TABLE 126.29 GUIDELINES FOR MANAGEMENT OF ACUTE ADOLESCENT PSYCHOSIS Diagnose underlying cause Request immediate psychiatric consultation Utilize medical hospitalization, if psychosis due to an underlying medical condition is suspected Request psychiatric consultation with psychotic drug intoxications, either immediately or when mental status stabilizes Use quiet room, family and friends, and constant medical supervision Use emergency agitation medications and restraints as necessary Recognize clinical variations of extrapyramidal reactions to antipsychotic medications POSTTRAUMATIC STRESS DISORDERS PTSD can occur in childhood and adolescence and is usually due to severe trauma during earlier years Children may be more sensitive to the effects of trauma than are adults and thus may have higher rates of PTSD Either the reemergence of the old trauma, the emergence of a new similar one, or the recollection of the original trauma can activate a PTSD Traumatic events involve situations where there was threatened or actual death, serious injury, or disease to someone Highly stressful experiences leading to PTSD in children may include but are not limited to any of the following: physical violence, verbal threats, sexual abuse, long-standing hunger and poverty, as well as medical interventions such as bone marrow transplant, and injury such as burns and motor vehicle accidents Children may respond to traumatic events with intense fear, helplessness or horror, or even disorganized or agitated behavior In addition, the traumatic event is persistently reexperienced in one or more ways, for example, persistent avoidance of stimuli associated with the trauma, numbing of general responsiveness, and persistent hyperarousal With children, PTSD probably emerges through a combination of traumatic events, along with a silent or nonaccepting environment that fails to provide the child with adequate protection and support A child’s PTSD symptoms may be observed through repetitive play by which themes or aspects of the trauma are expressed Recurrent and distressing dreams of the event may also occur Hallucinations and flashbacks may follow the child’s sudden reliving of the experience In addition, events that symbolize or resemble some aspect of the traumatic event may produce intense anxiety and distress; the connection between precipitating event and distress is not always evident to parents or child Other PTSD symptoms experienced by children include generalized numbing of responsiveness to events and people Stimuli associated with the trauma may be consistently avoided The emergency physician should also be alert for signs of increased arousal—anxiety and agitation, difficulty falling asleep, irritability or anger, suspiciousness, difficulty concentrating— and various physiologic complaints in response to events that resemble or symbolize the traumatic event The key task for the emergency physician is to recognize PTSD in the differential diagnosis of an agitated, confused, or even psychotic child or adolescent A careful history usually provides clues to this diagnosis Supportive management in the ED, including using family and friends, is often sufficient Low-dose antipsychotic medication may be recommended after psychiatry consultation for those who are frankly psychotic and who not respond to reality-based support Often, an antihistamine or anxiolytic medication may suffice The ED physician may also have an important role in the prevention of PTSD When patients are being treated for an acute traumatic episode, refer a patient for mental health counseling When parents dismiss or doubt the child’s symptoms or worries, the emergency physician can encourage the parents to respond supportively to their child When the physician suspects parental abuse, this concern must be addressed directly with the family Many children with PTSD benefit significantly from individual and family therapy If child and family are not already in treatment, a referral is appropriate PANIC ATTACKS Children experiencing panic attacks commonly present to the ED After ruling out any medical cause for the child’s symptoms, the ED physician should educate the patient and their family about the nature of panic attacks and discuss use of relaxation techniques Benzodiazepines should be avoided when possible, so as to help the patient and their family recognize that the symptoms of a panic attack are time limited and self-resolving If the panic attacks are frequent, cause significant distress, or are leading the patient/family to repeatedly seek medical care, referral to an outpatient mental health provider is indicated If left untreated, panic attacks can blossom into lifelong and severely impairing anxiety disorders However, with appropriate and early treatment, future panic attacks and their sequelae can be prevented CARING FOR CHILDREN WITH AUTISM SPECTRUM DISORDERS IN THE EMERGENCY DEPARTMENT Autism spectrum disorder (ASD) is a neurodevelopmental disorder defined by difficulties in social communication and restricted or repetitive behaviors and interests Individuals with ASD demonstrate challenges engaging in social reciprocity, appreciating nonverbal social behaviors, and establishing social relationships Characteristically, this population exhibits highly fixed interests and adherence to strict routines Autism is a clinical diagnosis that can be reliably identified as early as years of age, although core deficits in communication, social responsiveness, and play present as early as to 12 months of age Significant heterogeneity exists in clinical phenotype, severity, type, and frequency of symptoms Children with ASD may lack attention, avoid eye contact, struggle to talk about feelings, prefer not to be touched, repeat or echo words said to them, engage in repetitive actions, have trouble expressing needs in typical words or behaviors, display anxiety with changes in routine, and demonstrate exaggerated distress to modest sensory experiences Degree of disability is generally related to the level of support needed in school and with daily functioning The biology of ASD is incompletely understood as a disorder of neuronalcortical organization reflecting both genetics and environmental influences ASD affects all racial, ethnic, and sociodemographic populations, with disproportionately higher rates among boys and later identification in minority groups A 2014 prevalence study by the Centers for Disease Control reports overall in 59 children (1 in 37 boys and in 151 girls) carries a diagnosis of ASD Thirty-one percent have associated intellectual disability Clinical Considerations Predictable patterns of comorbid medical conditions have been described in those with ASD Investigators identify significantly higher rates of healthcare utilization among children with ASD for psychiatric, gastrointestinal, neurologic, and sleep disorders Eighty percent of children with ASD report at least one psychiatric diagnosis, including inattention and hyperactivity in 30% to 61%, anxiety in 11% to 40%, and depression in 7% to 26% Thirteen percent of emergency care visits among this population relates to psychiatric-related concerns as compared to 2% in children without ASD Families seek care most often for management of externalizing behaviors, such as physical aggression and disruptive conduct Similarly, many children with ASD require care for gastrointestinal and neurologic complaints Although 9% to 70% of individuals with ASD report concerning abdominal pain, constipation, chronic diarrhea, and symptoms of gastroesophageal reflux disease, there is no evidence for pathogenic mechanisms related to these conditions specific to ASD Notably, children with ASD and common gastrointestinal disorders may present atypically with behavior changes, irritability, disordered sleep, or new noncompliance with previously mastered demands Many individuals with ASD have restricted or selective diets and may be at risk for nutritional deficiencies causing illness Children with ASD frequently pursue neurologic intervention for impaired motor development and seizure management Epilepsy occurs in 25% to 46% of individuals with ASD Children with ASD in general have significantly higher rates of poisonings, self-injury, traumatic brain injuries, injuries to the face and neck, contusions, fractures, open wounds, and burns with lower rates of sprains and strains compared to peers without ASD Crucially, nearly half of children with autism are known to wander from caregivers with an associated risk for drowning being the most common cause of mortality in such circumstances Remarkably, two-thirds of children ages to 15 years report being bullied Self-injury is most common in patients with associated intellectual disability or limited functional communication abilities Such behavior may ... responsiveness to events and people Stimuli associated with the trauma may be consistently avoided The emergency physician should also be alert for signs of increased arousal—anxiety and agitation, difficulty... complaints in response to events that resemble or symbolize the traumatic event The key task for the emergency physician is to recognize PTSD in the differential diagnosis of an agitated, confused,... for mental health counseling When parents dismiss or doubt the child’s symptoms or worries, the emergency physician can encourage the parents to respond supportively to their child When the physician