Tài liệu Emergency Department Handbook Children and adolescents with mental health problems doc

Children and adolescents

with mental health problems

Edited by Tony Kaplan

Emergency �department Handbook

Tony Kaplan Emergency

Department Handbook

PUBLICATIONS

This practical handbook covers everything a practitioner needs to

know about dealing with children and adolescents who present

in an emergency department with mental health problems. It

provides an easily accessible framework of knowledge on child

and adolescent mental health, with comprehensive, easy-to￾follow guidance.

The book includes contributions from professionals across a

range of disciplines: paediatrics, child and adolescent psychiatry,

liaison psychiatry, emergency medicine, and social care. The

authors clarify the roles and responsibilities of every professional

involved in the care of young patients and their families in a

very vulnerable and potentially frightening situation. The book

is intended for psychiatrists at all levels dealing with young

people, paediatricians and emergency department clinicians,

teachers and trainers, and the heads of department, managers

and commissioners who work together to provide effective and

efficient services to meet the needs of this under-served client

group. The subjects covered include:

• understanding child and adolescent mental health problems

• their social and developmental contexts

• the management of common mental health problems in this

age group

• carrying out balanced risk assessments

• liaison with social services and the role of other agencies

• the legal context

• confidentiality and child protection

• diversity issues.

About the editor

Tony Kaplan is a Consultant Child and Adolescent Psychiatrist at the

Young People’s Crisis Recovery Unit, North London, and was Chair of

the Royal College of Psychiatrists’ working group on CAMHS in the

emergency department.

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Emergency Department

Handbook

Children and adolescents

with mental health problems

This page has been left

blank intentionally

Emergency Department

Handbook

Children and adolescents

with mental health problems

Edited by Tony Kaplan

RCPsych Publications

© The Royal College of Psychiatrists 2009

RCPsych Publications is an imprint of the Royal College of Psychiatrists,

17 Belgrave Square, London SW1X 8PG

http://www.rcpsych.ac.uk

All rights reserved. No part of this book may be reprinted or reproduced or utilised in any form

or by any electronic, mechanical, or other means, now known or hereafter invented, including

photocopying and recording, or in any information storage or retrieval system, without permission

in writing from the publishers.

British Library Cataloguing-in-Publication Data.

A catalogue record for this book is available from the British Library.

ISBN 978 1 901671 73 2

Distributed in North America by Publishers Storage and Shipping Company.

The views presented in this book do not necessarily reflect those of the Royal College of

Psychiatrists, and the publishers are not responsible for any error of omission or fact.

The Royal College of Psychiatrists is a charity registered in England and Wales (228636) and in

Scotland (SC038369).

Printed by Bell & Bain Limited, Glasgow, UK.

v

Contents

Acknowledgements vii

Contributors viii

Abbreviations x

List of tables, boxes and figures xi

1 Introduction 1

Tony Kaplan

2 Contextual factors in assessing children and adolescents 10

Helen Bruce

3 Emergency assessment and crisis intervention 19

Tony Kaplan

4 Child and adolescent mental health presentations in the 33

emergency department

Josie Brown

5 Self-harm: issues, assessment and interventions 63

Tony Kaplan

6 Violence and extreme behaviour 76

Lois Colling and Eric Taylor

7 Consent, capacity and mental health legislation 86

Mary Mitchell

8 Child abuse and child protection 98

Tricia Brennan

9 Cultural diversity and mental health problems 107

Begum Maitra

10 Special considerations 115

Tony Kaplan

11 Confidentiality and information sharing 121

Tony Kaplan and Tricia Brennan

12 Practitioners and pathways: a competency framework 126

Tony Kaplan, Paul Gill, Diana Hulbert, Avril Washington,

Ian Maconochie and Annie Souter

contents

vi

13 Issues for department heads and managers 144

Tony Kaplan

References 159

Appendix I Recommendations of the Joint Colleges Working 162

Group on CAMHS in the emergency department

Tony Kaplan

Appendix II Mental state examination checklist 169

Tony Kaplan

Appendix III Mental Health Act 2007: brief guide 172

Appendix IV Ten essential shared competencies for mental health 175

practice

Appendix V Protocols 177

Appendix VI Emergency department mental health risk 185

assessment tool

Diana Hulbert

Index 187

vii

Acknowledgements

This book is derived from the work of an inter-collegiate group that met under

the auspices of the Child and Adolescent Faculty Executive of the Royal College

of Psychiatrists, chaired by Dr Tony Kaplan, to examine the delivery of child and

adolescent mental health services in the setting of emergency departments in

the UK. We took reference from existing Royal College of Psychiatrists’ Council

Reports CR64, CR118 and CR122. This culminated in the Faculty document

Child and Adolescent Mental Health Problems in the Emergency Department and the

Services to Deal with These (Royal College of Psychiatrists, 2006a). Members of

the Working Group were: Josie Brown, Lois Colling, Tony Kaplan, Catherine

Lavelle, Helen Stuart and Julie Waine (all Royal College of Psychiatrists, Child

and Adolescent Faculty); Ian Maconochie and Avril Washington (Royal College

of Paediatrics and Child Health); and Diana Hulbert (College of Emergency

Medicine/British Association of Emergency Medicine).

I am very grateful to Dr Tricia Brennan for the trouble she took in proof￾reading the final draft of this book, Dr Sebastian Kraemer for his enduring

commitment, Dr Peter Bruggen for being the inspiration behind Chapter

3, and Drs Susannah Fairweather and Quentin Spender for their astute

editorial comments.

Special thanks

The chapter authors are especially grateful for contributions from the

following: Chapter 2, Tony Kaplan for the subsection on the importance of

attachment; Chapter 4, Lois Colling for the subsection on anxiety, Diana

Hulbert for the subsection on altered consciousness/altered mental status,

Tony Kaplan for the subsections on acute stress reactions and post-traumatic

stress disorder, and psychosis, and Catherine Lavelle for the subsections on

the side-effects of psychotropic medication and factors increasing index

of concern in substance misuse; Chapter 5, Quentin Spender for the

Differential Grid for Cutting; and Chapter 13, Catherine Lavelle for the

subsection on the paediatric liaison CAMHS team.

All specific references to the Scottish administrative and legal systems

were contributed by Dr Michael van Beinum.

viii

Contributors

Tricia Brennan, MBChB, DCH, FRCP, FRCPCH, FCEM, is Consultant

Paediatrician and Named Doctor for Child Protection for the Sheffield

Children's NHS Foundation Trust, and Designated Doctor for Child

Protection for Sheffield.

Josie Brown, MBChB, DRCOG, MRCPsych, is Consultant Child and

Adolescent Psychiatrist, Southampton General Hospital.

Helen Bruce, FRCPsych, is Consultant Child and Adolescent Psychiatrist,

East London NHS Foundation Trust, and Honorary Senior Clinical

Lecturer, Barts and the London School of Medicine and Dentistry.

Lois Colling, BSc, MRCPsych, Islington Primary Care Trust, London.

Paul Gill, MBBS, MRCPsych, is Consultant in Liaison Psychiatry, Sheffield

Health and Social Care NHSFT, The Longley Centre, Sheffield.

Diana Hulbert, BSc, MBBS, FRCS (Glas.), FCEM, is Emergency Medicine

Consultant, Department of Emergency Medicine, Southampton University

Hospitals NHS Trust

Tony Kaplan, MBChB, FRCPsych, Cert. Adv. Family Therapy (Sheldon

Fellow), Dip. Clin. Hypnosis (UCL), is Consultant Child and Adolescent

Psychiatrist at the New Beginning Young People’s Crisis Recovery Unit,

North London, part of the Barnet, Enfield and Haringey Mental Health

Trust.

Ian Maconochie, FRCPCH, FCEM, FRCPI, PhD, is Consultant Paediatrician

in the Paediatric Emergency Department, Imperial Academic Health

Sciences Centre, London.

Begum Maitra, MBBS, DPM, MRCPsych, MD (Psychiatry), is Consultant

Child and Adolescent Psychiatrist, and Jungian Analyst in the East

London NHS Foundation Trust (City and Hackney).

Mary Mitchell, MA, BM, MRCPsych, is Consultant Child and Adolescent

Psychiatrist, Leigh House Hospital, Winchester, part of the Hampshire

Partnership NHS Trust.

Annie Souter, CQSW Social Work, Dip. Social Work, Dip. Family Support

and Child Protection, is Team Manager, Children’s Social Care, Islington

Children’s Services, Whittington Hospital, London.

contributors

ix

Eric Taylor, MA, MB, FRCP, FMedSci, is Emeritus Professor, Institute of

Psychiatry, King's College London.

Avril Washington, MBBS, MRCP, FRCPCH, is Consultant Paediatrician,

Homerton University Hospital Foundation Trust.

x

Abbreviations

ADHD attention-deficit hyperactivity disorder

CAMHS child and adolescent mental health services

CBT cognitive–behavioural therapy

CRB Criminal Records Bureau

GCS Glasgow Coma Scale

GP general practitioner

NHS National Health Service

NICE National Institute for Health and Clinical Excellence

NSF National Service Framework

PMETB Postgraduate Medical Education and Training Board

PTSD post-traumatic stress disorder

SIGN Scottish Intercollegiate Guidelines Network

SSRI selective serotonin reuptake inhibitor

xi

Tables, boxes and figures

Tables

3.1 Predictable domains of stress for children 24

and adolescents

4.1 Glasgow Coma Scale 57

4.2 Adjusted Glasgow Coma Scale criteria for children 57

under 5 years

5.1 Differential Grid for Cutting 66

5.2 Pierce Suicide Intent Scale 75

Boxes

3.1 Nature of the stress: practice points 23

3.2 Factors contributing to vulnerability and resilience 25

3.3 Creating a positive environment during assessement 26

3.4 Questions to ask young people about the presenting 29

problem

3.5 Presenting problem: contexts and background 30

4.1 Core symptoms of acute stress reactions and PTSD 42

5.1 Factors indicating level of risk 74

6.1 Restraint in children and adolescents 78

6.2 Non-drug approcaches to calm the severely agitated 80

patient

7.1 How can parental responsibility be acquired? 90

7.2 Relevant laws in the UK 91

10.1 Accommodation options for children and adolescents 116

12.1 Staff at each access point along the care pathway 128

12.2 Essential information for making a referral 130

V.i Useful services/organisations to contact 179

tables, boxes & figures

xii

Figures

3.1 Behavioural outcomes of stress 22

6.1 Guidelines for rapid control of younger patients 82

(6–17 years old) who are acutely disturbed

12.1 Care pathway 127

V.i Assessment protocol for children and adolescents 178

presenting at Southampton University Teaching

Hospital following self-harm

1

Chapter 1

Introduction

Tony Kaplan

At some point, one in five children and adolescents in the UK will suffer

distress or disorganisation of their behaviour sufficient to be considered

‘disordered’ (Office for National Statistics, 2005). Much of this ‘disorder’

will be dealt with informally and resolve or persist at a low level,

accumulating over time to present at a later stage. Some children and

adolescents will be dealt with by various professionals in various capacities

– teachers, school nurses, general practitioners (GPs), social workers – and

never come to the attention of ‘specialists’. Some will be helped by child

and adolescent mental health services (CAMHS), without ever needing

hospital services. However, some children and adolescents will present

at an emergency department in a crisis, they and their families and carers

fraught with anguish, expecting the professionals they encounter to have

the answers to make things better. Yet what they often encounter is a service

stretched to capacity, staff trying to get the job done within a strictly limited

time frame, with limited experience of and training in child and adolescent

mental health problems and a lack of clarity over what can be done and

how to get it done.

This book may contribute to improving and expanding the understanding,

knowledge and skills of all practitioners in or called into the emergency

department to deal with a child or adolescent with a mental health crisis,

and so help them provide a better service to these young people and their

families, and afford these young patients and their families a better and

more useful experience at a time of crisis.

How big is the problem?

Five per cent of adults attending the emergency department present with

significant mental health problems. There are no comparable figures for

children and adolescents in the UK, but in the USA studies show a similar

proportion of children and adolescents (1 in 20) presenting to emergency

departments with mental health-related problems (Thomas, 2003). They

point to an increasing use of the emergency department for the emergency