A 12-year-old male came to the emergency room for increasing behavioral changes over 6 weeks. He was known to have autism and disruptive behaviors and he was biting and throwing objects more. He was also sleeping less. The family usually was able to manage him but they felt that he now needed to be evaluated. They had called their local medical physician who did not feel comfortable managing this change and therefore the child was sent to the regional children’s hospital. The history showed no medication changes (he was taking an antidepressive and an antiepileptic medication) and he was using the same brand of medication. There were no new medications in the household. There were no social changes. He did have a cold 3 weeks before, but was not ill currently. The family history was positive for diabetes and kidney disease. The review of systems was negative.
The pertinent physical exam showed a compliant male until an attempt was made to examine him. He then tried to hit and bite the examiner. The examination was completed with the assistance of the parents who were able to calm him. His growth parameters were 50-75%. These were increased from the previous trend of 25-75%. Genitourinary examination showed Tanner II pubic hair. Neurologically he was alert and appeared oriented to the hospital, examiner and family. His repetitive speech and answers to questions were appropriate for his baseline per his parents. The rest of his physical examination was negative. The laboratory evaluation included a complete blood count, electrolytes, liver function tests, erythrocyte sedimentation rate and urine drug screening which were all negative. The emergency room physician contacted the pediatrician for a telephone consultation to medically “clear the patient” before she called child psychiatry. The pediatrician noted that child did not appear to have an intercurrent illness, or by history or physical examination appeared to have a new illness. The child also had a stable social situation including no concerns about child abuse or neglect. When the pediatrician asked about recent weight and medicine changes , the emergency room physician said that the family had noted that he seemed to have recently increased his weight and height but that no changes in his medication had been made for a long time. The pediatrician noted that the diagnosis of possibly outgrowing the medication dosage and/or had recently initiated puberty which could also possibly alter his behavior. He did note that other testing could be done such as thyroid, cardiac and neuroimaging but that the history and physical examination did not appear to support it. Several days later the emergency room physician saw the pediatrician and told him that the parents felt comfortable with what had been done in the emergency room and felt they could continue to manage his behavior at home. They were going to call their son’s psychiatrist to schedule an appointment the day after the emergency room visit. Several months later, the pediatrician encountered the patient again for a pre-operative evaluation for a dental procedure. Upon seeing the weight changes, the psychiatrist had adjusted his medications and his behavior improved.
Emergency room and psychiatric health care professionals may consult a pediatric health care provider to help provide initial medical evaluation and ongoing medical care to patients with primary or concurrent psychiatric problems. Sometimes, medical clearance of the patient is needed before a patient is allowed to be placed in an inpatient psychiatric facility.
The medical evaluation for psychiatric illnesses depends on the presentation and underlying medical conditions. Inadvertent or intentional overdose of medication, known medication side effect or medication interactions, and drugs of abuse are common problems that present to the emergency room. A medication review including those taken by the patient and those available to the patient both legally and illegally is important in the history. Also drug interaction profiles can often identify known drug side effects or known drug interactions.
For children, intercurrent illnesses are often the cause of behavior changes. Children with known psychiatric or neurological problems can be particularly perplexing in deciding if it is a change or progression of the underlying medical or psychiatric problem, medication problem, intercurrent illness or development of a new disease process. Social changes also impact the medical condition. For example, a child may be in good seizure control, but becomes homeless and is not able to take the medication properly which causes increases in his/her temporal lobe epilepsy.
A thorough history including psychiatric and social history, and physical examination including a mental status examination are important in the initial evaluation. Patients with violent or unpredictable behavior need to be protected from hurting themselves and health providers and caregivers. This may necessitate use of medical and chemical restraints. Consultation with psychiatric professionals even if the patient is not medically stable is important so that appropriate psychiatric care can be initiated.
Studies have been done which look at the utility of routine or semi-routine laboratory testing with varied results. History, physical examination, and differential diagnosis should guide the use of laboratory testing.
A list of common medical tests that can be considered for evaluating a patient with psychiatric problems and possible medical causes are below:
- Complete blood count
- Electrolytes including BUN, creatinine, glucose and calcium
- Electrolyte imbalance
- Adrenal disease (hypo- and hyper-)
- Liver function tests
- Hepatic insufficiency and failure
- Reye’s syndrome
- Thyroid studies
- Thyroid disease (hypo- and hyper-)
- Toxicology screening including testing for specific drugs or problems
The list of drugs is extensive but common ones include polypharmacy, anticholinergic agents, benzodiazepines, corticosteroids, nonsteroidal
- Drugs of abuse
- Carbon monoxide
- Heavy metals
- Wilson’s disease
anti-inflammatory drugs, opioids and selective serotonin reuptake inhibitors.
- Lumbar puncture
- Cardiac failure
- Bacterial endocarditis
- Pulmonary insufficiency
- Cranial imaging – if intracranial pathology is suspected
- Brain abscess
- Intracranial hemorrhage
- Chest radiograph
- Pulmonary insufficiency
- Epilepsy – especially temporal lobe
- Rheumatological laboratories – C-reactive Protein, Erythrocyte Sedimentation Rate
- Polyarteritis nodosa
- Infectious disease laboratories – culture, microscopic or rapid diagnostic testing
- Typhoid fever
- Nutritional disease
- Niacin deficiency
Questions for Further Discussion
1. What are the indications for the proper use of medical and/or chemical restraints?
2. What procedures need to be followed to properly voluntarily or involuntarily admit a patient to a psychiatric facility?
3. What are risk factors for suicide attempts in children and teenagers?
4. What mental health services are available for children and teenagers in your local community?
- Symptom/Presentation: Behavior Problems
- Age: School Ager
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
To view current news articles on this topic check Google News.
Fleisher GR, Ludwig S. Synopsis of Pediatric Emergency Medicine. Williams and Wilkins. Baltimore, MD. 1996:789-802.
Sood TR, Mcstay CM. Evaluation of the psychiatric patient. Emerg Med Clin North Am. 2009 Nov;27(4):669-83, ix
ACGME Competencies Highlighted by Case
1. When interacting with patients and their families, the health care professional communicates effectively and demonstrates caring and respectful behaviors.
2. Essential and accurate information about the patients’ is gathered.
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
5. Patients and their families are counseled and educated.
8. Health care services aimed at preventing health problems or maintaining health are provided.
9. Patient-focused care is provided by working with health care professionals, including those from other disciplines.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
19. The health professional works effectively with others as a member or leader of a health care team or other professional group.
23. Differing types of medical practice and delivery systems including methods of controlling health care costs and allocating resources are known.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
25. Quality patient care and assisting patients in dealing with system complexities is advocated.
26. Partnering with health care managers and health care providers to assess, coordinate, and improve health care and how these activities can affect system performance are known.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital