doi:10.1111/jpc.13620
VIEWPOINT
Emergency paediatric psychiatry: An emerging sub-specialty Kenneth Nunn Department of Psychological Medicine, Children’s Hospital at Westmead, Sydney, New South Wales, Australia
In some sense psychiatry has always been dealing with emergencies. The terror of psychosis, the shut-down of depression, the rage and excesses of mania and the tragedy of suicide and those who seek it are old and familiar foes. However, the systematic study of the differences between psychiatry as it has been practiced for hundreds of years – ‘do they need to be kept out of sight?’ – or the last 200 years – ‘do they need to be taken to the asylum?’ – or the last 30 years – ‘do I need to go to hospital for treatment?’ – is a late development. The notion that a psychiatric emergency is something the community cannot manage is not a new one. The concept that a psychiatric emergency is something that might require specialised care, different skills and different training is new (Table 1). Emergency medicine as an organised specialty gathered strength slowly after the Second World War with the formation of national and international bodies in the late 1960s and 1970s. In 1967, the Casualty Surgeons Association was established in the UK. In the USA, in 1979, the American Board of Medical Specialties recognised emergency medicine as a medical specialty. Paediatric emergency medicine rapidly emerged in the 1980s as a sub-specialty area.1,2 As early as 1975, a ‘Handbook of psychiatric emergencies’ was published based on the Yale–New Haven Hospital Emergency Psychiatric Service Study.3 Child psychiatry took longer to organise. It was not until the early 2000s that studies, handbooks and chapters in emergency paediatric textbooks included child psychiatry. Only in the last 5 years has the Department of Psychological Medicine in The Children’s Hospital at Westmead introduced systematic teaching of and a formalised curriculum on emergency paediatric psychiatry (20 seminars). The emphasis on stabilisation rather than diagnosis, a problem and disposition focus rather than comprehensive assessment and specific treatment, arousal and risk reduction rather than definitive therapy are all typical emphases. In recent years, popular accounts of the work have been described,4 while the more general idea of crisis work with children has also been covered.5 Cameron’s excellent textbook of Paediatric Emergency Medicine has two modest chapters allocated to the area.6 Rutter’s Child and Adolescent Psychiatry,7 a wonderfully rich book in so many regards, has no chapter on emergency psychiatry. The growing need for emergency child and adolescent psychiatry has prompted the question as to whether most training
Correspondence: Professor Kenneth Nunn, Department of Psychological Medicine, Children’s Hospital at Westmead, Westmead, NSW 2145, Australia. Fax: +61 29845 2009; email:
[email protected]
around child psychiatry prepares young consultants – paediatric or psychiatric – for the task.8−17 It has also raised the issue of whether we should not have some clinicians developing special expertise in emergency child and adolescent psychiatry or paediatric emergency psychiatry. There is a growing consensus that an emergency component to every child psychiatrist’s training is necessary and that some might have a sub-specialty practice in this area. There is also a growing consensus that all paediatricians, but especially emergency paediatricians, need a solid understanding of emergency psychiatry.
Table 1 Characteristics of paediatric emergency psychiatry18–24 The target patient group – Children who are in imminent danger to themselves or others or whose distress is so extreme that expert help is required to relieve it. 2 Context of care – This may be community – or hospital-based but frequently occurs within the context of retrieval for, or presentation to, general medical or paediatric emergency departments. 3 Triage – Based on safety, stabilisation and relief of symptoms rather than definitive diagnosis or detailed developmental understanding. 4 Targets of treatment – Include broad neurobehavioural systems such as physiological arousal, behavioural self-regulation, social containment and cognitive coherence rather than very specific and stable psychiatric syndromes. 5 Time frame of focus – The immediate problem, the next 24 h, the period of risk, the time to transfer to less acute or more intensive care and discharge pre-occupy the emergency mind-set. 6 The discreteness of the task – There is a clear recognition that the task of emergency treatment is not comprehensive, is part of a chain of more detailed investigation and there is a need for effective longer-term solutions following stabilisation. 7 Transfer – To and from the context of emergency care is critical in the step-up and step-down of risk. 8 Repeat presentations – May represent appropriate pre-arranged management, unforeseen complications of treatment or failure of the previous arrangements post-discharge in terms of effective disposition. 9 Differentiating – The order of treatment priorities, the collaborating specialties and who is primarily in charge at what time (child protection, clinical toxicology, surgery or psychological medicine, etc.) is the daily grist of working through a given patient and their family’s reason for presentation. 10 Staff morale and affect – Contribution to the clinical teams involved around the child with a clear recognition that paediatric emergency psychiatry is frequently at the convergence point of multiple system failures in which all the individuals involved still need to be treated professionally. 1
Conflict of interest: None declared.
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References 1 Starr M, Babl F, Isaacs D. Paediatric emergency medicine. J. Paediatr. Child Health 2016; 52: 103–4. 2 Li M, Baker MD, Ropp LJ. Pediatric emergency medicine: A developing subspecialty. Pediatrics 1989; 84: 336–42. 3 Slaby AE, Lieb J, Tancredi LR. Handbook of Psychiatric Emergencies: A Guide for Emergencies in Psychiatry. New York, NY: Medical Examination Publishing Company, 1975. 4 Prager LM, Donovan AL. Suicide by Security Blanket, and Other Stories from the Child Psychiatry Emergency Service: What Happens to Children with Acute Mental Illness. Boston, MA: Praeger, 2012. 5 Haddad F, Gerson R. Helping Kids in Crisis: Managing Psychiatric Emergencies in Children and Adolescents. Arlington, VA: American Psychiatric Publishing, 2014. 6 Nunn KP. The treatment of the behaviourally disturbed adolescent. In: Cameron P, Jellinek G, Everitt I, Browne GJ, Raftos J, eds. Paediatric Textbook of Emergency Medicine, 2nd edn. Edinburgh: Elsevier, 2013; 386–90. 7 Thapar A, Pine DS, Leckman JF, Scott S, Snowling MJ, Taylor EA. Rutter’s Child and Adolescent Psychiatry, 6th edn. London: Wiley, 2015. 8 Nurius PS. Emergency psychiatric services: A study of changing utilization patterns and issues. Int. J. Psychiatry Med. 1983; 13: 239–54. 9 Dossetor D, Williams K, Woffenden S. Children and adolescents with acute alcohol intoxication/self-poisoning presenting to the emergency department. Arch. Pediatr. Adolesc. Med. 2002; 156: 345–8. 10 Hoyle JD Jr, White LJ. Treatment of pediatric and adolescent mental health emergencies in the United States: Current practices, models, barriers, and potential solutions. Prehosp. Emerg. Care 2003; 7: 66–73. 11 Starling J, Bridgland K, Rose D. Psychiatric emergencies in children and adolescents: An Emergency Department audit. Australas. Psychiatry 2006; 14: 403–7.
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