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A relatively high proportion of pediatric visits to the emergency department are related to psychiatric symptoms, oftentimes with suicidal or violent ideation.1 Given that pediatric emergencies related to psychiatric symptoms are on the increase, clinicians frequently are called to assess children and adolescents with symptoms of aggression and violence. Management of these cases can be tricky.
Case presentation
Henry is a 6-year-old boy with mild developmental delays and possible anxiety who was brought to the emergency department because of concerns on the bus. For about a month, Henry, who is repeating his kindergarten year, had been struggling with getting on and off the bus and with other transitions at school. These struggles had been attributed to anxiety. He was started on sertraline and the dose was increased about 2 weeks later. Soon thereafter he complained of stomach upset with the sertraline, refused to take the medicine, and had a very hard day at school. He required one-on-one attention for unsafe behavior most of that day, and he missed most of his lunch and recess. His school support team was able to get him onto the bus at the end of the day, but he refused to get off of the bus at home. He became violent with the bus driver, kicking and biting him until the police were called. The police called EMS and he was brought into the emergency department after fighting to get on the transport stretcher. He was eventually brought into a secure exam room in the emergency department, but was unable to be fully assessed because he would only make animal noises when approached. His father already had been called, but was unable to calm him down. The emergency department physician was unable to approach Henry because he began swinging at him as soon as the physician entered the room. An emergent psychiatric consultation was called to determine what medication to give to Henry to calm him down and to assess him for possible psychosis.
Case discussion
It sounds like Henry was having a severe tantrum exacerbated by a number of factors. First of all, this is a child who struggles with transitions. That day had been loaded with transitions, eventually leading him to be in an unfamiliar environment with many unfamiliar faces. Even the familiar face of his father wasn’t enough to help because he was overly stimulated and scared. Next, he was probably hungry. We know for certain that he missed lunch, and several hours into his presentation there were no breaks to deal with his basic needs. The first approach to assessment of aggressive behavior in the emergency setting is to try to care for the basic needs of the individual to deescalate the situation. Finally, he had recently been started on sertraline, a selective serotonin reuptake inhibitor. He had been having some dyspepsia and/or nausea with the sertraline, leading to his having missed some doses. Some children and adolescents have a discontinuation syndrome, which can be more severe in younger children and with medications that have shorter half-lives.2 In Henry’s case, a missed dose or two can be enough to trigger this discontinuation response leading to more aggressive behavior.
Case follow-up
The child and adolescent psychiatrist called to the case received a history from the primary team. When he started to try to talk with the parent outside of the room, the child became upset. He was able to gather the information that Henry also had skipped breakfast. In an attempt to calm the patient down, the psychiatrist addressed Henry using a nonjudgmental, nonconfrontational, collaborative approach, incorporating play. Henry responded to this approach and allowed the psychiatrist to ask a few questions about basic needs, and admitted that he was hungry. He was offered a turkey sandwich, which was rapidly ingested. The tantrum slowly subsided. Within about 30 minutes (and with some more food), the child was able to sit on his parent’s lap and finish the interview. The decision was made to have him follow up with his primary care provider to change to an SSRI with a longer half-life, such as fluoxetine, as he did seem to be experiencing some discontinuation even after missing just a dose or two of sertraline.
When dealing with emergent, aggressive behavior, food isn’t always the best medicine, but sometimes it is. Environmental barriers to the child’s regaining control include hunger, thirst, a full bladder, constipation, or other pain. Attending to these issues first sometimes can help avoid sedating medications, which can prolong emergency visits and lead to unwelcome side effects.
Dr. Althoff is associate professor of psychiatry, psychology, and pediatrics at the University of Vermont, Burlington. He is director of the division of behavioral genetics and conducts research on the development of self-regulation in children. Email him at pdnews@mdedge.com.
References
1. Pediatrics. 2011 May;127(5):e1356-66.
2. J Can Acad Child Adolesc Psychiatry. 2011 Feb;20(1):60-7.
A relatively high proportion of pediatric visits to the emergency department are related to psychiatric symptoms, oftentimes with suicidal or violent ideation.1 Given that pediatric emergencies related to psychiatric symptoms are on the increase, clinicians frequently are called to assess children and adolescents with symptoms of aggression and violence. Management of these cases can be tricky.
Case presentation
Henry is a 6-year-old boy with mild developmental delays and possible anxiety who was brought to the emergency department because of concerns on the bus. For about a month, Henry, who is repeating his kindergarten year, had been struggling with getting on and off the bus and with other transitions at school. These struggles had been attributed to anxiety. He was started on sertraline and the dose was increased about 2 weeks later. Soon thereafter he complained of stomach upset with the sertraline, refused to take the medicine, and had a very hard day at school. He required one-on-one attention for unsafe behavior most of that day, and he missed most of his lunch and recess. His school support team was able to get him onto the bus at the end of the day, but he refused to get off of the bus at home. He became violent with the bus driver, kicking and biting him until the police were called. The police called EMS and he was brought into the emergency department after fighting to get on the transport stretcher. He was eventually brought into a secure exam room in the emergency department, but was unable to be fully assessed because he would only make animal noises when approached. His father already had been called, but was unable to calm him down. The emergency department physician was unable to approach Henry because he began swinging at him as soon as the physician entered the room. An emergent psychiatric consultation was called to determine what medication to give to Henry to calm him down and to assess him for possible psychosis.
Case discussion
It sounds like Henry was having a severe tantrum exacerbated by a number of factors. First of all, this is a child who struggles with transitions. That day had been loaded with transitions, eventually leading him to be in an unfamiliar environment with many unfamiliar faces. Even the familiar face of his father wasn’t enough to help because he was overly stimulated and scared. Next, he was probably hungry. We know for certain that he missed lunch, and several hours into his presentation there were no breaks to deal with his basic needs. The first approach to assessment of aggressive behavior in the emergency setting is to try to care for the basic needs of the individual to deescalate the situation. Finally, he had recently been started on sertraline, a selective serotonin reuptake inhibitor. He had been having some dyspepsia and/or nausea with the sertraline, leading to his having missed some doses. Some children and adolescents have a discontinuation syndrome, which can be more severe in younger children and with medications that have shorter half-lives.2 In Henry’s case, a missed dose or two can be enough to trigger this discontinuation response leading to more aggressive behavior.
Case follow-up
The child and adolescent psychiatrist called to the case received a history from the primary team. When he started to try to talk with the parent outside of the room, the child became upset. He was able to gather the information that Henry also had skipped breakfast. In an attempt to calm the patient down, the psychiatrist addressed Henry using a nonjudgmental, nonconfrontational, collaborative approach, incorporating play. Henry responded to this approach and allowed the psychiatrist to ask a few questions about basic needs, and admitted that he was hungry. He was offered a turkey sandwich, which was rapidly ingested. The tantrum slowly subsided. Within about 30 minutes (and with some more food), the child was able to sit on his parent’s lap and finish the interview. The decision was made to have him follow up with his primary care provider to change to an SSRI with a longer half-life, such as fluoxetine, as he did seem to be experiencing some discontinuation even after missing just a dose or two of sertraline.
When dealing with emergent, aggressive behavior, food isn’t always the best medicine, but sometimes it is. Environmental barriers to the child’s regaining control include hunger, thirst, a full bladder, constipation, or other pain. Attending to these issues first sometimes can help avoid sedating medications, which can prolong emergency visits and lead to unwelcome side effects.
Dr. Althoff is associate professor of psychiatry, psychology, and pediatrics at the University of Vermont, Burlington. He is director of the division of behavioral genetics and conducts research on the development of self-regulation in children. Email him at pdnews@mdedge.com.
References
1. Pediatrics. 2011 May;127(5):e1356-66.
2. J Can Acad Child Adolesc Psychiatry. 2011 Feb;20(1):60-7.
A relatively high proportion of pediatric visits to the emergency department are related to psychiatric symptoms, oftentimes with suicidal or violent ideation.1 Given that pediatric emergencies related to psychiatric symptoms are on the increase, clinicians frequently are called to assess children and adolescents with symptoms of aggression and violence. Management of these cases can be tricky.
Case presentation
Henry is a 6-year-old boy with mild developmental delays and possible anxiety who was brought to the emergency department because of concerns on the bus. For about a month, Henry, who is repeating his kindergarten year, had been struggling with getting on and off the bus and with other transitions at school. These struggles had been attributed to anxiety. He was started on sertraline and the dose was increased about 2 weeks later. Soon thereafter he complained of stomach upset with the sertraline, refused to take the medicine, and had a very hard day at school. He required one-on-one attention for unsafe behavior most of that day, and he missed most of his lunch and recess. His school support team was able to get him onto the bus at the end of the day, but he refused to get off of the bus at home. He became violent with the bus driver, kicking and biting him until the police were called. The police called EMS and he was brought into the emergency department after fighting to get on the transport stretcher. He was eventually brought into a secure exam room in the emergency department, but was unable to be fully assessed because he would only make animal noises when approached. His father already had been called, but was unable to calm him down. The emergency department physician was unable to approach Henry because he began swinging at him as soon as the physician entered the room. An emergent psychiatric consultation was called to determine what medication to give to Henry to calm him down and to assess him for possible psychosis.
Case discussion
It sounds like Henry was having a severe tantrum exacerbated by a number of factors. First of all, this is a child who struggles with transitions. That day had been loaded with transitions, eventually leading him to be in an unfamiliar environment with many unfamiliar faces. Even the familiar face of his father wasn’t enough to help because he was overly stimulated and scared. Next, he was probably hungry. We know for certain that he missed lunch, and several hours into his presentation there were no breaks to deal with his basic needs. The first approach to assessment of aggressive behavior in the emergency setting is to try to care for the basic needs of the individual to deescalate the situation. Finally, he had recently been started on sertraline, a selective serotonin reuptake inhibitor. He had been having some dyspepsia and/or nausea with the sertraline, leading to his having missed some doses. Some children and adolescents have a discontinuation syndrome, which can be more severe in younger children and with medications that have shorter half-lives.2 In Henry’s case, a missed dose or two can be enough to trigger this discontinuation response leading to more aggressive behavior.
Case follow-up
The child and adolescent psychiatrist called to the case received a history from the primary team. When he started to try to talk with the parent outside of the room, the child became upset. He was able to gather the information that Henry also had skipped breakfast. In an attempt to calm the patient down, the psychiatrist addressed Henry using a nonjudgmental, nonconfrontational, collaborative approach, incorporating play. Henry responded to this approach and allowed the psychiatrist to ask a few questions about basic needs, and admitted that he was hungry. He was offered a turkey sandwich, which was rapidly ingested. The tantrum slowly subsided. Within about 30 minutes (and with some more food), the child was able to sit on his parent’s lap and finish the interview. The decision was made to have him follow up with his primary care provider to change to an SSRI with a longer half-life, such as fluoxetine, as he did seem to be experiencing some discontinuation even after missing just a dose or two of sertraline.
When dealing with emergent, aggressive behavior, food isn’t always the best medicine, but sometimes it is. Environmental barriers to the child’s regaining control include hunger, thirst, a full bladder, constipation, or other pain. Attending to these issues first sometimes can help avoid sedating medications, which can prolong emergency visits and lead to unwelcome side effects.
Dr. Althoff is associate professor of psychiatry, psychology, and pediatrics at the University of Vermont, Burlington. He is director of the division of behavioral genetics and conducts research on the development of self-regulation in children. Email him at pdnews@mdedge.com.
References
1. Pediatrics. 2011 May;127(5):e1356-66.
2. J Can Acad Child Adolesc Psychiatry. 2011 Feb;20(1):60-7.