Laura Prager, M.D.

Laura Prager M.D.

Suicide by Security Blanket

An Introduction to Emergency Child Psychiatry

Lessons learned in Child Psychiatry Emergency Services.

Posted Aug 23, 2012

For the last decade, I have been the Director of the Child Psychiatry Emergency Service at Massachusetts General Hospital (MGH). Until very recently, when Dr. Donovan joined the team, I ran the service by myself. I took call almost every night, heard about almost every child who came through the doors of our Acute Psychiatry Service (APS), and shepherded both the adult resident on site in the emergency room and the consulting child and adolescent psychiatry resident through the thought process that would lead them to a diagnosis, a treatment plan, and, ultimately, a disposition.

These residents who are in many different stages of training learn to become both messenger and ambassador; they are on the front line, evaluating the patient, calling me to retell the story, then returning to the patient and offering the treatment plan we have concocted together. My family has become accustomed to my beeper going off at odd hours; over the years that plaintive alarm has receded into the background noise of our household and become no more than a slightly annoying yet familiar interruption.

Although I sometimes find the residents’ presentations less than thorough, I never tire of hearing the stories. Psychiatric diagnosis and intervention depend primarily on the “history,” or the story the patient tells. In the emergency room, one always starts with the question, “What makes today different from all other days?” That is, why did this child end up here today rather than yesterday, last week, or tomorrow? With that question and with all the other necessary questions that follow, no detail is insignificant. Trainees tease me about my interest in what they consider simply trivial matters, especially during what they think should be a rapid emergency room evaluation.

What difference does it make if a family shows up during a school vacation week? Could it be that family members can only manage their bipolar child for a few days of constant togetherness before everyone runs out of energy and can no longer tolerate unpredictable hostility toward a younger sibling?

Does it really matter if the 17-year-old boy who presents with new signs such as paranoia or auditory or visual hallucinations is a high school athlete? It matters a lot if he is a wrestler and decides to take diet pills to lose weight, or, alternatively, to use anabolic steroids in a misguided attempt to increase muscle mass. One would hate to misdiagnose a delirium that stems from overuse of amphetamines (active ingredient in medicines given for Attention Deficit Disorder and also often found in diet pills) or “‘roid rage” as a new onset primary psychotic disorder.

Who cares if the 10-year-old’s mother has a driver’s license and access to a car? We do, if we are considering hospitalizing the child in the only available inpatient bed that is located at least an hour and a half from his home.

And, just when I think I’ve heard everything, another child arrives at our door with an incomprehensible problem or, at the very least, a new take on an old problem. Nine-year-old children should not have marijuana metabolites in their urine toxicology; a ten-year-old boy should not have to consider strangling himself with his security blanket because his life is not worth living; a 15-year-old girls should not have to switch from snorting heroin to injecting it in order to get someone’s attention. Parents or other caretakers do not bring children to the emergency room simply because everyone involved has had a bad day. Something somewhere has gone very wrong.

Imagine how desperate parents must be to show up, often in the middle of the night, admitting to us that they cannot manage their own child, and fearing that we will not only agree with them, but also take their child away. And, as I remind the residents at our weekly “child rounds” where the APS team reviews the child patients from the previous week, often enough, we do both.

Child Psychiatry, whether practiced in the emergency room or in the relatively unhurried comfort of the clinic setting, is a field dependent on collateral information and bound by systems of care. The child is the identified patient, but not always the only patient, and the emergency is usually in the eye of the beholder. The second grader sent directly to the APS because he is behaving like a chicken in the classroom and refusing to stop after many reminders to do so does not necessarily think that he is having a psychiatric emergency, although the teacher may disagree.

Children, for good or ill, come with parents or other custodial adults. They have teachers and guidance counselors, coaches and friends; they have pediatricians and sometimes therapists or psychopharmacologists. Those involved may have an important and informed perspective on the child’s strengths and weaknesses. For the second-grade chicken, his clucking probably tells a crucial but limited part of the story. Our job is to figure out how to interpret his “words,” fill in the blanks with the impressions and observations of the adults who care for him, and then, like a high-stakes game of Mad Libs, create a narrative that explains the child’s behavior and use that to guide our intervention.

What happens to the child, what services are available, what level of care is accessible, can sometimes depend more on the third party payer/insurance company than on the clinical picture. Even if the child’s difficulties could be managed by outpatient caregivers, they are so few and far between and so difficult to obtain that it is often easier to hospitalize a child on an inpatient psychiatric unit than to arrange for outpatient follow-up. Well-intentioned state initiatives created to provide community-based services for children such as in-home therapists, educational advocates, or afterschool programs cannot meet the demand. Insurers offer such minimal remuneration for outpatient mental health services that hospitals or free-standing community clinics can offer such assistance only if they are willing to lose money or are underwritten by a hospital or a state agency.

At the MGH, the entire Department of Child Psychiatry survives because the hospital administration is committed to supporting it. We are very lucky. Few institutions can or will do this. Fewer still will support a child psychiatry emergency service. As a result, children often come to the MGH APS from distant parts of Massachusetts or from other states. Designing a treatment plan for a child whose access to education, mental health and ancillary services are governed by a totally different set of rules only magnifies the difficulties.

This book arises from my fascination with the endlessly complex stories of children’s lives. It is so easy for a child living within some kind of psychosocial chaos to keep to himself, invisible and alone, until his problems, internal, external, or both, overwhelm his ability to cope.

Most of these children cannot advocate for themselves, and many have no one else to advocate for them. My desire to tell their stories also arises out of my frustration with our current mental health system, one that consistently fails to meet the needs of children because to do so is too expensive and too time consuming. It’s a system in which insurers will pay for inpatient admissions but not for consistent outpatient services that might obviate the need for those admissions; a system where children must “fail” the least restrictive (read: least expensive) level of care in order to qualify for a more intensive and much more expensive level of care; a system in which children must come to an emergency room in crisis in order for someone to pay attention. This system reinforces the misguided belief that a child with mental health problems is not as acutely ill or as desperate for care as a child with other kinds of medical problems.

Over the years, I have seen hundreds of patients and heard about many, many more. Residents often ask me how I tolerate being paged day after day and night after night. The answer is that behind every call waits a child’s story and a trainee’s uncertainty. Both must be heard. Whether a child arrives in the emergency room strapped to a stretcher, carried by a parent, or on his or her own two feet, few should leave without something changing—in his or her life, but often in ours as well. We see them in a moment of crisis, which offers us the opportunity to demand answers to previously unasked questions, or shed a glaring light on a hidden vulnerability or tightly held secret.

In the emergency setting, we wield enormous power: we can call for a state agency to investigate suspected parental abuse or neglect, physically restrain a child with leather straps, administer potent sedating medications, or commit a child to a locked unit against his will or the will of the parents. With that power comes responsibility; we must care for these children, keep them safe, and, despite the obstacles, help them and their families obtain the treatment they need. Sometimes we are successful; sometimes we are not.

Courtesy of Praeger Publishers/ABC-Clio, 2012