Psychiatric Emergencies in Children

Pediatric Assessment Principles - Tiny Patient Triage

• Developmental Context: Evaluate symptoms against age-specific norms & milestones.
• Multi-Informant: Crucial input from child, parents/guardians, teachers.
• Communication: Adapt to child’s age; use play, drawings. Observe interactions.
• Safety Priority: Assess risk: self-harm, harm to others, abuse/neglect.
• Medical Rule-Out: Exclude organic causes (delirium, infections, metabolic issues).
• 📌 Mnemonic: HEADS-ED for adolescent psychosocial interview.

⭐ In pediatric psychiatric emergencies, a thorough developmental history is as critical as the presenting complaint.

Suicidal Ideation & Self‑Harm - Youth Safety Net

• Risk Factors: Prior attempt, depression, substance use, family hx (suicide, mental illness), bullying, impulsivity, access to means, LGBTQ+ youth.
• Assessment:
  • Direct questioning: Ideation, Plan, Intent (IPI).
  • Differentiate Non-Suicidal Self-Injury (NSSI) from suicidal attempt (key: intent to die).
  • 📌 Mnemonic: IS PATH WARM (Ideation, Substance abuse, Purposelessness, Anxiety, Trapped, Hopelessness, Withdrawal, Anger, Recklessness, Mood changes).
• Management & Safety Net:
  • Immediate Safety First! Hospitalize if high risk (active SI with plan/intent).
  • Safety Plan: Coping strategies, support contacts (family, friends, crisis lines), restrict lethal means.
  • Involve family: Essential for monitoring, support, and adherence.
  • Therapy: Cognitive Behavioral Therapy (CBT), Dialectical Behavior Therapy (DBT).
  • Youth Safety Net: School counselors, helplines, community mental health services.

⭐ NSSI's primary function is often affect regulation rather than a desire to die, but it significantly increases the risk for future suicide attempts.

Aggression & Acute Psychosis - Calming Little Tempests

• Immediate Steps:
  • Ensure safety (child, staff).
  • Rule out organic causes (delirium, hypoglycemia, substance, CNS infection).
• Management:
  • 1st Line: Verbal de-escalation (calm tone, active listening), environmental modification (reduce stimuli, ensure safety), involve parents/caregivers.
  • Pharmacotherapy (if de-escalation fails/severe):
    • Agitation: Oral atypical antipsychotics preferred: Risperidone (0.25-0.5 mg PO), Olanzapine (2.5-5 mg PO). IM if uncooperative. Lorazepam (0.05 mg/kg PO/IM) for rapid tranquilization (short-term; ⚠️ paradoxical disinhibition).
    • Psychosis: Second-generation antipsychotics (SGAs) like Risperidone, Olanzapine. Start low, titrate slow. Monitor for EPS & metabolic side effects.
• Long-term: Address underlying disorders (ASD, ADHD, trauma), multidisciplinary psychosocial interventions.

⭐ Atypical antipsychotics (e.g., Risperidone) are preferred over Haloperidol for acute agitation in children due to lower Extrapyramidal Symptoms (EPS) risk.

Other Key Emergencies & Management - Child Psych First Aid

• Panic Attacks: Sudden intense fear, palpitations, dyspnea. Mgmt: Reassurance, calm environment, breathing exercises. Consider short-acting benzodiazepine (e.g., lorazepam 0.05 mg/kg) cautiously if severe.
• Conversion Disorder (Functional Neurological Symptom Disorder): Neurological symptoms (e.g., paralysis, blindness) without organic basis, often post-stressor. Mgmt: Reassurance, address underlying stress, avoid excessive investigations. Physiotherapy/psychotherapy helpful.
• Psychological First Aid (PFA) for Trauma/Acute Stress (e.g., disaster, abuse):
  • Core principles 📌 LLL:
    • Look: Check for safety, obvious urgent needs, signs of distress.
    • Listen: Approach respectfully, ask about needs/concerns, listen actively, non-judgmentally.
    • Link: Connect with information, practical support, loved ones, and professional services.
  • Aims: Provide safety, comfort, emotional support, practical help. Reduce distress & foster coping.
  • Do NOT force talking or psychological debriefing immediately post-trauma.

⭐ Psychological First Aid (PFA) is an evidence-informed modular approach to assist children, adolescents, adults, and families in the immediate aftermath of disaster and terrorism. It is NOT professional therapy or diagnosis but a humane, supportive response.

High‑Yield Points - ⚡ Biggest Takeaways

• Suicide risk assessment is crucial in children and adolescents presenting with distress.
• Always rule out organic causes (medical, substance-induced) in acute psychosis or delirium.
• Delirium in children manifests with fluctuating sensorium, agitation, and perceptual changes.
• Manage severe aggression with de-escalation first; consider atypical antipsychotics if needed.
• Child abuse and neglect are common precipitants; mandatory reporting is essential.
• DMDD features chronic irritability and temper outbursts, distinct from bipolar disorder.