). Other studies have reported personality disorders and schizophrenia/psychotic disorders, aggressive behavior, thoughts or actions of self-harm, medication refills, and autism spectrum disorders as reasons to visit the emergency services. Trends have shown a sharp rise in self-injury and suicide-related emergency visits among children and youth.[2] The common presentations can be seen in Figure 1.Figure 1: Presentation to emergency servicesSelf-harm behaviors encompass suicide attempts, deliberate self-harm, and nonsuicidal self-injury (for key terms in suicide literature, refer to IPS CPG on assessment and management of suicidal behaviors). The World mental health report 2022 highlights suicide to be the third leading cause of death in 15–29 years and the fourth leading cause of death in males in this age group. Overall, it is the fourth leading cause of death among 15–29 years old and accounts for 8% of all deaths in this age group. Aggression refers to a behavioral style aimed at deliberately harming other people or objects and is considered a way to adapt, but it can be abnormal when rules are broken. It is a common phenomenon and an important associated feature of psychiatric disorders affecting 10–20% of youth. “Terrible twos” refers to developmentally appropriate aggression in toddlers, which peaks at 30 months and declines by 5 years of age due to the development of self-control and cognitive competencies. Social and relational aggressions are indirect forms of aggression seen in school-going children. During adolescence, the awareness of self-identity and social standing with peers, desire to fit in, and the desire for popularity can lead to greater aggression. Acute confusional state, commonly known as “delirium” is characterized by an abrupt/acute onset of altered sensorium with a change/fluctuation in baseline mental status, inattention, disorganized thinking with or without perceptual abnormalities (delusions and/or hallucinations), and is the result of an underlying medical condition. It is a vastly underrecognized and underdiagnosed entity in children and adolescents and neither DSM 5 nor ICD 10/ICD 11 includes a definition of delirium specific to children and adolescents. Also, given the developmental stage of children, it becomes difficult to apply the definition of adult delirium as it is in children.[5] However, with the development and use of multiple validated tools to evaluate delirium in children and adolescents, it is being increasingly recognized and comprises 10% of all pediatric consultation–liaison referrals. It accounts for ~30% of referrals for critically ill children and is a marker for serious illness.[6] Like the types of adult delirium, delirium in children and adolescents is classified into three subtypes based on psychomotor state-hypoactive delirium (apathetic/uninterested child), hyperactive delirium (irritable, thrashing child), and mixed delirium (fluctuates between hypoactive and hyperactive state). While many clinical features of adult delirium may be applicable to children, yet some features are more prominent in children. These are irritability, agitation, affective lability, sleep-wake cycle disturbances, and fluctuations in symptoms. Perceptual abnormalities (delusions, hallucinations), speech disturbances, and memory impairments are less commonly seen in children. Acute onset developmental regression with loss of previously acquired skills, inconsolable child, and reduced eye contact with the caregiver are some unique features of delirium in young children. Psychosis is defined as a disruption in the thought process, delusions (false, unshakeable beliefs), and hallucinations (false perceptions in the absence of an external stimulus) as a presenting complaint in children and adolescents in the emergency setup may be a manifestation of a primary psychiatric illness, substance withdrawal or intoxication, or may occur in the context of a medical condition.[7] Among the various manifestations, anxiety symptoms/disorders are among the most common psychiatric conditions in children and adolescents and are associated with an increased risk of suicide attempts and significant morbidity and mortality. The course is considered chronic, persistent, and recurring with high levels of short-term and long-term impairment. At any given time, about 7% of youth worldwide have an anxiety disorder and are more common in girl. The lifetime prevalence rates among 13–18 years is approximately. 20% for specific phobia, 9% for social anxiety, 8% for separation anxiety, and 2% each for agoraphobia, panic, and generalized anxiety. Approximately 4% of children and adolescents experience posttraumatic stress disorder (PTSD) with increases seen in children exposed to trauma. Nearly one-quarter of adolescents presenting to the emergency services have been screened and found to have symptoms compatible with preexisting PTSD.[8] Occasionally, children present with an agitation which needs urgent intervention. Substance use may present as intoxication, withdrawal, or dual diagnosis. Studies have found that substance abuse and mental health conditions presenting to the emergency have overlap with one in five visits for substances complicated by mental health comorbidity. 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