Pts with behavioral issues coming to the ED

[helloimathrowaway]

Hi everyone,

I’m an early career psychiatrist, primarily work in the emergency setting, both adult and child/adolescent. I find that some of my most challenging cases in this setting tend to be the families that bring in their kids who have chronic severe behavioral issues (aggressive outbursts, elopement), usually in the setting of some combination of ADHD, trauma, and really messy family dynamics. These are usually the families that come in demanding that their kids be hospitalized and not wanting to hear no for an answer. Parents who think they’re always right and the psychiatrist is wrong despite having zero understanding of mental health.

I’d say I’m usually pretty good at setting strong boundaries and explaining why an acute hospitalization will not address a chronic issue. But I also do feel for the parents who live in constant fear that their chronically impulsive child will beat them up or run away or whatever the case may be. I mostly discharge these kids, but I’m also human and have hospitalized a few here and there who, looking back, I probably shouldn’t have.

My questions for the group:
-What questions do you ask that help you determine whether a hospitalization is warranted in this population? Some factors I personally look at are: whether the kid is connected to appropriate outpatient care already and the outpatient providers feel comfortable managing them, what the level of aggression/impulsivity is and whether it has worsened acutely, what’s driving the behaviors and whether a hospitalization will fix that or not, if the kid is on an appropriate medication regimen. The problem I run into is that 1) some parents will exaggerate things, and 2) some outpatient providers will be quick to wash their hands of these patients and families because well, they’re challenging.
-For those who are successful at it, how do you navigate these conversations about levels of care with these especially difficult families in a way that is taken seriously?

A couple case examples to illustrate my points/questions:
1) Teen girl who presented to the ED following a physical fight with her mom. The jist of the fight was that the mom initially grabbed her after they’d argued verbally for a bit, but the girl retaliated pretty badly. Mom was slightly scratched up and bruised but no major injuries. Lots of chronic parent-child conflict but first instance of aggression of that level, and no SI/HI/psychosis/mania on my evaluation. The girl was already in a partial program and had a chunk of it left to complete, wasn’t thrilled about being there but was attending. I discharged her. Mom was sweet and understood but wasn’t happy.
2) Different teen girl with chronic behavioral issues, came in for reportedly worsening aggression. Family had just started family therapy. Mom very obviously had a cluster B personality disorder, steamrolled everyone constantly, kept assigning irrelevant diagnoses to the kid and trying to convince me it was an issue with her meds, and exaggerated a lot. Really had to reign in my countertransference. I did ultimately discharge her, but it was an absolutely exhausting encounter.

Thanks in advance for any advice!

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[smalltownpsych]

Although hospitalization doesn’t treat a chronic issue sometimes a day or two makes sense to calm things down a bit. The stark reality is that if the environment doesn’t shift for these kinds of kids, nothing we do matters that much. Multisystemic therapy is what is required but implementation doesn’t happen anywhere that I have seen other than some expensive private pay residential programs. We need to stop the myth that we can fix these kids with medications and once a week therapy.

 

[lobstar]

Thinking back to residency these situations were the most exhausting and challenging among colleagues. It sounds like you're doing a lot of the right things. I mainly rely on whether the behavior itself warrants an admission and if the behavior is due to a psychiatric problem. Unfortunately whether it's treatable or not sometimes gets ignored. The mental health system just has no way to care for people who both can't take care of themselves and also attack/bother/annoy/endanger caretakers--kids, dementia, ASD, ID, etc.

For instance if the behavior is worse at home and still worse in the ED, trying to hit people, throwing things I think admission is reasonable. If they're calmed down in the ED looking at discharge as in your examples. At that point the question is how much time and energy do you have? Lots-spend the time maybe you'll get them to understand or be slightly less mad. Little- just say it's not indicated and they'll be the same or more mad.

You can only do so much. The part about how to handle the conversations--I would bet money you're doing a lot of the right things well. No matter how good you get caregivers are going to be mad. The big thing that helps me is that the patient is the patient. There's legitimate risks to their safety by being admitted and if they don't want to come in (and involuntary isn't indicated) it helps me disregard the emotional reaction of clearly malfunctional caregivers rather than watching the caregiver do some gymnastics and coercing the kid to sign in or something.

 

[calvnandhobbs68]

OP did you get a chance to look at this thread from a while back? Similar question that came up:

P

Thread 'Whether to admit “behavioral” children from ED'

Apr 28, 2023

I’m a CL psychiatrist who sees ED consults also (relatively new, <4 months) and am frequently seeing children presenting to the ED with the following:

- Behavioral issues, for example any combination of: threats at school toward peers, violence at home toward family, self-harming when dysregulated by banging head, hitting self, ingesting objects, etc.

- Most seem to carry diagnoses of ODD or DMDD, ADHD, conduct disorder, or ASD;

- They usually have an outpatient
psychiatrist who is at a loss of what to do and are hoping for inpatient admission for “stabilization”;

- They have had...

• Psyche0248
• Replies: 16
• Forum: Psychiatry

• 

 

[helloimathrowaway]

Thinking back to residency these situations were the most exhausting and challenging among colleagues. It sounds like you're doing a lot of the right things. I mainly rely on whether the behavior itself warrants an admission and if the behavior is due to a psychiatric problem. Unfortunately whether it's treatable or not sometimes gets ignored. The mental health system just has no way to care for people who both can't take care of themselves and also attack/bother/annoy/endanger caretakers--kids, dementia, ASD, ID, etc.

For instance if the behavior is worse at home and still worse in the ED, trying to hit people, throwing things I think admission is reasonable. If they're calmed down in the ED looking at discharge as in your examples. At that point the question is how much time and energy do you have? Lots-spend the time maybe you'll get them to understand or be slightly less mad. Little- just say it's not indicated and they'll be the same or more mad.

You can only do so much. The part about how to handle the conversations--I would bet money you're doing a lot of the right things well. No matter how good you get caregivers are going to be mad. The big thing that helps me is that the patient is the patient. There's legitimate risks to their safety by being admitted and if they don't want to come in (and involuntary isn't indicated) it helps me disregard the emotional reaction of clearly malfunctional caregivers rather than watching the caregiver do some gymnastics and coercing the kid to sign in or something.

Sorry if this is a basic question, but what do you consider a treatable problem? For example, a kid with severe ADHD who’s been off their meds for awhile, not already plugged into any outpatient care, and has become extra impulsive within that time period - I think this makes sense to admit and stabilize depending on the level of aggression/impulsive behavior. Or a kid who likely has severe ADHD but has never been diagnosed or treated for it. I do feel though, in these cases, it can be hard to separate what is untreated ADHD/comorbid dx vs what is trauma and family dynamic issues and not fully treatable through an inpatient stay. There’s always, always so much overlap.

@calvinandhobbes68 thank you so much for that thread suggestion. I did not know of it and will have a look!

 

[lobstar]

Sorry if this is a basic question, but what do you consider a treatable problem? For example, a kid with severe ADHD who’s been off their meds for awhile, not already plugged into any outpatient care, and has become extra impulsive within that time period - I think this makes sense to admit and stabilize depending on the level of aggression/impulsive behavior. Or a kid who likely has severe ADHD but has never been diagnosed or treated for it. I do feel though, in these cases, it can be hard to separate what is untreated ADHD/comorbid dx vs what is trauma and family dynamic issues and not fully treatable through an inpatient stay. There’s always, always so much overlap.

@calvinandhobbes68 thank you so much for that thread suggestion. I did not know of it and will have a look!

Yeah I think ADHD being treatable like you said. The chronic personality-ish poorly functioning family units, etc the inpatient unit is basically a break while outpatient follow up is arranged. Untreatable being more the severe ID, ASD, dementia, genetic conditions that there's no research backed treatment we provide on inpatient. As in some facilities don't have actual therapy available (and even if they do an inpatient unit isn't the place for long term therapy anyway) and these patients are typically ones who have tried multiple meds from multiple classes in various combinations and may have also gotten ECT or something without sustained benefit. The admission is more or less waiting it out ?for safety? while we make med changes that we can't be sure are even helping as the natural course of their condition might be to chill out for a few days when removed from the environment that precipitated problems to begin with. And then we get the issue that people then say random med change #17 actually helped and the chart forever says the same and they get more unhelpful polypharm and the cycle continues when they are admitted again 2 months later.

 

[Merovinge]

Please keep in mind that IP hospitalizations are concrete "proof" of severity of illness. This matters for coverage of residential/PHP/IOP services, but also things like therapeutic boarding schools and the ilk. Now if someone has already had a handful of them, 1 more is very unlikely to be making a difference on coverage of service, but it is important that kids with significant functional impairment are receiving these services when appropriate.

I live in a well-resourced area and we still have problems with kids who learn they can be flagrantly aggressive to family/peers/police and not have consequences. This sets up a very difficult feedback loop when parents are trying to enforce consequences for actions but the kid is quickly discharged from the ED with no charges.

 

[calvnandhobbs68]

Please keep in mind that IP hospitalizations are concrete "proof" of severity of illness. This matters for coverage of residential/PHP/IOP services, but also things like therapeutic boarding schools and the ilk. Now if someone has already had a handful of them, 1 more is very unlikely to be making a difference on coverage of service, but it is important that kids with significant functional impairment are receiving these services when appropriate.

I live in a well-resourced area and we still have problems with kids who learn they can be flagrantly aggressive to family/peers/police and not have consequences. This sets up a very difficult feedback loop when parents are trying to enforce consequences for actions but the kid is quickly discharged from the ED with no charges.

Sure but as you yourself said in the other thread:

Conduct disorder/ODD patients that are chronic in nature may be better served in the juvenile detention system which, depending on your area, have more wrap around services. If they are aggressive enough to be in this situation off-lable meds can certainly be considered. Mentoring and social engagement (group and/or individually) is often more helpful than therapy or pharmacologic based interventions. If someone needs to cool off for a few days, there are worse things than an IP admission, but it will certainly not fix the problem and these patients can cause havoc on IP units.

Understandably, many inpatient child/adolescent units will decline admissions primarily for aggression that doesn't seem to be able to be modified with a short term psychiatric stay no matter whether this would provide "proof" for severity of illness or not. They also don't want to get saddled with someone who's now a discharge nightmare because the parents won't take them back and they can't get them into any type of longer term program (which 100% happened to me in fellowship)...it's a lot easier to "leave" your kid on an inpatient unit than in the ER.

Some of this can be setup with firm expectation setting from the ER, a discussion like "it's ultimately up to the inpatient team but this would likely be a very short term admission of a few days and if the inpatient team says they're ready to go home, you're getting them back no matter how long it's been".

 

[Candidate2017]

I live in a well-resourced area and we still have problems with kids who learn they can be flagrantly aggressive to family/peers/police and not have consequences.

This happens just as often, or maybe more, in poor, high crime areas. Police can reduce paperwork and crime stats in their precincts simply by taking someone who commits a violent crime, short of murder, to the ED. Plus if alcohol/substances are involved, the police would rather not deal with close monitoring at the jail. And if the criminal is female, police feel it's a free pass to label it a mental health issue and punt. Invariably, these inpatients get a label of schizoaffective or bipolar and learn it pays to blame "my bipolar" to excuse their actions. Everyone gets rewarded.

 

[Merovinge]

This happens just as often, or maybe more, in poor, high crime areas. Police can reduce paperwork and crime stats in their precincts simply by taking someone who commits a violent crime, short of murder, to the ED. Plus if alcohol/substances are involved, the police would rather not deal with close monitoring at the jail. And if the criminal is female, police feel it's a free pass to label it a mental health issue and punt. Invariably, these inpatients get a label of schizoaffective or bipolar and learn it pays to blame "my bipolar" to excuse their actions. Everyone gets rewarded.

When I worked in a private Medicaid accepting hospital, these patients would be hospitalized almost 100% of the time as the hospital makes money by putting bodies into beds. This was almost never a desired outcome for the teen and while threatening your kid with hospitalization is not my favorite tactic of all time, when things are really getting off the hinge, the fact that this would actually occur, was a real deterrent.

Where I work now, the more affluent teens can at times find that simply bullying their way through family, school, and police is met without resistance. They get to the ED and say whatever, and then return home to sneak out of the house again the next night. This is not the type of learning that leads to good outcomes. I am not arguing that all these kids need to be hospitalized every time an event happens that leads them into the ED, but it's certainly worth thinking about the full array of consequences from an admit or discharge decision.

 

[helloimathrowaway]

Please keep in mind that IP hospitalizations are concrete "proof" of severity of illness. This matters for coverage of residential/PHP/IOP services, but also things like therapeutic boarding schools and the ilk. Now if someone has already had a handful of them, 1 more is very unlikely to be making a difference on coverage of service, but it is important that kids with significant functional impairment are receiving these services when appropriate.

I live in a well-resourced area and we still have problems with kids who learn they can be flagrantly aggressive to family/peers/police and not have consequences. This sets up a very difficult feedback loop when parents are trying to enforce consequences for actions but the kid is quickly discharged from the ED with no charges.

I’m interested to hear others’ perspectives on this. I have mixed feelings about aligning with parents in presenting hospitalization as a consequence for bad behavior. Like I mentioned upthread, I think hospitalizaiton for these ADHD/ODD/conduct kids can be justifiable in some circumstances, especially if there’s a component of their presentation that can be treated during a short inpatient stay. But I’m not convinced I need to be the one who enforces the “consequence” for their bad behavior.

I do think it’s a bit of a moral quandary for the emergency psychiatrist. Firstly, should we feel bad for leaving the parents to deal with their kids’ behavior? Which….to be honest, I (and most of us I’d guess) don’t usually do. When I discharge kids, I’m still providing aftercare and lots of psychoeducation - some families are amenable to this, others will sabotage these efforts because it’s not exactly what they want or doesn’t fit into their (rigid but often very flawed) understanding of the problem, which is a shame. Secondly, are we reinforcing dangerous behavior when we don’t hospitalize these kids? I think this is complicated, as I’d argue on the one hand that being brought to the ED is a consequence in and of itself, and it’s often unclear if being admitted would change these kids’ behaviors. I’ve had parents try to convince me left and right that “well after their last admission, they ship-shaped,” but….clearly that only lasted so long, and hospitalizing them over and over again isn’t going to help.

I’m kind of spitballing at this point and maybe preaching to the choir, but I’m enjoying the discussion about this. I also love the point that was made about setting expectations in the ER that inpatient stats are meant to be short and NOT “let me put my kid away for 30 days because I’m sick of them.” I absolutely try to put this into practice as much as I can.

 

[Merovinge]

I’m interested to hear others’ perspectives on this. I have mixed feelings about aligning with parents in presenting hospitalization as a consequence for bad behavior. Like I mentioned upthread, I think hospitalizaiton for these ADHD/ODD/conduct kids can be justifiable in some circumstances, especially if there’s a component of their presentation that can be treated during a short inpatient stay. But I’m not convinced I need to be the one who enforces the “consequence” for their bad behavior.

I do think it’s a bit of a moral quandary for the emergency psychiatrist. Firstly, should we feel bad for leaving the parents to deal with their kids’ behavior? Which….to be honest, I (and most of us I’d guess) don’t usually do. When I discharge kids, I’m still providing aftercare and lots of psychoeducation - some families are amenable to this, others will sabotage these efforts because it’s not exactly what they want or doesn’t fit into their (rigid but often very flawed) understanding of the problem, which is a shame. Secondly, are we reinforcing dangerous behavior when we don’t hospitalize these kids? I think this is complicated, as I’d argue on the one hand that being brought to the ED is a consequence in and of itself, and it’s often unclear if being admitted would change these kids’ behaviors. I’ve had parents try to convince me left and right that “well after their last admission, they ship-shaped,” but….clearly that only lasted so long, and hospitalizing them over and over again isn’t going to help.

I’m kind of spitballing at this point and maybe preaching to the choir, but I’m enjoying the discussion about this. I also love the point that was made about setting expectations in the ER that inpatient stats are meant to be short and NOT “let me put my kid away for 30 days because I’m sick of them.” I absolutely try to put this into practice as much as I can.

The path is see if things do in fact change after a few IP to PHP/IOP stays, if they don't, see if RTC helps. I am not sure what the alternative would be to a kid who is struggling heavily and not keeping themselves/those around them safe. I don't believe in giving up on children in the best resourced country in the history of the world. At times the interventions do need to exceed the effort the patient or the family is putting into the treatment, that's just part of CAP work that is different than adult interventions.

I do agree that IP stays are short, that's how they are exclusively done in my geography. If I see a kid has had even a 10-14 day stay, I extensively investigate it as that's already a yellow to red flag (much less a 30 day IP stay which I've seen zero times in privately insured kids).

As far as consequences go on a 0-10 (10 being all money is frozen, no phone/wifi access), an ED visit maybe ranks a 2/10 where an IP stay is clearly much higher.

Now of course there are caveats of parents who are clearly abusing the system, kids who actually want to be IP regularly (very rare to see this type of borderline presentation in teens but can happen), etc. Overall if a parent is begging for their kid to be hospitalized and they meet criteria for an IP stay I would need compelling information to deny that hospitalization. As an aside, this is the first family that will be suing you if something bad happens after you deny the admission.

 

[helloimathrowaway]

Appreciate that insight! I think the key often is distinguishing which parents are abusing the system vs which parents have genuinely tried everything and still can’t keep their kid safe, which imo is not always the easiest thing to do.

This is also veering into a slightly different topic, but I also struggle sometimes with getting a lot of pushback, especially from inpatient attendings with my system, for instances when I have chosen to admit a kid with this sort of profile. I imagine general ED docs go through this too, but it’s exhausting to be the at the brunt of “everyone thinks they know better than the emergency medicine/psychiatry doc.” I’m learning to be better at taking the heat though, it’s part of the job!

 

[lobstar]

Appreciate that insight! I think the key often is distinguishing which parents are abusing the system vs which parents have genuinely tried everything and still can’t keep their kid safe, which imo is not always the easiest thing to do.

This is also veering into a slightly different topic, but I also struggle sometimes with getting a lot of pushback, especially from inpatient attendings with my system, for instances when I have chosen to admit a kid with this sort of profile. I imagine general ED docs go through this too, but it’s exhausting to be the at the brunt of “everyone thinks they know better than the emergency medicine/psychiatry doc.” I’m learning to be better at taking the heat though, it’s part of the job!

I've always found the inpatient pushback ridiculous when working the ED, particularly the times when it's brought up that if they are admitted they will be harder to discharge or that it's not indicated. It's very 'Monday morning quarterback'.

A discharge from the ED is much more risky and challenging to me. Just like Merovinge said, the lawsuit will be directed at you. On inpatient you have 24/7 observation, time for additional collateral, dedicated social work; you can put together much more thorough documentation if you think admission is unhelpful and not indicated. If the inpatient team actually thinks it's not indicated they can discharge directly from inpatient the next day. I've noticed that when they have to eat the risk themselves and force the patient out, contact DHS, or file parent abandonment, suddenly they let the admission length of stay hit 7+ days...

Now if you actually do have an inpatient team that is putting some skin in the game and will immediately discharge people they don't think need to be there against the parent's wishes, well then that might actually be someone worth listening to and learning something from so that you can see how they successfully do that.

 

[smalltownpsych]

I've always found the inpatient pushback ridiculous when working the ED, particularly the times when it's brought up that if they are admitted they will be harder to discharge or that it's not indicated. It's very 'Monday morning quarterback'.

A discharge from the ED is much more risky and challenging to me. Just like Merovinge said, the lawsuit will be directed at you. On inpatient you have 24/7 observation, time for additional collateral, dedicated social work; you can put together much more thorough documentation if you think admission is unhelpful and not indicated. If the inpatient team actually thinks it's not indicated they can discharge directly from inpatient the next day. I've noticed that when they have to eat the risk themselves and force the patient out, contact DHS, or file parent abandonment, suddenly they let the admission length of stay hit 7+ days...

Now if you actually do have an inpatient team that is putting some skin in the game and will immediately discharge people they don't think need to be there against the parent's wishes, well then that might actually be someone worth listening to and learning something from so that you can see how they successfully do that.

Very much agree with this perspective. I would add that discharge the next day isn’t necessarily a repudiation of the need for admission. Sometimes sleeping on it is good for all of the parties involved so that we have time to come up with a better plan. When I was covering the ED I was making the “decision” (actually a recommendation to the physician) to admit and the decision to discharge so that made it a little smoother.