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Treatment of Psychiatric Emergencies in Children versus Adults
Assessing, diagnosing, and treating children and adults can be similar and different in many ways. A psychiatric emergency can be defined as any disturbance in thoughts, feelings, or actions for which immediate therapeutic intervention is neccesary (Sadock et al., 2014). Psychiatric emergencies can occur in various care settings. As a nurse working on an inpatient adult psychiatric unit, we very often admit individuals that have been brought in for a psychiatric emergency, such as suicidal ideations, suicidal attempts, homicidal ideations and attempts, and psychotic behaviors. At my clinical site, I have not witnessed a psychiatric emergency but have been educated about the previous psychiatric emergencies and how the clinic and providers handled those situations. As a future psychiatric mental health nurse practitioner (PMHNP), understanding the policies and protocols on how to address these emergencies is essential to ensure the client’s safety. Safety is important whether treating adults, children, or adolescents. I feel that I am more knowledgeable when treating adult psychiatric emergencies than children due to my current position, therefore this topic is interesting, and I feel could teach me a lot although emergencies could be handled differently based on the state in which PMHNPs are practicing.
Adult Psychiatric Emergency Scenario
A 22-year-old Caucasian male presents to the adult psychiatric unit for homicidal behaviors. His psychiatric diagnoses consist of major depressive disorder, dysthymia, impulse control disorder, mild intellectual disability, homicidal thoughts and behaviors, and autism spectrum disorder. The client is considered an adult with no legal guardian despite his long history of psychiatric disorders and treatment. He has presented to the unit previously and discharged and was a part of a support network with caretakers that come to his home to ensure he is complying with outpatient orders. He was brought into the emergency department by the police because he had his caregiver held at knife point. This behavior is reported frequently, and he has a constant change in caregivers due to his homicidal and aggressive behaviors. Upon admission to our unit, he was placed in restraints for agitated, uncooperative, and violent behavior. He has also been placed on a continuous observation order for his safety and the safety of other patients and staff. Various violent attacks have since occurred during his stay and the client is not stable for discharge after five days of inpatient psychiatric care. In my opinion, this case can be classified as a psychiatric emergency.
Addressing the psychiatric emergency for a child or adolescent
Regardless of the individual’s age or clinical setting, a psychiatric emergency is a life-threatening event requiring immediate attention (American Academy of Child and Adolescent Psychiatry, 2018). Few children or adolescents seek psychiatric intervention on their own, even when an event could be considered a psychiatric emergency (Sadock et al., 2014). Most psychiatric emergencies are initiated by parents, relatives, teachers, and healthcare providers (Sadock et al., 2014). If the individual I presented above were a child or adolescent that is brought in for a psychiatric emergency considered violent behaviors and tantrums, as a PMHNP it is essential to ensure the child/adolescent and those surrounding are safe. Once safety is ensured, then approaching the child/adolescent in a calm and nonjudgmental demeanor to evaluate him is next (Sadock et al., 2014). If the child/adolescent is calm and able to have a conversation with the practitioner while maintaining composure, then having the individual recount what happened could help with the assessment and treatment plan (Sadock et al., 2014). Since the client can pose a threat if he is describing the events, like the adult patient did while at the hospital, keeping sufficient staff close by as backup is vital for safety.
When assessing a child, the practitioner can allow them some time to calm down before reassessing the situation but with an adolescent, medication can help relax the individual to allow for an adequate assessment or if necessary for combative behavior, restraints may be appropriate (Sadock et al., 2014). In the case of the scenario I described, the patient was medicated and placed in restraints because an assessment of the client was unable to be obtained with the client being violent and uncooperative. When assessing children and adolescents, obtaining information from family members can be beneficial to understand the crisis the client is experiencing and displaying in violent outburst (Sadock et al., 2014). Medication is rarely needed for prepubertal children with no major psychiatric disorders to ensure safety because they are generally small enough to physically restrain if they are threat to themselves or others (Sadock et al., 2014). As a PMHNP, the difference in determining whether the child or adolescent needs to be admitted to an inpatient psychiatric unit would be whether the individual is able to calm down during an evaluation and comply with outpatient treatment so that a psychiatric emergency due to violence does not reoccur or if the individual continues to pose a danger to themselves or others during the evaluation period (Sadock et al., 2014).
Ethical issues when evaluating Children and Adolescents in a Psychiatric Emergency
When practicing as a PMHNP, considering the ethical and legal implications of caring for children and adolescents is essential when treating this population versus the adult population. As a PMHNP, it is vital to educate the individuals, children/adolescents and their parents, about the confidentiality of their assessment and treatment during the sessions but the ethical obligation as a provider to ensure their safety and do good and no harm; beneficence and nonmaleficence. In that case, what the child and adolescent shares with the provider is confidential unless it could pose a threat to their safety. Psychiatric emergency treatment in the event of imminent danger is provided regardless of the child or guardian opposition (Thapar et al., 2015). Psychiatric care that includes children, integrates families, since they are not yet independent and still follow adult authority, so there is only so much autonomy split between the client and their parents, although it is still important to consider the opinion of both parties (Koocher, 2003).
American Academy of Child and Adolescent Psychiatry. (2018). What is a psychiatric emergency? Retrieved from https://www.aacap.org/AACAP/Families_and_Youth/Facts_for_Families/FFF-Guide/What_is_a_Psychiatric_Emergency_126.aspx#:~:text=A%20psychiatric%20emergency%20is%20a%20dangerous%20or%20life-threatening,Immediately%20call%20911%20or%20your%20local%20emergency%20number.
Koocher, G. P. (2003). Ethical issues in psychotherapy with adolescents. Journal of Clinical Psychology, 59(11), 1247–1256. https://doi-org.ezp.waldenulibrary.org/10.1002/jclp.10215
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.
Thapar, A., Pine, D. S., Leckman, J. F., Scott, S., Snowling, M. J., & Taylor, E. A. (2015). Rutter’s child and adolescent psychiatry (6th ed.). Hoboken, NJ: Wiley Blackwell.
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