and adolescents 1 1 introduction Few seek psychiatric intervention even during crisis Usually seek by parents relatives teachers therapists physicians and child protective service workers ID: 600134
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Psychiatric Emergencies in Childrenandadolescents
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introductionFew seek psychiatric intervention even during crisis
Usually seek by parents, relatives, teachers, therapists, physicians, and child protective service workers.
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classificationlife-threatening referrals
Non life-threatening referrals
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Life-Threatening EmergenciesSuicidal behavior
Homicidal behaviorViolent Behavior and TantrumsFire settingChild Abuse: Physical and Sexual
Neglect: Failure to Thrive
Anorexia nervosa
Acquired Immune Deficiency Syndrome
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Non-Life-Threatening SituationsSchool refusal
Posttraumatic Stress DisorderDissociative disorder
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Suicidal Behavior
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IntroductionDepression as the most significant psychiatric risk factor
Majority of depressed individuals neither complete nor attempt suicide No mood disorder in many children and adolescents engaged in suicidal behavior
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DefinitionSuicidal behavior is a spectrum
passive thoughts of death (e.g., May be I would be better off dead) active suicidal ideation (e.g., I would like to kill myself) suicidal ideation with a plan and intent
Suicidal threats (verbalization of suicidal ideation)
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definition
Self-injurious behavior( relief of painful affect)suicidal attempt (self-destructive behavior with inferred or explicit intent to die)
Completed suicide ( suicide attempt results in death)
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Epidemiology
3-month prevalence study in 9- to 16-year-olds Wanting to die of around 1 percent
Ideation with a plan of 0.3 percent
Suicide attempt of 0.25 percent.
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Epidemiology In a study on 14- to 18-year-olds
The lifetime prevalence of suicide attempts was 7.1 percent rates for girls (10.1 percent) rates for boys (3.8 percent)
The annual suicide attempt rate for medically serious suicide attempts in adolescents (1 to 2 percent)
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Completed suicide 10-14 years olds
0.95/100,000 for female1.71/100,000, respectively, for male
15-19 years olds
3.52/100,000 for female
12.65/100,000 for male
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EpidemiologyThe rate of suicidal behavior increase with age
The most common method for adolescent suicide attempts is overdose, with the second-most-common method being wrist cuttingThe most common method in the United States for completed suicide is using firearms, followed by hanging, jumping, carbon monoxide poisoning, and taking an overdose.
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Risk factorsIntensity and intent
lethality precipitant motivationavailability of lethal agents.
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Intensity and IntentIn adolescent suicide attempt
chance of a reattempt within 1 year is 15-30% highest risk for reattempt is the first 3 months
In suicide attempters
risk for completed suicide is 10-60 folds
highest risk in attempts of high lethality and intent
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motivationkey to an effective treatment planWish to die in one third of adolescents who attempt suicide
Escape an intolerable situation, express hostility, or get attention and support in remainder
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PrecipitantMost common precipitants for suicidal behavior are:
Parent–child conflict In younger children and adolescentsDifficulties in peer and romantic relationships In older adolescents
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LethalityLethality refers to the medical dangerousness of the suicide attempt.
Intent and lethality are not always highly correlated, especially in children and young adolescents (gesture, impulsive attempts) Attempts resemble completers are much more likely eventually to complete suicide with regard to method (hanging or firearms)
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Availability of Lethal AgentsIn USA approximately 60 percent of youth suicides involve firearms
Hanging is the leading cause of death in many other countries.An association between the availability of guns, particularly handguns, and risk for completed suicide
Other cultural factors governing method choice.( low firearm-related suicide rate in Switzerland in spite of gun availability)
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EtiologyMental disorderSuicide in the Apparent Absence of Disorder
Health Risk BehaviorsMedical conditionsFamilial and Environmental Factors
Psychological factors
Exposure to Suicidal Behavior
Biological factors
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Mental DisorderThe rate of psychiatric disorder in completed and attempted suicide is 90 and 80 percent respectively.
Greater chronicity, severity, and complexity (e.g.,
comorbidity
) and more suicidal behavior
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Mental disorderMood disorders are strongly associated with more suicidal behavior
60 percent of adolescent suicide victims had a mood disorder at the time of death.High risk of suicidal attempts and completions in BMD(rapid cycling or a mixed state ) More insomnia, agitation, and irritability more suicidal behavior
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Suicide in the Apparent Absence of Disorder
No clear evidence for psychiatric disorder
in 40% of young adolescents
in 90% of old adolescents
The most common contributory
factors are:
disciplinary precipitant
an impulsive suicide attempt
the presence of a loaded gun in the home
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Health Risk Behaviors
Suicidal behavior most commonly occurs as part of a constellation of other health risk behaviors
Non suicidal self-injurious behavior
Binge drinking
Abnormal eating behavior
Weapon carrying
Unprotected sex
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risk factors for health risk behaviorsWeak parent–child relationship
Conflict in parent–child relationship poor connection between child and school association with deviant peers.
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Medical Conditionschronic illnesses such as epilepsy, diabetes, and asthma increase risk for depression and suicidal behavior
Poor physical health and disability has also been associated with suicidal behavior
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Psychological FactorsImpulsive aggression
NeuroticismHopelessness or pessimism Same-sex attraction
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Familial and Environmental Factors
Higher rates of depression, substance abuse, and assaultive behavior in the parents of adolescent suicide attempters and completersloss of a parent before the age of 12 years associated with an increased risk of recurrent suicidal behavior.
Attempted suicide among family and friends related to an increased risk of attempt in adolescents
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Familial and Environmental Factors Child suicide attempt associated with
Parent–child discord perceived lack of support High levels of criticism and hostility
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Familial and Environmental FactorsPhysical and sexual abuse and neglect as the most clinically significant family risk factor for suicidal behavior
Youth at risk for suicidal behavior are not well connected to school, work, or family
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Biological factorsThe associations of altered central serotonin with suicidal behavior and impulsive aggression
Altered central serotonergic function in adverse family environment, such as early separation, discord, socioeconomic stress, and abuse
Biological factor may result from both genetic and environmental predispositions.
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Course and PrognosisSuicidal behavior is highly recurrent.
15 to 30% of adolescents reattempt suicide with 1 year 0.5-1% per year is the risk for a completed suicide
High proportion of individuals with suicidal ideation with a plan go on to make an attempt within 1 year.
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Predictors of reattemptSeverity of depressionContinued suicidal ideation
Comorbid anxiety and conduct disorderImpulsive aggressive personality traits,
Hopelessness
Family discord
History of sexual abuse.
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TreatmentSuicidal ideation is highly correlated with the severity of depression
Concomitant decrease in suicidal ideation along with reduction in depressionA decline in the suicide rate that coincides with increased prescriptions for SSRIs.
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TreatmentNo definitive psychosocial or pharmacological treatments for suicidal behavior.
Treating the related psychiatric disorder and psychosocial difficulties, such as family discord and difficulties with emotion regulation and problem solvingA safty
plan to avoid precipitants for recurrent suicidal behavior and to cope with suicidal ideation if it reoccurs.
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Treatmentlithium may be efficacious in individuals with bipolar, and even
unipolar, depression.Emotion regulation and problem solvingBrief cognitive–behavioral therapy
Improving the detection and treatment of depression in primary care
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TreatmenT ,Current guidelines
Removing or securing lethal agents from the homeTreating the underlying psychiatric disordersAddressing the psychosocial issues, such as hopelessness, family discord, poor emotional regulation skills, or impaired social problem solving
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Violent Behavior and Tantrums
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AssessmentMake sure that both the child and the staff members are physically protected
physical restraint may be necessary before anything else is attemptedMost likely to calm down if approached calmly in a nonthreatening manner and given a chance to tell their side of the story to a nonjudgmental adult
looking for any underlying psychiatric disorder
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ManagementPrepubertal
children, in the absence of major psychiatric illness, rarely require medication to keep them safe, because they are generally small enough to be physically restrained if they begin to hurt themselves or others. It is not immediately necessary to administer medication to a child or an adolescent who was in a rage but is in a calm state when examined.
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managementMedication before a dialogue if adolescents and older children are assaultive, extremely agitated, or overtly self-injurious
No hospitalzation need if they are able to calm down during the course of the evaluation.
Hospitalization is necessary if adolescents continue to pose a danger to themselves or others during the evaluation period
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Child Abuse: Physical and Sexual
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AssessmentPhysical and sexual abuse occurs in girls and boys of all ages, in all ethnic groups, and at all socioeconomic levels.
The abuses vary widely with respect to severity and duration, but any form of continued abuse constitutes an emergency situation for a child fear, guilt, anxiety, depression, and ambivalence regarding disclosure commonly surrounds the child who has been abused.
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AssessmentThe
child and other family members must be interviewed individually to give each member a chance to speak privately. If possible, the clinician should observe the child with each parent individually to get a sense of the spontaneity, warmth, fear, anxiety, or other prominent features of the relationships.
One observation is generally not sufficient to make a final judgment about the family relationship
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Physical indicators of sexual abusesexually transmitted diseases (e.g., gonorrhea)
pain, irritation, and itching of the genitalia and the urinary tractdiscomfort while sitting and walking. In many instances of suspected sexual abuse, however, physical evidence is not present. Thus, a careful history is essential.
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School Refusal
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Assessment May occur in a young child who is first entering school or in an older child or adolescent who is making a transition into a new grade or school, or without an obvious external stressor.
In any case, school refusal requires immediate intervention, because the longer the dysfunctional pattern continues, the more difficult it is to interrupt.
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AssessmentSchool refusal is generally associated with separation anxiety.
Severe psychopathology, including anxiety and depressive disorders, is often present when school refusal occurs for the first time in an adolescent.Extreme worries that catastrophic events will befall their mothers, attachment figures, or themselves as a result of the separation.
Somatic complaints such as headaches, stomachaches, and nausea.
The stated reasons for refusing to go to school are often physical complaints.
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ManagementIn severe cases, however, a multidimensional, long-term family-oriented treatment plan is necessary
Whenever possible, a separation-anxious child should be brought back to school When the child's anxiety is not diminished by behavioral methods alone, tricyclic
antidepressants, such as
imipramine
(
Tofranil
), are helpful.
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