Adolescent Psychiatry - Volume 9, Issue 2, 2019

Background: Adolescent pregnancy is a major public health concern with medical, psychiatric, and social implications. Within this population, there is an elevated rate of co-occurring psychiatric conditions including mood disorders, anxiety disorders, suicidality, and substance use. However, little is known about the assessment and treatment of adolescent pregnancy within the context of these co-occurring psychiatric conditions, particularly in an emergency situation. Objective: This article utilizes a case report to illustrate the challenges faced in consultative psychiatry in the assessment and treatment of a pregnant suicidal youth with a complex psychosocial history. Topics addressed include: 1) The role of childhood trauma and suicidality in adolescent pregnancy 2) A consideration of the risks and benefits of treating adolescents with psychotropics during pregnancy. Methods: A literature search was performed with the key words of adolescent, pregnancy, child sexual abuse and psychiatric illness. In addition, expert opinions of a reproductive psychiatrist and a psychiatrist who had specialized in addiction and adolescents were enlisted on key aspects of the case formulation and treatment. Results: Several studies were found that focused on depression, substance abuse and trauma in adolescent pregnancy. There were more studies that looked at psychopharmacological treatment in adult pregnant women and a few that focused on adolescents. Conclusion: Addressing the crisis of psychiatric illness in adolescent pregnancy requires a thorough approach in understanding the severity of the illness and the contribution of child abuse and suicidality. Psychotherapeutic interventions are most certainly always necessary and beneficial when dealing with this population. Deciding when to start and maintain medication during pregnancy should be individualized, with considerations of the risks of untreated illness and of medication exposure.

Background: Increasingly, adolescents are presented to hospital emergency departments with suicidal ideation (SI) and depression. Even among those who come in with other complaints, depression and SI are common. Emergency personnel are placed in the default position of providing care for these patients, but often lack sufficient knowledge and skills to do this effectively. Objective: The aim of this pape is to offer guidance to emergency personnel and describe goals and strategies for screening and brief interventions. Methods: We review risk factors, assessment tools and evidence-based interventions that can be utilized by mental health professionals working in EDs and by ED staff in the absence of mental health professionals. Conclusion: Emergency departments can serve a critical role in risk management and treatment of adolescent depression and suicidal ideation. All patients presenting to the ED should be screened for current and past depression and suicidal ideation or attempts. Brief interventions can be delivered in the ED that can increase the likelihood that patients will receive follow- up care.

Background and Goals: Non-suicidal self-injury (NSSI) is a common presenting issue mental health providers experience in all levels of care from outpatient clinics to inpatient units. It is common among adolescents seen in emergency settings, either as a presenting problem or as a covert condition that may not be detected unless specifically assessed for. The presence of NSSI increases the risk of suicide. This article aims to help the clinician develop a better understanding of NSSI – what it may entail, the prevalence, and the motivations for why young people engage in it. Methods: We review the reasons adolescents injure themselves, the link between NSSI and psychiatric diagnoses and suicide, the assessment of NSSI, and treatment planning, with emphasis on ways to screen for NSSI and interventions that can be implemented in the Emergency Department. We illustrate the complexity of NSSI with the case of a young patient with a complex psychiatric history and an extensive history of self-injury. Results and Discussion: Despite the seeming intractability of NSSI, a number of evidencebased treatments exist. Treatment primarily involves specialized forms of psychotherapy, but interventions can be implemented in the ED that will reduce the immediate risk of NSSI while more definitive intervention is awaited. Conclusion: Mental health consultations in the ED should always include screening for NSSI. Mental health professionals in the ED can play an important role in the detection and treatment of this condition.

Background: Child and adolescent psychiatrists and clinicians often assess individuals who present with homicidal and violent thoughts. These assessments are critical, for patient safety and societal protection. The psychiatrist must ultimately decide if the patient can return to the community safely, regardless if the patient has initially presented to inpatient, outpatient, emergency room or school settings. While there is some consensus regarding the best practice in assessing risk for serious self-harm, approaches to the assessment of homicide and violence are far more disparate. Clinicians often determine risk based on known risk factors and type of violence threatened, and many offer a “risk level”. However, in the absence of an easy to use tool to assess risk, the judgment relies on clinician experience, talent and training, at the expense of a uniform, organized and comprehensive approach. Methods: We describe an assessment tool that uses a semi-structured interview to comprehensively evaluate an individual’s risk for violence. The tool guides the clinician to gather a detailed description of the current episode, then reviews the salient risk and protective factors and ends with a structured mental status exam developed to help characterize typical pathways to violence. Discussion: The steps in assessing children and adolescents presenting with homicidal threats in various clinical settings, as well as the steps in determining the appropriate level of care and treatment plan, will be discussed. The implementation of the assessment tool in an inpatient setting and the clinicians’ reaction to using it will also be discussed. Conclusion: The I-HAVAT© (Institute of Living-Homicide and Violence Assessment Tool) is a semi-structured method of assessing patients presenting with violent or homicidal threats by collecting and streamlining pertinent clinical information and ultimately increases the clinicians’ confidence level in making decisions and recommendations for determining the level of care and appropriate treatment plan.

Background and Aims: It is fairly common for adolescents with a presenting problem of acute agitation to present to the Emergency Department. These patients present challenges with respect to both differential diagnosis and management. Furthermore, with many adolescents having extended stays in emergency departments, it is important for ED physicians to have a basic familiarity with diagnosis and treatment. Methods: In this paper, we present a primer on the conditions underlying acute agitation and review approaches to management in the emergency department. Results and Discussion: Psychotic disorders, such as schizophrenia, are distinct from other conditions presenting with psychotic symptoms, which can range from depression to substance use to non-psychiatric medical conditions. Agitation, a state of excessive verbal and physical activity, can accompany any of these conditions. Unlike the case for adults, practice guidelines do not exist, and there is no fully agreed upon expert consensus yet. Emergency physicians should have a working knowledge of antipsychotic medications and need to consider pharmacological as well as non-pharmacological treatments for optimal management.

Adolescents with autism spectrum disorders (ASDs) have similar sexual desires and relationship needs to their neuro-typical peers. However, they may be more likely to demonstrate problematic sexual behaviors as they mature, due to lack of education about sexuality, vulnerability to sexual abuse, deficits in social communication and understanding, restricted and repetitive interests and behaviors, and sensory interests. Treatment for sexual acting out behaviors in adolescents with ASD has not been explored and current recommendations focus on prevention through sexual education, which provides little guidance to clinicians working with adolescents who are already displaying sexual acting out behaviors. Adapting treatments for problematic sexual behaviors in neuro-typical children and adolescents may be the first step, although adaptation is complicated by developmental abilities that may not match an adolescent’s chronological age. A thorough developmental and sexual assessment is the first step to designing an appropriate treatment plan. Further research should focus on adapting and applying current treatments for sexual acting out by the ASD population.

Aims and Scope: Eating disorders commonly present during the adolescent and young adult years, and are complex in that they are a group of psychiatric diagnoses with medical complications. Methods: The diagnosis of an eating disorder can often go undetected while a patient is being evaluated for organic causes of weight loss. Anorexia nervosa, in particular, has the highest mortality rate of any psychiatric diagnosis. In the Diagnostic and Statistical Manual of Mental Disorders 5th Edition (DSM-5), there are several diagnoses that are classified as eating or feeding disorders. Conclusion: This article will discuss anorexia nervosa and bulimia nervosa, with a focus on medical and psychiatric emergencies that are important for primary care providers to keep in mind when caring for adolescents and young adults.

Background: Adolescent substance use is a dynamic public health problem. Adolescence is a unique developmental period involving overlapping biological, psychological, and social factors which increase the rates of initiation of substance use. The developing adolescent brain is particularly susceptible to the effects of substances and most adults with substance use disorders began to have symptoms and problems in their adolescent years. Yet, for various reasons, most adolescents who use, misuse, abuse, or are addicted to substances do not perceive the need for treatment. Objective: Drug and alcohol use among adolescents is a common presentation in hospital Emergency Departments (EDs) and presents in different forms including in association with intoxication, withdrawal states, or trauma associated with drug-related events. For many adolescents with substance use, the Emergency Department (ED) is the first point of contact with medical personnel and thus also serves as a potential entry point into treatment. Methods: This article reviews the common ways drug and alcohol problems present in the ED, clinical assessment of the patient and family, screening, laboratory testing, brief interventions in the ED, and referral to treatment beyond the ED. Conclusion: Guidelines on how to manage the shifting terrain of adolescent substance use presenting in EDs across the nation continue to evolve. We highlight that considerable further research is needed to inform effective ED protocols to address this important individual and public health safety concern. Systems of care models which include collaborative teams of diverse stake holders are needed to effectively manage adolescents with substance use disorders.

Background & Aims: The past few years have seen an increase in the number of children and adolescents presenting to emergency departments with mental health complaints, including, but not limited to, depression, suicidality, and substance use-related conditions. This places many demands on the emergency physicians ranging from evaluating medical stability (also known as medical clearance) to arranging for psychiatric are, be it inpatient or outpatient. The goals of this article are to describe the current landscape of emergency care for the pediatric patient presenting with mental health issues and to highlight gaps in the current system. Methods: We review the literature on the epidemiology of mental health emergency visits and guidelines for the medical clearance of pediatric and adolescent patients. Results: The needs of young patients with mental health difficulties exceed the resources available in emergency care. Linkage to outpatient care is often inadequate and may be reinforcing and perpetuating the current mental health crisis witnessed country-wide in the US. Guidelines are lacking to standardize care in the ED, but there is a consensus that extensive routine laboratory testing is unnecessary. Conclusion: Evaluation of physical stability, known as medical clearance, is a process best customized to every patient’s individual needs. However, requirements of admitting psychiatric inpatient facilities may conflict with recommendations of ancillary testing.