Psychiatric Emergencies in Adolescents Dr John Callary Child & Adolescent Psychiatrist

Main Purpose  Convey an approach that emphasises safety first, with a view to resolving crises  May have to tolerate some diagnostic uncertainty  Medication usually has a relatively small role

Mental Illness in young people  Affects 10% of all children and adolescents  Only 1/5 of these receive necessary treatment  Suicide - a major cause of death in adolescence  High prevalence of substance abuse, depression and anxiety  Psychotic illnesses often first present in adolescence

Emergency Department  May be the first port of call for many young people with mental illness  Opportunity – but many limiting factors  May be a barrier to a comprehensive psychiatric evaluation

Emotional Crises in Adolescents  Self-harm, risk taking and suicidality  Aggression and violence  Antisocial behaviour  Withdrawal and phobic avoidance  Extreme family conflict  Psychotic presentations (incl BRP)  Combinations of any of above

Adolescent development  Psychological Development - Erikson’s stage V Identity v Role Confusion Identity v Role Confusion Early, Middle, Late Early, Middle, Late Regression Regression Trust v Mistrust, Autonomy v Shame, Initiative v Guilt, Industry v Work EthicTrust v Mistrust, Autonomy v Shame, Initiative v Guilt, Industry v Work Ethic Stage VI - Intimacy v Isolation Stage VI - Intimacy v Isolation  Neurodevelopment Limbic v Frontal, hormonal influencesLimbic v Frontal, hormonal influences  Systemic viewpoint Family Family Peers Peers Community Community

Adolescents Are NOT CHILDREN Are NOT CHILDREN Are NOT ADULTS Are NOT ADULTS  Beware of treating them as one or the other!  Countertransference – know it and monitor it (ie: having your buttons pushed)

Principles in Interviewing  Therapeutic alliance  Confidentiality  Respect - Importance  Clarity  Limits: Safety first

Interviewing Principles  Style is crucial Empathic listening Empathic listening “Pacing” “Pacing” Support / Space / Security Support / Space / Security  Order of interviewing

Some Specific Techniques  Details around suicide Thoughts Thoughts Threats Threats Plans Plans Self-harm Self-harm Attempts and attitude to survival Attempts and attitude to survival Access to means Access to means  Emotional bar charts  The adolescent’s own creativity and interests: eg metaphor  Rating Scales eg:Beck Depression Inventory

Family Therapy techniques ‘structural’  The family is a system  Symptoms of a sick family system  Joining - to effect structural change  Optimal family structure  Subsystems  Boundaries  Hierarchy  Alliances

Family Therapy techniques - ‘Solution Focussed’  Positive reinforcement  “Miracle question”  Noticing of exceptions  Timing of this approach

Management decisions  Assess & manage safety physical (any risk of having taken Overdose? Access to fire-arms or other weapons?) physical (any risk of having taken Overdose? Access to fire-arms or other weapons?) suicidality suicidality mandatory notification? mandatory notification? Adequate staff support Adequate staff support  Admit? where? referral issues, safety plan where? referral issues, safety plan  Detain? Therapeutic alliance, safety, age and legal guardians Therapeutic alliance, safety, age and legal guardians  Medication? (next slide)  Placement? Families SA/Crisis Care, family, friends, TAP, hospital links Families SA/Crisis Care, family, friends, TAP, hospital links

Medication  Agitation, Psychosis AntipsychoticsAntipsychotics olanzapine, risperidone, haloperidol, chlorpromazine, pericyazineolanzapine, risperidone, haloperidol, chlorpromazine, pericyazine BenzodiazepinesBenzodiazepines diazepam, midazolam, clonazepamdiazepam, midazolam, clonazepam  Depression, Anxiety, Dissociation SSRIsSSRIs sertraline, citalopram, fluvoxaminesertraline, citalopram, fluvoxamine less useful than in adultsless useful than in adults stronger placebo effectstronger placebo effect 4 % experience increase suicidal ideation4 % experience increase suicidal ideation

Key points  Adolescence – developmental stage  Systemic approach  Rapport and therapeutic alliance  Style of interviewing vitally important  Safety first  Diagnostic uncertainty common and must be borne  Medication is generally only adjunctive, though more vital in psychosis