Pediatric emergency medicine trisk 1047

(iii) the child is not actively suicidal or psychotic; (iv) the child can earnestly
engage in safety planning; (v) the family can take responsibility for safely
managing the child until formal psychiatric treatment is begun; and (vi)
adequate means restriction can be carried out. Before sending a family
home, the family should formulate an acceptable, concrete plan for how they
will manage the child.
Parents should be given guidelines for the prevention of suicide ( Table
126.20 ) and instruction in the early warning signs ( Table 126.21 ).
TABLE 126.18
AREAS TO ASSESS FOLLOWING A SUICIDE ATTEMPT
Social set
Intent
Method
History
Stress
Mental status
Support
TABLE 126.19
INDICATIONS FOR PSYCHIATRIC HOSPITALIZATION
FOLLOWING CHILDHOOD/ADOLESCENT SUICIDE ATTEMPT
1. Failure of rapport among physician, child, and family
2. Serious suicide attempt (lethality and intent)
3. Continuing active suicidality
4. Inability to engage in safety planning
5. Psychosis of child
6. Divisive/disturbed family, incapable of support and supervision
7. Denial of significance of suicide attempt


TABLE 126.20
PREVENTION OF CHILDHOOD AND ADOLESCENT SUICIDE:

GUIDELINES FOR PARENTS
Understand nature of parent—child dilemma during adolescence
Maintain physical contact—be around, combat tendency toward isolation
Maintain emotional contact—stay involved, show positive regard
Listen to child before responding—promote safety in talking
Respond to child once child has finished—take child seriously, do not
dismiss or attack
Encourage choices by adolescent
Acknowledge child and provide respect
Restrict means to suicide (such as firearms, knives, drugs/alcohol, motor
vehicles, toxins) as indicated


TABLE 126.21
PREVENTION OF CHILDHOOD AND ADOLESCENT SUICIDE:
WARNING SIGNS FOR PARENTS
Withdrawal (peers, parents, siblings)
Somatic complaints
Irritability
Crying
Diminished school performance
Sad or anxious appearance
Significant loss (rejection by peer group, breakup of romance, poor grades,
failure to achieve important goal)
Major event or change within family
Casual mention of suicide or being “better off dead”
Explicit suicide threat
Giving away of possessions
Abrupt improvement in mood (which may represent relief upon deciding
to carry out suicidal act)

Minor, seemingly unimportant suicide “gestures”
Apparent “accidents”
Other unusual behavior pattern—housebound behavior, breaking curfew,
running away, drug or alcohol abuse, bizarre or antisocial actions

DEPRESSION
Goals of Treatment
The goals of emergency treatment of the depressed pediatric patient are to
establish a safe and appropriate disposition plan and to provide brief
psychoeducational and therapeutic interventions to the patient and their
family.
CLINICAL PEARLS AND PITFALLS


Depression in pediatric patients may present with either sad or
irritable mood as its predominant symptom. Unlike depressed adults,
who tend to be consistently down or sad, depressed pediatric
patients will often have moments in which they seem happy—often
when they are engaged in a preferred activity. Clinicians should not
rule out depression based on these moments of what is referred to
as mood reactivity.

Clinical Considerations
Depression involves a pervasive sad or irritable mood, accompanied
frequently by self-deprecation and suicidal ideation. Depression also implies
a change in functioning from an earlier state of relatively good adjustment.
The depressed child typically experiences a profound sense of helplessness,
feeling unable to improve an unsatisfactory situation.
The prevalence of depression in children and adolescents is around 3%. It
is higher in children with anxiety and/or behavioral or significant medical

problems. Most children with depression present to the ED with other chief
complaints (somatic symptoms, school or behavior problems); the ED
clinicians must consider the possibility of depression in all children seen
with recurrent or vague somatic complaints. A large body of evidence
suggests that a genetic predisposition exists for depression, particularly
severe depression.
Depression manifests differently, depending on the stage of development.
In infancy, depression is usually the result of loss of important attachments
and/or nurturance and is seen as a global interference of normal growth and
physiologic functioning, including apathy, listlessness, staring, hypoactivity,
poor feeding and weight loss, and increased susceptibility to infection.
In school-aged children key features include dysphoric mood, irritability,
and self-deprecatory ideation. Dysphoric mood is manifested by looking or
feeling sad and forlorn, being moody and irritable, and crying easily. Selfdeprecatory thoughts are reflected by low self-esteem, feelings of
worthlessness, and suicidal ideation. Depression in this age can also appear
as other common symptoms, including multiple somatic complaints, school
avoidance, or underachievement, including learning disabilities or ADHD,
angry outbursts, runaway behavior, phobias, and fire setting.