Evaluation and Management of Children With Acute Mental Health or Behavioral Problems. Part II: Recognition of Clinically Challenging Mental Health Related Conditions Presenting With Medical or Uncertain Symptoms

Continuous Infusion of Dexmedetomidine for Maintenance of Sedation in an Aggressive Adolescent with Autism Spectrum Disorder in the Emergency Department

BACKGROUND

The treatment of aggressive behavior and agitation in pediatric patients with autism spectrum disorder (ASD) in the emergency department is topical and challenging.

CASE PRESENTATION

We described an adolescent with autism spectrum disorder treated ten times in the pediatric emergency department for severe episodes of aggressiveness and agitation. After resolving the acute phase of these behavioural crises, sedation was maintained with a continuous infusion of dexmedetomidine to prevent the resurgence of agitation and to organize discharge properly, considering the family's needs. The continuous infusion of dexmedetomidine allowed the patient to remain asleep most of the time during his stay at the emergency department. No adverse events were recorded.

CONCLUSIONS

The continuous infusion of dexmedetomidine could represent a safe and valuable tool to facilitate the permanence of the patient in the PED.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies

Mental and behavioral health (MBH) visits of children and youth to emergency departments are increasing in the United States. Reasons for these visits range from suicidal ideation, self-harm, and eating and substance use disorders to behavioral outbursts, aggression, and psychosis. Despite the increase in prevalence of these conditions, the capacity of the health care system to screen, diagnose, and manage these patients continues to decline. Several social determinants also contribute to great disparities in child and adolescent (youth) health, which affect MBH outcomes. In addition, resources and space for emergency physicians, physician assistants, nurse practitioners, and prehospital practitioners to manage these patients remain limited and inconsistent throughout the United States, as is financial compensation and payment for such services. This technical report discusses the role of physicians, physician assistants, and nurse practitioners, and provides guidance for the management of acute MBH emergencies in children and youth. Unintentional ingestions and substance use disorder are not within the scope of this report and are not specifically discussed.

The Management of Children and Youth With Pediatric Mental and Behavioral Health Emergencies

Mental and behavioral health (MBH) emergencies in children and youth continue to increasingly affect not only the emergency department (ED), but the entire spectrum of emergency medical services for children, from prehospital services to the community. Inadequate community and institutional infrastructure to care for children and youth with MBH conditions makes the ED an essential part of the health care safety net for these patients. As a result, an increasing number of children and youth are referred to the ED for evaluation of a broad spectrum of MBH emergencies, from depression and suicidality to disruptive and aggressive behavior. However, challenges in providing optimal care to these patients include lack of personnel, capacity, and infrastructure; challenges with timely access to a mental health professional; the nature of a busy ED environment; and paucity of outpatient post-ED discharge resources. These factors contribute to prolonged ED stays and boarding, which negatively affect patient care and ED operations. Strategies to improve care for MBH emergencies, including systems-level coordination of care, are therefore essential. The goal of this policy statement and its companion technical report is to highlight strategies, resources, and recommendations for improving emergency care delivery for pediatric MBH.

Behavioral Management of Children With Autism in the Emergency Department

ABSTRACT

Autism spectrum disorder (ASD) is characterized by impaired social communication in conjunction with patterned behaviors. Often associated with emotional dysregulation, irritability, aggression, depression, and suicidality, ASD youth frequently present to the emergency department for behavioral and mental health evaluation. Psychiatric comorbidities, agitation, and depression are commonly encountered. During these visits, practitioners must thoughtfully consider organic etiologies for presenting symptoms, formulate plans to address risk of agitation, and understand how to effectively formulate disposition options in this patient population.

Disparities in Pharmacologic Restraint Use in Pediatric Emergency Departments

OBJECTIVES

Emergency department (ED) utilization by children with mental and behavioral health (MBH) conditions is increasing. During these visits, pharmacologic restraint may be used to manage acute agitation. Factors associated with pharmacologic restraint use are not well described.

METHODS

This was a retrospective cohort study of ED visits from the Pediatric Health Information System database, 2010-2020. We included visits by children 3-21 years with a primary MBH diagnosis and identified visits with pharmacologic restraint. Regression models were used to analyze the association between patient- and hospital-level factors and restraint.

RESULTS

Of 545 800 ED MBH visits over the study period, 22 194 visits (4.1%) involved pharmacologic restraint use. In multivariable analysis, restraint was associated with ages 18-21 years (odds ratio [OR], 1.88; 95% confidence interval [CI], 1.59-2.22), male sex (OR, 1.25; 95% CI, 1.16-1.34), Black race (OR, 1.22; 95% CI, 1.09-1.35), visits starting overnight (OR, 1.68; 95% CI, 1.45-1.96), or the weekend (OR, 1.26; 95% CI, 1.22-1.30), and repeat ED visits (OR, 1.31; 95% CI, 1.17-1.47). Every 100-visit increase in average annual MBH volume was associated with a 0.09% decrease in restraint (95% CI, -0.15 to -0.04) with no significant association between average annual ED volume and restraint (95% CI, -0.25 to 0.25).

CONCLUSIONS

For children in the ED with MBH conditions, ages 18-21 years, male sex, Black race, visits starting overnight or the weekend, and repeat ED visits were associated with pharmacologic restraint. These results can inform strategies to reduce restraint use and ensure safe and equitable ED care.

Sensory-Friendly Emergency Department Visit for Patients with Autism Spectrum Disorder—A Scoping Review

Our goal was to develop non-pharmacologic strategies for addressing sensory challenges that patients with autism spectrum disorder (ASD) face in emergency departments (EDs). Search of five databases for articles written in English and published since 1980 returned 816 citations, of which 28 papers were selected for review. All studies were published in the last nine years, with 92.85% (n = 26) conducted in North America. We developed 26 consolidated strategies, encompassing five major domains, including guiding principles, care processes, people (behavior of staff members), objects, and places (facility design). Sensory-friendly care in ED requires an integrative approach and its success depends on guiding principles that tie various aspects of care and distinguishes ASD care from non-ASD care.

Adolescents' Utilization of a Tertiary-Level Pediatric Emergency Department in Italy

Aim

Describe the use of the emergency department of a tertiary-level children's hospital in Italy by adolescents.

Methods

This retrospective study was based on the medical records of patients aged 13 to 17 years, who accessed the emergency department of the Institute for Maternal and Child Health of Trieste, from 1 January to 31 December 2018. The primary outcome was to describe the leading causes of access, diagnoses, rate of hospitalization, and ward of destination among adolescent patients.

Results

During the study period, 24,599 patients accessed the department. Among them, 3,062 were adolescents, for a total of 3,895 unscheduled visits. The principal causes of access were trauma (45.3%) and organic diseases (38.8%). Two hundred and forty nine adolescents (6.4%) had mental health problems. One hundred and forty two adolescents (3.6%) Were Admitted to the Hospital, 54 of Whom (38%) to the Neuropsychiatric Ward, for Mental Health Problems.

Conclusions

Among adolescents seen in this Italian tertiary-level children's hospital, mental health problems represented a small proportion of emergency department visits but were the leading cause of urgent hospitalization.

Neuroleptic Malignant Syndrome in Children with Autism Spectrum Disorder (ASD): A Case Report and Brief Review of Recent Literature

Neuroleptic malignant syndrome (NMS) is a rare, life-threatening, idiosyncratic adverse reaction to antipsychotic drugs. Despite the increasing rates in the prescription of antipsychotics in pediatric patients with autism spectrum disorder (ASD), little is known about the occurrence and hallmarks of NMS in this specific population. NMS appears to be part of the larger catatonia domain, based on the frequent relationship between ASD and catatonia, on the shared, when not overlapping, clinical features with malignant catatonia, and on the effectiveness of catatonia treatments on the NMS/MC symptoms. The intrinsic difficulties of exploring NMS in ASD in controlled studies accounts for the subsequent lack of available information. Based on recent reports and on our case report, clinical features of NMS in the pediatric ASD population appear to be the same as the non-ASD population. Further studies are needed to confirm these results.

How to recognize and manage psychosomatic pain in the pediatric emergency department

Aim

Children and adolescents affected by somatization and somatic symptom disorder commonly refer to emergency services. Due to the absence of specific guidelines for the emergency setting and to a possible lack of knowledge, these patients are at risk of being unrecognized and mismanaged. This study aims at proposing a clinical practice to approach and manage these patients and their families in the emergency setting.

Methods

This manuscript derived from the work of a research group of italian pediatric emergency physicians and anesthesiologists, with an expertise in pain management, members of the PIPER group. The research group reviewed the literature about psychosomatic pain and somatic symptom disorder and developed a clinical practice specific for the pediatric emergency setting.

Results

The manuscript provides information about the main clinical features shared by patients with psychosomatic pain and about current diagnostic criteria and appropriate management in the emergency setting. Furthermore, it highlights the possible pitfalls in which the emergency physician may run into dealing with these patients.

Conclusion

This clinical practice should be seen as a starting point toward a better understanding of patients with psychosomatic pain and a standardization of care in the pediatric emergency setting.

Drug Prescribing and Outcomes After Pharmacogenomic Testing in a Developmental and Behavioral Health Pediatric Clinic

OBJECTIVE

To describe drug prescribing and outcomes after pharmacogenomic (PGx) testing in children with developmental and/or behavioral disorders.

METHODS

This is a single-clinic retrospective analysis of patients aged 5 to 17 years with documented behavioral and/or development disorder(s) and having received PGx testing between May 2015 and May 2017. The primary endpoint was frequency of PGx-guided medication changes after testing. Secondary endpoints included frequency of medications in each category from the PGx report (use as directed, use with caution, and use with increased caution), changes in therapy within each category, frequency and type of actionable genes, symptomatic improvement, and frequency of medication changes up to 6 months after PGx-guided therapy.

RESULTS

Of 200 patients, 75% were male, 78% were white, 83% had attention-deficit/hyperactivity disorder, and 45% had anxiety, and their mean age was 10 years. Most common reasons for ordering PGx testing were lack of response (83%) and/or adverse events (42%). Approximately 84% had PGx-guided medication change(s) after testing. At baseline, 50% of medications were categorized in "use as directed," 40% in "use with caution," and 11% in "use with increased caution." After testing, 8%, 29%, and 30% of medications in "use as directed," "use with caution," and "use with increased caution" categories were discontinued; 85% were added or continued from "use as directed" category. The most common actionable genes were ADRA2A (47%), COMT (22%), and CYP2D6 (20%). Sixty percent were on the same medication(s) suggested by the PGx report 6 months later, and 64% had provider-documented symptomatic improvement.

CONCLUSION

Pharmacogenomic testing may affect drug prescribing and clinical outcomes in a pediatric behavioral health clinic.

Depression in Children and Adolescents: The Pediatrician at the Front Lines

Pediatricians are the primary care providers for most children and adolescents in the United States, so they need to feel comfortable caring for children and teens with depression. This topic is an extremely important one because the top three reasons teens die or get injured are related to accidents (3.7 per 100,000 for those ages 5-14 years and 28.5 per 100,000 for those ages 15-24 years), suicide (1 per 100,000 in the younger age group, and 12.5 deaths per 100,000 in those ages 5-14 years), and homicide (0.7 per 100,000 in those age 5-14 years, and 10.8 per 100,000 in those age 15-24 years). Each year, 21% of children ages 9 to 17 years are diagnosed with a mental or addictive disorder associated with at least minimum impairment, with 11% of these children having significant functional impairment and another 5% demonstrating extreme functional impairment. We know that one-half of all lifetime cases of mental health disorders start by age 14 years. This includes serious adult psychiatric illnesses such as major depressive disorder, anxiety disorders, and substance abuse. Three-quarters are present by age 24 years; therefore, interventions aimed at prevention or early treatment need to focus on youth. [Pediatr Ann. 2018;47(7):e261-e265.].

The Emergency Department: Challenges and Opportunities for Suicide Prevention

Emergency departments (EDs) can offer life-saving suicide prevention care. This article focuses on the ED and emergency services as service delivery sites for suicide prevention. Characteristics of EDs, models of emergency care, ED screening and brief intervention models, and practice guidelines and parameters are reviewed. A care process model for youths at risk for suicide and self-harm is presented, with guidance for clinicians based on the scientific evidence. Strengthening emergency infrastructure and integrating effective suicide prevention strategies derived from scientific research are critical for advancing suicide prevention objectives.