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- Pediatric visits for behavioral and mental health issues is on the rise.
- From 2008 to 2015, rates of PED visits for suicidal thoughts/attempts doubled.
- Shortage of pediatric psychiatrists: 8,300 nationwide with a need for 30,000.
- Deinstitionalized Movement of 1980's, has worsened this ED crisis-based culture.
- 50% of all mental illness begins by age 14.
- 1 in 5 children experience a mental disorder in a given year.
- Aggressive or agitated behavior in pediatric patients is different from adults.
- Children are more amenable to environmental and behavioral techniques, especially verbal de-escalation, once a trigger is identified.
- If not successful, avoid physical restraints and consider medications instead.
- Review current or previously prescribed medications, and consider extra/early/higher dosing. If naive to medications:
- First line is Diphenhydramine.
- Followed by Chlorpromazine, Risperidone, and Olanzapine
- Thorazine should be avoided in children under 12 years due to extra-pyramidal effects.
- Lorazapam not recommneded in children under 12 years, as it can cause disinhibition and worsen behavior.
- Avoid sedating children with neurodevelopmental disorders as they can have paradoxical reactions to diphenhydramine and benzodiazepines, and antipsychotics sometimes are not as effective.
- Boarding is common due to lack of resources, so starting treatment in the ED is imperative.
References
Hospitalization for Suicide Ideation or Attempt: 2008-2015. Pediatrics. Pelmons. 2018
Special Considerations in the Pediatric Psychiatric Population. Psychiatric Clinics. Santillanes 2017.
Sarah Edwards, DO. Medical & Program Director. Child and Adolescent Psychiatry. University of Maryland School of Medicine.