Special Risk Management Issues in Child and Adolescent Psychiatry

Numerous studies have documented the increasing prevalence of mental health and substance abuse issues in youths nationwide. As many as 1 in 5 children and adolescents in the United States have a behavioral or emotional disorder. Multiple factors are associated with the high percentage (up to 70%) of youths with mental health problems who do not receive appropriate mental health services,¹ including:

• A national shortage of child psychiatrists and other mental health professionals.
• A shortage of inpatient psychiatric beds.
• Long wait times for outpatient appointments.
• Problems with timely access to individualized and appropriate care.
• Insurance coverage and reimbursement issues.
• Limited access to empirically validated interventions such as specific psychotherapies, alternatives to hospitalization, and out-of-home placement (eg, respite, acute crisis services, day treatment, intensive community-based services, and other diversionary programs).

As a result, many youths are presenting with acute/emergency mental health issues to adult psychiatrists and traditionally "adult" psychiatric treatment settings, such as emergency departments, substance abuse treatment centers, court clinics, and juvenile justice settings.

This article focuses on 4 main issues in child and adolescent psychiatry risk management: confidentiality, suicidality and self-mutilating behaviors in traditional and high-risk populations/settings, homicidality, and prescription of psychotropic medications to juveniles. Additional risk management strategies for psychiatric evaluation/treatment of children and adolescents are summarized in Table 1.

A current debate in child psychiatry concerns the child/adolescent's right to privacy versus the parents' right to know. Teen pregnancy status, substance abuse, and testing and treatment of sexually transmitted diseases are some of the more controversial issues with regard to whether parents should have access to their children's medical information. Generally, the custodial parents have a legal right to the medical records of their children.

This legal right stems from the ethical tenet that barring an emergency situation, custodial consent is necessary for the evaluation and treatment of a child. However, recent literature supports the view of many clinicians, namely, that doctor-patient confidentiality is essential for minors to be forthcoming with information during evaluation and treatment, and the treatment alliance is significantly impaired when confidentiality is not protected. As a result, it is not uncommon for clinicians in outpatient settings to protect the privacy of their pediatric patients except in emergency situations (eg, suicidal or homicidal ideation, imminent risk of harm to self or others) or under mandated child abuse reporting statutes (suspected physical or sexual abuse or neglect).²

It is often useful to establish parameters of what is confidential versus nonconfidential with the parent and the youth—the expectations and boundaries are delineated and documented for the patient and his or her parent—before the start of treatment. Whether the minor's privacy is legally protected varies by jurisdiction. Although the Health Insurance Portability and Accountability Act (HIPAA) of 1996 provides protection of privacy for patients, HIPAA regulations specifically exclude minors from the federal standards. However, some states have granted minors privacy and confidentiality. In these states, HIPAA regulations specify that parental access to their children's medical records should follow the state statutes.³

There are often disagreements regarding access to or admissibility of certain records in legal proceedings (eg, divorce, custody and visitation disputes, and litigation regarding emotional or psychic harm and posttraumatic stress disorder) and the potential harm or risks of divulging this information. The inclusion or exclusion in the legal proceedings of confidential material is typically decided by the presiding judge. When questions arise in clinical settings regarding whether to protect or disclose confidential records or health information, consultation with colleagues, administrators, and risk management personnel is often invaluable and, if indicated, additional legal consultation is recommended.²

In a child custody evaluation, it is usually best to have access to all family members and collateral information and records. Cases should be accepted only if the court has appointed the evaluator, or if both parties agree on the evaluator. The child psychiatrist should conduct the evaluation as a neutral, impartial evaluator. The evaluator may also consult one party to review documents or to critique the evaluation of the opposing party or court's expert. If the evaluator has seen only one parent, opinions should not be given on ultimate custody or on the parent not seen.

An essential component of risk management when working with adolescents in traditional outpatient, inpatient, day treatment programs, or other psychiatric settings is risk of harm to self, which includes suicide attempts and self-mutilating behaviors. Milton and colleagues⁴ found that a risk assessment had been completed only 38% of the time by physicians with patients who later committed suicide. Accordingly, it is not surprising that suicide is the most frequent impetus for lawsuits against mental health professionals.⁵ Given that suicide is the third leading cause of death for persons aged 15 to 24 years,⁶ clinicians who work with adolescents may be particularly vulnerable. An awareness of suicide risk factors allows a practitioner to provide optimal care while mitigating risk.

In assessing suicide risk factors that are specific to juveniles, Juhnke⁷ adapted the SAD PERSONS scale⁸ to a child and adolescent population (Table 2). The acronym remains, but the individual letters have some variations to represent factors that are more applicable to this population. Previous suicide attempt ("P") is the most important risk factor because it may be a significant predictor of future suicide attempts,⁹ especially if the first attempt was within the preceding 3 months.¹⁰

To address the issue of suicidality, psychiatrists may instinctively want to engage in a verbal or written contract with the child or adolescent. However, a contract for safety does not serve as a replacement for a thorough suicide risk assessment,¹¹ because little empirical evidence exists for the usefulness of such contracts.^12,13 Contracts should only be considered for those who are deemed capable of giving informed consent, and even in these circumstances, they should be used with caution.

All necessary safety precautions should be put in place (eg, hospitalization or increased frequency of visits and monitoring, and increased supervision by parents or family). Further empirical research is needed to determine whether contracting for safety merits consideration as a future component of the suicide risk assessment.¹⁴

In addition to suicide, risk of self-harm includes self-mutilation, which has an equal prevalence in males and females.^15,16 Self-mutilation (ie, purposeful nonlethal injuries such as self-biting, skin cutting, and burning) is evident in a significant portion of adolescents who attempt suicide.¹⁷ Intentional acts of self-harm (usually cutting one's skin with a sharp object) are distinct from suicide attempts in that adolescents are not trying to kill themselves at the time of the self-inflicted injury. However, individuals who self-mutilate may be at greater risk for future suicide attempts.¹⁸ Effective self-mutilation prevention techniques for an outpatient population include esteem building, augmenting coping skills, increasing healthy decision making, and fostering positive relationships.¹⁹

Risk management of suicidality and self-mutilating behavior are particularly important in populations such as those with comorbid mental health and substance abuse disorders, those with eating disorders, youths engaging in high-risk behaviors (eg, unprotected sexual intercourse), those with poor impulse control, those with juvenile justice or adult court involvement, and incarcerated youths.

Two essential components of a successful suicide prevention program in high-risk settings (eg, juvenile justice/correctional, residential, and other out-of-home placements) are properly trained staff and ongoing communication between direct-care personnel and clinical staff. Continued observation and ongoing clinical reassessment with the opportunity for referral, when clinically indicated, for emergency mental health evaluation are particularly important in suicide prevention for youths with suicidal ideation and self-mutilating behaviors.

Recently incarcerated adolescents may be at particular risk for suicide because of strong affect, such as anger about loss of freedom, sadness over separation from family, or shame regarding criminal behavior. However, the risk of suicide is not exclusive to adolescents new to a juvenile justice setting; those who have been locked up for awhile may be harboring feelings of hopelessness if they are not going to be released soon. A thorough suicide risk assessment in a juvenile correctional setting should include information on ideation and suicide attempts in the community and during previous incarcerations or hospitalizations, feelings of helplessness or hopelessness, withdrawal symptoms from drugs or alcohol, family history of attempted or completed suicide, and any recent losses or other stressors.²⁰