common children psychiatry problem

1. PSYCHIATRY EMERGENCY
IN CHILDREN

2. INTRODUCTION
 Can be divided into 2
 Life-threatening
 Urgent but non life threatening
 Emergency setting often site of initial
evaluation of chronic problem.
 Assessment is made
 by interview the child and the individual family bith
alone and together
 Obtain history from informants outside the family
if possible

3. FAMILIAL RISK FACTOR.
 Physical and sexual abuse
 Recent family crisis: loss of parent, divorce,
oss of job, family move
 Severe family dysfunction including parental
mental illness

4. LIFE THREATENING
EMERGENCIES
 SUICIDAL BEHAVIOUR
 VIOLENT BEHAVIOR AND TANTRUMS
 FIRE SETTING
 CHILD ABUSE: PHYSICAL AND SEXUAL
 NEGLECT:FAILURE TO THRIVE
 ANOREXIA NERVOSA
 ACQUIRED IMMUNE DEFICIENCY
SYNDROME (AIDS)

5. SUICIDAL BEHAVIOUR
 Most common reason among adolescent
 Assessment is to determine the circumstances of
suicidal ideation or behavior, lethality and persistence
of suicidal intention
 Evaluation of family sensitivity, supportiveness, and
competence must be done to assess the ability to
monitor the child suicidal potential
 During emergency evaluation, clinician must decide
whether the child may return home and have out
patient treatment or need hospitalization
 By psychiatric history, mental status exam and assess
of family functioning helps to establish the general
level of risk.

6. MANAGEMENT
 Hospitalization or admission
 If self injurious happened
 If medically clear, must decide whether require
admission
 If the patient persist of suicidal ideation and show
sign of psychosis and severe depression
 High risk profiles adolescent
 Those with substance abuse and aggressive behavior
 Severe depression or who had made the suicide
attempt before
 young children who made suicide attempts even if
low lethality with a chaos, dysfunction family

7. VIOLENT BEHAVIOR AND
TANTRUMS
 First thing, all patient and staff members are
physically protected.
 If child appears calm down, ask the child to
recounted what happened and ask whether
the child feel sufficient to do so. If child agree,
then approach calmly and softly.
 If not, give child several minutes
to calm down or if adolescent
give medication that help to relax

8. Cont..
 If adolescent clearly combative, necessary
physical restraint.
 They will most likely calm down if approached
calmly in a non treatening manner and give them
chance to tell their side of story to nonjudgemental
adults
 Psychiatrist should speak to family
and other who have
been a witness
the episode to
understand the context
it occur and how worst
It is.

9. MANAGEMENT
 Prepubertal children with absence major
psychiatric illness rarely require medication
 Patient who are assaultive needs medication
before the dialogue
 Children with history of repeated, self-limited,
severe tantrum, if they able to calm during
evaluation – no admission
 Adolescent who continue pose danger to
themselves and others – hospitalization
necessary

10. FIRE SETTING
 Young children patient who has accidentally lit a
fire,
 Normally children will be interested in playing
with matches and lit up the fire.
 If child has strong interest, level of family
supervision must be clarified
 Clinician must differentiate between who
accidentally or impulsively set a single fire
 Clinician must also identify the children who
engage repeated fire with premeditation and
leaves without making attempt to extinguish it.

11.  In repeated fire setting, psychiatrist must
determine whether the underlying
psychopathology exists in child or in the family
members.
 Evaluate family interaction
 Children with conduct disorder (triad)
 Enuresis
 Cruelty to animal
 Fire setting

12. MANAGEMENT
 Prevent further incident
 Not indication of hospitalization unless
continued direct threat exists that the patient will
set another fire
 Parent must be empathically counseled that the
child must not be left alone at home and should
never left to take care of younger siblings
without direct adult supervision
 Behavioral technique of child and the family to
develop positive reinforcement for alternate
behaviour

13. CHILD ABUSE:PHYSICAL AND
SEXUAL
 Occur in girls and boys of ages, in all ethnic
groups, at all socioeconomic levels.
 Young children who are being sexually abused
may
 exhibit precocious sexual behavior with peers
 present a detailed sexual knowledge beyond their
developmental level.

14.  Children who being abused often display
sadistic and aggressive behavior
 Abused child victimized by family
members
 Is place in irreconcilable position of to endure
continued abuse silently
 to defy the abuser by disclosed experience and
be responsible for destroying the family and risk
being abandoned and disbelieved by the family

15. MANAGEMENT
 Both child and family must be interviewed
individually.
 Observe the child with each parent individually to
get sense of spontaneity, fear, anxiety or other
prominent feature of relationship.
 Physical indicators: sexually transmitted disease
 Physician should speak directly about the issue
without leading the child in any direction as might
frightened them
 Use of anatomically correct dolls help the child
identify body parts and show what had happened.

16. Anatomically correct doll

17. NEGLECT: FAILURE TO
THRIVE
 In child neglect, all physical, mental, emotional
condition of child is impaired.
 Parent who neglect their child are:
 Very young parent
 Ignorant parent about the emotional and concrete needs
of a child
 Parents with depression
 Substance abuse parent
 Parent with mental illness
 Neglect can contribute to failure to thrive, usually
infant under 1 year of age becomes malnourished in
absence of organic cause. (extreme form)

18. Typically it occur under circumstances
where adequate nourish is available but the
disturbance within the relationship between
caretaker and a child

19.  Observation of mother and child may reveal a
nonspontaneous tense interaction with withdrawal on
both side. both are seems to depressed.
 Rare form of failure to thrive, not necessarily
malnourished is syndrome of psychosocial dwarfism
 characterized by:
 Marked growth retardation
 delayed epiphyseal malnutrition
 disturbed relationship between parent and child
 Bizarre social and eating behavior of child
 Half of the may have decreased growth hormone
 Children become more rapid grow if removed from
troubled environment.

20. MANAGEMENT:
 Decide whether the child is safe in the home.
 If neglect suspected, report to local child
protective service agency
 Follow up needed before discharging the child
from emergency setting
 Education for the family begin during
evaluation
 Family must be told in non threatening manner
 Tell that the entire family needs to monitor the
child’s progress
 Tell to receive help in overcome the obstacle that
interfere the child’s emotional and physical well

21. ANOREXIA NERVOSA
 Commonly in female (10times)
 Characterized by:
 Refusal to maintain body weight lead to at least 15%
below the expected weight
 Distorted body image
 Persistent fear of becoming fat
 Absence of at least 23 menses cycle
 Begin after puberty
 Reach emergency
 when weight loss approaches 30% of body weight
 When metabolic disturbance becomes severe.

22.  Hospitalization is necessary
 As to control
 the ongoing starvation
 Potential dehydration
 Medical complication of starvation
 electrolyte imbalance
 Cardiac arrythmia
 Hormonal changes.

23. AIDS
 Transmission by
 perinatal transmission from infected mother
 2ry to sexual abuse by an infected person
 Intravenous drug in adolescent
 Sexual activities with infected person in adolescent
 Children and adolescent may present for
emergency at the urging of family member of peer
 During assessment of the risk for HIV, education to
both patient and family can be initiated
 Counseled about the behavior and about safe-sex
practice to the possible high risk behavior person

24. Cont…
 Children brain is the after primary site of infection
 Deformities:
 Encephalitis
 Decreased brain development
 Neuropsychiatric symptoms
 Virus may present initially in CSF before shows up in blood
 Organic mood disorder, organic personality disorder and frank
psychosis can occur
 Symptoms of AIDS dementia complex
 Changes in cognitive function
 Frontal lobe disinhibiton
 Social withdrawal
 Slowed information processing
 Apathy

25. URGENT NON LIFE
THREATENING
 SCHOOL REFUSAL
 MUNCHAUSEN SYNDROME BY PROXY

26. SCHOOL REFUSAL
 May occur in whom is first entering school
(young children) or whom is making transition
into new grade or school (adolescent)
 Also can happen without obvious external
stressor.
 Generally associated with:
 separation anxiety (separate with the parents)
 May exhibit fear and depression – somatic complaint
 Severe tantrum and desperate pleas
 School phobia
 Anxiety and depressive disorder in adolescent
 Usually adolescent will have physical complaints

28. MANAGEMENT:
 If caused by separation anxiety – explained to the
family and start intervention immediately
 If possible, the next day the child should be
brought to school despite the distress and ask
help from the school staff.
 Then praise the child for tolerating the school
situation
 If its going for months or year and family
members unable to cooperate, treatment
program to move child back to school from
hospital.
 If behavioral method not efficient, give tricyclic
antidepressant (imipramine)

29. MUNCHAUSEN SYNDROME BY
PROXY
 Form of child abuse by parent usually
mother repeatedly fabricates or inflicts
injury/illness in child whom later medical
intervention is sought.
 Usually the mother
 has the medical knowledge which then being
put to the child as symptoms
 the mother may engaged some scenes with
the hospital staff regarding the treatment to
the child.
 On careful observation, mother might not
exhibit appropriate sign of distress upon
the child condition

30.  Illness appear in child can involve any of the
organ but certain are commonly presented:
 Bleeding from one to multiple sites
 Seizures
 CNS depression

31. THANK YOU.