Post- Rufina

 Respond to  your  colleagues by recommending at least one additional way you would treat a  child or adolescent client differently than you would an adult and at  least one additional way you would address the legal and ethical issues  involved.  

NOTE: Positive Comment

                                                        Main Discussion

Psychiatric  emergencies are severe behavioral changes that may result from  worsening mental illness. Psychiatric emergency is any disturbance in  thoughts, feelings, or actions that require immediate therapeutic  intervention (Stahl, S. M., 2014). The providers approach, attitudes and  work environment may escalate the situation and interfere with the  quality of care. Certain therapeutic measures can reduce the intensity  of the situation and provide a more dignified way for patients to  recover from the crisis. It is thus important that the PMHNP understand  how to assess patient’s emergency status and address their unique needs  while maintaining safety.

  Case selected.

Patient  is a 25-year-old AA male who presents to the emergency department with  psychotic behavior in believing he should kill his mother which led to  his attempt to stab his mother. Patient is admitted for inpatient  psychiatric stabilization. Patient has a history of schizoaffective  disorder and major depression that was managed with use of clozapine  150mg twice a day and Zoloft 100mg daily. Family reported that patient  has a history of medication non-compliant and had been on different  psychiatric medications in the past but were not working for him.  Additional reports by his parents shows that patient had missed several  doses of his medication, decompensated and they had notices some changes   recently including increase agitation, delusional believes that he is  the savior in the family and God had directed him to cast the demon in  his mother. Reports also that he had drawn a picture of himself with  knives cutting a woman he portrayed as a demon with blood flowing with a  man standing to the side, laughing. Patient currently stated that he  participates in a meeting with angels from which he gets directives on  how to attack his mother which led to his attempt to stab his mother.  Because of this, patient was considered dangerous to his mother per  admitting physician. Patients symptoms include psychosis, extreme  agitation, paranoia, verbal outburst, combative and very difficult to  redirect. Patient has no known drug allergies per parents.  Verbal  restraint was used including letting patient know what will happen if  he does not comply, respecting his autonomy, empathetic listening,  decrease environmental stimulation, reassure patient that they will be  safe, and maintain a safe environment. The patient was given emergency  medications including haloperidol lactate 5mg, lorazepam 2mg, and  diphenhydramine 50mg all IM for severe agitation and danger to others.  To prevent re-hospitalization within 12-24 hours of discharge, the  physician ordered outpatient therapy and continued use of clozapine and  Zoloft along with necessary lab work.

 How I would treat the client differently if he or she were a child or adolescent

Children and adolescent are usually brought for treatment when  their behavior or thoughts come to the attention of parents, teachers,  social workers, or school.  For pediatric patients in a mental health  crisis, the typical chaotic nature of the situation may easily further  exacerbate an already traumatized state of the patient. Just like in  adults, as a PMHNP I would perform an evaluation to determine the type  of emergency and contributing factors in child and adolescent emergency  by assessing not just the child but also the entire family.  Additionally, safety and protection are essential mandate in psychiatric  emergency evaluation especially when the patient pose imminent threat  to self or others. What I will do different when interviewing children  especially younger children is to assess the underlying cause of the  violent behavior and delusional symptoms within a developmental context. Specifically,  I would clarify that "bizarre thinking " or accounts of seeing or  hearing things that others do not see or hear are different from  developmentally appropriate fantasy or difficulty while distinguishing  inner voices from distressing hallucinations. On like in adults where  they can provide information during the interview, when it comes to  younger children, I would need to obtain information from parents or  guardian. For adolescents,  I would obtain information from the patient first then talk to their  parent or guardian if the adolescent is able to tell most of their own  story. This may also help to give a sense of autonomy and control to the  adolescent which promote cooperation with the interview process.   However, information from family is very crucial particularly for a  child who is psychotic, frightened, unable, or unwilling to corporate  with the provider to help understand how the situation occurred and the  severity of the behavior. 

Same  interviewing strategies used in adult may be used including speaking in  a soft voice respecting patients’ autonomy, assuring safety, validating  feelings, offering distractions (like video games) especially with very  young children, and clear limit-setting can be helpful. However,  children should be evaluated in a carefully planned setting with doors  closed for limiting access, and be sure appropriate backup is available  (Margret, C. P., & Hilt, R., 2018).  

In  violent situations children may require a different approach in  deescalating the situation than adults. Safety is the essential mandate  in an aggression evaluation, with the interviewer specifically looking  for imminent threats, plans, targeted people, and access to means of  harm (Margret, C. P., & Hilt, R., 2018). Because adults are much  stronger, they may require physical restrain specially to administer  medication to calm the patient. Verbal restrain such as providing verbal  directions in a nonthreatening manner, setting limits, and assuring the  child that treatment may help them calm may be used for children first.  However, if the child is dangerously out of control and aggressive,  they may need medication to keep them calm and safe.

Legal or ethical issues I would consider when working with a child or adolescent emergency case

The  ethical issue I will consider when working with children and adolescent  is respect for their autonomy, privacy, and confidentiality. For very  young children parents must consent to treatment and the health care  provider treating the child should make every reasonable effort to  obtain and document informed consent. (American Academy of Pediatrics,  2015). Just like adults, maintaining a patient’s confidentiality is an  important ethical consideration when providing care to children and  adolescents. However, when  a PMHNP is concerned that the patient may be at imminent risk for harm  to self or others, confidentiality requirements no longer apply (Chun,  T. H., Katz, E. R., & Duffy, S. J., 2013). This means that the PMHNP  in this situation may disclose information collected  from patient to  caregivers or others as needed and may obtain information from others  such as friends, family members, school personnel, employers and other  without obtaining consent from the patient or guardians (Chun, T. H.,  Katz, E. R., & Duffy, S. J., 2013. Patient  autonomy is a major principle in making decisions about an individual’s  health, and as a PMHNP we are obligated to respect this right and allow  patients to practice their autonomy in the course of their treatment  (Parsapoor, A., Parsapoor, M. B., Rezaei, N., & Asghari, F., 2014).  However, a psychiatric emergency and age may limit a child’s ability to  make such decisions. Regardless, it is always important to involve the  child in informed decision making even if the consent is signed by the  parents or guardian.

References

Chun, T. H., Katz, E. R., & Duffy, S. J. (2013). Pediatric mental health emergencies and special 

health care needs. Pediatric clinics of North America, 60(5), 1185–1201. Retrieved from,

 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3792398/

Da Silva, A. G., Baldaçara, L., Cavalcante, D. A., Fasanella, N. A., & Palha, A. P. (2020). The 

Impact of Mental Illness Stigma on Psychiatric Emergencies. Frontiers in psychiatry, 11, 

573. https://doi.org/10.3389/fpsyt.2020.00573

Margret, C. P., & Hilt, R. (2018). Evaluation and Management of Psychiatric Emergencies in 

Children. Pediatric Annals, 47(8), e328–e333. https://doi-

org.ezp.waldenulibrary.org/10.3928/19382359-20180709-01

Parsapoor, A., Parsapoor, M. B., Rezaei, N., & Asghari, F. (2014). Autonomy of children and 

adolescents in consent to treatment: ethical, jurisprudential and legal considerations. 

Iranian journal of pediatrics, 24(3), 241–248. Retrieved from, 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4276576/

Stahl, S. M. (2014). Prescriber’s Guide: Stahl’s Essential Psychopharmacology (5th ed.). New 

York, NY: Cambridge University Press.