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Suicide by security blanket, and other stories from the child psychiatry emergency service: what happens to children with acute mental illness

answer that, I would like to return full circle tothe excellent introduction by Gary Kupfer. I fully agree that lessons learned in pediatric psycho- oncology can, indeed should, be used by practi- child psychiatry attendings at the Massachusetts tioners in any field who deal with medically ill General Hospital Psychiatric Emergency Room.
children. I no longer work exclusively—rarely at The most important question they ask when all, in fact—with children with malignancies, and a child and his family arrive in crisis at the yet this book provided much needed informa- emergency room is, with a hint of a biblical tion related to my practice. It is an excellent read, undertone, “What makes this day or night and I hope that it would find its enthusiastic different from all others?”(p. 85). As emergency audience among child psychiatry consultation/ doctors, they are the gatekeepers to inpatient liaison practitioners, oncologists, nurses, and admissions, they provide rapid diagnosis to social workers who deal with medically ill chil- determine whether a patient is safe to go home, dren and, dare I say it, any mental health pro- and they teach other clinicians how to make these fessional who is interested in the impact of stress on his or her practice. Pediatric hematology- The patient vignettes are written for 2 audi- oncology services have been at the very front of ences: they provide a disturbing opportunity for our knowledge on the psychosocial impact of lay people to see how children may present in chronic illness. They have provided funding, crisis in an emergency room and the urgent need research knowledge, and emphasis on those to focus on diagnosis and disposition, and they aspects of care to a degree that very few other describe cases that can help clinicians to hone specialized services have. We should benefit from their diagnostic skills, learn about relevant laws their wisdom, and this textbook provides an protecting children, and understand how to excellent opportunity to do just that.
best to make these difficult decisions. There areno easy algorithms; rather, clinicians need good interviewing skills and an ability to tolerate having only a limited understanding while making The composite patients portrayed are familiar to those of us who practice child psychiatry: anadolescent having her first psychotic break, achild who needs to be evaluated to see if he is “safe to return to his school” after he threatens to 1. Glassman AH, O’Connor CM, Califf RM, et al; Sertraline Antide- pressant Heart Attack Randomized Trial (SADHEART) Group.
stab his second grade teacher, and a boy who is Sertraline treatment of major depression in patients with acute MI terrified by his fear of contamination by germs or unstable angina. JAMA. 2002;288:701-709.
2. O’Connor CM, Jiang W, Kuchibhatla M, et al; SADHART-CHF Investigators. Safety and efficacy of sertraline for depression in The authors elaborate on the delicate effort patients with heart failure: results of the SADHART-CHF (Sertra- to determine if a child is in imminent danger line Against Depression and Heart Disease in Chronic HeartFailure) trial. J Am Coll Cardiol. 2010;56:692-699.
and the negotiations with the child’s guardianswho may have different concerns. Why woulda 5-year-old repeatedly have dark, complex intersecting lines drawn on her upper inner thighs from just below her underwear to all the way down her knees? In a busy emergency room, the clinicians often do not have the luxury of follow-up to find out if they made the correct determination with these high-stakes decisions.
The authors wonder if their efforts are “futile” (p. 75) or if they have an impact on patients in the short term to help bridge patients and families to critical therapeutic services. They include a touching story about Austin, a bewildered15-year-old with Asperger syndrome. He had JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRY moved to a new state precipitously and this had about to hurt themselves or others, emergency disrupted his routines and he was inconsolable when he arrived at the emergency room with his The authors describe Dahlia, a patient who, mother on New Year’s Eve looking for help.
despite intensive community resources and out- During the assessment, the psychiatric resident patient treatment, routinely requires emergency provided concrete suggestions for easing his room services when she is too unsafe and needs transition and connected the family to outpatient temporary hospitalization. Sadly, she was born services. Austin calls the emergency room every addicted to opiates and by 3 years old had lived New Year’s Day to offer an update and to thank with 3 different foster families, and by 4 years the staff for helping him. It is rare to have this old she had explosive tantrums including one kind of acknowledgement; gratitude in these where she dislocated another girl’s shoulder. The settings is more about a death averted or an authors end by describing themselves as “care- givers who want to make a difference . learn as Often the families can have intense reactions much as possible about the child in front of us, when their children are struggling. The authors do muster the limited resources available in the not sugarcoat how some clinicians can be dismis- system, make safety our priority, and hope for sive of parents’ fear and describe the effort of other the best” (p. 106). These brave clinicians have doctors to be empathic and provide comfort. A 9- shared heartbreaking stories of suffering children year-old boy was referred to the emergency room by narrating the complexity, uncertainty, and after he went down to his playroom and tried to compassion required to provide care in a broken strangle himself. He did not have any rope, so he system so that patients and families can have used his scarf. He also had written a list outlining a safety net when they are in the emergency room why he wanted to die. Although this was a fair- ly straightforward decision to hospitalize thispatient, his parents were alarmed and threatened legal action if this happened, and the beleaguered resident felt under attack. The attending psychia- trist avoided an escalating confrontation by joining with the mother in their shared desire to make her son feel better. The psychiatrist’s gentle approachaverted a power struggle.
Massachusetts, where the authors and I prac- Disclosure: Dr. Henderson reports no biomedical financial interests or tice child psychiatry, is in the process of a transi- tion. The Rosie D. Decision is a legal mandate to Dr. Kataoka reports no biomedical financial interests or potentialconflicts of interest.
provide children with psychiatric support in the Dr. Shemesh reports no biomedical financial interests or potential least restrictive setting possible by providing quick access to clinicians who can mobilize home- Dr. Rappaport reports no biomedical financial interests or potential based services and therapeutic mentors. This may mean that over time, as services are provided Note to Publishers: Books for review should be sent to Schuyler W.
more intensively and earlier, there may be a de- Henderson, M.D., M.P.H., NYU Child Study Center, One ParkAvenue, 7th Floor, New York, NY 10016 (email: crease in emergency room visits. However, when children are extremely aggressive or imminently JOURNAL OF THE AMERICAN ACADEMY OF CHILD & ADOLESCENT PSYCHIATRYVOLUME 52 NUMBER 9 SEPTEMBER 2013


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