- Email: [email protected]
4.0 As Needed Medications (PRNs): Do We Know What to Do When All Else Fails?
SYMPOSIA 3.4 — 4.1
involved patients who were prescribed psychotropic medication. Patients with traumatic stress disorders were nine times more likely to have or have used psychotropics in their lifetime (P ¼ 0.001). Patients with thoracic transplants (e.g., heart and lung) were more likely to develop medical traumatic stress disorders than patients with abdominal transplants (e.g., liver and kidney) (P < 0.01). SOT patients with medical and nonmedical traumatic stress disorders used more psychiatric consultation than their nontraumatized peers (P < 0.001). Patients with traumatic stress disorders had higher hospital lengths of stay and more difficulties with adherence (P < 0.01). Conclusions: Pediatric and young adult SOT patients with traumatic stress warrant more intensive psychiatric and medical support. Medical traumatic stress may be predictable in certain SOT patients. This identified population would benefit from increasing psychoeducation of patients and teams, along with more tailored interventions for prevention and treatment. The differences between medical and nonmedical traumatic stress deserve further study.
PTSD, PTA, RF http://dx.doi.org/10.1016/j.jaac.2017.07.592
3.4 POSTTRAUMATIC GROWTH IN HOSPITALIZED CHILDREN AND ADOLESCENTS Eva C. Ihle, MD, PhD, University of California, San Francisco Benioff Children’s Hospital, [email protected] Objectives: This presentation will describe the phenomenon of posttraumatic growth through a review of the literature on complex developmental trauma and salutogenesis. A description of a multidisciplinary approach to support posttraumatic growth (PTG) will also be presented. Methods: A review of the literature on adverse childhood events, complex developmental trauma, medical trauma in children, positive psychology, and PTG will be presented. This seminar will then describe a multidisciplinary, collaborative approach [developed at University of California, San Francisco Benioff Children’s Hospital (UCSF BCH)] to enhance well-being and support PTG. Results: There is much attention being paid to the role that complex developmental trauma and adverse childhood events (ACEs) play in determining the overall well-being of children and adolescents. One ACE that is particularly relevant to consultation-liaison (C/L) pediatric psychiatrists is the threat to bodily integrity; serious medical illness (and its treatment) is one such threat. ACEs have been associated with the maladaptive consequences of the stress response. However, it is important to highlight the auspicious role of stress in addition to its adaptive role (supporting survival). One positive aspect of stress is PTG where individuals gain strength and insight from crises. When medical trauma can be reframed as a stressor that promotes PTG, ACE is transformed from something pathogenic to an experience that is salutogenic. At UCSF BCH, a number of specialists play complementary roles in the effort to support salutogenesis. Our multidisciplinary, collaborative approach involves child and adolescent C/L psychiatrists, pediatric palliative care physicians, psychologists, and child life specialists in the effort to promote coping and enhance the emotional well-being of hospitalized patients. Conclusions: Medical trauma can be considered an ACE that challenges the resilience of both patients and their families. Interventions informed by the field of positive psychology can enhance resilience by supporting salutogenesis. Diverse disciplines can work collaboratively to support well-being and enhance PTG.
STRESS, PYI, PRE http://dx.doi.org/10.1016/j.jaac.2017.07.593
SYMPOSIUM 4 AS NEEDED MEDICATIONS (PRNS): DO WE KNOW WHAT TO DO WHEN ALL ELSE FAILS? Gabrielle A. Carlson, MD, SUNY at Stony Brook, Gabrielle. [email protected]; Christopher Bellonci, MD, Tufts Medical Center, [email protected] Objectives: Prolonged tantrums/outbursts with verbal and physical aggression pose a danger to the child and others and are a challenge to manage.
S306
www.jaacap.org
Although all forms of physical seclusion and/or chemical restraint are eschewed as sometimes dangerous and generally ethically unjustified, interventions are not equivalent. The child’s age, developmental status, diagnosis, and concomitant medication are critical. Staff training, staffing levels, milieu, physical location, and treatment goals are important. It is noteworthy that there is no guidance in child and adolescent psychiatry for what to do when efforts to avoid severe agitation are unsuccessful. There are no randomized trials in children or outcome studies to advise us whether time out, seclusion, or medications/PRNs used to reduce restrictive measures provide any short- or long-term benefit for children, their parents, and/or their schools. Treatment data on reducing “irritability” and aggression over a period of six to eight weeks exist, but there are no data on their short- or long-term effectiveness in emergency and inpatient settings. The goal of this symposium is to examine PRN interventions for acutely agitated children in emergency and inpatient settings. Methods: There will be four presentations and a discussion. Results: The first presentation will use data from around the country regarding the substantial differences in prescribing practices in emergency department settings. The second study will examine retrospective data on PRN use in crisis/restraint events over a five-year period (2011–2016) in a busy city emergency department. The third study examines both seclusion and PRN use in three cohorts of psychiatrically hospitalized children (ages 5–12 years) from 2003 to 2015 and describes prescribing trends and relative effectiveness of these interventions. The final presentation summarizes the pharmacokinetics of the medications we use with the goal of helping the audience understand what we can realistically expect from the drugs we use. Conclusions: Management of severely agitated children who at least acutely require intervention for their safety and that of those around them requires a good deal more systematic research than has occurred to date. Our hope is that this symposium will begin to examine some of the issues that will move the field to further scrutiny of this problem.
IMD, AGG, PPC http://dx.doi.org/10.1016/j.jaac.2017.07.595
4.1 PRN MEDICATION UTILIZATION OVER FIVE YEARS IN A SPECIALIZED CHILD PSYCHIATRIC EMERGENCY PROGRAM Ruth Gerson, MD, Bellevue Hospital/NYU School of Medicine, [email protected] Objectives: Youths increasingly present to emergency departments (EDs) with agitated behavior or aggression attributed to psychosis, anxiety, mania, or intoxication or related to underlying behavioral disorder. They can be dangerous to themselves, staff, and other patients in the ED and may require restraint. Although reduction of restraint and injury is a priority of every ED, there are little published data on the use and effectiveness of PRN medications to treat or prevent acute agitation. Further work is needed to understand PRN usage and identify efficacy of different PRN medications to guide clinical practice. Methods: This report describes the use of PRN medications during restraint events in a specialized child psychiatric emergency program between the program’s opening in 2011 until December 2016. During this period, 8,800 youth (ages 2–17 years) were seen, and 185 experienced restraint. Chart review examined patient demographics, diagnosis, medication utilization, and efficacy. Results: The youth who experienced restraint ranged in age from six to 17 years. Diagnoses included internalizing, externalizing, and developmental disorders, as well as substance intoxication. The medications used predominantly included most commonly diphenhydramine, chlorpromazine, haloperidol, lorazepam, and risperidone, among others, at a range of doses. Documented efficacy of medication varied significantly as we will report. Conclusions: There are currently no published consensus guidelines for the psychopharmacological management of agitation and little published literature comparing effectiveness of different PRN medications or comparing those medications to placebo. A review of PRN prescribing practices in a specialized child psychiatric emergency program, where all patients are
J OURNAL
OF THE
AMERICAN A CADEMY OF CHILD & ADOLESCENT P SYCHIATRY VOLUME 56 NUMBER 10S OCTOBER 2017
involved patients who were prescribed psychotropic medication. Patients with traumatic stress disorders were nine times more likely to have or have used psychotropics in their lifetime (P ¼ 0.001). Patients with thoracic transplants (e.g., heart and lung) were more likely to develop medical traumatic stress disorders than patients with abdominal transplants (e.g., liver and kidney) (P < 0.01). SOT patients with medical and nonmedical traumatic stress disorders used more psychiatric consultation than their nontraumatized peers (P < 0.001). Patients with traumatic stress disorders had higher hospital lengths of stay and more difficulties with adherence (P < 0.01). Conclusions: Pediatric and young adult SOT patients with traumatic stress warrant more intensive psychiatric and medical support. Medical traumatic stress may be predictable in certain SOT patients. This identified population would benefit from increasing psychoeducation of patients and teams, along with more tailored interventions for prevention and treatment. The differences between medical and nonmedical traumatic stress deserve further study.
PTSD, PTA, RF http://dx.doi.org/10.1016/j.jaac.2017.07.592
3.4 POSTTRAUMATIC GROWTH IN HOSPITALIZED CHILDREN AND ADOLESCENTS Eva C. Ihle, MD, PhD, University of California, San Francisco Benioff Children’s Hospital, [email protected] Objectives: This presentation will describe the phenomenon of posttraumatic growth through a review of the literature on complex developmental trauma and salutogenesis. A description of a multidisciplinary approach to support posttraumatic growth (PTG) will also be presented. Methods: A review of the literature on adverse childhood events, complex developmental trauma, medical trauma in children, positive psychology, and PTG will be presented. This seminar will then describe a multidisciplinary, collaborative approach [developed at University of California, San Francisco Benioff Children’s Hospital (UCSF BCH)] to enhance well-being and support PTG. Results: There is much attention being paid to the role that complex developmental trauma and adverse childhood events (ACEs) play in determining the overall well-being of children and adolescents. One ACE that is particularly relevant to consultation-liaison (C/L) pediatric psychiatrists is the threat to bodily integrity; serious medical illness (and its treatment) is one such threat. ACEs have been associated with the maladaptive consequences of the stress response. However, it is important to highlight the auspicious role of stress in addition to its adaptive role (supporting survival). One positive aspect of stress is PTG where individuals gain strength and insight from crises. When medical trauma can be reframed as a stressor that promotes PTG, ACE is transformed from something pathogenic to an experience that is salutogenic. At UCSF BCH, a number of specialists play complementary roles in the effort to support salutogenesis. Our multidisciplinary, collaborative approach involves child and adolescent C/L psychiatrists, pediatric palliative care physicians, psychologists, and child life specialists in the effort to promote coping and enhance the emotional well-being of hospitalized patients. Conclusions: Medical trauma can be considered an ACE that challenges the resilience of both patients and their families. Interventions informed by the field of positive psychology can enhance resilience by supporting salutogenesis. Diverse disciplines can work collaboratively to support well-being and enhance PTG.
STRESS, PYI, PRE http://dx.doi.org/10.1016/j.jaac.2017.07.593
SYMPOSIUM 4 AS NEEDED MEDICATIONS (PRNS): DO WE KNOW WHAT TO DO WHEN ALL ELSE FAILS? Gabrielle A. Carlson, MD, SUNY at Stony Brook, Gabrielle. [email protected]; Christopher Bellonci, MD, Tufts Medical Center, [email protected] Objectives: Prolonged tantrums/outbursts with verbal and physical aggression pose a danger to the child and others and are a challenge to manage.
S306
www.jaacap.org
Although all forms of physical seclusion and/or chemical restraint are eschewed as sometimes dangerous and generally ethically unjustified, interventions are not equivalent. The child’s age, developmental status, diagnosis, and concomitant medication are critical. Staff training, staffing levels, milieu, physical location, and treatment goals are important. It is noteworthy that there is no guidance in child and adolescent psychiatry for what to do when efforts to avoid severe agitation are unsuccessful. There are no randomized trials in children or outcome studies to advise us whether time out, seclusion, or medications/PRNs used to reduce restrictive measures provide any short- or long-term benefit for children, their parents, and/or their schools. Treatment data on reducing “irritability” and aggression over a period of six to eight weeks exist, but there are no data on their short- or long-term effectiveness in emergency and inpatient settings. The goal of this symposium is to examine PRN interventions for acutely agitated children in emergency and inpatient settings. Methods: There will be four presentations and a discussion. Results: The first presentation will use data from around the country regarding the substantial differences in prescribing practices in emergency department settings. The second study will examine retrospective data on PRN use in crisis/restraint events over a five-year period (2011–2016) in a busy city emergency department. The third study examines both seclusion and PRN use in three cohorts of psychiatrically hospitalized children (ages 5–12 years) from 2003 to 2015 and describes prescribing trends and relative effectiveness of these interventions. The final presentation summarizes the pharmacokinetics of the medications we use with the goal of helping the audience understand what we can realistically expect from the drugs we use. Conclusions: Management of severely agitated children who at least acutely require intervention for their safety and that of those around them requires a good deal more systematic research than has occurred to date. Our hope is that this symposium will begin to examine some of the issues that will move the field to further scrutiny of this problem.
IMD, AGG, PPC http://dx.doi.org/10.1016/j.jaac.2017.07.595
4.1 PRN MEDICATION UTILIZATION OVER FIVE YEARS IN A SPECIALIZED CHILD PSYCHIATRIC EMERGENCY PROGRAM Ruth Gerson, MD, Bellevue Hospital/NYU School of Medicine, [email protected] Objectives: Youths increasingly present to emergency departments (EDs) with agitated behavior or aggression attributed to psychosis, anxiety, mania, or intoxication or related to underlying behavioral disorder. They can be dangerous to themselves, staff, and other patients in the ED and may require restraint. Although reduction of restraint and injury is a priority of every ED, there are little published data on the use and effectiveness of PRN medications to treat or prevent acute agitation. Further work is needed to understand PRN usage and identify efficacy of different PRN medications to guide clinical practice. Methods: This report describes the use of PRN medications during restraint events in a specialized child psychiatric emergency program between the program’s opening in 2011 until December 2016. During this period, 8,800 youth (ages 2–17 years) were seen, and 185 experienced restraint. Chart review examined patient demographics, diagnosis, medication utilization, and efficacy. Results: The youth who experienced restraint ranged in age from six to 17 years. Diagnoses included internalizing, externalizing, and developmental disorders, as well as substance intoxication. The medications used predominantly included most commonly diphenhydramine, chlorpromazine, haloperidol, lorazepam, and risperidone, among others, at a range of doses. Documented efficacy of medication varied significantly as we will report. Conclusions: There are currently no published consensus guidelines for the psychopharmacological management of agitation and little published literature comparing effectiveness of different PRN medications or comparing those medications to placebo. A review of PRN prescribing practices in a specialized child psychiatric emergency program, where all patients are
J OURNAL
OF THE
AMERICAN A CADEMY OF CHILD & ADOLESCENT P SYCHIATRY VOLUME 56 NUMBER 10S OCTOBER 2017