CCPR: Dr. Gerson, you direct the only emergency room (ER) in the US that isa dedicated child psychiatry ER. What have you learned that can be helpful for office-based psychiatrists who are evaluating a child who may or may not need to be sent to an ER?Dr. Gerson: We have a unique program, and we’re pretty busy—we see about 2,100 kids a year, many referred by schools or providers in the community. Office-based cli- nicians that we talk to have often been frustrated with their prior experiences of send- ing patients to the ER. Often they have sent a patient to the ER expecting inpatient admission, and then felt frustrated when admission didn’t happen.CCPR: What typically goes wrong?Dr. Gerson: The problem often comes down to communication. When community providers send kids to the ER, families often have to wait several hours, usually in an ER that is also treating either adult psychiatric patients (who can be scary to kids and families) or medically ill children. Kids get scared and frustrated and when the ER cli- nician finally gets to talk to them, they are not forthcoming or they minimize the issues that brought them to the ER. And often the parent doesn’t really understand why they are there. When the ER staff tries to reach the referring psychiatrist, it’s late and the
office is closed, so the ER staff never gets to hear the full story. So I suggest that referring clinicians call ahead of time to tell us what the issue is and what your concerns are, or leave us your cell phone number so that we can reach you.CCPR: I’d imagine that you get some inappropriate referrals?Dr. Gerson: Yes, occasionally. Often they come directly from the schools. Unfortunately, many schools have seen budget cuts to their mental health and counseling programs, and so we get a lot of kids sent in for “psychiatric clearance.” For example, a kid has a tantrum and gets violent. Or, in order to get out of taking a test, the child writes, “I want to die” on the test page and then gets referred to the ER.
CCPR: What are some scenarios we see in our offices that we might be able to manage without resorting to sending our patients to the ER?Dr. Gerson: A common issue is when kids report hearing voices. In such cases we always have to consider new onset psychosis, which is indeed an indication for an ER visit. But new onset psychosis, particularly in a young child, is fairly rare, and voices can also be a symptom of anxiety, depression, or autism. The “voice” might actually be an imaginary friend. Depending on the age, kids can be very concrete, such as a young girl we saw recently who said “yes” when asked about hearing voices and then when I asked her more questions she elaborated, “I’m hearing your voice right now.” I’ve also seen kids in the ER who said they were hearing voices in order to escape a punishment, such as a kid who steals something or hits someone and when confronted with punish- ment says, “The voice in my head told me to do it.” So you have to look at the context: Do they only hear the voice when they get into trouble? Is it truly a hallucination or just an uncomfortable thought or their imagination? One kid came in to the ER for “hallu- cinations” of a talking doll with a knife, and his description sounded just like Chucky the doll, from the horror movie. I asked him, “Are you seeing Chucky?” and he said that in fact he and his dad had watched the movie recently, and that, “Every time I close my eyes I see Chucky.”
CCPR: What about cases of kids with established psychiatric disorders who report voices? It may be hard to assess the level of urgency.Dr. Gerson: It can be tricky. I once evaluated a child with OCD (obsessive-compulsive disorder) who was hearing voices saying that he was going to hurt himself or someone else. But when we asked more about the voices they seemed more like intrusive thoughts and worries than hallucinations. They were ego-dystonic (he said, “I don’t want to do it”), always said the same thing (“You’re going to hurt someone”), and only appeared when he was upset and anxious. We concluded that he didn’t need to be hospitalized, but that he needed treatment for his OCD, starting with psycho-education. Just as you would for another kind of obsessional worry in OCD, we taught him that thoughts are just thoughts, that thoughts don’t make things come true, and that he can learn to control his thoughts. For him, as with many kids with OCD, just telling him that “hearing” a voice doesn’t mean he’s going to act on it was therapeutic.CCPR: What about kids who have become aggressive or violent? It will often be hard to determine what caused the violence and whether they need to go to the ER.Dr. Gerson: If a kid is hurting people or can’t be calmed down, go to the ER. But wesee a lot of kids who have outbursts in the psychiatrist’s office and these can often be de-escalated before an ER visit. It’s important to step back and look at the trigger for the outburst. Did the mom set a limit? Did a kid tease him at school? Did a parent tell the psychiatrist something the kid is embarrassed about? Was he recently talking about a trau- matic experience? Or is he getting aggressive because he’s paranoid or hearing voices?CCPR: Can you tell us about the distinctions between types of aggression?
The first piece of a safety plan is, what are the early warning signs of an impending crisis?
Dr. Gerson: I find that the distinction between reactive and instrumental aggression is helpful. “Reactive aggression” is reacting to some provoking trigger, such as someone teasing you or hitting you. Instrumental aggression is, “I want this, so I’ll use aggression to get it,” such as what criminals and sociopaths do. Most kids’ aggression is reactive, and if you help the kid identify the trigger, you can teach him a different reaction. If a kid starts revving up in your office, help him voice what made him angry and empathize with him. For example, “Wow, when your mom said just now that you weren’t working hard on your homework, that made you feel really upset.” You’re not approving of their behavior, just showing that you understand and empathize with their feelings. It’s surprising how often a simple empathic statement can help to de-escalate a child. Kids are so used to adults immediately punishing them when they act up, that if instead, you make an empathic comment, often it really gives them pause and shuts down the tan- trum. Then, you show the kid ways to think about problem solving. For the kid who got mad when talking about homework, you could ask, “I bet you’ve been trying hard on your homework but I wonder is there something that’s been making it tougher to do? Was the assignment too hard or confusing, or was something else on your mind?” Often you can discover the kid is having learning difficulties or that there are distractions or stressors at home. Then you teach them other ways to express themselves and get their needs met—perhaps instead of throwing things and hitting, they can ask their mom for help or ask to take a five-minute break. You can also dig even deeper and see if sleep problems, parents’ divorce, teasing at school, or untreated ADHD or anxiety are making a kid more vulnerable to having an aggressive outburst in response to a trigger. Then you can help the child and family address those things. Overall, you are using the crisis as a learning moment instead of sending them to the ER.
For suicidal children and adoles- cents, once the acute presentation has been managed, avoid medications that could be lethal in overdose (tricyclic antidepressants, benzodiazepines, narcot- ics). If these medications are necessary, provide only a few days’ supply and have a responsible caregiver lock up the sup- ply and directly provide single doses to
the child.The most common side effects of
emergency psychiatric medications are respiratory depression and extrapyra- midal reactions (EPS). With benzodi- azepines in particular, vitals should be monitored, dosing should be limited to recommended ranges, and there should be consideration of other issues that may also affect respiratory or central nervous system (CNS) depression (illicit drugs, alcohol, opiates, apnea). EPS can be managed with Benadryl or Cogentin or by using the antipsychotics less likely to produce EPS.
Avoid meds for agitation if you can --and if you must, try voluntary meds by moth first. Physical restraints are a last resort.
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