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

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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 .

Presentation to emergency services

Self-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. Almost all mental health subcategory was positively associated with substance use.[9]

ASSESSMENT OF CHILDREN AND ADOLESCENTS PRESENTING WITH PSYCHIATRIC EMERGENCIES

Development of a therapeutic alliance

This is the key to a comprehensive assessment. A solid alliance enables improved outcomes. A strong alliance includes understanding the patient and parents’ priorities, cultural competence, and interpersonal warmth. When working with children or youth with mental illness or at risk of suicide, developing a strong working alliance with parents, caregivers is an important component of the overall relationship-building process. A therapeutic alliance is an interpersonal process that has relational, cognitive, and emotional dimensions and goes beyond superficial friendliness. The task of the clinician is to reach, together with the person, a shared understanding of the person’s illness and suicidality.

The qualities associated with the development of a strong therapeutic alliance are – credibility, warmth, genuineness, empathy, flexibility, regular solicitation of feedback, and common understanding regarding treatment goals. Key aspects of a therapeutic relationship are highlighted in Table 1 .

Table 1

Key aspects on therapeutic relationship

History taking and examination

The basic tenets of psychiatric assessment, i.e., thorough history taking, general physical examination along with a detailed neurological examination, mental status examination, and relevant investigations are to be followed while evaluating children and adolescents presenting with psychiatric emergency. The history should be collected from as many sources as possible; this becomes important because of various reasons like the child may not have acquired speech and language skills, may be having neurodevelopmental conditions which prevent him from active communication, may not feel safe, secure, and confident to discuss stressful issues, or may be defiant and not ready to talk. It is essential to interview both the parent and child separately. Various techniques for gathering information can be employed, such as interview, play observation, and behavior observation. It is also essential to observe their interaction. This will help the clinician understand the genesis of the various issues and plan intervention. Parents and children may be able to share all concerns in the absence of the other. Children may be able to confide in the therapist in the absence of parents.[10]

History taking should include:

All details of behavior under evaluation – onset, duration, frequency, precipitating/maintaining/relieving factors

Birth and developmental history to assess for neurodevelopmental conditions like intellectual disability, attention deficit hyperactivity disorder, autism spectrum disorder, learning disability

Psychosocial information: family structure, family and peer relationships, living situation, any adverse situations/childhood experiences (like trauma and abuse), neighborhood environment, type of parenting

Thorough physical examination of all systems (neurologic, cardiac, respiratory) and vital signs recorded. Information obtained through history and examination will guide the choice of investigations to be carried out. Mental status examination helps to understand a person’s emotional state and cognitive capabilities and limitations. It starts with assessing the individuals’ level of awareness and orientation to the surroundings, eye contact, communication ability, general appearance, degree of distraction, speech, affective state, thought process (worries, delusions, concerns), hallucinations, evidence of separation anxiety. Cognitive assessment includes assessing for memory disturbances, gross level of intelligence and reasoning ability – whether appropriate to age or not, understanding of problems at hand. It is always a good idea to ask for the skills/strengths/interests of the child while doing a mental status examination.

Suicidal behavior is one of the most common presenting psychiatric emergencies in children. In the assessment of suicidality, various factors need to be considered, as highlighted in Table 2 .[11] Key terms used have already been described in the section on suicide. (IPS CPG on assessment and management of Suicidal Behaviors).

Table 2

Assessment of suicidality

It is inevitable for a psychiatrist to screen all patients for suicide risk and carry out a comprehensive suicide assessment in suspected children and adolescents. Given the risk of suicide, the risk assessment is necessary to categorize risk and recommend the level of care appropriate to the child. It is also essential to ask questions in relation to suicidality as described in Table 3 .[12,13]

Table 3

Important questions in interview

Various screening instruments are available to assess suicidality in children and adolescents.

ASQ (Ask Suicide Screening Questions) developed by National Institute of Mental health consists of brief suicide screening questions that take 20 s to administer.

Suicide risk assessment

It is a one-to-one assessment in which the distressed person is thoroughly interviewed regarding current suicidal desire/ideation, capability, intent, reasons for dying, reasons for living, suicide attempt plan, past attempts, and protective factors, thus, enabling risk identification and planning intervention. It is essential to evaluate the motivation and intent of any previous attempt and the understanding of the lethality of the suicide act or plan. The various factors to be assessed are mentioned in Table 4 .[14,15]

Table 4

Suicide risk in children and adolescents

The SAFE T (Suicide assessment five-step evaluation and triage):

This is a tool and a pocket card which guides psychiatrists through a comprehensive risk assessment. It includes the following five steps:[16]

Table 5

High-risk level – severe symptoms or acute precipitating event, protective factors are not relevant, potential lethal attempt or persistent ideation with suicide intent; intervention includes – admission is indicated, suicide precautions to be administered.

Moderate risk level – multiple risk factors, few protected risk factors, suicidal ideation with a plan with no intent or behavior, admission may be necessary subject to risk factors. Developing a crisis plan is essential.

Low-risk level – Modifiable risk factors, strong protective factors present, presence of thoughts of death with no plan/intent/behavior. A patient can be managed in outpatient settings. Facilitate symptom reduction. Give emergency contact numbers.

Protective factors: As highlighted in Table 5 , these are factors that mitigate/reduce suicide risk. Adolescents face challenges such as transitioning to adulthood, facing new independence, identity formation, and changing social situations at school and home. They are also at risk of anxiety or depression due to significant physical, hormonal, and social situations at school and home.[15]

Nonsuicidal self-injury (NSSI): Another presentation in pediatric emergencies. Defined as direct, repetitive, socially unacceptable injury to body tissues without suicidal intent. As per ICD 10 (International Statistical Classification of Diseases and related health problems), these exist as a symptom and not as a diagnostic entity. It may vary from deliberate self-harm with suicidal intent to involuntary or stereotyped behavior in developmentally disabled. A common form of deliberate self-harm is cutting and burning. It may be a way to cope with distress, punish themselves, self-soothe or manipulate the environment, or cry for help. Stereotypic behaviors include hitting, biting, head banging, and scratching.[14] Certain risk factors which predispose to nonsuicidal self-injury include female sex, earlier NSSI, earlier suicidal ideations and attempts, symptoms of depression, and presence of stress. Also, a higher frequency of NSSI is associated with an increased risk of suicidal ideations and suicidal attempts.[17]

A clinician must be aware that NSSI and suicidal behavior are discrete entities, but they may occur in the same person at different points. Table 6 shows some of the differences between suicide attempts and NSSI.[17,18]

Table 6

Differentiate between NSSI and suicide attempt

Risk assessment for aggression

For children and adolescents presenting to the emergency department with aggressive behavior, it is important to evaluate for some of the more commonly associated psychiatric disorders with aggression like conduct disorder, oppositional defiant disorder, attention deficit hyperactivity disorder, substance use disorder, depression, disruptive behavior disorder, autism spectrum disorder, intellectual disability, and gaming disorder.[19] There is evidence of an increase in physical aggression in adolescents with pathological gaming.[20]

A comprehensive assessment including developing therapeutic alliance, gathering detailed multi-informant history, examination, mental status examination remains the first steps to plan an effective intervention.

Performing a risk assessment is important since this involves the safety of the patient and people around. This reflects not only the safety measures that need to be undertaken but also the needs of the child and can direct intervention. Relevant factors for risk assessment are shown in Table 7 .[21]

Table 7

Risk factors and correlates for aggression and conduct disorder[22]

Assessing for reversible causes for altered sensorium

While assessing a child or adolescent who presents with behavioral abnormalities and altered sensorium additional information should be gathered with respect to the onset of symptoms, type of symptoms-altered sensorium, inattention, memory disturbances, sleep-wake cycle disruptions, agitation, perceptual abnormalities, disturbances in thought processes, any fluctuation in symptoms, medical history including acute/chronic medical illnesses/infection, medications, pain, anemia, etc., and metabolic derangements. Altered sensorium can be due to various factors, and some of the modifiable factors (listed in the Table 8 ) can be remembered in the form of an acronym “BRAIN MAPS” given by Smith et al. 2013.[23]

Table 8

Modifiable factors contributing to development of delirium in children (Smith et al. 2013)[23]

Assessment for causes leading to the presentation as psychosis

Assessment of children presenting with psychosis requires knowledge of various causes that can present with psychosis as a presenting complaint, and some of them are listed in Table 9 .[7]

Table 9

Causes of psychosis/psychotic symptoms in children

For assessment of children presenting with psychotic symptoms, a thorough medical evaluation should be carried out and medical stabilization should be done whenever required. Drug ingestion/overdose whether intentional or unintentional may not be recognizable immediately as children are not usually in a position to provide information. So, efforts for rapport building with the child and the family should start at the first contact and continue thereafter. Additionally, it is imperative to provide support to the caregivers when their child is being evaluated. It is also to be remembered that transient psychotic-like symptoms may be just a developmental phase in the young child; however, such presentations require a careful information elicitation and continued monitoring of symptoms.[10]

Individuals with a primary psychiatric illness usually have normal vital signs; normal orientation to surroundings and hallucinations are mostly auditory in nature. In contrast, individuals with psychotic symptoms in the context of an underlying medical condition may have abnormal vital signs, disorientation, positive signs on physical examination, visual, and tactile hallucinations. There are certain indicators for an underlying medical condition in the context of psychotic symptoms, which can be helpful in arriving at a differential diagnosis. These are:

Symptoms like disorientation, visual hallucinations, fluctuations in mental status, emotional liability, etc.

One should always clinically assess for the altered sensorium since altered sensorium and psychosis in young children can be difficult to differentiate.

Assessment of anxiety and agitation in children and adolescents

Anxiety and agitation can have a myriad reason. One needs to differentiate from developmentally appropriate worries, fears, and responses to a stressor, as described in Table 10 .[24,25]

Table 10

Difference between developmentally normal anxiety and pathological anxiety

Detailed clinical history and examination help ascertain key areas of concern and presence (or absence) of problems. A patient may present with an overwhelming surge of anxiety, stress, and fear. They may present as distress, cry spells, tantrums, freezing, clinging, or not wanting to leave a familiar person. Panic attacks peak in late adolescence, affecting 5–10% of adolescence. They express a fear of death with autonomic symptoms such as tachycardia, palpitations, sweating, shortness of breath, chest pain, choking sensation, nausea, abdominal pain, tremors, tingling, and numbness. Children with marked stress and fear in social situations may cry and throw a tantrum and present as a panic attack.

Children who experience trauma following an actual or threatened death, accident, injury, or threat to physical integrity or witness an event (such as sexual abuse, assault, shooting, or an earthquake) may present with PTSD. A response in the form of intense fear, helplessness, and horror may present in emergency settings.[24] In an emergency setting, altered consciousness with fluctuating attention needs to be differentiated from trance states or black outs. They may also have depersonalization or derealization episodes.[26] A child’s belief in an alternate self or imaginary self which control child’s behavior and may present in the ED.

Comorbid psychiatric illnesses which may have anxiety include (but are not limited to) depression, attention deficit hyperactivity disorder (ADHD), and behavior, bipolar, obsessive-compulsive, eating, learning, language, and substance-related disorders. It is necessary to look for comorbid medical illness, hyperthyroidism, caffeinism, migraine, asthma, diabetes, chronic pain/illness, lead intoxication, hypoglycemic episodes, hypoxia, pheochromocytoma, central nervous system disorders, cardiac arrhythmias, cardiac valvular disease, systemic lupus erythematosus, allergic reactions, and dysmenorrhea. Medications that can cause anxiety include (but are not limited to) bronchodilators, nasal decongestants and other sympathomimetics, antihistamines, steroids, dietary supplements, stimulants, antidepressants, antipsychotics, and withdrawal from benzodiazepines (particularly short-acting).[27] In children who present with seizure-like episode, a clinician needs to differentiate between a dissociative convulsion and an epileptic seizure.[28]

USE OF RATING SCALES

There are various rating scales that can be used to augment information obtained by clinical interviews. Some of the rating scales that can be used for various presenting emergencies are listed in Table 11 .

Table 11

Rating scales used in children and adolescents in the emergency setting

INVESTIGATIONS

The choice of special investigation to be advised (e.g., MRI brain, lumbar puncture, EEG, autoimmune panel, urine for porphobilinogens, specific metabolic studies, etc.) usually is guided by the information gathered through history and examination. The investigations may include a complete blood count, toxicology screen for substances, renal function test, liver function test, electrocardiogram, neuroimaging, and many more.

DIAGNOSIS

Diagnosis should be made as per the standard nosological system. However, it should be remembered that a final diagnosis may not be easy to make in an emergency setting (underlying medical conditions will be picked up on investigations), and some psychiatric symptoms like aggression, suicidal behavior, agitation, altered behavior, psychotic symptoms are a presentation of many disorders. Therefore, a thorough history, physical and neurological examination, and mental status examination will help to come to a provisional diagnosis.

MANAGEMENT OF PSYCHIATRIC EMERGENCIES IN CHILDREN AND ADOLESCENTS

The decision for admission

The main goal of assessment of children and adolescents in the emergency setting includes triage and focused care, medical stabilization, ensuring the safety of the child or adolescent, relevant investigations, diagnostic clarification, deciding the treatment setting (inpatient- psychiatry, inpatient-pediatrics, intensive care unit or outpatient services). Patients with severe symptoms often warrant admission.

Medical stabilization includes care of hemodynamic status (A – airway, B – breathing, C- circulation), nutritional status, physical activity, pain, sedation. Thereafter, the first step should be an assessment for altered behavior/delirium. In any case where altered behavior is present, the management of altered behavior takes precedence (the management of altered behavior is described in the sections below).

Children and adolescents with active suicidal ideations and attempts should be hospitalized if the child’s condition is unstable. Caregivers’ supervision is to ensure that drugs and any means of self-harm should be inaccessible to the child/adolescent at risk.[14]

Steps for suicide prevention in wards are necessary. It is essential to remodel wards to prevent suicide attempts in the ward. Eliminate structures that support hanging objects, exposed pipes, and towel hooks. Install windows that do not open from the inside. Remove harmful objects from the vicinity. Nonsharp utensils are advised to be used. Attendant or caregiver supervision is to be maintained throughout. In children and adolescents, partial hospitalization offers intensive multidisciplinary treatments and skilled observation and support. This can be offered in those who are disturbed but have a supportive care environment. This allows intervention to stabilize the emotional condition and address stressors.

Treatment in emergency services

The treatment will vary depending on the cluster of symptoms.

Self harm

A detailed discussion with the family and child about specific issues, triggers, and situations that result in suicidal behavior must be carried out. A written, verbal no-suicide contract is commonly discussed with the child and is also used as a probe to understand if the thoughts on suicide change in the child. A verbal or written no-suicide contract has not shown evidence of preventing subsequent suicides.[14] However, safety planning should be conducted in the emergency department.

It is here that the mental health professional provides an important function of triage, referring suitable patients for subsequent treatment. Rotheram-Borus et al., 1996[52] described a brief emergency room crisis intervention procedure for adolescent attempters. The aims are to facilitate a good experience between family and emergency service staff, set realistic expectations about follow-up treatment, and obtain a commitment from adolescents and relative toward follow-up. A detailed discussion with the patient and family about specific issues or situations which enable suicidal behavior, ongoing stressors, and identifying potential precipitating factors are important.[14] In the emergency situation, once the wound care and dressing are completed, a complete psychological assessment is necessary. Upon evaluation when it is clear that the self-harm is NSSI, then interventions focusing on developing motivation to change, facilitate family support, and strengthen positive affect can be taken up in regular outpatient care.[53]

Safety planning

A safety plan is a document with six steps where the clinician and patient discuss warning signs, coping strategies, ways to reach out for help, and make an environment safer. It involves collaborative work in which the individual develops a personalized list of coping strategies. The steps of safety planning are shown in Table 12 .[11,12]

Table 12

Safety planning measures

Example of elements of a safety plan

Step 1: Warning sign

Step 2: Internal coping strategies – Things I can do to distract myself/cope

Step 3: Social situations or people that can help to distract me

Step 4: People whom I can reach out to for help

Step 5: Professionals or agencies I can contact during a crisis:

Make the environment safe:

A study done on adolescents to assess the association between profiles and mental health utilization reveals five profiles of elevated suicide risk with differing patterns of risk factors which includes the history of multiple suicide attempts, suicidal ideations in the last month, depression, substance use, aggressive behavior, and abuse.[54]

Pharmacologic treatment

Pharmacologic approaches involve the treatment of the underlying psychiatric condition.

Lithium reduces suicidality and suicide attempts in previous attempters. However, in children and adolescents’ supervision is to be exercised in view of a potential overdose in suicidal children.[14] SSRIs (selective serotonin reuptake inhibitors) are used to treat the underlying depression. These are considered first-choice medications in suicidal children and adolescents. The clinician must keep a watch on emerging side effects such as suicidal ideas in such patients. One of the major concerns with the use of antidepressants among children and adolescents is the emergence of suicidal ideations (Black box warning) against the use of antidepressants. A cautious approach needs to be considered using antidepressants among children and adolescents, and they must be monitored for any treatment for emergent suicidal behavior. Clozapine can also be used in children and adolescents with suicidality as off label use.[14] Studies have reported the use of ketamine in youth with a decrease in suicidality; however, findings need to be substantiated with longitudinal studies, safety, efficacy, and abuse potential in youth.[55]

Specific psychotherapies

Whilst crisis intervention is possible in emergency settings, once stabilized the child may be engaged in other forms of therapy, such as cognitive behavioral therapy (CBT), interpersonal psychotherapy, and dialectic behavior therapy. Family therapy is specifically designed to treat depression and suicidal thoughts/behaviors. It is to protect adolescents against suicidal ideations and risk behaviors by improving family processes and securing parent–child bond.

When children and adolescents report suicidal ideas, they experience intolerable agony, hopelessness, and helplessness. They may impulsively respond to desperation by attempting suicide. Psychotherapeutic techniques aim at reducing intolerable feelings and thoughts and reorienting the cognitive and emotional perspectives of the suicidal child and adolescent.[14]

It is essential for the clinician to relate to the child

Electroconvulsive therapy: Suicidality is one indication for electroconvulsive therapy in children. ECT is considered in patients with a failure to respond to two adequate trials or in conditions that are life-saving. As per the Mental Healthcare Act, 2017, Electroconvulsive therapy can be given to children with informed consent obtained from guardians and with permission from the Mental Health review board.[56] However, this cannot be in an emergency setting.

Follow-up and discharge planning

A checklist can be kept in mind before discharging a patient who has attempted suicide.

Children and adolescents shall never be discharged from the emergency without the verifying account from the parent.

The doctor and parent need to be advised to monitor for warning signs:

Thoughts of dying – if the child voices thought of dying, disappearing, shooting, other forms of self-harm, or jumping.

Change in behavior – sad, withdrawn, irritable, anxious, restless, indecisive, difficulty in concentration

Aggression

The Centre for Education and Research on Mental health therapeutics (CERT) guidelines for the Treatment of Maladaptive Aggression (TMAY) II recommend the following:[57]

Treatment planning in an aggressive patient should include a review of aggressive behavior, including triggers, warning signs, repetitive behaviors, response to treatment, and prior seclusion and restraint events associated with aggressive acts, along with diagnosing and treating the underlying psychiatric illness. Cognitive limitations, neurological deficits, and learning disabilities need to be taken into consideration.

De-escalation strategies include helping patients manage anger outbursts by using anger management and stress reduction techniques. The de-escalation strategies include allowing children to use self-direction, prompts to manage their own behavior, ignoring peer provocation, negotiating with peers, and use self-directed time out. Prompts that aid children in using these strategies should be a primary treatment intervention and should be included in the treatment plan.

Aggression is often preceded by a period of escalating agitation. Psychosocial interventions help regain self-control and can help avoid the need for physical and chemical restraints. When the youth exhibit warning signs of aggression, behavioral interventions such as verbal interventions, time out, or quiet time can be used. A stat dosing or injectable can be used to avoid the aggressive episode when anticipated. In case less restrictive options fail and there is a danger to self or other and/or imminent danger of damaging property, restraint can be used. All restrained patients should have their pulse, blood pressure, and range of motion in their extremities checked every 15 min. (Refer to the section on aggression in psychosis.)

As per the Centers for Medicare and Medicaid Services restraint guidelines, regulations apply to both physical and chemical restraints. Documentation is required for the need and monitoring of restraint of 100% of patients.

Above 18 years of age – every 4-h restraint is to be renewed. The outline of the assessment and management of self harm can be found in Algorithm 1.