MULTIPLE INFORMANTS: WHO DEFINES “EMERGENCY”?
Unlike adult emergencies, in child and adolescent mental health it is often the child's parent/guardian who labels a situation as a “crisis” or identifies a need for emergency care. An adult with whom the child interacts may feel overwhelmed in his or her own capacity to manage a child’s behavior or may interpret a child’s behavior as dangerous or inappropriate. 8 Thus, it may not be the child’s behavior, per se, that is significant but its interpretation by the child’s caregiver. For example, a behavior that is acceptable to, or managed by, the parent in the home may not be tolerated in a school setting. While the child is usually able to answer concretely the question of “Why did your mother bring you to the ED today?” (“Because I got into a fight with my little brother”), he is unlikely to label his own behavior as problematic or emergent.
It is the role of the consultant/physician to decide whether the child’s behavior is a true emergency. The consultant determines whether the child’s behavior represents a change in usual day-to-day functioning; is clinically meaningful, diagnostically relevant, and out of the realm of “normal” development; or is a reaction to a specific environment or caregiver (in which case, altering the environment may alleviate the problematic behavior).
When the parent is not the primary referral source, the consultant should seek out collateral contacts and, ideally, speak to the person who labeled the child’s behavior as emergent. For example, since the events in Columbine, Colo, and other national tragedies, schools have increasingly implemented zerotolerance policies for violence or threatening behavior.24 This may lead to increased ED presentations for children who violate school policy by making threats and who require evaluation before being allowed back into school. The parents typically lack a clear understanding of what transpired at school, because the patient is likely to report a “he said/she said” interaction with another student. In addition, the child may be unwilling to accept responsibility for any of his actions and out of anger, frustration, or discomfort, may be difficult to engage in an interview.
If the parent did not bring written documentation from the school, the consultant should call the school principal, teacher, or counselor to determine the exact nature and context of the offense. This type of information is essential if hospitalization is an option for disposition, because it may be difficult to justify an admission without a first-person account of the dangerous behavior. If the parents do not have documentation from the school describing what happened or if the clinician is unable to contact school personnel, a general assessment of dangerousness may be conducted. Not having an accurate description of the current precipitating factor may curtail options for disposition. The same principles apply if a patient is referred to the ED by a treating therapist or psychiatrist.
LEGAL ISSUES
Consent to treat
Although obtaining consent for medical treatment is typically waived in situations of life-threatening emergencies, the majority of patients presenting to a psychiatric emergency service do not typically require life-sustaining treatment. This results in the need to obtain consent before initiating assessment/ treatment.25 Obtaining consent becomes complicated if the parents are divorced, the child is a ward of the county or state, or the adult bringing the child to the emergency setting is not his legal guardian. Reasonable attempts should be made to obtain consent before treatment, and such efforts should be documented. Clinicians should consider consulting with hospital attorneys in cases of married parents who disagree about evaluation and treatment.25
States have begun to acknowledge a minor’s right to consent to certain medical, mental health, and substance use treatments without parental knowledge. There are 5 types of consent laws for minors: emancipated minor, mature minor, age of consent to medical treatment, age of consent to voluntary commitment, and age of consent to outpatient treatment.25 State laws vary with regard to the age at which a minor may consent to mental health treatment. It is important to be familiar with your specific state’s law. In some states, children as young as 14 years can consent to mental health treatment without parental consent or knowledge.
Limits of confidentiality
Before starting an evaluation, clinicians should review limits of confidentiality with patients. Clinicians should use discretion when deciding what to reveal to a third party—for example, contacting school personnel who initiated a referral necessitates revealing that the patient is being evaluated, but does not warrant disclosure of diagnostic formulation, treatment recommendations, or family issues.25 In the case of a parent’s refusing the release of information, the identification of the situation as emergent would permit the breach of confidentiality. 25 The individual state’s law should be reviewed to determine specific practices with respect to confidentiality (for example, whether minors can prevent disclosure of confidential information to parents).
Reporting child abuse and neglect
All physicians, psychologists, and social workers are required to report abuse and neglect. States vary regarding whether there must be knowledge of abuse or merely suspected abuse to initiate a report, and many states impose penalties (fines, misdemeanor charges) on providers for failure to report abuse. Methods for reporting suspected abuse are available online through the US Department of Health and Human Services at: http://www.childwelfare.gov/responding/reporting.cfm
The federal Child Abuse Prevention and Treatment Act (CAPTA) (42 United States Code Annotated §5106g), amended by the Keeping Children and Families Safe Act of 2003, sets forth broad guidelines for defining child abuse and neglect: “Any recent act or failure to act on the part of a parent or caretaker, which results in death, serious physical or emotional harm, sexual abuse, or exploitation; or an act or failure to act which presents an imminent risk of serious harm.”26 CAPTA establishes a minimum standard of abuse, with each state creating its own statute defining abuse and neglect. A searchable database of state statutes is available online through the National Clearinghouse on Child Abuse and Neglect Information: http://www.childwelfare.gov/systemwide/laws_policies/
search/index.cfm.
DISPOSITION DECISION MAKING
The most difficult aspect of the evaluation process is clinical decision making regarding the most appropriate disposition for a child or adolescent who may be a danger to himself or others.27 There are 2 primary decisions to be made in this type of evaluation: whether the patient presents a clear danger to himself or others, and what is the most appropriate level of care for the patient. Decision making in the ED has been further complicated by the role of managed care in mental health service delivery and the necessity for treatment decisions to be cost-effective and clinically appropriate.28
In making a disposition decision, the clinician must consider the constraints of the mental health service delivery system. Although the emphasis in the clinical literature is typically placed on treating young persons in the least restrictive and most clinically appropriate setting,29 there are continued financial incentives for inpatient hospitalization over the development of communitybased programs.30 Despite the need, there may not be sufficient numbers of community- based mental health programs; indeed, lack of access to care in the community setting is often hypothesized as the reason for the increase in ED visits for mental health concerns.1,2,31
In general, there has also been a decrease in available psychiatric inpatient beds32 and fewer days of inpatient care among child and adolescent populations. 33 It is possible that children needing a high level of care are presenting to and receiving treatment from outpatient settings because of a lack of inpatient beds. This may prompt overflow patients seeking mental health care (those in crisis, but not emergent) to visit EDs. Efforts to refer these nonemergent patients back to community mental health centers may be difficult because of long waiting lists for appointments.
In deciding disposition for children, the consultant must also assess the parents’ ability to supervise when the patient is expressing suicidal thoughts, their ability to follow through with recommended appointments, and their attitudes toward the patient. For example, a frustrated parent who is angry with his child may be limited in his ability to carefully monitor the child. Using a continuum of care model (from least to most restrictive), Table 3 provides possible dispositions for children and adolescents.
Psychopharmacology in the ED
Given the variability in who conducts emergency evaluations of psychiatric patients,34 prescribing medication in the ED may not always be an option (for example, if the consultant is a social worker or psychologist). Because there are often limited means of ensuring that the patient will engage in follow-up care after discharge from the ED, it may not be advisable to initiate a medication intervention that requires observation and monitoring by a physician.
Hospitalization
While attention has been paid to risk factors for presenting to an ED35,36 and for committing suicide,37,38 there has been less empiric research examining decision making and, more specifically, factors to weigh when deciding whether to hospitalize a young patient. Factors to consider when evaluating the benefits of hospitalization for children and adolescents have been published by the AACAP.39
A review of the research found certain variables to be key determinants in disposition decision making for adults: severity of symptoms (particularly psychotic symptoms), suicidal and/or homicidal ideation, and previous hospitalization. 40 Because this research was conducted on adult patients, it is not clear whether the findings transfer to a child and adolescent population. Recent studies, however, examined this issue in child populations. One such study identified at least 3 factors that could predict psychiatric hospitalization: cooccurrence of suicidal and assaultive behaviors as presenting problems, substance use in a child, and a family member (typically a parent) with a substance use problem.41
There is also some debate regarding the relevance of diagnosis to decision making about disposition.41,42 While specific diagnoses are associated with dangerous behaviors, a patient can be dangerous even without a strict DSMIV- TR diagnosis. In addition, the reliability of diagnoses made in the ED is questionable,43 which raises concern about their use in determining patient disposition.
The use of rating scales
Psychiatric emergency settings vary with regard to whether they use standardized instruments in emergent evaluations and what measures they use. Possible domains of assessment include factors related to suicidality (risk, intent, lethality), specific psychopathology, and admission criteria for hospitalization. Reviews and examples of such measures have been published elsewhere, 20,21,44-47 but few of the published measures have been developed or evaluated in ED settings.
CONCLUSION
The emergency assessment of children and adolescents is a challenging task. A successful evaluation necessitates not only a thorough assessment of the patient’s emergent symptoms but also his social environment. Also required is an understanding of how symptom presentation in children/adolescents might differ from that in adults, as well as across age groups (see “Take-home points,” below). If the trend of children and adolescents presenting to EDs for emergency complaints continues, research and advanced training for providers in this specialty are likely to follow.
Take-home points
- The assessment of any child or adolescent with a psychiatric emergency has 2 components: review of psychiatric symptoms and risk factors for suicide and/or violence toward others and assessment of social factors influencing the patient’s functioning.
- The length of child and adolescent psychiatric consultations will be greater than those of adults, given the necessity of establishing collateral contacts. It is rare that the patient will identify a situation as a crisis. As a result, a complete assessment necessitates interviews of adult figures in the child’s life who are defining the situation as emergent.
- Keys to successful interviewing of children/adolescents are to establish rapport, speak to the child and ask questions on a level that matches developmentally, include the child/adolescent in the process, and follow the child’s lead regarding willingness to talk.
- In the emergency department, where time is limited, small efforts to gain rapport (such as talking to the child first) go a long way, but an evaluation and disposition can be based solely on collateral contacts if the patient is not cooperative or is an “unreliable” reporter of events.
- In case of child and adolescent evaluations, issues of consent and confidentiality may be complicated by the patient’s status as a minor. Unlike adult evaluations, there are multiple levels of consent (patient, parent, county, and state) and confidentiality to be considered. This necessitates familiarity with the age of consent in the jurisdiction within which one practices, laws of confidentiality, and careful attention to who has custody of the patient.
- When considering disposition options for children and adolescents, in addition to assessing the patient, the clinician must conduct an assessment of the parents/ guardians. In some instances, a child may have to be placed in a more restrictive setting than medically indicated if the caregiver cannot or will not supervise the child, will not follow up with recommendations, or is threatening toward the child. The goal is always to place the child in the least restrictive setting that can still maintain his or her safety.
When this article was written, Dr Goldstein was a senior instructor in child and adolescent psychiatry at Case Western Reserve University School of Medicine and a clinical psychologist at University Hospitals of Cleveland. She is currently a postdoctoral fellow at the Johns Hopkins Bloomberg School of Public Health in Baltimore. Dr Findling is professor of psychiatry and pediatrics at Case Western Reserve University School of Medicine and director, division of child and adolescent psychiatry, at University Hospitals of Cleveland. The authors report no conflicts of interest regarding the subject matter of this article. This article first appeared in Psychiatric Issues in Emergency Care Settings (2005;4(1):7-18).
Questions? Comments?
We welcome your questions or comments about any articles or columns in Psychiatric Times. Send to Editor, Psychiatric Times, 330 Boston Post Road, Box 4027, Darien, CT 06820-4027; or by e-mail to PTedit@cmp.com. Letters may be referred to authors and correspondence may be edited and published for the benefit of our readers.
