UMEM Educational Pearls

Title: Pediatric Behavioral and Mental Health in the Emergency Department

Posted: 3/29/2019 by Rose Chasm, MD (Updated: 12/26/2024)
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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.

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.