Faculty Bibliography

OBJECTIVE:Impairing emotional outbursts, defined by extreme anger or distress in response to relatively ordinary frustrations and disappointments, impact all mental health care systems, emergency departments, schools, and juvenile justice programs. However, the prevalence, outcome, and impact of outbursts are difficult to quantify because they are transdiagnostic and not explicitly defined by current diagnostic nosology. Research variably addresses outbursts under the rubrics of tantrums, anger, irritability, aggression, rage attacks, or emotional and behavioral dysregulation. Consistent methods for identifying and assessing impairing emotional outbursts across development or systems of care are lacking. METHOD/METHODS:The American Academy of Child and Adolescent Psychiatry Presidential Task Force (2019-2021) conducted a narrative review addressing impairing emotional outbursts within the limitations of the existing literature and independent of diagnosis. RESULTS:Extrapolating from the existing literature, best estimates suggest that outbursts occur in 4%-10% of community children (preschoolers through adolescents). Impairing emotional outbursts may respond to successful treatment of the primary disorder, especially for some children with attention-deficit/hyperactivity disorder whose medications have been optimized. However, outbursts are generally multi-determined and often represent maladaptive or deficient coping strategies and responses. CONCLUSION/CONCLUSIONS:Evidence-based strategies are necessary to address factors that trigger, reinforce, or excuse the behaviors and to enhance problem-solving skills. Currently available interventions yield only modest effect sizes for treatment effect. More specific definitions and measures are needed to track and quantify outbursts and to design and assess the effectiveness of interventions. Better treatments are clearly needed.

OBJECTIVES/OBJECTIVE:The increasing rates of depression and suicidality in children and adolescents are reflected in the increasing number of mental health-related visits to emergency departments. Despite the high rates of traumatic exposure experienced by high-acuity children and adolescents and a known link to suicidal ideation, the systematic review of trauma history is not a consistent part of emergency department assessments for suicide ideation or attempt. In the present study, we examined the prevalence of suicidality as well as traumatic exposures in children and adolescents presenting to a dedicated pediatric psychiatric emergency department. METHODS:Suicide ideation, suicide attempts, and trauma exposure history were identified through a retrospective chart review of youth (n = 861) who presented to a dedicated child psychiatric emergency department during a 1-year period. Bivariate analyses comparing demographic and trauma history for children with and without suicidality and a multivariable logistic regression were performed. RESULTS:Childhood adversity was common, with 52% of youth reporting at least one type of trauma exposure. Emotional abuse, physical abuse, and sexual abuse/assault were associated with suicidality. Any trauma exposure and the total number of different trauma exposures were associated with reported suicide attempt. After adjusting for sociodemographic characteristics, children who reported a history of emotional abuse had 3.2-fold increased odds of attempted suicide. Children who reported a history of being a victim of bullying had 1.9-fold increased odds of current suicidal ideation. CONCLUSIONS:Traumatic experiences were common in youth presenting with suicidality. Traumatic experiences are frequently underrecognized in treatment settings because they are not part of routine evaluations and are often overlooked when trauma-related symptoms are not the presenting problem. Addressing traumatic experiences underlying depression and suicidal ideation is a necessary step in effective treatment. Emergency departments need to implement routine screening for traumatic exposures in children presenting with suicidal ideation or attempt.

OBJECTIVE:Given the increasing rates of youth suicide, it is important to understand the barriers to suicide screening in emergency departments. This review describes the current literature, identifies gaps in existing research, and suggests recommendations for future research. METHODS:A search of PubMed, MEDLINE, CINAHL, PsycInfo, and Web of Science was conducted. Data extraction included study/sample characteristics and barrier information categorized based on the Exploration, Preparation, Implementation, Sustainment model. RESULTS:All studies focused on inner context barriers of implementation and usually examined individuals' attitudes toward screening. No study looked at administrative, policy, or financing issues. CONCLUSIONS:The lack of prospective, systematic studies on barriers and the focus on individual adopter attitudes reveal a significant gap in understanding the challenges to implementation of universal youth suicide risk screening in emergency departments.

OBJECTIVES/OBJECTIVE:Agitation and restraint among pediatric psychiatric patients are a frequent, yet little studied, source of morbidity and, rarely, mortality in the emergency department (ED). This study examined agitation and restraint among youth patients in a specialized pediatric psychiatric ED, considering clinical and sociodemographic characteristics of those who required restraint to determine the clinical correlates of agitation and restraint in this population. METHODS:This descriptive study was a 6-year retrospective chart review of all patients restrained for acute agitation. Demographics, clinical characteristics, diagnoses, and reasons for restraint were collected. Relationships between sociodemographic and clinical variables to types of restraints used were examined, along with change over the study period in rate of and mean time in restraint. RESULTS:The average restraint rate was 1.94%, which remained fairly consistent throughout study period, although average time in restraint decreased significantly. Restraints were more common in males. Adolescents were overrepresented in the ED population, and after controlling for this, restraint rates were similar in adolescents and younger children. Physical aggression was the most frequent precipitant, although among adolescents verbal aggression was also a precipitant (more so than in younger children). Disruptive behavior disorder diagnoses were most frequently associated with restraint. CONCLUSIONS:A lower rate of restraint is reported here than has been seen in programs where youths are treated in medical or adult psychiatric EDs. Hospitals without specialized pediatric psychiatric emergency programs should invest in staff training in deescalation techniques and in access to pediatric psychiatric treatment. The finding that, of youth restrained, a significant proportion were under 12 years old and/or carried diagnoses not typically associated with aggressive behavior, indicates that crisis prevention, management, and treatment should include younger populations and diverse diagnostic groups, rather than focusing narrowly on older patients with psychotic or substance use disorders.

Objectives: Agitation and aggressive outbursts are common among pediatric patients seeking mental health evaluation in the emergency department (ED). Such actions can increase morbidity among patients, slow down care, and raise the risk of injury among staff. Yet there is little to guide ED clinicians in identifying those at risk for agitation and dysregulation, identifying etiology of agitation, or choosing nonpharmacologic and pharmacologic strategies for prevention and de-escalation of agitation and dysregulation.
Method(s): The 2019 Pediatric BETA (Best Practices in the Evaluation and Treatment of Agitation) guidelines were created utilizing Delphi methodology to obtain a consensus among a national group of emergency child and adolescent psychiatry experts. Ruth Gerson, MD, will review these guidelines as well as subsequent research on the management of agitation in pediatric patients in the ED.
Result(s): Consensus guidelines recommend a multimodal approach to managing agitation with the choice of intervention based on the etiology of agitation.
Conclusion(s): Participants will learn best practices for nonpharmacologic and pharmacologic de-escalation of agitation, as well as strategies for risk identification and prevention. AGG, IMD, PPC
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OBJECTIVES/UNASSIGNED:To address escalating youth suicide rates, universal suicide risk screening has been recommended in pediatric care settings. The emergency department (ED) is a particularly important setting for screening. However, EDs often fail to identify and treat mental health symptoms among youths, and data on implementation of suicide risk screening in EDs are limited. A systematic review was conducted to describe the current literature on universal suicide risk screening in EDs, identify important gaps in available studies, and develop recommendations for strategies to improve youth screening efforts. METHODS/UNASSIGNED:A systematic literature search of PubMed, MEDLINE, CINAHL, PsycINFO, and Web of Science was conducted. Studies focused on universal suicide risk screening of youths served in U.S. EDs that presented screening results were coded, analyzed, and evaluated for reporting quality. Eleven studies were included. RESULTS/UNASSIGNED:All screening efforts occurred in teaching or children's hospitals, and research staff administered suicide screens in eight studies. Thus scant information was available on universal screening in pediatric community ED settings. Large variation was noted across studies in participation rates (17%-86%) and in positive screen rates (4.1%-50.8%), although positive screen rates were influenced by type of presenting concern (psychiatric versus nonpsychiatric). Only three studies concurrently examined barriers to screening, providing little direction for effective implementation. STROBE guidelines were used to rate reporting quality, which ranged from 51.9% to 87.1%, with three studies having ratings over 80%. CONCLUSIONS/UNASSIGNED:Research is needed to better inform practice guidelines and clinical pathways and to establish sustainable screening programs for youths presenting for care in EDs.

OBJECTIVES/OBJECTIVE:Pediatric mental health emergency department (ED) visits continue to rise with 19% to 62% of youth presenting to the ED ultimately returning for a mental health-related complaint. To better understand the needs of children returning to the ED, this study examines the clinical, demographic, and environmental factors associated with revisits to a dedicated child psychiatric ED. METHODS:Clinical factors, home environment, and mental health service utilization of 885 children presenting to a dedicated child psychiatric ED over a 1-year period were abstracted by retrospective chart review. Bivariate analyses comparing demographic and clinical characteristics for children with and without revisits and a multivariable logistic regression were performed. RESULTS:Of the children presenting to the ED, 186 (21.0%) had at least 1 revisit in the subsequent 180 days. Thirty-one percent of initial visits presented as urgent, 55% presented as emergent. Children presenting with more severe symptoms at their initial visit were more likely to return within 6 months. Female gender, suicidal and disruptive behavioral symptomatology, and a diagnosis of oppositional defiant disorder were associated with repeat visits. Children with mental health system involvement were more likely to have revisits than those who were "treatment naive." CONCLUSIONS:Revisits to the ED are driven by both clinical factors, including severity and psychosocial complexity, and barriers to accessing services. Addressing the problem of return ED visits will require the development of a robust mental health service system that is accessible to children and families of all socioeconomic levels.

Regulatory agencies are increasingly taking on the important issue of effective risk assessment, risk stratification, and treatment planning for youth with psychiatric illness.¹ The Joint Commission mandates a suicide assessment for patients "who exhibit suicidal behavior or who have screened positive for suicidal ideation" followed by risk stratification: after "this assessment, patients should be classified as high, medium or low risk of suicide."² We anticipate that just as screening for depression and suicidality was initially restricted to emergency departments and inpatient units before being rolled out across all care settings, so risk stratification requirements will roll out to these other settings as well.

Introduction/UNASSIGNED:Agitation in children and adolescents in the emergency department (ED) can be dangerous and distressing for patients, family and staff. We present consensus guidelines for management of agitation among pediatric patients in the ED, including non-pharmacologic methods and the use of immediate and as-needed medications. Methods/UNASSIGNED:Using the Delphi method of consensus, a workgroup comprised of 17 experts in emergency child and adolescent psychiatry and psychopharmacology from the the American Association for Emergency Psychiatry and the American Academy of Child and Adolescent Psychiatry Emergency Child Psychiatry Committee sought to create consensus guidelines for the management of acute agitation in children and adolescents in the ED. Results/UNASSIGNED:Consensus found that there should be a multimodal approach to managing agitation in the ED, and that etiology of agitation should drive choice of treatment. We describe general and specific recommendations for medication use. Conclusion/UNASSIGNED:These guidelines describing child and adolescent psychiatry expert consensus for the management of agitation in the ED may be of use to pediatricians and emergency physicians who are without immediate access to psychiatry consultation.