Mental Illness in Children

In a bustling Emergency Department, a 14-year-old girl presents with acute onset shortness of breath. While vital signs are stable except for tachypnoea, the patient appears visibly panicked. After ruling out life-threatening conditions, a detailed history reveals the trigger; witnessing a heated argument between her parents. This is a common scenario, emphasising the importance of recognising the interplay between psychological and physiological factors in paediatric presentations.

Whilst emergency physicians prioritise ruling out critical diagnoses, effectively managing these cases requires a nuanced approach. After observation and stabilisation, these patients are often discharged with a referral to Child and Adolescent Mental Health Services (CAMHS).

The post-pandemic era has witnessed a significant surge in childhood mental health issues, with recent data suggesting that at least 1 in 5 children now experience mental illness; a 50% increase since 2017.1 This highlights the critical need for increased awareness and understanding of childhood mental health within the emergency department setting.

Mental health issues can begin from a young age, and their prevalence changes as people grow older.

The histogram shows the mental and behavioural health conditions by age as per the data from U.S. Centers for Disease and Control Prevention (CDC).2

The increasing prevalence of mental illness in the context of the growing use of substances abuse, along with the limited availability of mental health resources, has led to higher rates of self-harm amongst young people. Almost 24% of 17-year-olds self-harm each year & and suicide remains the leading cause of death for young people in the UK.3

Suicide rates among young people are significantly higher than those among older populations, particularly for males.

In children aged 5-14 years:

• Males have a suicide rate of 1.5 per 100,000.
• Females have a suicide rate of 0.4 per 100,000.

In adolescents aged 15-24 years:

• Males have a suicide rate of 22 per 100,000.
• Females have a suicide rate of 4.9 per 100,000.

These figures, however, only represent confirmed deaths and do not include suicide attempts.

The exceptionally long waiting lists for mental health services can lead to their symptoms escalating over time and eventually presenting to emergency departments in crisis. It is infrequent that such children are seen in the ED by mental health professionals and receive evidence-based assessment or treatment by the specialist team from the offset. 

Is the ED an ideal place for young people with a mental crisis? 

The ED is a key entry point for crisis care and a link for community services and can be perceived as a safety net for patients and families in urgent need of psychiatric care.     

The most common mental health presentations to a paediatric ED are4:

• Anxiety disorders
• Substance abuse and overdoses
• Mood disorders
• Suicide behaviours and aggression

The ED is theoretically equipped to contain and triage the mental health crises in a quick and safe manner. 

Adolescents prefer to use Emergency Departments over primary care due to multiple reasons. One of these is the concern around lack of confidentiality about bullying, mental health, sexual health and sexual identity.  

However, a lack of privacy, an overstimulating ED environment, exposure to other medically and mentally ill individuals and the inability to have a timely specialist assessment makes the ED an unideal place for children and young people experiencing a crisis; but there are few alternatives and patients cannot be left without support.  This learning session gives you an overview on how to conduct an emergency assessment, whilst at the same time diffusing the crisis and containing a potentially explosive and unsafe situation. 

Psychosis

Psychosis is a disorder of thinking (delusions) and perception (hallucinations).

Patients are often brought in by relatives; they might be fearful, apprehensive, irritable andagitated in the ED.  

Children with psychosis might experience a decline in their social and cognitive functioning prior to the psychotic symptoms. This can manifest as:

• Social withdrawal
• Worsening school performance
• Bizarre or eccentric thoughts and behaviours
• Self-neglect
• Paranoia
• Anxiety
• Irritability
• Hostility
• Aggression

The mnemonic for psychosis is THREAD:

For children presenting with psychotic symptoms for the first time, antipsychotic medication should not be initiated unless in consultation with a consultant psychiatrist. If a child or adolescent exhibits signs of psychosis, it is crucial to seek immediate assistance from a mental health specialist such as a CAMHS (Child and Adolescent Mental Health Services) professional.

Learning bite

A child with psychosis might experience a decline in their social and cognitive functioning prior to developing psychotic symptoms.

Acute Mania

The hallmark of a manic episode is the presence of an irritable, elevated mood state, which represents a significant change from the child’s usual mood state and persists for at least a week.

The change in mood is usually accompanied by a change in the child or young person’s (CYP) perception of themselves, manifested by grandiosity. More than half of the adolescents with mania might develop psychotic symptoms.5

The FIND strategy5 is used to assess symptoms in a youth with mania.

• Frequency
• Intensity
• Number
• Duration

During a manic episode, CYP can show:

• Decreased need for sleep;
• Pressured speech;
• Racing thoughts;
• Increased interest in multiple activities;
• Increased sexual behaviours due to poor impulse control and poor judgement;
• provocative clothing style.

There might be an increased productivity in the initial days of a maniac episode, but this is self-limited due to the increasing distractibility.

For diagnosing bipolar disorder in children6:

• Mania must be present;
• Euphoria must be present on most days and for most of the time, for at least 7 days;
• Irritability is not a core diagnostic criterion.

Whilst grandiosity is a hallmark of bipolar affective disorder across all ages, its presentation in prepubertal children can be nuanced. Instead of the typical grandiose displays, these children may primarily exhibit severe oppositional behaviour, reflecting their developmental stage.

The mnemonic for mania is DIGFAST, developed by William Falk.

Depression

CYP with depression are seen as irritable rather than depressed or sad.

Up to 60% also have suicidal ideation and 30% attempt suicide.7

Depressed CYP experience irritability or depressed mood, which persists for more than two weeks and is associated with deterioration in functioning.

They may also exhibit:

• Anhedonia;
• Social withdrawal;
• Declining school performance;
• Disrupted sleep patterns;
• Changes in appetite or weight;
• Fatigue

A negative self-appraisal, low self-esteem and cognitive distortions in thinking lead CYP to have thoughts of worthlessness, hopelessness, guilt, death and suicide.

Younger children might present with somatic symptoms or behavioural problems, as they don’t have the ability to verbalise thoughts of guilt and hopelessness or identify their own mood state.8 Psychotic or melancholic symptoms are less likely to present in younger children with depression.8

The mnemonic for depression is SIGECAPS, developed by Carrey Gross.9

Learning bite

CYP with depression are seen as irritable rather than depressed or sad, and this persists for more than two weeks.

Anxiety Disorders

There are multiple subtypes of anxiety disorders in CYP, but the following are those disorders which may require immediate attention in the ED.

• Acute stress disorder;
• Post traumatic stress disorder;
• Panic disorder;
• Social phobia.

A) Acute stress disorder

Acute stress disorder is limited to one month following the traumatic event. The child or young person’s subjective report of symptoms is more focused on the trauma than the re-experiencing of it.

When CYP discuss traumatic events, they often describe having experienced it in a dissociative manner. For example, they may describe watching the event happening to them, lacking an emotional response to the event, or having incomplete recollection of the event.

Learning Bite

Acute stress disorder is limited to one month following the traumatic event. Children often describe it in a dissociative manner.

B) Post traumatic stress disorder (PTSD)

PTSD requires the presence of a traumatic event in which the individual experiences extreme fear, hopelessness or horror.

In younger children this may be expressed through agitated or disorganised behaviour.

The traumatic experience leads to:

• Re-experiencing the symptoms associated with the trauma;
• Avoidance of stimuli associated with the trauma;
• Hyper-arousal, which causes significant distress or functional impairment.

Many individuals exposed to severe trauma experience some symptoms, but these typically resolve within a month. When symptoms persist for longer than a month, a diagnosis of PTSD is warranted.

Parents may not always be aware of their child’s exposure to trauma, or they may be the perpetrators. The avoidance behaviours characteristic of PTSD can make it difficult for young people to report or recall traumatic experiences, hindering diagnosis.

Young children may re-enact traumatic events through play, experience frightening dreams unrelated to trauma, become aggressive, or develop separation anxiety or fears. Older children and adolescents may exhibit general anxiety symptoms, substance use, or self-harming behaviours.

The mnemonic for PTSD is TRAUMA10

Learning bite

A diagnosis of PTSD is made when the symptoms persist for more than 1 month. Parents may not be aware of their child’s exposure to trauma, or they may be the perpetrators. The avoidance behaviours characteristic of PTSD makes it difficult for young people to recall traumatic experiences, hindering diagnosis.

Treatment:

Consider an individual trauma-focused Cognitive Behavioral Therapy (CBT) intervention for the child. Do not offer drug treatments for the prevention or treatment of PTSD in children and young people aged under 18 years.11

C) Panic disorder

A panic attack is a sudden onset of intense fear and physical symptoms, reaching a peak within ten minutes. These symptoms can include palpitations, shortness of breath, numbness or tingling, dizziness, sweating, shaking, and a feeling of choking.

Children and adolescents may experience panic attacks in response to anxiety-provoking stimuli within anxiety disorders or other mental health conditions.

A diagnosis of panic disorder is considered when panic attacks occur repeatedly, with or without triggers, and the individual experiences persistent worry about future attacks, leading to significant changes in behaviour to avoid them.

D) Social phobia

Children and adolescents with social phobia experience significant distress and fear in social situations, leading to avoidance and anticipatory anxiety.

Younger children may struggle to express their anxiety verbally, manifesting it through tantrums or crying spells. Older children and adolescents might experience physical symptoms like nausea, abdominal pain, or headaches when confronted with social situations. As a result, they may avoid unfamiliar activities or those requiring active participation.

The severity of social phobia can vary, from simply avoiding raising one’s hand in class to refusing to attend school or social gatherings altogether.

Learning Bite

Younger children may express their social phobia through tantrums or crying spells. Older children and adolescents might experience physical symptoms like nausea, abdominal pain, or headaches when confronted with social situations.

Eating Disorders

Eating disorders are characterised by abnormal or disturbed eating behaviors.  They are associated with the highest mortality rates among psychiatric disorders. Standardised mortality ratios were found to be 5.86% in a recent meta-analysis. 1 in 5 individuals with Anorexia Nervosa who died had committed suicide.12

The peak incidence is in girls aged 15-19 years. In crisis, they present due to the clinical complications associated with malnutrition or due to behavioural changes resulting from the eating disorder. They encompass a range of conditions, including:

Anorexia Nervosa: Individuals with Anorexia Nervosa restrict their food intake or engage in excessive exercise in order to prevent weight gain. This is often driven by a distorted body image and an intense fear of gaining weight.

Bulimia Nervosa: People with Bulimia Nervosa experience cycles of binge eating, where they consume large amounts of food uncontrollably, followed by compensatory behaviours such as vomiting, misuse of laxatives, or excessive exercise to counteract the effects of the binge eating.

Binge Eating Disorder: consuming large amounts of food within a short period. Unlike bulimia, individuals with binge eating disorders do not engage in compensatory behaviours.

Avoidant/Restrictive Food Intake Disorder (ARFID): Individuals with ARFID avoid or restrict certain foods due to sensory sensitivities (taste, smell, texture) or past negative experiences with food, such as choking, vomiting, or abdominal pain.

Other Specified Feeding or Eating Disorders (OSFED): This category encompasses individuals who exhibit eating disorder symptoms that don’t fully meet the diagnostic criteria for anorexia, bulimia, or binge eating disorder.

In children and adolescents, the clinical complications of eating disorders tend to appear late and suddenly and are potentially lethal. In the differential diagnosis of Anorexia Nervosa, clinical causes of malnutrition must be considered, together with other diagnoses that might cause weight and appetite loss.

Behavioural disorders can present to the ED with aggression and severe disruptive behaviour. They include:

1. Attention deficit hyperactivity disorder (ADHD)
2. Oppositional defiant disorder
3. Conduct disorder

1) Attention deficit hyperactivity disorder (ADHD)

The primary symptoms of Attention Deficit Hyperactivity Disorder (ADHD) are:

• Inattention;
• Hyperactivity;
• Impulsivity.

Children and adolescents with ADHD exhibit these symptoms before the age of 7 years old and experience significant functional impairment in at least two settings. Symptoms occur frequently and can be exacerbated in group settings or during activities that require concentration or interest.

Hyperactivity and impulsivity can manifest as disruptive and noisy behaviour, difficulty remaining still or waiting, and frequent injuries due to excessive movement. Children with ADHD who present to the ED are often brought in due to aggressive or disruptive behaviour.

2) Oppositional defiant disorder

Oppositional defiant disorder is characterised by a persistent pattern of defiant, disobedient, and hostile behaviour towards authority figures. This pattern must be present for at least six months and significantly interferes with academic, social, or occupational functioning. Children and adolescents with this disorder often argue with parents, refuse to follow rules, and are more likely to exhibit these behaviours at home. They may lose their temper and become aggressive, typically verbally, but without the severe aggression seen in conduct disorder.

3) Conduct disorder

Children and adolescents with conduct disorder demonstrate a disregard for the wellbeing of others and exhibit minimal guilt or remorse for harming others.

They engage in a consistent pattern of behaviour that violates the basic rights of others or disregards societal norms. This often includes a history of school suspensions, physical aggression, destructive behaviour, lying to avoid consequences, and stealing.

The four primary symptom clusters of conduct disorder are:

• Aggression or threats towards people or animals;
• Deliberate property damage;
• Repeated violations of rules at home or school;
• Persistent lying to avoid consequences.

This behaviour significantly interferes with social, academic, or occupational functioning.

Adolescents who use substances often seek help in the ED due to intoxication or withdrawal symptoms. However, it’s important to evaluate their substance use patterns to determine if they have substance abuse or dependence.

Both conditions are linked to psychosocial impairment or academic difficulties.

1) Substance abuse

Substance abuse is characterised by the continued use of a substance despite negative consequences, including potential or actual harm. The mnemonic WILD is often used to describe the key features of substance abuse.9

2) Substance dependence

Prolonged exposure to an addictive substance can lead to a habitual and compulsive pattern of use. The individual loses control over their substance use, both in terms of the amount and frequency. This can impair their functioning as they prioritise substance use over other activities like relationships, hobbies, school or work.

Individuals with substance dependence develop tolerance, requiring higher doses to achieve the same effect or experiencing withdrawal symptoms when use is reduced or stopped.

The mnemonic ADDICTeD is often used to describe the characteristics of substance dependence:

The mnemonic for substance dependence is ADDICTeD.9

Pathophysiology

The pathophysiology of childhood mental illness is complex and can involve a combination of factors, including genetics, biology, psychological trauma, and environmental stress.

Mental health determinants13

Risks to Mental Health

Pre-conception and prenatal period:

• Unwanted pregnancy
• Pregnancy during adolescence
• Malnutrition, low birth weight, micronutrient deficiency (E.g.: iodine)
• Risky behaviours in the pregnant mother, e.g. use of tobacco, alcohol and drugs13

Infancy and early childhood:

• Separation from the primary caregiver
• Postnatal depression in the mother
• Maltreatment/neglect by the parents
• Malnutrition or parasitic diseases

Childhood:

• Negative experiences from family life and/or school
• Domestic violence
• Bullying
• Parental loss
• Poor housing/living conditions
• Parents with mental illness/substance-use disorder15

Adolescence:

• All the risk factors mentioned in “childhood” above
• Tobacco, alcohol, and substance use

Schematic overview of risks to mental health over the life course13
Source: WHO, Risks to mental health: an overview of vulnerabilities and risk factors (Adapted from: Foresight project, 2008; Kieling et al, 2011; Fisher et al, 2011)

ED clinical evaluation includes taking a detailed history (including a collateral history), a physical examination and a mental status examination.

Acute mental health problems can present to the ED with or without an acute psychiatric disorder. In addition to assessing for the presence of a psychiatric disorder, it is also important to assess for acute mental health problems, such as suicidal behaviour, aggression, parent-child conflict, adjustment issues, abuse, and homelessness. Prior to the urgent mental health assessment, acute medical complications need to be excluded.

The first step in the mental health assessment is establishing the therapeutic alliance. There are many ways to do this but, most importantly in a busy ED, the clinician needs to sit down, make eye contact and not appear distracted or rushed (e.g., seeing the patient in a private cubicle, rather than in a corridor). Provide a calm and safe atmosphere. Be empathic.

Assessment of a child or adolescent differs from that of an adult in several respects. Whereas most adults seek help on their own behalf, children rarely do so. Depending on age and development, some children are simply unable to provide certain historical and clinically relevant information, which signifies the importance of a collateral history from informants including parents, caretakers, and teachers.

To make accurate judgements about the child’s behaviour we have to be conscious of the developmental level of the child. Children less than 12 years of age are less likely to reliably answer questions about mood, onset, and duration of symptoms.  It may be better to see the child together with the parents or parents and child separately.

Building Rapport and Assessing Children

When interviewing children, it’s often helpful to begin with neutral topics to establish comfort and assess their speech, discourse, and thought patterns. Simple questions can be used to evaluate their behaviour and mood, such as: “Have you been crying frequently in the past few days?”

Rather than asking directly why a child feels, thinks, or behaves in a certain way, it’s more beneficial to understand their subjective experience.

Adolescents and Confidentiality

Adolescents value privacy and independence and are more likely to share information if they know it will be kept confidential. This should be discussed at the outset of the interview.

Clinicians should explain under what circumstances they might need to share information with parents, such as when there are safety concerns (e.g., suicidal or homicidal thoughts) or when abuse is suspected. Sensitive issues like substance abuse, sexual activity, or pregnancy generally don’t require breaking confidentiality unless there are exceptional circumstances, such as a CYP repeatedly driving under the influence or a disclosure of a sexual assault in an underage child. In these cases, it’s often best to encourage the CYP to share this information directly with their parents first.

Differentiating Psychiatric Diagnosis from Mental Health Problems: It’s important to distinguish between a psychiatric diagnosis and a mental health problem. Those presenting with an acute psychiatric disorder may have different treatment needs than someone experiencing adjustment difficulties after a break-up.

Treatment history: A detailed review of past treatments is necessary, including information on duration, drug dosages, side effects, adherence to treatment plans, allergies, and whether the patient experienced positive or negative outcomes.

Co-occurring disorders: In emergency situations, the most urgent and immediate disorder should be addressed first. For example, in the case of an adolescent with both mania and ADHD, mania would be the primary focus of treatment in the ED setting.

Family assessment: During an urgent assessment, it’s essential to focus on high-risk family mental health problems such as suicide, substance abuse, mood disorders, and psychosis. A family history of psychiatric illness may indicate an increased risk for the identified patient developing similar conditions.

Once patients have been medically stabilised, the ED clinician needs to determine the patient’s suicide risk.

To foster an open dialogue, create a calm and supportive environment. Empathy is key;young people are more likely to disclose their suicidal thoughts if they feel understood and valued. Be accepting of their beliefs and feelings, avoiding judgment to maintain a trusting therapeutic relationship.

As before, clearly outline the limits of confidentiality at the outset. While confidentiality is essential, there are exceptions: if the young person poses a danger to themselves or others, or if they are being harmed, confidentiality may be breached to protect their safety.

Directly inquiring about suicidal thoughts and plans is not harmful; in fact, it can be therapeutic. Many individuals find these thoughts distressing and are willing to discuss them when asked.

Introduce the topic gently through general questions, moving gradually to more direct questioning, for example:

• Have you ever had the feeling that you didn’t want to get up one day?
• Have you ever had thoughts that you can’t go on?
• Do you ever think that if you went to sleep and didn’t wake up that that would be ok?
• Have you ever thought about ending your life?
• Have you ever thought of a plan to end your life?
• If yes – tell me about your plan.
• How close have you come to acting on your plan?

Personal risk factors:

• Psychiatric illnesses: Depression, bipolar disorder, substance-use disorders, conduct disorders, and psychosis with command hallucinations.
• Depression: High levels of hopelessness, lack of future orientation.
• Suicide history: Previous suicide attempts, passive suicidal thoughts.
• Life events: Recent major life events, especially losses or humiliations.
• Family history: Suicide in family members.14

Lethality: Clinicians need to assess the lethality of the attempt – including both objective and subjective realities.

It is important to take a careful history of the events leading up to and following the attempt. Questions to ask regarding lethality include:

• Was the attempt carefully planned or impulsive?
• Was rescue anticipated or likely?
• Were there preparations and measures taken to ensure death was likely?
• Did they believe they would die? E.g. even if they took 4 x Paracetamol tablets, did they do this with the belief that this would kill them?
• Was personal business finalised? (e.g., giving away possessions, did they write a letter?)
• Were lethal means available?

Start with open-ended questions such as “what happened to bring you here?”  This allows patients to tell their story in their own words. Then follow up with more direct questions to determine the patient’s thoughts and emotions before, during and after the event. For example (in case of a self-inflicted wound with a knife):

• How were you feeling the day before you injured yourself?
• How did you get the knife?
• What were you thinking and feeling when you injured yourself?
• Where were you when you decided to injure yourself?
• Who was there? Were you alone?
• How many times did you attempt to make the cut?
• What happened after you injured yourself?
• How did you feel after you injured yourself?
• How do you feel now that you didn’t kill yourself?
• What do you think you have learnt from all of this?
• How might you react next time?

Managing Suicide Risk in CYP

CYP identified as being at high risk of suicide often require hospitalisation for their safety. In cases where individuals are uncooperative or pose an immediate threat to themselves, involuntary admission may be necessary, adhering to local laws and procedures.

Learning Bite

Directly inquiring about suicidal thoughts and plans is not harmful.

Laws for Detention of Psychiatric Emergencies in the ED

Compulsory Detention: This requires a patient to be suffering from a mental disorder and in need of immediate hospitalisation for their own protection or the protection of others.

• Section 2 (England and Wales): Allows for detention up to 28 days for assessment and treatment. Requires recommendations from two doctors and approval from an approved social worker.
• Mental Health Act 2003 (Scotland): Enables a registered medical practitioner to grant an emergency detention certificate authorising detention for 72 hours.
• Mental Health Order 1986 (Northern Ireland): Requires two or three doctors, including the RMO, to recommend admission for assessment of mental disorder. Can be initiated by a nearest relative or approved social worker and lasts for 7 days, renewable up to 14 days.
• Section 136 (England): Allows for detention in a public place of a person who appears to be mentally disordered and causing disturbances.

For those assessed as being at low to medium risk, a comprehensive discharge plan should be developed in collaboration with the patient and family. This plan should include detailed information on follow-up appointments, contact details, and any prescribed medications. A crucial component is discussing the creation of a safe home environment, which involves limiting access to potentially harmful means, such as sharps or medications. Finally, the CYP and family should be reassured that they can return to the emergency department at any time if their situation worsens, although ideally, they would be given access to a 24/7 crisis service via CAMHS so that they didn’t have to.

High-Risk Factors for Suicide

Individuals at high risk for suicide often exhibit a combination of the following:

• Mental State: Severe depression, command hallucinations, delusions of death, feelings of hopelessness, despair, worthlessness, or intense anger and hostility.
• Suicide Ideation: Active suicidal thoughts, a clear plan, or a previous attempt with high lethality.
• Substance Abuse: Substance use can increase the risk of impulsive behaviour and impair judgement.
• History: Inconsistencies in reported information or difficulty accessing relevant records.
• Support Systems: Lack of supportive relationships or a hostile environment can contribute to increased risk.

Involuntary Hospitalisation

For patients deemed to be at high risk, involuntary hospitalisation may be necessary if there is:

1. Persistent and intense suicidal thoughts;
2. A serious suicide attempt;
3. Severe underlying mental disorder.

Patients deemed at high risk for self-harm or other adverse outcomes should be closely monitored and actively sought if they leave the facility. Informing local authorities is essential in these cases.

When hospitalisation is not feasible, alternative options include voluntary commitment, home observation with round-the-clock supervision, or ongoing outpatient management. A contingency plan should be in place for rapid reassessment if the patient’s condition deteriorates.

Follow-up reassessments are crucial:

• High-risk patients: Within 24 hours
• Medium-risk patients: Within one week
• Low-risk patients: Within one month

Patients with no foreseeable risk can be referred to outpatient mental health services or their primary care physician for ongoing care and management of any underlying mental health concerns.

Investigate to rule out medical causes for the child or young person’s symptoms on a case-by-case basis, if indicated.

Important differentials for psychiatric diseases are:

1. Hypoglycaemia
2. Cerebral hypoxia
3. Drug intoxication and withdrawal
4. Neurological disease
5. Neurological infections e.g. meningitis, encephalitis

Investigations to be considered in ED:

• Full Blood Count. An elevated white cell count may indicate infection. Severe anaemia may contribute to cerebral hypoxia.
• Urea and Electrolytes. Identify hypocalcaemia, hypomagnesaemia, hypernatraemia, hyponatraemia, metabolic acidosis.
• Blood Glucose level. Identify hypoglycaemia.
• Liver Function Tests
• Thyroid Function Tests
• +/- CT scan
• +/- Urine toxicology
• +/- EEG
• Other: ECG, LP, Urine pregnancy test

De-escalation

• Use calming techniques and distraction. The parents may have an idea of what may be helpful.
• Utilise members of the multidisciplinary team to assist, e.g. CAMHS, adult mental health services, security and the nursing staff.
• Offer the child or young person the opportunity to move away from the situation in which the violence or aggression is occurring, for example to a quiet room or area. Do not be afraid to ask parents to step away if they are fueling the situation.

Restrictive interventions

• Use restrictive interventions only if all attempts to diffuse the situation have failed and the child becomes aggressive or violent.
• Do not use punishments, such as removing contact with parents or carers or access to social interaction, withholding nutrition or fluids, or corporal punishment, to force compliance.

Manual restraint

• If possible, allocate a staff member who is the same sex as the child to carry out manual restraint.

Mechanical restraint

• Do not use mechanical restraint in children.
• Mechanical restraint in young people is used only in high‑secure settings, in accordance with the Mental Health Act 1983 and with support and agreement from a multidisciplinary team that includes a consultant psychiatrist in CAMHS.

Rapid tranquilisation

• This should only be done with involvement of the ED Consultant, and preferably the CAMHS team.
• Use intramuscular (IM) Lorazepam for rapid tranquilisation in a child and adjust the dose according to their age and weight.
• If there is only a partial response to IM Lorazepam, check the dose and consider a further dose.
• Monitor the child as per guidance. The CYP should never be secluded or left in a poorly-visible location.

• EDs primarily focus on addressing immediate physical health crises. This can inadvertently lead to the neglect of potential underlying mental health concerns. However, if the underlying cause of a child’s distress is not identified and addressed, it may result in recurrent ED visits.
• Younger children are unable to verbalise their thoughts and mood, so can present to ED with somatic symptoms or behavioural problems.
• Children with depression can present with irritability rather than being low in mood which can make the diagnosis challenging.
• In PTSD, parents may not be aware of their child’s traumatic exposure, or they might even be the perpetrator. The avoidance behaviour characteristic of PTSD also makes it difficult for the child to recall the traumatic event. This makes the diagnosis ever more challenging for the ED physician.
• Mental illness can be accompanied by suicidal ideation and thoughts of self-harm. If the emergency physician fails to recognise these thoughts, it can have serious consequences, including the potential for the child to die by suicide.
• A common misconception is that children and young people must be “medically cleared” or “medically well” before psychiatric assessment. This causes unnecessary delays in care. Current RCPsych guidance discourages the term “medical clearance” and instead recommends that medical and mental health assessments occur in tandem once the patient is medically stable, to optimise safety and reduce ED length of stay.15

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