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982 SECTION 12: Pediatrics (Table 148-8), requiring early ventricular shunt placement. Even minor cervical hyperflexion and extension injuries can cause symptoms in children with Chiari malformation; any deceleration injury, even mild, requires cervical spine stabilization and assessment for spinal cord injury due to instability of the craniocervical junction. Consider Chiari II malformation as a possible cause of new-onset stridor in the child with meningomyelocele. Monitor closely for progression to complete airway obstruction. Diagnosis requires emergent MRI of the craniocer vical junction. If respiratory function is not severely compromised and the airway remains stable, outpatient disposition may be considered in consultation with subspecialists caring for the child.  URINARY TRACT Complications of a neurogenic bladder include recurrent urinary tract infection, urinary retention or incontinence, and complications of self-catheterization. Medications or prophylactic antibiotics may be prescribed to enhance continence and minimize damage to the upper urinary tract. Because bacterial colonization of the urine is common, only treat symptomatic infection with antibiotics. Suspect formation of a false passage during self-catheterization with difficult catheter passage, pain, or urethral bleeding. Do not attempt recatheterization in the ED for these symptoms, for fear of compounding the underlying injury, but obtain urologic consultation. Long-term indwelling catheterization predisposes the patient to the development of latex allergy. REFERENCES The complete reference list is available online at www.TintinalliEM.com. TABLE 148-8 Symptoms of Chiari II Malformation Infant Older Child Apnea Vision dysfunction Vocal cord paralysis Motor incoordination Stridor Headache Oral motor dysfunction Hand weakness Vision disturbances Upper extremity weakness Incoordination Behavioral Disorders in Children Quynh H. Doan Tyler R. Black INTRODUCTION Pediatric mental health emergencies encompass a range of conditions, including psychiatric conditions such as mood and anxiety disorders (depression, bipolar disorder, suicidal ideation, obsessive compulsive disorders, posttraumatic stress syndrome), exacerbations of behavioral disorders (attention-deficit/hyperactivity disorder, aggressive outbursts, conduct disorders), deteriorating neurodevelopmental disorders (autistic spectrum disorders, tic disorders, intellectual disabilities), addictive disorders, and eating disorders. The psychological and sometimes physical aftermath of child maltreatment, mass casualty incidents and disas ters, and exposure to violence and unexpected deaths are also likely causes of mental health emergencies. 1-4 CHAPTER Traditionally, the role of the emergency provider includes medically stabilizing children presenting with a mental health complaint, differ entiating physical from mental health causes of symptoms, performing a psychosocial assessment, and directing patients and families toward appropriate resources for acute and long-term needs. Initial manage ment may include pharmacologic therapy, physical restraint, and refer ral for inpatient admission. 2,5 More recently, increased recognition of the burden of unidentified mental health concerns among vulnerable youth has led to calls for universal screening of psychosocial status for youth seeking medical care in the ED.

ent may include pharmacologic therapy, physical restraint, and refer ral for inpatient admission. 2,5 More recently, increased recognition of the burden of unidentified mental health concerns among vulnerable youth has led to calls for universal screening of psychosocial status for youth seeking medical care in the ED. Barriers to universal screening for mental health conditions in the ED include time restrictions, lack of familiarity with screening instruments, often fragmented or limited local community resources, and reluctance to broach the subject of mental health on the part of families seeking urgent medical care. Despite these barriers, a number of brief screening tools targeting specific conditions such as suicidal risk (Ask Suicide-Screening Ques tions and Risk of Suicide Questionnaire; see later section, “Suicidal Ideation and Attempts”), depression (Beck Depression Inventory-II), anxiety (revised parental and child versions of the Screen for Child Anxiety-Related Disorders), and alcohol use disorder ( Diagnostic and Statistical Manual of Mental Disorders , Fourth Edition, 2-Item Scale), have been validated in the ED population to identify youth requiring further assessment. 7 Although concerns about privacy and confidentiality are sometimes raised by families, a study of mental health screening in the ED suggests that most parents and youth find the process acceptable, and clinicians report that screening does not interfere with medical care. EPIDEMIOLOGY The mental health crisis involves all socioeconomic and ethnic groups and is not unique to any one geographic area, state, or region. A metaanalysis of worldwide prevalence of mental health disorders suggests that North America has the highest prevalence of mental health dis orders in children and adolescents (19.9%) with lower rates in Europe (12%) and Africa (8.3%); there is a peak prevalence among youth age 12 to 18 years. 9 National surveillance data from the United States and Canada report a prevalence of pediatric mental health disorders of 10% to 20% and suicide as the second most common cause of mortality among youth. 10,11 Although the prevalence of youth mental health disorders remains stable, acute care visits for mental health–related issues are on the rise. In the United States, both the absolute number (from 565,000 to 823,000) and proportion of all ED visits (from 2.0% to 2.8%) by children and youth for a mental health problem are on the rise. 12 The Pediatric Emergency Care Applied Research Network reported that 3.3% of all participating pediatric ED visits were made for psychiatric-related visits. These visits are more frequently arriving by ambulance, are associated with longer length of stay, and result in admission to the hospital more commonly than other causes for ED visits. 13 Between 2006 and 2011, ED visits for a mental health–related concern increased in the United States by 21%, and hospitalizations for a mental health condition increased by 50%. 14 In Canada, ED visits and hospitalizations for mental health conditions increased by 66% and 55%, respectively, from 2007 to 2017. Pediatric psychiatric emergencies show seasonal variation and are more common during the school year, peaking in May and November, while reaching a nadir in July and August. While the visit distribution over days of the week appears to be even, visits occur more frequently in the evening, coinciding with a time period when most outpatient commu nity mental health resources are not easily reachable. The cause of the dramatic rise in pediatric mental health emergen cies is multifactorial and complex.

visit distribution over days of the week appears to be even, visits occur more frequently in the evening, coinciding with a time period when most outpatient commu nity mental health resources are not easily reachable. The cause of the dramatic rise in pediatric mental health emergen cies is multifactorial and complex. Factors contributing to the high prevalence of mental illnesses among youth include family instability or dysfunction, economic crisis or financial hardship, inadequate numbers of mental health professionals (especially those with pediatric expertise), lack of access to care, shortage of funding for mental health services, and failure to seek care due to cultural stigma. 1 In addition, social network ing exposes youths to cyberbullying, online harassment, social isola tion, and “Facebook depression, ” adding further risks for developing mental health illnesses. 16 Multiple economic forces negatively impact Tintinalli_Sec12_p0669-0996.indd 982 8/2/19 7:59 PM

care due to cultural stigma. 1 In addition, social network ing exposes youths to cyberbullying, online harassment, social isola tion, and “Facebook depression, ” adding further risks for developing mental health illnesses. 16 Multiple economic forces negatively impact Tintinalli_Sec12_p0669-0996.indd 982 8/2/19 7:59 PM CHAPTER 149: Behavioral Disorders in Children 983 history of psychiatric or organic disease may indicate a potential genetic predisposition. In addition to noting these standard components of history, conduct a focused psychosocial assessment. Children and adolescents presenting to the ED with behavioral or psychiatric emergencies should be asked about exposure to violence at home or school. See also Chapter 150, “Child Abuse and Neglect. ” Two assessment tools have been designed for this use in the ED: HEADS-ED and HEARTSMAP . HEADS-ED recommends a psychiatric assessment by a mental health clinician for a cumulative score of ≥7 and if the suicide risk score is ≥2. 19 HEARTSMAP provides specific recommendations for the type (social, youth health, psychiatric, and protective) and urgency (in ED consultation vs. community-based resources) of mental health service needs (Table 149-3). 20,21  PHYSICAL EXAMINATION Assess vital signs, airway, breathing, and circulation, and then perform a detailed neurologic examination. Alterations in vital signs may provide clues to potential intoxication, ingestions, or organic pathology (endo crinologic and metabolic). Tachycardia, hypertension, pyrexia, and tachypnea may suggest intoxication with stimulants such as amphet amines, cocaine, and “ecstasy” (3,4-methylenedioxymethamphetamine). Assess for other toxidromes including anticholinergic symptoms or signs of salicylate toxicity. Pupillary responses, the presence or absence of nystagmus, skin temperature and moisture, and the condition of the mucous membranes are all helpful in identifying toxidromes (see Chapter 176, “General Management of Poisoned Patients”). Focus the neurologic examination on level of consciousness, gait and coordination, and reflexes, and administer the Mini-Mental Sta tus Examination as appropriate for age (Table 288-2). Note the child’s affect and general appearance, content and organization of thought, and articulation and expression of speech. Pressured speech with flight of ideas may signal acute mania, whereas echolalia, “word salad, ” and other disordered thought may indicate acute psychosis.  LABORATORY TESTING AND IMAGING Laboratory tests and imaging are dictated by the history and physical examination. Pubertal girls should have a urine pregnancy test. Urine drug screening can be helpful when intoxication from drugs of abuse is suspected. Obtain serum acetaminophen (Tylenol ® ) and salicylate (aspirin) levels in children who have ingested drugs or attempted suicide, as self-report of quantity and type of drug used is not always reliable. Hyperglycemia, hypoglycemia, and hyperammonemia can cause alterations in mental status, so check serum glucose and con sider ammonia in obtunded patients. Obtain a 12-lead ECG in cases of potential ingestion or intoxication to identify interval prolongation or conduction abnormalities. Document normal sinus rhythm at baseline before initiating psychotropic medications that may accentuate long QT disorders. Screening laboratory tests performed in psychiatric emer gencies vary by institution, and many inpatient psychiatric facilities require basic chemistry panels and screening for thyroid disorders. See Chapter 140, “ Altered Mental Status in Children, ” for further discussion of the approach to altered mental status. Imaging studies are rarely indicated or helpful except as directed by the history and physical examination.

psychiatric facilities require basic chemistry panels and screening for thyroid disorders. See Chapter 140, “ Altered Mental Status in Children, ” for further discussion of the approach to altered mental status. Imaging studies are rarely indicated or helpful except as directed by the history and physical examination. Chest radiographs may identify TABLE 149-1 Medical and Psychiatric Causes of Altered Mental Status in Children Medical Conditions Psychiatric Conditions CNS disorders Acute mania Brain tumor Bipolar disorder Temporal lobe epilepsy Depression Trauma Acute psychosis (e.g., schizophrenia) Infection (abscess, encephalitis, meningitis) Personality disorder Metabolic/endocrine disorders Conduct disorder Hyperglycemia, hypoglycemia Thyroid disease Uremia Hepatic failure Porphyria Collagen vascular diseases Lupus erythematosus Vasculitis Hyperpyrexia Intoxication or withdrawal Drugs of abuse (alcohol, stimulants, depressants, hallucinogens) Medications (antipsychotics, corticosteroids) Environmental substances (anticholinergics, heavy metals) the availability and delivery of mental health services 1,4,5,17,18 and have transformed EDs into the safety net for a fragmented mental health infrastructure.5 A lack of mental health follow-up or aftercare further contributes to the problem: of patients discharged from psychiatric emergency facilities, 40% to 60% do not receive aftercare, increasing the risk of repeat ED visits. CLINICAL ASSESSMENT  GENERAL GOALS First, identify and treat acute life-threatening medical emergencies. Next, determine if the child poses an imminent threat to his or her own life or the life of others, as this determines the need for hospitalization. Finally, exclude organic causes for psychiatric presentations. Table 149-1 lists medical and psychiatric conditions that may present with agitation, psychosis, or obtundation. Table 149-2 enumerates some general characteristics that may distinguish organic from psychiatric causes of psychosis.  HISTORY Focus the history on the chief complaint and details of the present ing symptoms, circumstances, and precipitating events (e.g., social stressors). The timing and sequence of events, associated symptoms, and review of systems may help to distinguish organic from psychiatric conditions. Auditory hallucinations are associated with psychosis, but visual hallucinations may indicate intoxication or organic causes. A history of head injury, chronic or progressive headaches, visual changes, vomiting (especially morning vomiting), and deterioration of motor skills or gait suggests an intracranial process such as a brain tumor or subdural hematoma. Constitutional symptoms that may provide clues to an organic etiology include temperature instability, palpitations, and changes in appetite, stool patterns, hair, or skin. The past medical history and family history will help identify the pattern and chronicity of the presenting symptoms. Similarly, a review of medications, including adherence to prescribed medication regimens, and their efficacy will guide the treatment plan and disposition. A family TABLE 149-2 Differentiation of Organic and Psychiatric Psychosis Characteristic Organic Cause Psychiatric Cause History: onset and progression Acute Gradual/progressive Vital signs Often disturbed Usually normal Physical examination Focal neurologic symptoms May be present Usually absent Mental status Delirium, visual hallucinations, agitation Anger, sadness, auditory hallucinations, agitation Laboratory findings May be altered Usually normal Tintinalli_Sec12_p0669-0996.indd 983 8/2/19 7:59 PM

ns Often disturbed Usually normal Physical examination Focal neurologic symptoms May be present Usually absent Mental status Delirium, visual hallucinations, agitation Anger, sadness, auditory hallucinations, agitation Laboratory findings May be altered Usually normal Tintinalli_Sec12_p0669-0996.indd 983 8/2/19 7:59 PM TABLE 149-3 HEARTSMAP Structured Mental Health Screening Tool Psychosocial Sections Probing Questions Scoring (With Descriptors) 0 1 2 3 Current Resources Home Is there difficulty or fighting at home between family members? How do you get along with [guardian/parents/family]? How do you feel about your home environment? No concerns Supportive of youth’s difficulties but some conflicts Unsupportive (parents at risk for burnout) Frequent conflicts Dysfunctional (parental burnout) Homelessness Major conflicts Social supports neither requested nor initiated Social supports involved (resource requested and services initiated) Education and activities How is school going for you? Are there any difficulties going to school or staying in class? What do you do for fun? Has that changed recently? No concerns Struggle to maintain Difficulty attending Attends more than misses Performance decline Missing classes/activities Misses more than attends Failing/major issues Not attending Completely truant (excluding holidays) Educational/activity issues not yet addressed Functional plan in place (counselor involved) Alcohol and Drugs How much is alcohol use a part of your life? Do you use any substances like marijuana? How about any others? Do you ever use drugs or alcohol to feel better or to make a problem go away? No concerns Infrequent Mild recreational use Regular recreational use Mild substance misuse Bingeing recreational use Substance abuse No detox or rehabilitation services suggested yet Substance use services in place (referred and offered) Relationships and bullying How are things going for you with friends and relationships? Do you have a close person/group of people that you can rely on? Do you feel teased, bullied, or excluded by others? Do you have any struggles with your sexual identity or sexual preference? No concerns Minor conflicts/ bullying Struggle to maintain Conflicts/bullying Negative changes Conflicts/bullying Negative changes No support or resources initiated Educational or social plan in place (school author ity or social worker aware and addressing) Thoughts and anxiety Do you consider yourself a worrier or think a lot about the past or future? Do you ever experience panic/extreme fear that comes out of the blue? Do you ever have times where you feel your brain is playing tricks on you? No concerns Anxiety/odd thoughts (minimal impact) Anxiety/odd thoughts (minimal impact) Anxiety/odd thoughts (minimal impact) No psychiatric assessment or services initiated yet (no appointment in sight) A mental health clinician such as psychiatrist, counselor, or psychologist is involved or will be involved shortly and is available in the long term Safety Do you sometimes feel hopeless or that life is not worth living, or have you ever felt that you or your family would be better off if you were dead? In the past few weeks, have you seriously considered ending your life, or have you ever tried to end your life? In the past few weeks, have you thought of harming yourself? No concerns Fleeting or improving thoughts Nonsuicidal self-injury Fleeting or improving thoughts Nonsuicidal self-injury Fleeting or improving thoughts Nonsuicidal self-injury No plan for current safety concern Safety planning in place and consistent with cur rent suicidality/homicidality Sexual health Are you involved in any sexual activities, not limited to penetration? Do you use any mode of contraception?

ghts Nonsuicidal self-injury Fleeting or improving thoughts Nonsuicidal self-injury No plan for current safety concern Safety planning in place and consistent with cur rent suicidality/homicidality Sexual health Are you involved in any sexual activities, not limited to penetration? Do you use any mode of contraception? What of form of protection against sexually transmitted disease do you use, if any? Do you get any counseling about sexual health from a doctor or nurse? No concerns Sexually active and safe practice (contraception and sexually transmitted disease protection) Stable partner but inconsistent use of protection and contraception Multiple partners or no use of protection or contraception Involved in sex trade Sexual health issues not yet approached with healthcare professional Has a primary care provider and issues of sexual health/family planning addressed Mood and behavior How would you rate your mood, with 0 being as low as possible and 10 being perfectly happy? Do you feel down or depressed recently? Do you feel really happy or energetic lately? No concerns Mood instability (minor) Mood instability (minor) Mood instability (minor) No psychiatric assessment or services initiated yet (no appointment in sight) A mental health clinician such as psychiatrist, counselor, or psychologist is involved or will be involved shortly and is available in the long term Abuse To child: Has anyone ever hurt you by touching you in a way you didn’t like? To adolescent: Have you ever experienced abuse, either physical, emotional, or sexual? To caregiver: Do you have any concerns of abuse or mistreatment? No concerns Concern has been raised and reported to the ministry Historical concerns Current concern of abuse or neglect/not reported Notification has occurred Notification has not yet occurred Professionals and resources Do you feel that there are people or places you can go to for help? Who is working with you on these issues? Does the current plan to help make sense to you? Service plan in place or available Referred for service but access delayed (wait-listed) Longitudinal services unavailable, but necessary Not yet referred or refusing services/treatment Note: For full functionality with scoring algorithm–triggered management recommendations, use the online version at www.openheartsmap.ca. Tintinalli_Sec12_p0669-0996.indd 984 8/2/19 7:59 PM

but access delayed (wait-listed) Longitudinal services unavailable, but necessary Not yet referred or refusing services/treatment Note: For full functionality with scoring algorithm–triggered management recommendations, use the online version at www.openheartsmap.ca. Tintinalli_Sec12_p0669-0996.indd 984 8/2/19 7:59 PM CHAPTER 149: Behavioral Disorders in Children 985 aspiration in the obtunded vomiting patient. Abdominal radiographs may identify radiopaque foreign objects or ingestions. Neuroimaging can exclude intracranial mass lesions in those with suggestive clinical signs and symptoms. MANAGEMENT OF PSYCHIATRIC PRESENTATIONS A detailed summary of child and youth mental health issues is beyond the scope of this book. Formal diagnoses of mental health conditions usually occur after the ED presentation. Therefore, this section will focus on the approach to, and treatment of, psychiatric presentations. Many care environments use social workers, youth care workers, nurses, and other clinicians to conduct significant portions of the mental health assessment in the ED.  SUICIDAL IDEATION AND ATTEMPTS Suicide is complex. Contrary to belief, adolescents are not at higher risk for suicide than adults, and the risk for suicide completion starts at age 10 and increases throughout the teen years ( Figure 149-1). 22 Although it is one of the most common causes of death in youth (4.7 per 100,000 per year between the ages of 10 and 19, more than neoplasm, respiratory, and cardiovascular deaths combined), 22 the vast majority of youth who have suicidal thinking or behaviors do not go on to complete suicide (Table 149-4). 23-25 Risk prediction is currently not possible. 26 Therefore, focus on identifying risk/protective factors and acuity, collateral his tory, clinical synthesis, and safety management. A number of risk factors are associated with increased suicide risk, and suicide risk is fluid and can change rapidly. Identification of risk factors should be carried out with the goal of separating chronic (longstanding and unlikely to change) from acute (recent and possible to change) risk factors. Chronic risk factors convey ongoing risk and are important for informing systemic rather than individual approaches. Acute risk factors allow for individual approaches for suicide safety planning. Protective factors reduce risk overall and should be considered in risk factor identification. A representative, noncomprehensive list of risk and protective factors is presented in Table 149-5. 22-26 Assessment scales and tools for assessment should be used to gather information to contribute to the assessment process rather than rigid structures to guide decision making. In the ED, brief screening ques tionnaires such as the Ask Suicide-Screening Questions ( Table 149-6) can help identify patients with suicidal thinking. 27 The Ask Suicide- Screening Questions assess four areas: (1) current thoughts of being better off dead; (2) current wish to die; (3) current suicidal ideation; and (4) past suicide attempt. A positive response to any one question identified 97% of those at risk for suicide (sensitivity 96.7%, specificity 87.6%). The Columbia–Suicide Severity Rating Scale (available for download at http://www.cssrs.columbia.edu/scales_practice_cssrs.html) can help guide assessment of suicidal thinking and behaviors and has been validated for use in multiple settings, including the ED, for both adolescents and adults. 28,29 The internal validity and usability rates are high for such scales. Some more commonly used scales, such as the SADPERSONS, have little evidentiary support, contain many inaccurate assumptions about suicide risk, and do not accurately predict suicide. 30-34 Clinical interview, impression, and analysis are crucial aspects of suicide risk assessment.

ility rates are high for such scales. Some more commonly used scales, such as the SADPERSONS, have little evidentiary support, contain many inaccurate assumptions about suicide risk, and do not accurately predict suicide. 30-34 Clinical interview, impression, and analysis are crucial aspects of suicide risk assessment. Collateral history for the youth (e.g., parents, caregivers, clinicians, teachers) adds to the confidence of the assessment Suicide rate (per 100,000 per year) 91 01 11 21 31 41 51 6 Age (Y ears) 17 18 19 20 Male FemaleBoth FIGURE 149-1. Suicide rates by sex, United States, 1999 to 2016. [From Centers for Disease Control and Prevention, National Center for Health Statistics. Underlying Cause of Death 1999-2016 on CDC WONDER Online Database, released December 2017. Data are from the Multiple Cause of Death Files, 1999-2016, as compiled from data provided by the 57 vital statistics jurisdictions through the Vital Statistics Cooperative Program.] TABLE 149-4 Frequencies of Suicide Items in Youth 12 to 17 Years of Age, in the United States 1-Year Prevalence Frequency Feeling sad or hopeless for 2 weeks* 31.5% 1:3.2 Nonsuicidal self-injury 18.0% 1:5.6 Suicidal ideation* 17.2% 1:5.8 Suicide planning* 13.6% 1:7.4 Suicide attempt (any)* 7.4% 1:13.5 Suicide attempt (potentially lethal)* 2.7% 1:41.6 Death by suicide† 0.0059% 1:16,899 Note: Data is from 2017, except nonsuicidal self-injury (meta-analysis 2014) and death by suicide (2016). *Females generally twice as likely. †Males generally four times as likely. Tintinalli_Sec12_p0669-0996.indd 985 8/2/19 7:59 PM

.5 Suicide attempt (potentially lethal)* 2.7% 1:41.6 Death by suicide† 0.0059% 1:16,899 Note: Data is from 2017, except nonsuicidal self-injury (meta-analysis 2014) and death by suicide (2016). *Females generally twice as likely. †Males generally four times as likely. Tintinalli_Sec12_p0669-0996.indd 985 8/2/19 7:59 PM 986 SECTION 12: Pediatrics and can significantly affect the quality of the risk assessment. If an interview has poor reliability or rapport, the “collected data” may be inaccurate. The tone of the patients themselves, their family, and the support network around them can alter the impression of hope or despair. The importance of clinical and interpersonal factors cannot be understated and is why a reliance on rigid data, forms, or quantities is perilous. Safety management, following an adequate risk assessment, flows naturally from identified risk and protective factors. By dividing risk factors into acute and chronic categories, targeted interventions for any acute risk factors can be made. Creating safety plans for families and youth to use when suicidal ideation occurs can increase compliance with followup programming, 36 encourages appropriate re-presentation to the ED, and provides a sense of structure and support to families struggling with suicide concerns. Figure 149-2 provides an emergency approach to suicidal presentations, and the approach can be done in a multidisciplinary way—a physician is not required for any one step. Determination of the risk factors will influence the services consulted; social issues require social support services, whereas psychiatric issues require mental health supports. Rigid consultation of all suicidal patients to psychiatric care is neither necessary nor effective; inpatient and involuntary approaches to patients are beneficial when the risk profile is simply too high to manage in the outpatient environment and inpatient services are required to reduce the identified risk factors. Examples of nonpsy chiatric risk reduction maneuvers include removing lethal means, securing firearms, creating safety plans, referring to social support services, TABLE 149-5 Selection of Common Chronic and Acute Risk Factors and Protective Factors for Suicide Chronic Risk Factors History of suicidal thinking or behavior Any suicidal factor by history is one of the only consistent predictive measures for suicide risk. History of mental health disorder Lifetime risk of suicide is increased in almost all mental health disorders. Age Exceedingly rare <10 y of age. Risk starts at approxi mately age 10 and increases consistently until the age of 24. Adolescents are less at risk for suicide than adults. Sex Males 4–5 times more likely by adolescence. Ethnic or cultural risk group Aboriginal youth, homeless youth, LGBTQ (lesbian, gay, bisexual, transgender, or queer) youth. Chronic illness Any chronic illness causing pain, disability, or fatigue. Family history of suicide Closer-degree relatives infer a greater risk. History of trauma, abuse, neglect, loss Duration, frequency, and severity of trauma is additive. Acute Risk Factors Recent suicidal thoughts or behaviors Ideation < planning < nonlethal attempt < lethal attempt. New/changing suicidality should prompt full assessment. Suicide planning Passive (nonspecific wish to die) confers less risk than active (specific, formed plan). Accessibility to lethal means Unsecured substances, medications, firearms. Feasibility of plan. High agitation/anxiety presentation Strong (yet poorly specific) prediction of acute suicide risk. Current mental health/ substance use disorder Those with lack of treatment response, noncompliance to treatment, or worsening or rapidly changing disorders should be targets of suicide risk reduction.

Feasibility of plan. High agitation/anxiety presentation Strong (yet poorly specific) prediction of acute suicide risk. Current mental health/ substance use disorder Those with lack of treatment response, noncompliance to treatment, or worsening or rapidly changing disorders should be targets of suicide risk reduction. Family dysfunction/caregiver unavailable Chaotic, dysfunctional homes confer suicide risk. A responsible caregiver must be in place to institute safety management measures. Lack of professional supports Can include supports that are not effective. Recent crisis/major life change Conflicts, relationships, school, failures, losses, etc. Directly addressing these crises reduces risk. Protective Factors Parent connectedness Sport/activity participation Positive social supports Safety of environment Strong professional supports Future orientation Good therapeutic connection Strong cultural identity Responding to treatment TABLE 149-6 Ask Suicide-Screening Questions Tool for Suicidality Question (Yes/No) Interpretation 1. In the past few weeks, have you wished you were dead? “No” to all 4 questions is a negative screen. “Yes” to any question is a positive screen; proceed to question 5 below.2. In the past few weeks, have you felt that you or your family would be better off if you were dead? 3. In the past week, have you been having thoughts about killing yourself? 4. Have you ever tried to kill yourself? (If yes, how? When?) 5. Are you having thoughts of killing yourself right now? (If yes, describe.) “Yes” is an acute positive screen and requires emergent mental health evaluation and safety plan. “No” is a nonacute positive screen and requires further safety assessment. Note: Ask Suicide-Screening Questions tool can be found at https://www.nimh.nih.gov/labs-at-nimh/ asq-toolkit-materials/asq-tool/asq-screening-tool.shtml. Immediate Safety Manage medical sequelae Remove threats and address agitation Interview and Gather Both patient and family Access available collateral (charts, people) Consider Risk Factors Synthesis of gathered information and quality of interview; separate acute from chronic risk factors Address Risk Factors Consult psychiatry for acute, worsening, or untreated psychiatric concerns; address identified acute risk factors Communicate Ensure appropriate follow-up Document and communicate identified risks FIGURE 149-2. Approach to suicidality in the ED. Tintinalli_Sec12_p0669-0996.indd 986 8/2/19 7:59 PM

s Address Risk Factors Consult psychiatry for acute, worsening, or untreated psychiatric concerns; address identified acute risk factors Communicate Ensure appropriate follow-up Document and communicate identified risks FIGURE 149-2. Approach to suicidality in the ED. Tintinalli_Sec12_p0669-0996.indd 986 8/2/19 7:59 PM CHAPTER 149: Behavioral Disorders in Children 987 providing family supports, and addressing social and school concerns. Resolution of any triggering crisis severely reduces severity risk.  NONSUICIDAL SELF-INJURY Nonsuicidal self-injury is “the deliberate, self-inflicted destruction of body tissue without suicidal intent and for purposes not socially sanctioned, ” 37 and refers to a wide variety of behaviors including cut ting, burning, carving, punching, and picking. Approximately 18% of adolescents have engaged in nonsuicidal self-injury in the past year, and recent studies report that as many as 47% of females have tried it, even briefly. Nonsuicidal self-injury begins in puberty and is twice as com mon in females, peaking in middle adolescence and declining thereafter. Although it increases suicide risk, over 90% of youth presenting to crisis services with nonsuicidal self-injury have no intent of suicide. 38 Biologic predispositions to self-injury include an absent stress cortisol response, sensitivity of opioid receptors, and genetics. First, address the sequelae of the injury, and focus on the distress and events that led to self-injury. Avoid overreaction to superficial injuries; comments such as “Y ou could have killed yourself ” or “These injuries look awful” may harm the patient and even increase subsequent behav ior. Such comments can confuse the message that self-injury is different from suicide. Second, conduct suicide risk assessment, especially for new or changing self-injury or in the presence of other developing mental health issues. Explain the difference between nonsuicidal self-injury and suicidal behaviors to caregivers. Finally, provide social and mental health support resources to improve distress tolerance, stress management, and family supports.  AGGRESSION Aggression can occur prior to ED presentation, before or during assessment, and in subsequent care. Consider patient and environmental safety, potential trauma to the child or family, engagement and de-escalation whenever possible, and safe medication and restraint policies. Pharmacologic interventions require consideration of the intention of the intervention. If the underlying issue is psychosis or mania, potent antipsychotic medications are warranted. However, if agitation is behavioral, reactionary, or anxiety driven in nature, and the goal of intervention is sedation, many less potent and potentially less danger ous approaches can be taken. An approach to aggression in the ED is outlined in Table 149-7, with pharmacologic options in Table 149-8. 40,41 TABLE 149-7 Approach to the Pediatric Aggressive Patient Safety Secure patient and staff safety. Recognize the compromise between security and safety: higher-security measures (e.g., pharmacologic or physical restraint) may also confer greater risk for patient harm. Use these measures when appropriate. Engagement Youth often use aggression as their last resort to express or achieve something: expressing anger, being left alone, inter fering in treatment, or receiving something desired. Engaging the youth whenever possible to help achieve these goals can reduce the need for further measures. ALWAYS allow the situation to “step down” (i.e., reoffer oral medications before injection). Interventions, in the order they should be attempted when possible: 1. Environment and engagement 2. Pharmacology (voluntary) 3. Pharmacology (involuntary)

e to help achieve these goals can reduce the need for further measures. ALWAYS allow the situation to “step down” (i.e., reoffer oral medications before injection). Interventions, in the order they should be attempted when possible: 1. Environment and engagement 2. Pharmacology (voluntary) 3. Pharmacology (involuntary) 4. Seclusion and restraint Secure the environment for patient safety and to encourage engagement. Environments with safe furniture and objects, full observation abilities, and adequate staffing are required. See Table 149-8. Consider low doses and reengage as necessary. See Table 149-8. Minimize the need for reinjection of medica tions by choosing dosing appropriately. Physical restraint is often necessary. Offer oral medications immediately before intramuscular medications. Ensure the facility has appropriate seclusion and restraint policies. All seclusion and restraint policies require 1:1 obser vation. Remove restraints as soon as possible. Consider the possibility of rhabdomyolysis with physical restraints and asphyxia with person-to-person holds. TABLE 149-8 Pharmacologic Management of the Agitated Child Drug Child Dosing Adolescent Dosing Notes Appropriate for Sedation in Children Diphenhydramine 1 milligram/kg May repeat q30min 25–50 milligrams PO/IM Maximum: 200 milligrams/24 h 50–100 milligrams PO/IM Maximum: 300 milligrams/24 h Anticholinergic. Directly treats dystonia from antipsychotic treatment. Caution in suspected delirium as antihistamines are notoriously respon sible for worsening and causing delirium. Liquid form available. Lorazepam 0.05 milligram/kg May repeat q30min 0.5–2 milligrams PO/IM Maximum: Until sedated or ataxic 1–2 milligrams PO/IM Maximum: Until sedated or ataxic Paradoxical reaction can occur (but unlikely, and though vigilance is nec essary, do not withhold benzodiazepines to avoid this unless documented reaction). Respiratory depression. Sublingual tablet available. Appropriate for Sedation and/or Psychosis in Children Olanzapine 0.1 milligram/kg May repeat q30min 2.5 milligrams PO/IM Maximum: 5 milligrams/24 h 5–10 milligrams PO/IM Maximum: 20 milligrams/24 h c sparing. Dystonic reaction can occur but unlikely. Warning: IM preparation coadministered with benzodiazepine IM is not recommended because it can cause bradycardia and hypotension. Dissolvable tablet available. Anticholinergic. Risperidone 0.05 milligram/kg May repeat q60min 0.25–0.5 milligram PO Maximum: 2 milligrams/24 h 0.5–1 milligram PO Maximum: 4 milligrams/24 h c sparing. Dystonic reaction can occur. Dissolvable tablet and liquid form available. Methotrimeprazine 1 milligram/kg PO 0.5 milligram/kg IM May repeat q30min 12.5-25 milligrams PO 12.5-25 milligrams IM Maximum: 100 milligrams/24 h PO 50 milligrams/24 h IM 12.5–50 milligrams PO 12.5–50 milligrams IM Maximum: 200 milligrams/24 h PO 100 milligrams/24 h IM Hypotension, QTc prolonging, lowers seizure threshold. Anticholinergic. Appropriate for Psychosis in Children (when other treatments unavailable or failed) Haloperidol 0.05 milligram/kg May repeat q60min 0.5–2 milligrams PO/IM Maximum: 5 milligrams/24 h 2–5 milligrams PO/IM Maximum: 10 milligrams/24 h c prolonging. Extrapyramidal symptoms very likely in youth,42-46 especially dystonia. Consider coadministration of prophylactic anticholinergic (e.g., diphenhydramine as above or benztropine 1–2 milligrams PO/IM). Tintinalli_Sec12_p0669-0996.indd 987 8/2/19 7:59 PM