Respond  to  your  colleagues by recommending at least one additional way you  would treat a  child or adolescent client differently than you would an  adult and at  least one additional way you would address the legal and  ethical issues  involved.  

(NOTE: Positive Comment)

                                                        Main Discussion

Psychiatric  emergencies are severe behavioral changes that may  result from  worsening mental illness. Psychiatric emergency is any  disturbance in  thoughts, feelings, or actions that require immediate  therapeutic  intervention (Stahl, S. M., 2014). The providers approach,  attitudes and  work environment may escalate the situation and interfere  with the  quality of care. Certain therapeutic measures can reduce the  intensity  of the situation and provide a more dignified way for  patients to  recover from the crisis. It is thus important that the  PMHNP understand  how to assess patient’s emergency status and address  their unique needs  while maintaining safety.

  Case selected.

Patient  is a 25-year-old AA male who presents to the emergency  department with  psychotic behavior in believing he should kill his  mother which led to  his attempt to stab his mother. Patient is admitted  for inpatient  psychiatric stabilization. Patient has a history of  schizoaffective  disorder and major depression that was managed with use  of clozapine  150mg twice a day and Zoloft 100mg daily. Family reported  that patient  has a history of medication non-compliant and had been on  different  psychiatric medications in the past but were not working for  him.  Additional reports by his parents shows that patient had missed  several  doses of his medication, decompensated and they had notices  some changes   recently including increase agitation, delusional  believes that he is  the savior in the family and God had directed him  to cast the demon in  his mother. Reports also that he had drawn a  picture of himself with  knives cutting a woman he portrayed as a demon  with blood flowing with a  man standing to the side, laughing. Patient  currently stated that he  participates in a meeting with angels from  which he gets directives on  how to attack his mother which led to his  attempt to stab his mother.  Because of this, patient was considered  dangerous to his mother per  admitting physician. Patients symptoms  include psychosis, extreme  agitation, paranoia, verbal outburst,  combative and very difficult to  redirect. Patient has no known drug  allergies per parents.  Verbal  restraint was used including letting  patient know what will happen if  he does not comply, respecting his  autonomy, empathetic listening,  decrease environmental stimulation,  reassure patient that they will be  safe, and maintain a safe  environment. The patient was given emergency  medications including  haloperidol lactate 5mg, lorazepam 2mg, and  diphenhydramine 50mg all IM  for severe agitation and danger to others.  To prevent  re-hospitalization within 12-24 hours of discharge, the  physician  ordered outpatient therapy and continued use of clozapine and  Zoloft  along with necessary lab work.

 How I would treat the client differently if he or she were a child or adolescent

Children and adolescent are usually brought for treatment when  their  behavior or thoughts come to the attention of parents, teachers,   social workers, or school.  For pediatric patients in a mental health   crisis, the typical chaotic nature of the situation may easily further   exacerbate an already traumatized state of the patient. Just like in   adults, as a PMHNP I would perform an evaluation to determine the type   of emergency and contributing factors in child and adolescent emergency   by assessing not just the child but also the entire family.   Additionally, safety and protection are essential mandate in  psychiatric  emergency evaluation especially when the patient pose  imminent threat  to self or others. What I will do different when  interviewing children  especially younger children is to assess the  underlying cause of the  violent behavior and delusional symptoms within  a developmental context. Specifically,  I would clarify that “bizarre  thinking ” or accounts of seeing or  hearing things that others do not  see or hear are different from  developmentally appropriate fantasy or  difficulty while distinguishing  inner voices from distressing  hallucinations. On like in adults where  they can provide information  during the interview, when it comes to  younger children, I would need  to obtain information from parents or  guardian. For adolescents,  I  would obtain information from the patient first then talk to their   parent or guardian if the adolescent is able to tell most of their own   story. This may also help to give a sense of autonomy and control to  the  adolescent which promote cooperation with the interview process.    However, information from family is very crucial particularly for a   child who is psychotic, frightened, unable, or unwilling to corporate   with the provider to help understand how the situation occurred and the   severity of the behavior. 

Same  interviewing strategies used in adult may be used including  speaking in  a soft voice respecting patients’ autonomy, assuring  safety, validating  feelings, offering distractions (like video games)  especially with very  young children, and clear limit-setting can be  helpful. However,  children should be evaluated in a carefully planned  setting with doors  closed for limiting access, and be sure appropriate  backup is available  (Margret, C. P., & Hilt, R., 2018).  

In  violent situations children may require a different approach in   deescalating the situation than adults. Safety is the essential mandate   in an aggression evaluation, with the interviewer specifically looking   for imminent threats, plans, targeted people, and access to means of   harm (Margret, C. P., & Hilt, R., 2018). Because adults are much   stronger, they may require physical restrain specially to administer   medication to calm the patient. Verbal restrain such as providing  verbal  directions in a nonthreatening manner, setting limits, and  assuring the  child that treatment may help them calm may be used for  children first.  However, if the child is dangerously out of control and  aggressive,  they may need medication to keep them calm and safe.

Legal or ethical issues I would consider when working with a child or adolescent emergency case

The  ethical issue I will consider when working with children and  adolescent  is respect for their autonomy, privacy, and confidentiality.  For very  young children parents must consent to treatment and the  health care  provider treating the child should make every reasonable  effort to  obtain and document informed consent. (American Academy of  Pediatrics,  2015). Just like adults, maintaining a patient’s  confidentiality is an  important ethical consideration when providing  care to children and  adolescents. However, when  a PMHNP is concerned  that the patient may be at imminent risk for harm  to self or others,  confidentiality requirements no longer apply (Chun,  T. H., Katz, E. R.,  & Duffy, S. J., 2013). This means that the PMHNP  in this situation  may disclose information collected  from patient to  caregivers or  others as needed and may obtain information from others  such as  friends, family members, school personnel, employers and other  without  obtaining consent from the patient or guardians (Chun, T. H.,  Katz, E.  R., & Duffy, S. J., 2013. Patient  autonomy is a major principle in  making decisions about an individual’s  health, and as a PMHNP we are  obligated to respect this right and allow  patients to practice their  autonomy in the course of their treatment  (Parsapoor, A., Parsapoor, M.  B., Rezaei, N., & Asghari, F., 2014).  However, a psychiatric  emergency and age may limit a child’s ability to  make such decisions.  Regardless, it is always important to involve the  child in informed  decision making even if the consent is signed by the  parents or  guardian.

References

Chun, T. H., Katz, E. R., & Duffy, S. J. (2013). Pediatric mental health emergencies and special 

health care needs. Pediatric clinics of North America, 60(5), 1185–1201. Retrieved from,

 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3792398/

Da Silva, A. G., Baldaçara, L., Cavalcante, D. A., Fasanella, N. A., & Palha, A. P. (2020). The 

Impact of Mental Illness Stigma on Psychiatric Emergencies. Frontiers in psychiatry, 11, 

573. https://doi.org/10.3389/fpsyt.2020.00573

Margret, C. P., & Hilt, R. (2018). Evaluation and Management of Psychiatric Emergencies in 

Children. Pediatric Annals, 47(8), e328–e333. https://doi-

org.ezp.waldenulibrary.org/10.3928/19382359-20180709-01

Parsapoor, A., Parsapoor, M. B., Rezaei, N., & Asghari, F. (2014). Autonomy of children and 

adolescents in consent to treatment: ethical, jurisprudential and legal considerations. 

Iranian journal of pediatrics, 24(3), 241–248. Retrieved from, 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4276576/

Stahl, S. M. (2014). Prescriber’s Guide: Stahl’s Essential Psychopharmacology (5th ed.). New 

York, NY: Cambridge University Press.