Diagnostic issues

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Organic causes should always be considered first, including substance intoxication, side-effects or toxic effects of medication, intracranial disorders, seizures, and general medical disorders. A drug history should always be obtained and a physical examination carried out whenever indicated. A sudden deterioration of behaviour or emotion in a child who is previously functioning well should always alert us to the possibility of an organic cause. Seizure disorder can sometimes present as violent behaviour, which usually has the characteristic of episodic occurrence with normal functioning in between. Delirium in children may present with a behaviour problem, particularly in the form of disinhibition.

The next important diagnostic group comprises the psychotic disorders. On the whole, they are rare in childhood, but increase in frequency from mid- to late adolescence. Ruling out their presence is important to reassure the parents and others. Obviously, it is important to detect, monitor, and treat a prodromal state. (4)

Mood disorders often underline violence or suicidal behaviour. Psychomotor retardation is uncommon in children and the depressive symptoms may go unrecognized. In children and adolescents, depressive mood may be described as irritability by the carers. An individual interview with the child or adolescent is needed to elicit the depressive symptoms. Suicidal ideas and behaviour should always be asked about whenever there is a mood problem.

Severe anxiety disorders can precipitate a crisis. Severe separation anxiety problems in preschool children can be extremely stressful for the parents. Severe acute post-traumatic disorder can seriously interrupt a child's functioning. Children who have witnessed serious violence or experienced severe trauma or disaster require urgent help.

Severe obsessive-compulsive disorder sometimes presents with marked oppositional-defiant behaviour, and family members may be deeply involved with the compulsive rituals. In addition, severe obsessive-compulsive disorder is an important differential diagnosis for young people who are suspected of suffering from psychosis/5.)

Severe eating disorder may initially present as an emergency because of a sudden deterioration in the adolescent's physical health. He or she will usually deny the problem, whereas the parents are concerned but feel powerless to help. If the condition is life-threatening and the adolescent is old enough to refuse consent, then involuntary admission for treatment may be required.

The assessment of suicidal risk is one of the most important tasks of emergency psychiatry and must be taken seriously. Always ask about suicidal thoughts if the patient talks about unhappiness, or appears to be sad, or if there is a history of mood problem or withdrawal. Serious risk factors include older male adolescent, a history of suicidal attempt, substance abuse, mental illness, and access to lethal weapons. (6) Even if the suicidal risk is low, talking about it will help the patient to feel understood, and is also an important sign that the child or adolescent definitely requires further help. Sometimes the suicidal risk is unrecognized by the parents or guardians, who must be informed if there is such a risk.

Violent and out-of-control behaviours are usually related to conduct disorders. However, other disorders may underline violence such as mood disorder, severe anxiety, substance abuse, and pervasive developmental disorder.

Personality disorder should be considered in the older adolescents. They may present with suicidal behaviour, substance abuse, and physical violence. Their co-operation with treatment is usually unsatisfactory. Often they are seen by outpatient services and yet continue to use the emergency service when they are under stress. Good co-ordination between the two services with the establishment of a management protocol will reduce the disruption and improve management.

Many psychiatric disorders can be associated with an emergency psychiatric presentation. However, a brief assessment for the acute crisis may be insufficient, so it is important to explain to the parents and the patient that further assessment may be required.

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