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. This page has been left blank intentionally 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 reect 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 gures 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 Condentiality 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 nal 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 specic 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 Shefeld Children's NHS Foundation Trust, and Designated Doctor for Child Protection for Shefeld. 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, Shefeld Health and Social Care NHSFT, The Longley Centre, Shefeld. 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, Eneld 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. [...]... 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. .. organisation and planning of services, and for commissioners a subsection to help to identify components of services that need to be in place to meet the needs of these children and adolescents, and to determine quality standards for these services Why do children and adolescents with mental health- related problems go to the emergency department? Children and adolescents present to the emergency department. .. collaboration with the Department of Health, has issued guidelines and recommendation for service standards and developments to deal with mental health problems across the lifespan presenting to emergency departments Essentially, for CAMHS, this recommends that CAMHS liaison teams deal with children and adolescents presenting during normal working hours, and that a rota of CAMHS specialists is available to do emergency. .. above-mentioned doctors or services The Joint Colleges’ Working Group on CAMHS in the emergency department are conducting a survey of all emergency departments in the UK to establish the level of CAMHS provision and training in these departments Assessing children and adolescents: what’s different? The biggest differences in considering the needs of children and adolescents with mental health, emotional and behavioural... accordingly for anyone who deals with children, adolescents and their families who present in the emergency department with a mental health- related problem or set of problems It is for first-line practitioners, for their seniors who will consult with them, for their teachers and trainers who will help them develop their skills and knowledge, and for the heads of departments, managers and commissioners required... 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... assessment of psycho-emotional and behaviour-related problems – between 1995 and 1999, while general paediatric attendance increased by 2%, child and adolescent mental health referrals increased by 60% Thomas (2003) suggests that the increases are attributed to the greater knowledge of mental health problems in children and adolescents, and hence a greater demand for services, and to the increase in self-harm... Contextual factors in assessing children and adolescents Helen Bruce* Presentation Children and adolescents change with age in a way that is much more obvious and pronounced than in later life Children and adolescents, more so than adults, are embedded in and influenced by their family and social systems The way in which a child or an adolescent presents to the emergency department will be determined... influences the time, nature and severity of the crisis, the organisation of emergency mental health services in the ecology of a healthcare system may influence the outcome of the crisis’ There are often different organising assumptions and expectations regarding the assessment of paediatric medical patients and the assessment of children and adolescents with mental health problems The expectation for... the delivery of CAMHS emergency services in the UK Emergency departments are one of a range of provisions that address the needs of children, adolescents and families with acute bio-psychosocial problems Some areas will have specialised paediatric emergency departments Some will have primary care out-of-hours assessment centres Others will have specialised mental health emergency and assessment centres, . Children and adolescents with mental health problems Edited by Tony Kaplan EMERGENCY DEPARTMENT HANDBOOK � Tony Kaplan Emergency Department Handbook PUBLICATIONS This. the emergency department. This page has been left blank intentionally Emergency Department Handbook Children and adolescents with mental health problems This