What are the treatment plans for high-acuity pediatric patients presenting with Emergency Department (ED) visits for aggression or suicidality in psychiatry?

From the Guidelines

For high acuity pediatric psychiatric patients, treatment plans should prioritize immediate safety, family involvement, and a multidisciplinary approach to yield the best outcomes in terms of morbidity, mortality, and quality of life. When considering the management of such patients, it's crucial to focus on the most recent and highest quality evidence available. The most recent guideline from [@\1@] emphasizes the importance of establishing a safety plan for patients with depression, which includes restricting lethal means, engaging a concerned third party, and developing an emergency communication mechanism. This approach is particularly relevant for suicidal patients, where immediate safety is paramount, with constant observation, removal of dangerous items, and risk assessment using tools like the Columbia Suicide Severity Rating Scale. Pharmacological interventions may include SSRIs like fluoxetine with close monitoring for increased suicidality in the first weeks, or in acute situations, benzodiazepines such as lorazepam for severe agitation. For aggressive patients, de-escalation techniques should be attempted first, followed by medications like risperidone or aripiprazole, with physical restraints used only as a last resort with proper monitoring. Family involvement is crucial across all conditions, with psychoeducation and therapy integration, as highlighted by [@\1@], which suggests that better adherence to treatment is associated with the identification and tracking of specific treatment goals and outcomes. Multidisciplinary approaches including psychiatrists, psychologists, social workers, and pediatricians yield the best outcomes, as they can provide comprehensive care tailored to the specific needs of the patient. Some key points to consider in the treatment and care of high acuity pediatric psychiatric patients include:

• Immediate safety measures for suicidal patients
• Family involvement and psychoeducation
• Multidisciplinary approach to care
• Pharmacological interventions tailored to the patient's condition
• Regular reassessment of treatment efficacy and safety
• Clear documentation of all interventions and responses
• Consideration of cultural factors and developmental appropriateness in communication and treatment planning, as suggested by [@\1@]. Given the emphasis on recent and high-quality evidence, the recommendations from [@\1@] provide a strong foundation for the management of high acuity pediatric psychiatric patients, focusing on safety, family involvement, and a multidisciplinary approach to improve outcomes in terms of morbidity, mortality, and quality of life.

From the Research

High Acuity Pediatric Patient Treatment Plans Psychiatry

ED (Emergency Department) Treatment

• Non-pharmacologic methods for managing agitation in pediatric patients in the ED, such as de-escalation techniques and environmental modifications 1
• Multimodal approach to managing agitation in the ED, with etiology of agitation driving choice of treatment 1
• Medication use, including immediate and as-needed medications, with specific recommendations for child and adolescent psychiatry expert consensus 1

Aggression Treatment

• Individual-level interventions, such as cognitive-behavioral therapy and dialectical behavior therapy, to address aggressive behaviors in inpatient and residential settings 2
• Systems-level interventions, such as milieu therapy and behavioral modification programs, to address aggressive behaviors in inpatient and residential settings 2
• Considerations for the field, including the need for standardized measurement of emotion dysregulation and operationalization of dysregulation in a standard way 2

Suicidality Treatment

• Selective serotonin reuptake inhibitors (SSRIs) may reduce the risk of suicidal behavior in pediatric patients, with escitalopram associated with the greatest risk reduction 3
• Safety of antidepressants, antipsychotics, anti-attention-deficit/hyperactivity disorder (ADHD) medications, and mood stabilizers in children and adolescents, with a safer profile emerging for escitalopram, fluoxetine, lurasidone, methylphenidate, and lithium 4
• Considerations for provider wellness and competency in caring for pediatric patients with acute psychiatric needs, including suicide risk assessments and disposition and safety planning 5