Skip to main content

Advertising Disclaimer »

Main menu

  • Journals
    • Pediatrics
    • Hospital Pediatrics
    • Pediatrics in Review
    • NeoReviews
    • AAP Grand Rounds
    • AAP News
  • Authors/Reviewers
    • Submit Manuscript
    • Author Guidelines
    • Reviewer Guidelines
    • Open Access
    • Editorial Policies
  • Content
    • Current Issue
    • Online First
    • Archive
    • Blogs
    • Topic/Program Collections
    • AAP Meeting Abstracts
  • Pediatric Collections
    • COVID-19
    • Racism and Its Effects on Pediatric Health
    • More Collections...
  • AAP Policy
  • Supplements
  • Multimedia
    • Video Abstracts
    • Pediatrics On Call Podcast
  • Subscribe
  • Alerts
  • Careers
  • Other Publications
    • American Academy of Pediatrics

User menu

  • Log in
  • Log out
  • My Cart

Search

  • Advanced search
American Academy of Pediatrics

AAP Gateway

Advanced Search

AAP Logo

  • Log in
  • Log out
  • My Cart
  • Journals
    • Pediatrics
    • Hospital Pediatrics
    • Pediatrics in Review
    • NeoReviews
    • AAP Grand Rounds
    • AAP News
  • Authors/Reviewers
    • Submit Manuscript
    • Author Guidelines
    • Reviewer Guidelines
    • Open Access
    • Editorial Policies
  • Content
    • Current Issue
    • Online First
    • Archive
    • Blogs
    • Topic/Program Collections
    • AAP Meeting Abstracts
  • Pediatric Collections
    • COVID-19
    • Racism and Its Effects on Pediatric Health
    • More Collections...
  • AAP Policy
  • Supplements
  • Multimedia
    • Video Abstracts
    • Pediatrics On Call Podcast
  • Subscribe
  • Alerts
  • Careers

Discover Pediatric Collections on COVID-19 and Racism and Its Effects on Pediatric Health

American Academy of Pediatrics
From the American Academy of PediatricsClinical Report

Executive Summary: Evaluation and Management of Children and Adolescents With Acute Mental Health or Behavioral Problems. Part I: Common Clinical Challenges of Patients With Mental Health and/or Behavioral Emergencies

Thomas H. Chun, Sharon E. Mace, Emily R. Katz, AMERICAN ACADEMY OF PEDIATRICS, COMMITTEE ON PEDIATRIC EMERGENCY MEDICINE, AMERICAN COLLEGE OF EMERGENCY PHYSICIANS and PEDIATRIC EMERGENCY MEDICINE COMMITTEE
Pediatrics September 2016, 138 (3) e20161571; DOI: https://doi.org/10.1542/peds.2016-1571
Thomas H. Chun
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Sharon E. Mace
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
Emily R. Katz
  • Find this author on Google Scholar
  • Find this author on PubMed
  • Search for this author on this site
  • Article
  • Info & Metrics
  • Comments
Loading
Download PDF
  • Abbreviation:
    ED —
    emergency department
  • Executive Summary

    The number of children and adolescents seen in emergency departments (EDs) and primary care settings for mental health problems has skyrocketed in recent years, with up to 23% of patients in both settings having diagnosable mental health conditions.1–4 Even when a mental health problem is not the focus of an ED or primary care visit, mental health conditions, both known and occult, may challenge the treating clinician and complicate the patient’s care.4

    Although the American Academy of Pediatrics has published a policy statement on mental health competencies and a Mental Health Toolkit for pediatric primary care providers, no such guidelines or resources exist for clinicians who care for pediatric mental health emergencies.5,6 Many ED and primary care physicians report a paucity of training and lack of confidence in caring for pediatric psychiatry patients. The 2 clinical reports (www.pediatrics.org/cgi/doi/10.1542/peds.2016-1570 and www.pediatrics.org/cgi/doi/10.1542/peds.2016-1573) support the 2006 joint policy statement of the American Academy of Pediatrics and the American College of Emergency Physicians on pediatric mental health emergencies,7 with the goal of addressing the knowledge gaps in this area. Although written primarily from the perspective of ED clinicians, they are intended for all clinicians who care for children and adolescents with acute mental health and behavioral problems.

    The clinical reports are organized around the common clinical challenges pediatric caregivers face, both when a child or adolescent presents with a psychiatric chief complaint or emergency (part I) and also when a mental health condition may be an unclear or complicating factor in a non–mental health clinical presentation (part II). Part II of the clinical reports (www.pediatrics.org/cgi/doi/10.1542/peds.2016-1573) includes discussions of somatic symptom and related disorders, adverse effects of psychiatric medications including neuroleptic malignant syndrome and serotonin syndrome, caring for children with special needs such as autism and developmental disorders, and mental health screening. This executive summary is an overview of part I of the clinical reports. The full text of the below topics can be accessed online at (www.pediatrics.org/cgi/doi/10.1542/peds.2016-1570). Key considerations are shown in the following sections.

    1. ED Medical Clearance of Pediatric Psychiatric Patients

    • Definition

      1. Medical clearance is the process of excluding potential medical conditions causing or exacerbating the patient’s psychiatric symptoms as well as evaluating the patient for medical diseases or injuries for which acute diagnostic or therapeutic interventions in the ED may be indicated.8,9

      2. Some favor the term “medically stable,” because the goal of the ED visit is not to exclude all possible medical etiologies but rather to rule out acute medical conditions.10

      3. For patients with unexplained vital sign abnormalities, a concerning history, or physical examination findings or with new onset or acute changes in their neurologic or psychiatric symptoms, a careful evaluation for potential underlying medical conditions may be important.11

    • Laboratory Testing

      1. Despite the large number of medical conditions (see Table 1 at [www.pediatrics.org/cgi/doi/10.1542/peds.2016-1570]) that can present with mental health symptoms, there is a growing body of both pediatric and adult literature that casts doubt on the utility of routinely obtaining laboratory or radiologic testing for these patients.12–19 This literature supports the position of the American College of Emergency Physicians for focused medical assessments and judicious testing of these ED patients.11

      2. Mental health consultants often request pregnancy (females), toxicology, and sexually transmitted infection testing for adolescent patients. Whether to obtain these or other medical tests or evaluations can usually be decided with a direct conversation between the ED and mental health clinicians.

    2. Suicidal Ideation and Suicide Attempts

    • Epidemiology

      1. Suicide is one of the leading causes of death in adolescents,20 and suicide attempts are one of the most common ED mental health presentations.21,22 Epidemiologic studies in teenagers have found that 16% reported seriously considering suicide and 7.8% have attempted suicide in the past year.23

      2. More females consider and attempt suicide, although males are far more likely to die of suicide because of their frequent use of more lethal means (eg, firearms, hanging).23 Native Americans have the highest suicide rates among ethnic groups.21

    • Risk factors: previous suicide attempt(s); mood (eg, depression, bipolar disorder, mood swings, irritable mood, etc), impulsivity, or disruptive behavior disorders; substance abuse; recent psychiatric hospitalization; family history of suicide; interpersonal violence (eg, physical or sexual abuse, bullying, antisocial behavior); homelessness or runaway behavior; self-identification as lesbian, gay, bisexual, or transgender; hopelessness; history of aggressive or impulsive behavior; cultural/religious beliefs; recent loss or stress (eg, relational, social, work, financial, etc) of the patient or family; physical illness; recent high-profile suicides; access to lethal methods; social isolation; and barriers or unwillingness to seek mental health care.24–29

    • Assessment

      1. Suicidal ideation and attempts are often precipitated by psychosocial stressors.29 As such, evaluating the pediatric patient for suicide risk includes inquiring about his or her current psychosocial situation, interviewing both the patient and his or her caregivers (eg, family members, school or mental health personnel), and assessing for the aforementioned suicide risk factors.

      2. The ED management of patients with suicidal ideation and attempts includes an evaluation of their current mental health state. Children and adolescents frequently misjudge the lethality of their actions. A potential pitfall is to equate the lethality of a suicide attempt with the patient’s suicide intent. A patient whose suicide attempt had low medical lethality may, in fact, have a significant wish to harm himself or herself or to die.30–32

      3. The ED workup of patients presenting for suicidal ideation or attempt includes evaluation for signs of self-injury (which can be concealed under clothing) or occult toxidromes as well as questions about suicidal intent, suicide plans, and other self-injurious behaviors.

    • Disposition: The decision for inpatient versus outpatient management depends on many factors, including a careful assessment of suicide risk, and may include consultation with a mental health clinician. Outpatient management may be considered for low-risk patients (those with a low risk of future self-harm, adequate supervision, mental health follow-up, and safety planning; eg, the patient can identify his or her warning signs or triggers for recurrent suicidal ideation and have appropriate coping strategies if he or she becomes suicidal again, such as healthy activities and social support, and means restrictions, that is, limiting access to mechanisms for self-harm, such as firearms, other weapons, medications, etc).33 “Contracting for safety”/suicide prevention agreements are controversial and remain unproven.34

    • Involuntary hospitalization: Under certain circumstances, physicians may insist on admission to a psychiatric unit over the objections of patients and/or their parents/guardians, when clinically indicated. Every state has laws governing involuntary admission for inpatient psychiatric hospitalization. These laws vary from state to state, as do laws regarding confidentiality and an adolescent’s right to seek mental health or substance abuse treatment without parental consent. As such, it may be beneficial for ED clinicians to familiarize themselves with their state’s relevant laws, statutes, and involuntary commitment procedures. For more information on related state laws, contact the American Academy of Pediatrics’ Division of State Government Affairs at stgov@aap.org.

    3. Restraint of the Agitated Patient

    • Agitated behavior is the final common pathway for a wide number of medical and psychiatric conditions and, in some cases, a combination of the two. Determining the underlying cause of the agitation often guides treatment choices.

    • The 4 guiding principles of working with agitated patients are as follows35:

      1. prioritizing the safety of the patient and the treating staff;

      2. assisting the patient in managing his or her emotions and regaining control of his or her behavior;

      3. utilizing age-appropriate and the least-restrictive methods possible; and

      4. recognizing that coercive interventions may exacerbate the agitation.

    • Monitoring and evaluation of restrained patients (see Table 6 at [www.pediatrics.org/cgi/doi/10.1542/peds.2016-1570]) may include the following36–38:

      1. in-person evaluation by a licensed independent practitioner within 1 hour of placement of restraints;

      2. review and renewal of restraint orders on a frequent basis (1–8 hours, depending the patient’s age); and

      3. frequent assessment of vital signs, injury attributable to restraint, nutrition and hydration status, peripheral circulation, hygiene and elimination status, physical and psychological status, and readiness to discontinue restraint.

    • Verbal restraint/de-escalation

      1. A calming (eg, quiet room, soft/decreased lighting, elimination of triggers of agitation) and safe (eg, removal or securing of objects that can be used as weapons, padded walls) physical environment may help de-escalate a patient.35,39,40

      2. Common verbal restraint (see Table 2 at [www.pediatrics.org/cgi/doi/10.1542/peds.2016-1570]) strategies include the following41:

        • a. respecting personal space;

        • b. minimizing behavior and/or interventions the patient may find provocative;

        • c. using clear, concise language and expectations;

        • d. active listening, especially regarding the patient’s goals; and

        • e. offering clear, realistic choices without “bargaining.”

    • Chemical restraint

      1. The most commonly used medications for agitation are antihistamines, benzodiazepines, and antipsychotics.42,43

      2. Choice of medication(s) usually depends on many factors, including the severity and underlying cause of the agitated behavior; collaboration between ED, psychiatric, and pharmacy colleagues; and which medication(s), if any, the patient is currently taking (see Tables 3 and 4 at [www.pediatrics.org/cgi/doi/10.1542/peds.2016-1570]).42,43

        • a. Diphenhydramine may be used for mild agitation.

        • b. Benzodiazepines are common first-line drugs for medical causes of agitation.

        • c. Either benzodiazepines or antipsychotics may be used for psychiatric causes of agitation.

        • d. Some experts favor a combination of an antipsychotic with either a benzodiazepine or an antihistamine for severe agitation.43,44

      3. Monitoring and precautions

        • a. For patients receiving chemical restraint, consider the same monitoring and reassessment precautions as for physical restraint.37,38

        • b. Antipsychotics may cause QTc prolongation and dysrhythmias, especially in patients with underlying cardiac conditions and/or who are taking other QTc-prolonging medication.45–47 Many medications commonly used in pediatrics (see Table 5 at [www.pediatrics.org/cgi/doi/10.1542/peds.2016-1570]) can affect QTc duration. If there are significant concerns for dysrhythmia, cardiac monitoring may be considered for patients receiving antipsychotics.

        • c. Antipsychotics can exacerbate symptoms in patients with anticholinergic or sympathomimetic toxidromes or delirium.

    • Physical restraint

      1. Physical restraints have resulted in the death of psychiatric patients and have disproportionately affected children.48,49

      2. Federal, regulatory, and accreditation agencies all have guidelines and regulations regarding physical restraint.37,38

      3. Guidelines for when physical restraint may be indicated include the following11,50–54:

        • a. an imminent risk of harm to self or others;

        • b. significant risk of disrupting treatment; and

        • c. less restrictive means have failed.

      4. For the application of restraints, when possible:

        • a. apply restraints with ≥5 providers, one for each extremity and one for the patient’s head;

        • b. use leather or other age-appropriate restraints; and

        • c. secure restraints to the bed frame.

      5. To maximize safety during physical restraint, experts suggest, when possible38:

        • a. staff training of alternatives to and proper application of restraints;

        • b. continuous patient monitoring;

        • c. utilize the supine position, with free cervical range of motion and elevation of the head of the bed, to reduce aspiration risk;

        • d. utilize the prone position only if other measures have failed or are not possible; if the prone position is used, monitoring for airway obstruction and excessive pressure on the back and neck of the patient may be helpful, because death has been associated with these factors and prone restraint; experts suggest discontinuing prone positioning as soon as possible38;

        • e. minimize covering of the patient’s face or head, to reduce aspiration risk;

        • f. minimize use of high vests, waist restraints, or beds with unprotected side rails to reduce the risk of respiratory compromise and falls;

        • g. minimize restraint of medically compromised or unstable patients; and

        • h. in cases of agitation attributable to suspected illicit stimulant use, chemical restraint may be preferable, because a rapid increase in serum potassium secondary to rhabdomyolysis may result in cardiac arrest.

    4. Coordination With the Medical Home

    • Coordinating mental health care with the medical home (ie, patient-centered care, coordinated and integrated by the patient’s personal physician) offers several benefits.55,56

      1. Coordinating with the medical home decreases redundant care for high-risk or high-utilization patients.

      2. The medical home may be a unique opportunity to address mental health care without stigma.55

      3. For patients without a medical home, identifying and promptly referring them to a personal physician may be beneficial.

      4. Children and adolescents with mental health problems and those taking psychiatric medications are at increased risk of medical problems, including asthma, ear infections, headaches or migraines, seizures, and obesity/metabolic syndrome.

    Lead Authors

    Thomas H. Chun, MD, MPH, FAAP

    Sharon E. Mace, MD, FAAP, FACEP

    Emily R. Katz, MD, FAAP

    American Academy of Pediatrics, Committee on Pediatric Emergency Medicine, 2015-2016

    Joan E. Shook, MD, MBA, FAAP, Chairperson

    James M. Callahan, MD, FAAP

    Thomas H. Chun, MD, MPH, FAAP

    Gregory P. Conners, MD, MPH, MBA, FAAP

    Edward E. Conway Jr, MD, MS, FAAP

    Nanette C. Dudley, MD, FAAP

    Toni K. Gross, MD, MPH, FAAP

    Natalie E. Lane, MD, FAAP

    Charles G. Macias, MD, MPH, FAAP

    Nathan L. Timm, MD, FAAP

    Liaisons

    Kim Bullock, MD – American Academy of Family Physicians

    Elizabeth Edgerton, MD, MPH, FAAP – Maternal and Child Health Bureau

    Tamar Magarik Haro – AAP Department of Federal Affairs

    Madeline Joseph, MD, FACEP, FAAP – American College of Emergency Physicians

    Angela Mickalide, PhD, MCHES – EMSC National Resource Center

    Brian R. Moore, MD, FAAP – National Association of EMS Physicians

    Katherine E. Remick, MD, FAAP – National Association of Emergency Medical Technicians

    Sally K. Snow, RN, BSN, CPEN, FAEN – Emergency Nurses Association

    David W. Tuggle, MD, FAAP – American College of Surgeons

    Cynthia Wright-Johnson, MSN, RNC – National Association of State EMS Officials

    FORMER MEMBERS AND LIAISONS, 2013-2015

    Alice D. Ackerman, MD, MBA, FAAP

    Lee Benjamin, MD, FACEP, FAAP - American College of Physicians

    Susan M. Fuchs, MD, FAAP

    Marc H. Gorelick, MD, MSCE, FAAP

    Paul Sirbaugh, DO, MBA, FAAP - National Association of Emergency Medical Technicians

    Joseph L. Wright, MD, MPH, FAAP

    Staff

    Sue Tellez

    American College of Emergency Physicians, Pediatric Emergency Medicine Committee, 2013–2014

    Lee S. Benjamin, MD, FACEP, Chairperson

    Isabel A. Barata, MD, FACEP, FAAP

    Kiyetta Alade, MD

    Joseph Arms, MD

    Jahn T. Avarello, MD, FACEP

    Steven Baldwin, MD

    Kathleen Brown, MD, FACEP

    Richard M. Cantor, MD, FACEP

    Ariel Cohen, MD

    Ann Marie Dietrich, MD, FACEP

    Paul J. Eakin, MD

    Marianne Gausche-Hill, MD, FACEP, FAAP

    Michael Gerardi, MD, FACEP, FAAP

    Charles J. Graham, MD, FACEP

    Doug K. Holtzman, MD, FACEP

    Jeffrey Hom, MD, FACEP

    Paul Ishimine, MD, FACEP

    Hasmig Jinivizian, MD

    Madeline Joseph, MD, FACEP

    Sanjay Mehta, MD, Med, FACEP

    Aderonke Ojo, MD, MBBS

    Audrey Z. Paul, MD, PhD

    Denis R. Pauze, MD, FACEP

    Nadia M. Pearson, DO

    Brett Rosen, MD

    W. Scott Russell, MD, FACEP

    Mohsen Saidinejad, MD

    Harold A. Sloas, DO

    Gerald R. Schwartz, MD, FACEP

    Orel Swenson, MD

    Jonathan H. Valente, MD, FACEP

    Muhammad Waseem, MD, MS

    Paula J. Whiteman, MD, FACEP

    Dale Woolridge, MD, PhD, FACEP

    Former Committee Members

    Carrie DeMoor, MD

    James M. Dy, MD

    Sean Fox, MD

    Robert J. Hoffman, MD, FACEP

    Mark Hostetler, MD, FACEP

    David Markenson, MD, MBA, FACEP

    Annalise Sorrentino, MD, FACEP

    Michael Witt, MD, MPH, FACEP

    Staff

    Dan Sullivan

    Stephanie Wauson

    Footnotes

    • This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

    • Clinical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, clinical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

    • The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

    • All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

    • FINANCIAL DISCLOSURE: The authors have indicated they do not have a financial relationship relevant to this article to disclose.

    • FUNDING: No external funding.

    • POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

    References

    1. ↵
      1. Mahajan P,
      2. Alpern ER,
      3. Grupp-Phelan J, et al; Pediatric Emergency Care Applied Research Network (PECARN)
      . Epidemiology of psychiatric-related visits to emergency departments in a multicenter collaborative research pediatric network. Pediatr Emerg Care. 2009;25(11):715–720pmid:19864967
      OpenUrlCrossRefPubMed
      1. Pittsenbarger ZE,
      2. Mannix R
      . Trends in pediatric visits to the emergency department for psychiatric illnesses. Acad Emerg Med. 2014;21(1):25–30pmid:24552521
      OpenUrlCrossRefPubMed
      1. Sheldrick RC,
      2. Merchant S,
      3. Perrin EC
      . Identification of developmental-behavioral problems in primary care: a systematic review. Pediatrics. 2011;128(2):356–363pmid:21727101
      OpenUrlAbstract/FREE Full Text
    2. ↵
      1. Grupp-Phelan J,
      2. Wade TJ,
      3. Pickup T, et al
      . Mental health problems in children and caregivers in the emergency department setting. J Dev Behav Pediatr. 2007;28(1):16–21pmid:17353727
      OpenUrlCrossRefPubMed
    3. ↵
      1. Committee on Psychosocial Aspects of Child and Family Health; Task Force on Mental Health
      . The future of pediatrics: mental health competencies for pediatric primary care [policy statement]. Pediatrics. 2009;124(1):410–421pmid:19564328
      OpenUrlAbstract/FREE Full Text
    4. ↵
      1. Foy JM,
      2. Kelleher KJ,
      3. Laraque D; American Academy of Pediatrics Task Force on Mental Health
      . Enhancing pediatric mental health care: strategies for preparing a primary care practice. Pediatrics. 2010;125(suppl 3):S87–S108pmid:20519566
      OpenUrlFREE Full Text
    5. ↵
      1. Dolan MA,
      2. Mace SE; American Academy of Pediatrics, Committee on Pediatric Emergency Medicine; American College of Emergency Physicians and Pediatric Emergency Medicine Committee
      . Pediatric mental health emergencies in the emergency medical services system. Pediatrics. 2006;118(4):1764–1767pmid:17015573
      OpenUrlAbstract/FREE Full Text
    6. ↵
      1. Glauser J,
      2. Marshall M
      . Medical clearance of psychiatric patients. Emerg Med Rep. 2011;32(23):273–286
      OpenUrl
    7. ↵
      1. Riba M,
      2. Hale M
      . Medical clearance: fact or fiction in the hospital emergency room. Psychosomatics. 1990;31(4):400–404pmid:2247567
      OpenUrlCrossRefPubMed
    8. ↵
      1. Zun LS
      . Evidence-based evaluation of psychiatric patients. J Emerg Med. 2005;28(1):35–39pmid:15657002
      OpenUrlCrossRefPubMed
    9. ↵
      1. Lukens TW,
      2. Wolf SJ,
      3. Edlow JA, et al; American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department
      . Clinical policy: critical issues in the diagnosis and management of the adult psychiatric patient in the emergency department. Ann Emerg Med. 2006;47(1):79–99pmid:16387222
      OpenUrlCrossRefPubMed
    10. ↵
      1. Agzarian MJ,
      2. Chryssidis S,
      3. Davies RP,
      4. Pozza CH
      . Use of routine computed tomography brain scanning of psychiatry patients. Australas Radiol. 2006;50(1):27–28pmid:16499723
      OpenUrlCrossRefPubMed
      1. Donofrio JJ,
      2. Santillanes G,
      3. McCammack BD, et al
      . Clinical utility of screening laboratory tests in pediatric psychiatric patients presenting to the emergency department for medical clearance. Ann Emerg Med. 2014;63(6):666–75.e3pmid:24219903
      OpenUrlCrossRefPubMed
      1. Fortu JM,
      2. Kim IK,
      3. Cooper A,
      4. Condra C,
      5. Lorenz DJ,
      6. Pierce MC
      . Psychiatric patients in the pediatric emergency department undergoing routine urine toxicology screens for medical clearance: results and use. Pediatr Emerg Care. 2009;25(6):387–392pmid:19458561
      OpenUrlCrossRefPubMed
      1. Janiak BD,
      2. Atteberry S
      . Medical clearance of the psychiatric patient in the emergency department. J Emerg Med. 2012;43(5):866–870pmid:20117904
      OpenUrlCrossRefPubMed
      1. Santiago LI,
      2. Tunik MG,
      3. Foltin GL,
      4. Mojica MA
      . Children requiring psychiatric consultation in the pediatric emergency department: epidemiology, resource utilization, and complications. Pediatr Emerg Care. 2006;22(2):85–89pmid:16481922
      OpenUrlCrossRefPubMed
      1. Santillanes G,
      2. Donofrio JJ,
      3. Lam CN,
      4. Claudius I
      . Is medical clearance necessary for pediatric psychiatric patients? J Emerg Med. 2014;46(6):800–807pmid:24642041
      OpenUrlCrossRefPubMed
      1. Shihabuddin BS,
      2. Hack CM,
      3. Sivitz AB
      . Role of urine drug screening in the medical clearance of pediatric psychiatric patients: is there one? Pediatr Emerg Care. 2013;29(8):903–906pmid:23903675
      OpenUrlCrossRefPubMed
    11. ↵
      1. Tenenbein M
      . Do you really need that emergency drug screen? Clin Toxicol (Phila). 2009;47(4):286–291pmid:19514875
      OpenUrlCrossRefPubMed
    12. ↵
      1. Shain BN; American Academy of Pediatrics, Committee on Adolescence
      . Suicide and suicide attempts in adolescents. Pediatrics. 2016;138(1):e20161420
      OpenUrlAbstract/FREE Full Text
    13. ↵
      1. Centers for Disease Control and Prevention, National Center for Injury Prevention and Control
      . Web-based Injury Statistics Query and Reporting System (WISQARS) [database]. Available at: www.cdc.gov/injury/wisqars/. Accessed July 7, 2015
    14. ↵
      1. Ting SA,
      2. Sullivan AF,
      3. Boudreaux ED,
      4. Miller I,
      5. Camargo CA Jr
      . Trends in US emergency department visits for attempted suicide and self-inflicted injury, 1993-2008. Gen Hosp Psychiatry. 2012;34(5):557–565pmid:22554432
      OpenUrlCrossRefPubMed
    15. ↵
      1. Eaton DK,
      2. Kann L,
      3. Kinchen S, et al; Centers for Disease Control and Prevention
      . Youth risk behavior surveillance—United States, 2011. MMWR Surveill Summ. 2012;61(4 SS-4):1–162pmid:22673000
      OpenUrlPubMed
    16. ↵
      1. Brown J,
      2. Cohen P,
      3. Johnson JG,
      4. Smailes EM
      . Childhood abuse and neglect: specificity of effects on adolescent and young adult depression and suicidality. J Am Acad Child Adolesc Psychiatry. 1999;38(12):1490–1496pmid:10596248
      OpenUrlCrossRefPubMed
      1. Esposito-Smythers C,
      2. Spirito A
      . Adolescent substance use and suicidal behavior: a review with implications for treatment research. Alcohol Clin Exp Res. 2004;28(5 suppl):77S–88Spmid:15166639
      OpenUrlCrossRefPubMed
      1. Foley DL,
      2. Goldston DB,
      3. Costello EJ,
      4. Angold A
      . Proximal psychiatric risk factors for suicidality in youth: the Great Smoky Mountains Study. Arch Gen Psychiatry. 2006;63(9):1017–1024pmid:16953004
      OpenUrlCrossRefPubMed
      1. McDaniel JS,
      2. Purcell D,
      3. D’Augelli AR
      . The relationship between sexual orientation and risk for suicide: research findings and future directions for research and prevention. Suicide Life Threat Behav. 2001;31(suppl):84–105pmid:11326762
      OpenUrlCrossRefPubMed
      1. McKeown RE,
      2. Garrison CZ,
      3. Cuffe SP,
      4. Waller JL,
      5. Jackson KL,
      6. Addy CL
      . Incidence and predictors of suicidal behaviors in a longitudinal sample of young adolescents. J Am Acad Child Adolesc Psychiatry. 1998;37(6):612–619pmid:9628081
      OpenUrlCrossRefPubMed
    17. ↵
      1. Overholser J
      . Predisposing factors in suicide attempts: life stressors. In: Spirito A, Overholser JC, Overholser J, eds. Evaluating and Treating Adolescent Suicide Attempters: From Research to Practice. New York, NY: Academic Press; 2002:42–54
    18. ↵
      1. Brown GK,
      2. Henriques GR,
      3. Sosdjan D,
      4. Beck AT
      . Suicide intent and accurate expectations of lethality: predictors of medical lethality of suicide attempts. J Consult Clin Psychol. 2004;72(6):1170–1174pmid:15612863
      OpenUrlCrossRefPubMed
      1. Plutchik R,
      2. van Praag HM,
      3. Picard S,
      4. Conte HR,
      5. Korn M
      . Is there a relation between the seriousness of suicidal intent and the lethality of the suicide attempt? Psychiatry Res. 1989;27(1):71–79pmid:2922447
      OpenUrlCrossRefPubMed
    19. ↵
      1. Swahn MH,
      2. Potter LB
      . Factors associated with the medical severity of suicide attempts in youths and young adults. Suicide Life Threat Behav. 2001;32(1 suppl):21–29pmid:11924691
      OpenUrlCrossRefPubMed
    20. ↵
      1. Sher L,
      2. LaBode V
      . Teaching health care professionals about suicide safety planning. Psychiatr Danub. 2011;23(4):396–397pmid:22075742
      OpenUrlPubMed
    21. ↵
      1. American Academy of Child and Adolescent Psychiatry
      . Practice parameter for the assessment and treatment of children and adolescents with suicidal behavior. J Am Acad Child Adolesc Psychiatry. 2001;40(7 suppl):24S–51Spmid:11434483
      OpenUrlCrossRefPubMed
    22. ↵
      1. Richmond JS,
      2. Berlin JS,
      3. Fishkind AB, et al
      . Verbal de-escalation of the agitated patient: consensus statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012;13(1):17–25pmid:22461917
      OpenUrlCrossRefPubMed
    23. ↵
      Health and Human Services Division, US General Accounting Office, ed. Report to Congressional Requestors: Mental Health: Improper Restraint or Seclusion Places People at Risk. Washington, DC: US General Accounting Office; 1999
    24. ↵
      1. Centers for Medicare and Medicaid Services; Department of Health and Human Services
      . Medicare and Medicaid programs; hospital conditions of participation: patients’ rights. Final rule. Fed Regist. 2006;71(236):71377–71428pmid:17171854
      OpenUrlPubMed
    25. ↵
      1. The Joint Commission
      . Standards on Restraint and Seclusion. Oakbrook Terrace, IL: The Joint Commission; 2009
    26. ↵
      1. Cowin L,
      2. Davies R,
      3. Estall G,
      4. Berlin T,
      5. Fitzgerald M,
      6. Hoot S
      . De-escalating aggression and violence in the mental health setting. Int J Ment Health Nurs. 2003;12(1):64–73pmid:14685961
      OpenUrlCrossRefPubMed
    27. ↵
      1. American Psychiatric Association, Task Force on the Psychiatric Use of Seclusion and Restraint
      . Seclusion and Restraint: The Psychiatric Uses. Washington, DC: American Psychiatric Association; 1985. Task Force Report 22.
    28. ↵
      1. Fishkind A
      . Calming agitation with words, not drugs: 10 commandments for safety. Curr Psychiatr. 2002;1(4):32–39
      OpenUrl
    29. ↵
      1. Adimando AJ,
      2. Poncin YB,
      3. Baum CR
      . Pharmacological management of the agitated pediatric patient. Pediatr Emerg Care. 2010;26(11):856–860; quiz: 861–863pmid:21057285
      OpenUrlCrossRefPubMed
    30. ↵
      1. Sonnier L,
      2. Barzman D
      . Pharmacologic management of acutely agitated pediatric patients. Paediatr Drugs. 2011;13(1):1–10pmid:21162596
      OpenUrlCrossRefPubMed
    31. ↵
      1. Marder SR
      . A review of agitation in mental illness: treatment guidelines and current therapies. J Clin Psychiatry. 2006;67(suppl 10):13–21pmid:16965191
      OpenUrlCrossRefPubMed
    32. ↵
      1. Labellarte MJ,
      2. Crosson JE,
      3. Riddle MA
      . The relevance of prolonged QTc measurement to pediatric psychopharmacology. J Am Acad Child Adolesc Psychiatry. 2003;42(6):642–650pmid:12921471
      OpenUrlCrossRefPubMed
      1. Olsen KM
      . Pharmacologic agents associated with QT interval prolongation. J Fam Pract. 2005;(suppl):S8–S14pmid:15938993
      OpenUrlPubMed
    33. ↵
      1. Yap YG,
      2. Camm AJ
      . Drug induced QT prolongation and torsades de pointes. Heart. 2003;89(11):1363–1372pmid:14594906
      OpenUrlFREE Full Text
    34. ↵
      1. Nunno MA,
      2. Holden MJ,
      3. Tollar A
      . Learning from tragedy: a survey of child and adolescent restraint fatalities. Child Abuse Negl. 2006;30(12):1333–1342pmid:17109958
      OpenUrlCrossRefPubMed
    35. ↵
      1. Weiss EM,
      2. Altamira D,
      3. Blinded DF, et al
      . Deadly restraint: a Hartford Courant investigative report. Hartford Courant. October 11–15, 1998:A10
    36. ↵
      1. American Academy of Pediatrics Committee on Pediatric Emergency Medicine
      . The use of physical restraint interventions for children and adolescents in the acute care setting. Pediatrics. 1997;99(3):497–498pmid:9041311
      OpenUrlAbstract/FREE Full Text
      1. Currier GW,
      2. Walsh P,
      3. Lawrence D
      . Physical restraints in the emergency department and attendance at subsequent outpatient psychiatric treatment. J Psychiatr Pract. 2011;17(6):387–393pmid:22108395
      OpenUrlCrossRefPubMed
      1. Downes MA,
      2. Healy P,
      3. Page CB,
      4. Bryant JL,
      5. Isbister GK
      . Structured team approach to the agitated patient in the emergency department. Emerg Med Australas. 2009;21(3):196–202pmid:19527279
      OpenUrlCrossRefPubMed
      1. Glezer A,
      2. Brendel RW
      . Beyond emergencies: the use of physical restraints in medical and psychiatric settings. Harv Rev Psychiatry. 2010;18(6):353–358pmid:21080773
      OpenUrlCrossRefPubMed
    37. ↵
      1. Rossi J,
      2. Swan MC,
      3. Isaacs ED
      . The violent or agitated patient. Emerg Med Clin North Am. 2010;28(1):235–256pmid:19945609
      OpenUrlCrossRefPubMed
    38. ↵
      1. American Academy of Child and Adolescent Psychiatry Committee on Health Care Access and Economics Task Force on Mental Health
      . Improving mental health services in primary care: reducing administrative and financial barriers to access and collaboration. Pediatrics. 2009;123(4):1248–1251pmid:19336386
      OpenUrlFREE Full Text
    39. ↵
      1. Schwenk TL
      . The patient-centered medical home: one size does not fit all. JAMA. 2014;311(8):802–803pmid:24570242
      OpenUrlCrossRefPubMed
    • Copyright © 2016 by the American Academy of Pediatrics
    PreviousNext
    Back to top

    Advertising Disclaimer »

    In this issue

    Pediatrics
    Vol. 138, Issue 3
    1 Sep 2016
    • Table of Contents
    • Index by author
    View this article with LENS
    PreviousNext
    Email Article

    Thank you for your interest in spreading the word on American Academy of Pediatrics.

    NOTE: We only request your email address so that the person you are recommending the page to knows that you wanted them to see it, and that it is not junk mail. We do not capture any email address.

    Enter multiple addresses on separate lines or separate them with commas.
    Executive Summary: Evaluation and Management of Children and Adolescents With Acute Mental Health or Behavioral Problems. Part I: Common Clinical Challenges of Patients With Mental Health and/or Behavioral Emergencies
    (Your Name) has sent you a message from American Academy of Pediatrics
    (Your Name) thought you would like to see the American Academy of Pediatrics web site.
    CAPTCHA
    This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.
    Request Permissions
    Article Alerts
    Log in
    You will be redirected to aap.org to login or to create your account.
    Or Sign In to Email Alerts with your Email Address
    Citation Tools
    Executive Summary: Evaluation and Management of Children and Adolescents With Acute Mental Health or Behavioral Problems. Part I: Common Clinical Challenges of Patients With Mental Health and/or Behavioral Emergencies
    Thomas H. Chun, Sharon E. Mace, Emily R. Katz, AMERICAN ACADEMY OF PEDIATRICS, COMMITTEE ON PEDIATRIC EMERGENCY MEDICINE, AMERICAN COLLEGE OF EMERGENCY PHYSICIANS, PEDIATRIC EMERGENCY MEDICINE COMMITTEE
    Pediatrics Sep 2016, 138 (3) e20161571; DOI: 10.1542/peds.2016-1571

    Citation Manager Formats

    • BibTeX
    • Bookends
    • EasyBib
    • EndNote (tagged)
    • EndNote 8 (xml)
    • Medlars
    • Mendeley
    • Papers
    • RefWorks Tagged
    • Ref Manager
    • RIS
    • Zotero
    Share
    Executive Summary: Evaluation and Management of Children and Adolescents With Acute Mental Health or Behavioral Problems. Part I: Common Clinical Challenges of Patients With Mental Health and/or Behavioral Emergencies
    Thomas H. Chun, Sharon E. Mace, Emily R. Katz, AMERICAN ACADEMY OF PEDIATRICS, COMMITTEE ON PEDIATRIC EMERGENCY MEDICINE, AMERICAN COLLEGE OF EMERGENCY PHYSICIANS, PEDIATRIC EMERGENCY MEDICINE COMMITTEE
    Pediatrics Sep 2016, 138 (3) e20161571; DOI: 10.1542/peds.2016-1571
    del.icio.us logo Digg logo Reddit logo Twitter logo CiteULike logo Facebook logo Google logo Mendeley logo
    Print
    Download PDF
    Insight Alerts
    • Table of Contents

    Jump to section

    • Article
      • Executive Summary
      • Lead Authors
      • American Academy of Pediatrics, Committee on Pediatric Emergency Medicine, 2015-2016
      • Liaisons
      • Staff
      • American College of Emergency Physicians, Pediatric Emergency Medicine Committee, 2013–2014
      • Former Committee Members
      • Staff
      • Footnotes
      • References
    • Info & Metrics
    • Comments

    Related Articles

    • No related articles found.
    • PubMed
    • Google Scholar

    Cited By...

    • Drugs Used to Treat Pediatric Emergencies
    • Adolescents Experiences During "Boarding" Hospitalization While Awaiting Inpatient Psychiatric Treatment Following Suicidal Ideation or Suicide Attempt
    • Trends in Psychiatric Emergency Department Visits Among Youth and Young Adults in the US
    • Frequency of Pediatric Emergencies in Ambulatory Practices
    • Google Scholar

    More in this TOC Section

    • Recommended Childhood and Adolescent Immunization Schedule: United States, 2021
    • Ethical Considerations in Pediatricians’ Use of Social Media
    • 2021 Recommendations for Preventive Pediatric Health Care
    Show more From the American Academy of Pediatrics

    Similar Articles

    Subjects

    • Current Policy
    • Emergency Medicine
      • Emergency Medicine
    • AAP Policy Collections by Authoring Entities
      • Committee on Pediatric Emergency Medicine
    • Journal Info
    • Editorial Board
    • Editorial Policies
    • Overview
    • Licensing Information
    • Authors/Reviewers
    • Author Guidelines
    • Submit My Manuscript
    • Open Access
    • Reviewer Guidelines
    • Librarians
    • Institutional Subscriptions
    • Usage Stats
    • Support
    • Contact Us
    • Subscribe
    • Resources
    • Media Kit
    • About
    • International Access
    • Terms of Use
    • Privacy Statement
    • FAQ
    • AAP.org
    • shopAAP
    • Follow American Academy of Pediatrics on Instagram
    • Visit American Academy of Pediatrics on Facebook
    • Follow American Academy of Pediatrics on Twitter
    • Follow American Academy of Pediatrics on Youtube
    • RSS
    American Academy of Pediatrics

    © 2021 American Academy of Pediatrics