A child comes into the Emergency Room because the parents are worried about their behavior. The adult psychiatry resident, not schooled in child development, is called to make an assessment, to triage this patient. Send them home, admit them, call for help, these are the choices. My task today, in one hour, so nearly an impossible task, is to teach psychiatry residents how to begin to triage these children and adolescents. Given that I do a three-hour assessment, and the reality for these residents is that they have, at most, one hour to make this decision, I need to help them pare down my three hours, such that they distill the most important clinical issues. Clearly, this is an inverse situation, in that I, with more experience, could do one-hour assessments, and these residents, in order to learn, should be given three hours, but alas, that is not the current reality.
I will begin by helping them think about where the presenting problem lies?
Behavioral disorders are the most acute, since those issues can lead to immediate self-destruction or harm to others. We all worry, I will tell them, about seeing the next school shooter, and somehow, tragically, missing the acuity of the situation. At the same time, we know that we will let children and adolescents out of the emergency room, only to find out later, that violence ensued. Our tools are flawed. Our ability to predict, hopelessly fallible.
Next, I will talk about how to get a history, by thinking about the child in four domains.
Returning to the reason for landing in the Emergency Room, the major questions are “why now” and “says who?’ Pre-pubertal children can usually, but of course, not always, return to the care of their parents, but post-pubertal adolescents are much more challenging because they have the means to independently cause destruction. On the other hand, if the parents are part of the problem, or if there is any suspicion of abuse, then the Psychiatry Resident is charged with contacting the authorities, with the possible outcome that the child will land in an emergency foster care situation. The dance between being sympathetic and suspicious of the parents begins. Likewise, this same dance with the child begins as well. Is the child a victim of his circumstances or are the parents victimized by this child, or is it some combination? Eventually, after the data is obtained, both by direct interview and record review, the resident is charged with making a diagnostic formulation and treatment recommendations. Finally, these ideas need to be conveyed to the parents in a way which minimizes defensiveness, as talking to a parent about psychiatric issues in their child is a very delicate conversation. As complicated as all this is, the most challenging issue will be finding outpatient referrals. Child psychiatrists are in short supply, and as such, most families have tremendous difficulties finding good care. Further, the good care that is available is not always well-known to those that work in emergency rooms.
At the conclusion of my lecture, as most of my teaching goes, there is usually a heavy feeling associated with the uncertainties in our field, which is tied together with huge responsibilities, leading to an uncomfortable sense of fear and uneasiness in the provider. I will joke about how this uneasiness might be correlated with the shortage of child psychiatrists. Maybe though, this is no joke.