EMERGENCY PSYCHIATRY

PSYCHIATRIC EMERGENCY IN CHILD

AND ADOLESCENTS

INTRODUCTION

The hospital emergency department (ED) is an important and frequently accessed entry
point for children and youth. Approximately 10% of the population under age 18 have a
psychiatric illness that warrants treatment.

Precipitating factors for child psychiatric emergencies:

Family factors • Parental separation

• Parental abandonment
• Illness or death in the family
• Poor parent-child communication
School Factors • Academic failure
• Peer problems
• Bullying
Individual factors • Physical and intellectual disability.
• Chronic physical illness
• Isolation
• Impulsive behaviour.
• Poor social skills
• Broken romantic relationship.
Social factors. • Socio-economic disadvantages
• Social discrimination
• Isolation
• Neighbourhood violence.

UNDERSTANDING THE GUARDIAN’S MOTIVATION FOR SEEKING CARE

Adults bring youths to the ED not only for severe psychiatric illness but also for poor social
adjustment, psychosocial problems, and disconnects in the systems of care that surround
the youth and family. The reasons adults bring the child can be sorted into three domains:
Anxiety, Anger, and Adequacy.
Adults may be anxious about how a youngster is acting or feeling. Perhaps the child
seems different from other youths or perhaps he has said something about their distress or
done something that causes the adult to take notice or refuse to leave their room or go to
school; perhaps others have alerted the adult about concerning behavior.

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An adult may become angry – either directly at the child or at his/her actions. Perhaps
the child is destructive of property, disobedient of rules, or back-talking in a way that
infuriates adults. Coming to an ED setting may represent the hope that others will intervene
as the adult feels too angry to deal with the situation aptly.

At other times, there can be a mismatch between the ability of the parent to
adequately supervise and provide for a youngster’s needs. Perhaps the child is extremely
challenging to manage, e.g., constantly running into the street, wandering off with
strangers, etc., and “industrial strength” parenting skills are needed but not yet developed.

AGE-SPECIFIC PRESENTATIONS AND CONSIDERATIONS

PRE-SCHOOLERS

The types of problems this age group can have fall into four main categories:
(1) Developmental disabilities
(2) Attentional/activity level concerns
(3) Anxiety/trauma related issues
(4) Parental challenges. (The evaluation of the familial interaction is critical.)

Autism Spectrum Disorder by itself does not usually cause the type of disturbance that
would lead a parent to seek an emergency evaluation in this age group. Parents can,
however, grow frustrated with the challenges of parenting these children.

Attention deficit hyperactivity disorder (ADHD) youngsters can be extremely difficult to

parent and supervise. Their activity level and impulsive behaviors can lead to parents
seeking an evaluation in the emergency department.

Anxiety and other responses to traumatic events can bring young children to an Emergency
Department for evaluation – sometimes without any pathological symptoms on the part of
the child. For example, a three-year-old witnessing the death of a parent, who then goes on
to develop nightmares, could easily prompt an “emergency” evaluation.

Children experience the same symptom clusters after traumatic events as adults: re-
experiencing, avoidance/numbing, and arousal. Youngsters may not have the cognitive
maturity to express their concerns in words, so play may become the mode of
communication.

ELEMENTARY SCHOOL AGE

Types of problems that this age group can have been similar to those seen in preschoolers,
but additional considerations include the onset of mood disorders as well as increased
disruptive behaviour.

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• ADHD youths can be referred for evaluation as they are often off-task,
underachieving, and disruptive in a classroom setting.

• Learning disorders, also present in about 5% of children, can begin to be seen at this
time, as school becomes more demanding. This setting can then lead to increased
frustration and ultimately disruptive behavior as the child tries to conceal their
insecurities, lack of understanding, or mistakes.

• The median age of onset of separation anxiety (leading to problems such as school
refusal, avoidance, tantrums, etc.) is seven years old, with a prevalence of about 4%.
This can seem like a “new” problem in a previously well-adjusted
toddler/preschooler at home and could cause concern for parents if going to and
staying in, school is not easy.

• 1% of children in this age group have depression. A young child who is constantly
tearful and says that he/she wants to die can certainly lead a caregiver to bring
him/her to the emergency department.

The biggest challenge in an ED care setting is the school-age youngster who is brought in for
“aggression” or “disruptive behavior.” The youth may not have any clear problem with
worries, attention, or mood but is openly defiant, disruptive, and difficult to manage.

ADOLESCENCE
During adolescence, the risk increases for substance use, mood disorders including
depression and bipolar disorder, and in very rare cases, psychotic illnesses. Aggression as
the primary problem, either leading to the use of the ED setting or in the ED itself, is a
serious concern.

The following are some specific adolescent-related emergency situations.

1. SUICIDE-RELATED

Every year, 3% of adolescents attempt suicide and require medical attention. An additional
30% of the adolescent population will have suicidal ideation at some point in any given year.
While adolescent girls are more likely than boys to attempt suicide (21–31% versus 13 –
20%), adolescent boys are more likely to succeed. Girls tend to choose less lethal means,
such as overdose or cutting, whereas boys tend to choose hanging.

The emergency department (ED) often serves as a crucial site of care—to identify risk
factors, provide interventions, and facilitate further treatment—for individuals with a high
risk of self-harm.

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RISK FACTOR EVALUATION

Risk Factors Descriptions

Suicidal ideation As a core tenet for many psychometrics and screening tools for
suicidality, the endorsement of current suicidal ideation often signals a
higher risk of subsequent suicidal behaviors.
Suicidal attempts In numerous studies, past suicidal attempts significantly increased the
rates of future suicide-related behaviours and suicide completion in
outpatient, inpatient, or ED setting
Acute and chronic Among pediatric ED patients screening positive for suicidality,
stressors approximately 80% reported the presence of a recent life stressor,
such as interpersonal relationships, school-related stressors, the
health of self/friends/family, witness/victim of violence, and bullying

Access to lethal The most common methods of completed suicide seemed to be

methods suffocation/hanging, firearms, and overdose/poisoning
Gender Deaths by suicide in youths are significantly more common in males

Genetics of suicide (eg, A family history of suicide also seemed to convey greater risks of
family history) suicide-related behavior in youths

Psychiatric history/ Among youths with suicidal ideation, an estimated 89.3% would
recent hospitalization meet criteria for a DSM-IV diagnosis
Substance abuse In adolescents, alcohol or substance abuse was associated with more
depressive symptoms, severe suicidal ideation, recent suicide
attempt, and suicide completion
Interpersonal violence History of maltreatment also increases the risk of completed suicide.
(eg, a victim of Bullying seems to be significantly associated with increased rates of
physical/sexual abuse, mood symptoms and suicide-related behaviors in adolescents
bullying)

Intrapersonal 10% of adolescents will engage in NSSI at least once before the age
violence/NSSI of 15
Physical illness Chronic physical illnesses in youths are associated with a slight
increase in NSSI, suicidal ideation, and suicidal attempts
Social relationships Conflicts with parents or loss of a parent increased the risks of
completed suicide in prepubescent children
Special populations LGBTQ youths reported significantly higher rates of mood symptoms,
suicidal ideation, suicidal attempt, and higher severity of suicidality

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SUICIDE SCREENING TOOLS IN THE EMERGENCY DEPARTMENT

There are many tools available for screening suicidality in the emergency department.
Suicidal Ideation Questionnaire, Suicide Behaviors Questionnaire, Ask-Suicide Screening
Questionnaire, Beck Scale for Suicide Ideation (BSSI), and Universal Adolescent Suicide
Screening are among some.

DIFFERENTIAL DIAGNOSIS

Most children and adolescents who express suicidal thoughts, make suicidal attempts, or
intentionally injure themselves have either diagnosed or undiagnosed psychiatric disorders.

• Depression
Some children of depression have feelings of sadness and hopelessness that often come
with depression can often lead children to feel that things will never change or improve
and that suicide is their only escape from pain and misery. Some children cut themselves
to escape the numbness that can accompany depression or to attempt to alleviate the
emotional pain of feeling depressed.
• Bipolar Disorder
Bipolar disorder can increase the risk of suicidality in children and teens for several
reasons. First, it impairs rational thinking and makes teens more impulsive, putting them
at risk for impulsive self-destructive behavior. Second, the symptoms of bipolar disorder
are difficult to manage, often contribute to interpersonal problems, and can affect self-
esteem.
• Anxiety Disorders
Excessive anxiety is a very distressing and uncomfortable experience and can be difficult
to tolerate for an extended period, so adolescents may cut themselves to relieve the
tension. Some teens with anxiety are acutely self-conscious and embarrassed by their
symptoms, which may lead to shame and suicidal thoughts or behavior.

• Substance Use
Drugs and alcohol lower inhibitions, impair the ability to think clearly and make good
choices, and increase the likelihood that someone will act impulsively. Thus, many
suicide attempts are made when the person is intoxicated.
• Trauma and Posttraumatic Stress Disorder
PTSD patients may feel intense shame, blame themselves for the traumatic event, or
feel so besieged by traumatic memories that they feel self-harm or suicide is the only
way to cope.
• Psychosis
Some children with psychosis experience auditory hallucinations in which “the voices
told me to cut” or “the voices told me to kill myself,” and these youths are at very high
risk for suicide and self-harm. Other youths have delusions that are very frightening to
them, such as that they are evil or cursed, and may lead to suicidal thoughts or
behaviors
• Attention-Deficit/Hyperactivity Disorder

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ADHD children can raise the risk that they will do something to harm themselves in the
midst of a conflict, during a stressful moment, or when experiencing a strong emotion
without fully considering the possible outcomes or being able to think rationally about
alternative ways of coping.
• Autism Spectrum Disorder
ASD children can also often be targets of teasing or bullying by peers or be socially
isolated because they seem “odd” to peers. This can put them at increased risk of
suicide when faced with acute stress.

MANAGEMENT OF SUICIDAL BEHAVIOR

At the emergency department, young persons who have made a suicide attempt should be
assessed by an experienced mental health professional, including interview with parents or
relatives and a thorough risk assessment.

o Onsite Stabilization
o There is a common misconception that discussing suicide will "put the idea in their
head" and cause children to attempt suicide. This is not the case. In fact, open and
nonjudgmental communication about suicide sends the message to teens that adults
care about them, are capable of dealing with these issues, and know how to help.
o Catch the Warning Signs
physical evidence of cutting or burning; talking about death or dying; drug or alcohol
use; hopelessness about the future; recent loss; changes in personality or motivation;
social withdrawal; loss of interest in activities; poor sleep, eating, hygiene, or
concentration; changes in school performance; bizarre or erratic behavior; and feelings
of low self-esteem, guilt, or worthlessness.
o Listen and Empathize
If a child has been cutting herself or engaging in self-injury, ask about it without passing
judgement to understand the child's perspective. It can be upsetting for an adult to
discover that a child they care about is harming themselves. However, try to remain
calm and avoid strong emotions, as the child will often hide the self-harm for fear of
upsetting others. Ask the child when and how she hurt herself, as well as her intention
at the time. Whether she harmed herself with suicidal intent or for other reasons,
identify any factors or stressors that contributed to the self-injury. What tool she used to
hurt herself, how she felt afterwards, and whether she considered doing it again. Any
injury should be visually examined to determine whether the child requires medical
treatment, such as stitches.

o Collaborate with others to Find Solutions

Often, the child will request that things be kept private, and it is critical to be upfront
with the child about who will be notified and why. If a parent is to be informed, the child
should be informed and given the option of telling the parent or being present when this
occurs. The need to ensure the child's safety should be emphasised as the primary
reason for informing others.

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When a child finds out to be suicidal at school or another program, parents should
be notified immediately and invited to pick up the child and discuss what the child has said
with staff. The child should be evaluated immediately by a mental health professional,
preferably one who already knows the child if the parent can do so in a safe manner. This
evaluation should take place on the same day.
If the child is too aggressive, disorganized, angry, or unpredictable for a parent to
safely transport her to the hospital, emergency medical services should be contacted, and
the child should be escorted to the hospital by ambulance, accompanied by a parent. If the
child has taken an overdose or has cut herself deeply, 108 should be called and the child
should be taken to the ER immediately for both medical and psychiatric evaluation.
Management should be tailored to each patient's specific risk factors. Interventions
should not be limited to specific psychopharmacological or psychotherapeutic interventions
but should be part of a comprehensive treatment plan that includes all strategies for coping
with acute stress. These principles may include:

• Strategies to improve adherence to treatment (e.g., offering short interventions that are
acceptable to the youth; sometimes focusing on support is more effective than insight-
oriented psychotherapy).
• Active involvement of the patient and parents in the planning and implementation of
interventions.
• Protecting the patient if major adversities threatening the patient’s mental and physical
health are present.
• Offering support to the family (e.g., in case of marital conflict, problems arising from
divorce, parental mental illness, poor parenting practices, parental substance misuse)
• Enlisting support from child welfare agencies if indicated
• Organizing for relief from excessive demands (e.g., school demands exceeding patients’
current capacity)
• Treating underlying psychiatric disorders
• Regular monitoring for the recurrence of suicidal behavior and an emergency plan for
acute suicidal crises.
• Offering flexible treatment sessions, time and frequency adapted to the patient’s needs.
• Establishing effective communication between all the professionals involved (social
worker, psychotherapist, child psychiatrist, pediatrician).

Psychopharmacological Treatment

There are no specific medications for suicidality. However, medication may be needed to
treat underlying psychiatric disorders.

2. PSYCHOSIS OR PSYCHOTIC-LIKE PRESENTATIONS

According to a systematic review, the prevalence of psychotic symptoms in young

individuals is relatively high (median 17% among 9 to 12-year-olds and 7.5% among 13 to
18-year-olds) (Kelleher et al,2012). The young person may present to the psychiatric
emergency if the psychotic symptoms worsen, impede functioning, or pose an immediate
risk to the patient or others.

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Schizophrenia is more common in adolescent boys than in girls, as men typically develop
symptoms earlier than women. Positive symptoms of schizophrenia (hallucinations and
delusions) are the most likely to appear in an ED.

Workup of psychosis should begin with a physical exam with a focus on neurological
examination, vital signs, weight, height, body mass index (BMI), and waist circumference.

Tips for evaluation of adolescents/children with psychosis and agitation in the ED

Step 1 Take a good history.
Do not automatically accept labels as schizophrenia or bipolar disorder
Step 2 Never assume a child/ adolescent is medically healthy just because the
are young.
Many drugs do not show up on urine screen- ask and ask about drug use
Step 3 If pharmacological intervention is required use as low dose as possible
Beware of paradoxical inhibition with benzodiazepines and
antihistaminics.

clinical features of psychosis in the young patient

Primary thought disorder: Rarest of all emergency department visit for youth.
schizophrenia, schizoaffective Look for negative symptoms and poor ability to relate
disorder to staff/providers.

Drug-induced agitation and Sudden in onset

psychosis May or may not related to a identifyable substance
Often occurs in conjunction with polysubstance use
Hallucination/agitation and paranoia may be
prominent
Mood disorders: depression, Screen carefully for psychotic symptoms even if mood
bipolar disorders symptoms are prominent
Psychotic symptoms increase the odd for self harm,
agitation

Other Differential diagnoses for adolescent patient who are agitated and psychotic are:
1. traumatic brain injury,
2. autoimmune disorders (lupus and NMDA receptor encephalitis),
3. congenital disorders,
4. toxic substance-induced,
5. iatrogenic (anti-malarial, steroids, isoniazid),
6. cerebrovascular disorders,
7. space occupying lesions (tumors),

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8. metabolic (pheochromocytoma, Wilson’s disease),

9. dietary (B12 deficiency, vitamin D deficiency,
10. sepsis / infectious disorders (HIV, neurosyphilis),
11. neurologic disorders (Parkinson’s disease, Huntington’s disease, multiple sclerosis),
12. seizure disorders (partial complex seizures, temporal lobe epilepsy),
13. endocrine disorders (hyperthyroidism, hypothyroidism, hyperparathyroidism)

EVALUATION OF THE TEENAGER WITH PSYCHOTIC SYMPTOMS

When an adolescent presents with acute psychosis for the first time, a reasonable workup
could include neuroimaging, which has the advantage of providing comfort to parents who
are searching for an organic explanation for their child's acute psychosis, drug screens, and
laboratory tests (to assess for infections, metabolic abnormalities, and vitamin deficiencies).

A toxic or drug-related cause of psychosis must be considered. Stimulants (cocaine,

amphetamines) and cannabis are the substances most likely to induce acute psychosis and
agitation. Acute psychosis can also result from the withdrawal from alcohol and
benzodiazepines.

Commonly used psychosis rating scale

Brief psychiatric rating scale Based on the clinician’s interview with the patient
and observations of the patient’s behavior over the
previous 2-3 days

Positive and negative syndrome scale Requires a 45-minute clinical interview during
which the patient is rated from 1 to 7 on 30
different symptoms based on the interview as well
as on reports of family members and other
informants.

MANAGEMENT

Choosing Medication for a Patient with Agitation in Psychosis:

Pharmacotherapy for agitation aims to: (1) address the underlying cause of the patient's
distress; and (2) calm the patient down enough to allow for an accurate and efficient
assessment and course of treatment. This includes administration of medication that is
calming, quick-acting, and not unduly sedative.
The selection of medication during a crisis can be influenced by a patient's prior psychiatric
treatment, established diagnosis, and previously helpful medication regimen.
Benzodiazepines like lorazepam can be used both orally as well as intramuscularly in the
dose of 0.5mg to 2mg orally or 0.05mg- 01mg/kg/body weight intramuscularly. However,
lorazepam may cause paradoxical worsening, sedation, or respiratory suppression.

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Apart from benzodiazepines, various neuroleptics can be used in psychotic agitation as

mentioned in the table below:

3. AGITATION

Agitation is much like a vital sign, signalling distress and dysfunction in the patient
warranting evaluation and Management. Often agitation is reactive, occurring in response
to a perceived provocation or stressor.

Causes of aggression in children and adolescents

Young Children Adolescents
Reaction to interpersonal conflicts and difficulties in Bipolar Disorder
their environment (inconsistent or abusive parenting,
lack of appropriate discipline)
Psychosis Depression
Severe ADHD Substance abuse/reaction
Seizure Disorder Schizophrenia

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Risk factors for development of agitation and aggression in youth:

Nonmodifiable risk factors: Modifiable risk factors:

o Past history of aggression o Psychological factors
o History of property destruction o Impulsivity
o History of physical or sexual abuse o Poor distress tolerance
o History of interpersonal violence o Limited insight
o History of previous psychiatric o Difficulty establishing trust in others
hospitalization
o History of previous disciplinary action o Negative world view
at school/other environments
o Traumatic brain injury o Lack of empathy
o Developmental delay/cognitive delay o Difficulty with authority figures
o Male gender
o Low family income
o Criminal history or gang involvement
Psychiatric factors: Physical health factors:
o Disruptive behavior disorder o Central nervous system disorders
o Conduct disorder o Metabolic disorders
o Autism spectrum disorder o Endocrine disorders
o Severe anxiety, irritability, or mood o Genetic disorders
lability
o Psychotic disorder o Acute or chronic pain
o Delirium o Poor sleep
o Catatonia o Inflammation or infection
o Substance use, intoxication or
withdrawal (particularly at early age)

Clinicians dealing with a patient exhibiting acute agitation may have limited time for
evaluation, but even a quick assessment of the patient and the chart can provide critical
information for management and is feasible in any situation. Even the most brief
assessment should include a focused review of the presenting history, previous diagnoses,
and episodes of agitation (including triggers and response to intervention), as well as vital
signs.
The physical examination can be useful in identifying factors that contribute to
agitation. If the child is unwilling to cooperate during the examination, a visual assessment
of gait, pupil size, general appearance, and a review of recent vital signs can reveal
important clues to physical or genetic disease, intoxication, and developmental/functional
disability.
A thorough head-to-toe examination should look for possible head trauma,
hemotympanum, neck stiffness, vision, and hearing deficits, dental issues, signs of infection
or cardiorespiratory decompensation, evidence of peripheral or central nervous system
dysfunction, and any localized pain. Clinical history, physical examination, symptom
evolution, and careful clinical judgment should all be taken into consideration when
evaluating results from lab and imaging tests.

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Nonpharmacologic Approaches to Prevention and Management of Agitation

The first line of agitation management involves environmental, communication, and

behavioural interventions. The use of medications does not preclude the use of these
nonpharmacological interventions, which can be used concurrently.

• Environmental strategies to prevent and de-escalate agitation.

The Emergency Department environment can be hectic, triggering, or unpredictable.

Agitation can be triggered by high levels of ambient noise and smells, variability in
lighting and temperature, physical stimuli (pain, fatigue, hunger), frustration, and
frequent interaction with strangers (including touch and invasive interventions).
Children with intellectual disabilities, autism spectrum disorder, impulsivity, attention
deficits, or low frustration tolerance may be especially vulnerable to environmental
stressors. Every patient's initial ED assessment should include the identification of any
specific sensitivities or sensory triggers.
Escalation can be avoided with basic interventions like dimming lights, stopping
unimportant interventions (like routine vital sign checks or intravenous (IV) hep-locks),
relocating the child to a space where they can move around freely without being
disturbed, or providing preferred sensory tools or distraction strategies (like an iPad or a
beloved cartoon).
If the child becomes more disruptive, they should be taken to a quiet, secure area of
the emergency room, away from other patients. Any object that may be dangerous
should have restricted access.

• Communication strategies for de-escalating agitation

Effective communication is critical in all aspects of agitation management.

Communication with the child should be conducted in a neutral, empathic tone. Often,
getting down to the patient's eye level and speaking in a soft and inviting tone with
clear, concrete, and simple language helps the child process information or follow
through on requests. Body language should be respectful, non-confrontational, relaxed
but confident, with no sudden movements or intrusions into personal space. Repetition
may be required to allow agitated children to process and to ensure that they are heard.

• Family engagement

Family members involvement has been shown to reduce anxiety and behavioral
escalation in all patients, especially those with intellectual disabilities or autism. Families
can offer reassurance and comforting physical touch, as well as comforting items from
home, to help the child relax while in the emergency room.
In some cases, family members or other visitors may irritate the child or be the primary
cause of the child's agitation. In those cases, some time off from a family member or
visitor may be beneficial to the patient. Praise for adaptive behaviors, as well as
validation of the patient's emotions, can be extremely effective in preventing
behavioural escalation while also de-escalating agitation.

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• Behavioural strategies for de-escalation of agitation

Distraction techniques, child life services, social engagement, and cognitive

behaviour therapy can help children manage anxiety and distress in the ED
environment.

• Restraint and seclusion

Use of restraint and seclusion should be reserved only for when nonpharmacologic
strategies, management of physical health comorbidities, and cause-focused
medication use are unsuccessful in curbing agitation and the patient poses an
imminent threat of harm to self or others. Close monitoring should be used with the
use of quality indicators to ensure that the use of restraint and seclusion is heavily
monitored and mitigated when possible with proper documentation.

Psychopharmacologic management of agitation

Chemical restraint refers to using emergency medications to manage aggressive or

disruptive behaviour. The American Academy of Child and Adolescent Psychiatry Practice
Parameter defines chemical restraint as the involuntary use of psychoactive medication
during a crisis to control aggressive behaviour.

Precautions:
• Whenever possible, use medication that the patient is familiar with or has previously
been prescribed.
• Previous drug effects should be considered as a reference.
• Anticipate and prepare for any potential side effects of medication.
• Benzodiazepines have been shown to disinhibit young children, causing them to
become agitated rather than calmer.
• Oral medication is preferable whenever safe and feasible.

The following can be considered:

a. PO or IM diphenhydramine: 1mg/kg/dose
b. PO risperidone: 0.25mg–2mg
c. PO or IM lorazepam: 0.05mg/kg/dose (with caveat as noted above)
d. PO or IM haloperidol: 0.025–0.075mg/kg/dose.

CONVERSION DISORDER

Conversion disorder is characterized by neurological symptoms (paralysis, tremor, and

aphonia) that cannot be attributed to an organic cause. This disorder typically appears
between the ages of 12 and 16 and is rarely seen before the age of 7. According to studies,
psychiatric comorbidities are common (50% or even 60%), with anxiety disorders and major
depressive episodes being the most frequently observed. Somatic comorbidities can also
exist.

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Dissociative disorders are characterised by disruptions or discontinuities in normal functions

such as consciousness, memory, identity, emotion, perception, body representation, motor
control, and behaviour. It may manifest as "positive" symptoms such as depersonalisation,
derealization, or fragmentation of identity, or as subjective "negative" experiences with loss
of access or control over mental functions such as memory, resulting in dissociative
amnesia. Children and adolescents who have experienced traumatic events, such as
maltreatment, abuse, natural disasters, or war, are more likely to develop dissociative
disorders.

RISK FACTORS

For children, the most common stressful life events are:

1) family conflicts,
2) a change in family situation (new member or separation of a family member),
3) academic difficulty
4) relationship problem with peers
5) poor academic performance
6) harassment.

ASSESSMENT AND DIAGNOSIS

A comprehensive psychiatric and developmental history is required for the assessment of
dissociative disorders. The child's temperament, academic performance, and peer
relationships should all be evaluated. The family's functioning should be investigated. A
comprehensive medical, neurological, and mental health examination should be performed.
An assessment of psychosocial circumstances and problems should be conducted to
determine which ones are temporally associated with the onset of dissociative symptoms.
An attempt should be made to determine the presence of physical and psychological
symptoms in other family members or neighbours who could serve as models. In addition,
the child's and parents' perceptions of dissociative symptoms should be assessed.

RULING-OUT PHYSICAL AND OTHER PSYCHIATRIC DISORDER

If dissociative symptoms appear for the first time in a preschool child, a strong suspicion of
an underlying physical or psychiatric disorder should be kept in mind because dissociative
disorders are very rare in this age group.
Investigations for ruling out physical or psychiatric disorders are follows:

Investigations Disorders
EEG (Video EEG) seizure disorder
IQ test Intellectual disability or borderline intellectual
functioning
Urine drug screen Substance abuse
Neuroimaging Structural lesions eg. Brain tumours
Blood tests Eg. Post ictal Prolactin elevation, physical disorders

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Pseudo seizures or nonepileptic seizures are a common manifestation of dissociative

disorders in children that must be distinguished from true epileptic seizures.
Differences between dissociative convulsion and epileptic seizure as follows:

DISSOCIATIVE CONVULSION EPILEPTIC SEIZURE

Preictal phase
Anxiety Wide range of auras
Seizures may be induced Rarely induced
Ictal phase
Inconsistent and variable sequence of Consistent and invariable sequence of
events events
Occur only when others are present Can occur when alone or during sleep
Gradual onset Abrupt onset
Prolonged duration (>2min.) Short duration (<2min.)
Asymmetrical limb movements, pelvic symmetrical movements
thrusting, sideways shaking of head
Rare incontinence, injury due to fall, Incontinence, injury due to fall, frothing,
frothing, tongue biting tongue biting often present if generalized
Normal autonomic reactivity, pupillary Disturbed autonomic reactivity, pupillary
responses Responses
Vocalizations may occur throughout Single vocalization, if present, at onset
seizure
Avoids noxious stimuli Cannot avoid noxious stimuli
Resists eye opening, or there is avoidant Cannot resist eye opening
gaze
Normal ictal EEG Abnormal ictal EEG
Post ictal phase
No postictal delirium Typical postictal delirium
Subsequent recall of events during ictus no or fragmentary recall of events during
ictus
No rise in serum prolactin Rise in serum prolactin10-20min.
postictally

DIFFERENTIAL DIAGNOSIS AND COMORBIDITIES

Dissociative symptoms may be the presenting symptoms of an underlying undetected

psychiatric disorder such as separation anxiety disorder, generalised anxiety disorder, panic
disorder, school phobia, depression, or, in some cases, impending psychosis. Then,
dissociative disorder may coexist with oppositional defiant disorder, attention deficit
hyperactivity disorder, and intellectual disability, particularly in boys. Therefore, it is
important to screen for all age appropriate psychiatric disorders in the child to avoid missing
an underlying primary or comorbid diagnosis.

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TREATMENT

The treatment usually consists of two parts:

(a) early treatment directed towards symptom removal.
(b) long-term treatment directed towards the resolution of stressors, and prevention of
further episodes.
Establishing therapeutic rapport and alliance with the child is essential for successful
therapy. It is also critical to have good doctor-parent interactions because the
parents must play part of the team in the treatment of their child.

PSYCHOSOCIAL EXPLANATION OF DISSOCIATIVE SYMPTOMS

Key points of psychoeducation are:

• It needs to be understood that the child is experiencing real symptoms and suffering,
but the causes may be psychological rather than physical.
• The harmlessness of the symptoms should be emphasized. It should be noted that
the symptoms are not harmful or fatal.
• Symptoms that do not indicate a serious physical disease are common. These
symptoms may be better explained by the mind-body relationship. For example,
anxiety can cause palpitations, tremors, rapid breathing, sweating, and so on.
• Emotions can trigger physical symptoms, even in children.
• Although stresses might not seem serious or significant to adults, they might be
major issues that should worry in a children’s point of view.

ADDRESSING THE PSYCHOSOCIAL PROBLEMS

In the case of adolescents, if the problem has been disclosed to the doctor or ward staff in
confidence, the adolescent's consent should be obtained before discussing it with the
family. during the treatment, attention should be directed towards the child and his
functioning rather than the symptoms. This promotes a speedy recovery.

Behavioral management of children are:

o Reassuring the child that he/she is not seriously ill.
o Encouraging the child to gradually resume normal daily activities and functioning.
o Encouraging physical exercise and play
o Relaxation exercises e.g. deep and slow abdominal breathing
o Paying attention to the child when normal without symptoms.
o Engaging the child in age-appropriate activity of interest like drawing, colouring,
story book reading etc.
o Encouraging joint activities with parents
o Praise and appreciate for positive behaviour.

SYMPTOM SUBSTITUTION
As the dissociative symptoms subside, the child may develop new dissociative symptoms in
their place.In such cases, consistent limit setting may be required for the continuation of

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psychological treatment. Regular follow-up visits are necessary so that the patient does not
have to 'produce' a symptom to see the therapist.

SECONDARY GAINS

Reduction in secondary gains is not advisable very early in the treatment because of three
reasons:
1) The physician himself may not be certain about the origin of the symptoms.
2) The family may perceive reduction in secondary gain as neglect of the child.
3) Initially the family may not have full confidence in the physician and the hospital
ability to take care.
Eventually the family could be given adequate explanations for secondary gains. Reducing a
child's secondary gains should be accompanied by an alternative, healthy, socially
acceptable, and age-appropriate role or activities in which the child can be trained and
rewarded for doing something positive.

MEDICATION
Only concurrent anxiety, depression, or behavioural issues may be treated with medication;
dissociative symptoms cannot be treated with medication. However, some families continue
to demand medication despite repeated explanations. In such cases, a placebo may be used
to keep the child in treatment while also overcoming family resentment or hostilities.

NEED FOR HOSPITALIZATION

Inpatient care is advised when the diagnosis is uncertain, severe symptoms are present, the
family is in great distress, or the symptoms are resistant to outpatient treatment.

DUAL DIAGNOSIS

If the dissociative symptoms coexist with the physical disorder, the physical disorder should
be addressed first. When the physical disorder is stabilised, any remaining dissociative
symptoms should be managed according to the guidelines.

CONCLUSION

Emergency child psychiatry is becoming increasingly important and relevant. Emergency

rooms are being used more frequently as a first interface of call for mental health services
as well as for the evaluation of child and adolescent crises. For all mental health
practitioners who might work with children, this is a pertinent field of learning.

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