Adolescents in crisis: When to admit for self-harm or aggressive behavior
Assess suicide risk, family support, other factors when considering hospitalization
Ms. R, age 17, has a history of major depression, obsessive-compulsive disorder, and self-harm through superficial cutting of her arms and inguinal region. She reports that 10 days ago she ingested 7 times her prescribed fluoxetine dosage of 20 mg/d and aripiprazole dosage of 2 mg/d because she no longer wanted to feel emotional pain. She did not tell anyone she did this or seek medical attention.
Ms. R complains of chronic difficulties with her stepfather, who she describes as alcoholic. She feels her depression is worsening and support from her mother has deteriorated. Ms. R’s parents say they are trying to respond to their daughter, but she will not talk with them and some nights she does not return home. Ms. R admits to staying overnight in local mall parking lots to be alone. Her psychiatrist recommends acute inpatient care for Ms. R’s safety.
Admitting an adolescent such as Ms. R to a psychiatric inpatient facility may be necessary to address a crisis. Interdependent links among the patient, family, and support network complicate the determination of whether an adolescent requires inpatient care. To make the best decision, a psychiatrist needs to understand the youth’s difficulties within family, school, and community.
Who needs inpatient care?
Inpatient treatment remains an important part of the continuum of care for adolescent psychiatric treatment. 1 Inpatient treatment typically is reserved for patients whose psychiatric disorder impairs multiple areas of functioning or poses a significant danger to self or others and for whom less-restrictive treatment resources are not appropriate or available. 2 The number of psychiatric hospitalizations for adolescents is increasing, although lengths of stay are decreasing. 3,4
Psychiatric inpatient care is appropriate for patients who require 24-hour nursing care and psychiatric monitoring to stabilize symptoms when they are in acute crisis and have a high risk of harm, and for initiation of treatments required for stabilization and integration into a less-restrictive setting. 5 The decision to admit an adolescent rests on:
- the clinician’s ability to evaluate the risk of harm and functional status
- how much support the family and/or caregivers can provide
- the clinician’s knowledge of treatment resources available to the adolescent and family. 6
Exploring suicide risk
Understanding potential lethality of suicidal thought and intent is complex and requires assessing suicidal behavior, the patient’s past and current intent, the risk of engaging in or repeating a suicide act, the underlying diagnosis, and protective factors. To quantify imminent suicide risk, directly address suicidality when interviewing an adolescent, progressing from past thoughts to current intent, plan, and ability to carry out such a plan (Table 1) . 7
Planning and lethality. Also examine the patient’s degree of planning for a suicide attempt, efforts to avoid discovery and rescue, and his or her perceived lethality of a suicide attempt or plan. Patients who develop a coherent plan that would successfully avoid discovery clearly are at highest risk. Lethality of method is frequently misunderstood—especially among younger individuals—and thus their perception of the dangerousness of an attempt is more important than reality. Previous suicide attempts and chronic suicidality with recent escalation imply greater risk.
Motivation. Exploring the feelings that motivate a suicide attempt, intent, or ideation will help assess risk. Common motivations include:
- escaping from stress or hopelessness from perceived intolerable circumstances
- rejoining a dead loved one
- getting notice or attention from a parent, romantic interest, or other important individual
- injuring others around them.
Serious suicide risk may persist if the motivating feelings are not addressed satisfactorily. 7
Unclear signals. An adolescent who expresses a clear intent to die, has a plausible plan, and is unable to work with or rejects caregivers’ attempts to help is at high risk and requires a secure setting, such as hospitalization. Typically, however, patients do not give such clear indicators; in these cases, consider other factors.
Unstable and unpredictable behavior implies serious short-term risk. Factors that indicate difficulties in a patient’s ability to maintain a safety plan include:
- a history of multiple suicide attempts or escalating seriousness of ideation
- inability to be truthful and form an alliance with the clinician
- difficulties in expressing and regulating emotions
- presence or likelihood of intoxication.
Psychosis, command hallucinations, high impulsivity, cycling associated with bipolar disorder, and substance abuse also are associated with high suicide risk. 8
The clinician must determine whether an adolescent can form an alliance to report suicidal ideation, intent, or plan to a family member or other responsible adult, and if the family/caregivers are willing and capable of providing support, supervision, and compliance with future treatment recommendations that will ensure safety. If the answers are no, the patient requires hospitalization.
Suggested questions for assessing adolescent suicidality
Have you had thoughts of hurting yourself?
Have you ever tried to hurt yourself?
Have you ever wished you were not alive?
Have you had thoughts of taking your life?
Have you done things that are so dangerous that you knew you might get hurt or die?
Have you ever tried to kill yourself?
Have you had recent thoughts of killing yourself?
Do you have a plan to kill yourself?
Are the methods to kill yourself available to you?
Do you have access to guns?
Source: Adapted from reference 7
CASE CONTINUED: Unsafe at home
Ms. R feels she cannot be safe at home and cannot reliably form an alliance with her mother and stepfather to discuss whether her self-harm behaviors would escalate to serious injury or death. As a result, she is admitted to a psychiatric hospital. Inpatient care includes family intervention and a plan to intensify outpatient therapy. When Ms. R is discharged after 6 days, she reports improved mood and ability to contract with her family.
Besides suicidality, aggressive and combative behaviors in adolescents may lead to psychiatric referral. 9–11 Overt homicidal ideation is not common; typically, patients exhibit escalating, disruptive, aggressive episodes in the home, school, or community that pose risk to themselves or others. Families seek clinical help because they feel unable to keep their child safe at home.
Aggressive behavior is linked to multiple patient factors, such as male gender, history of abuse and neglect, out-of-home placement in community systems, developmental disorders, mental retardation, disruptive behavior disorders, and learning disabilities. Aggressive behavior may include planned proactive situational-reactive or impulsive aggression, or it can stem from an altered mental status caused by illicit drug intoxication, medications, psychosis, or severe mood disorders. 9-12
Psychiatric hospitalization of aggressive adolescents raises safety concerns, and some practitioners perceive that treatment is ineffective for these patients. However, high rates of psychiatric comorbidity and indications that positive outcomes are possible suggest that many aggressive youth can benefit from intervention. 1,11
Because of the crisis nature of acute aggression and the often conflicted, hidden, and stressful situations these patients and families or caregivers are experiencing, hospitalization often is needed to stabilize the adolescent.
Assessment work with family/caregivers is vital because patients typically minimize the intensity of their aggressive behavior. Use a structured scale—such as the modified Overt Aggression Scale—to help quantify the severity of aggressive episodes, determine dangerousness, and establish a common language and measurement among caregivers, patients, and clinicians. 13
The family/caregivers’ capacity and willingness to provide a safe environment, to avoid triggering events, and to provide support to de-escalate a potential crisis also determine if safety can be maintained in the home or if hospitalization is required. Hospitalization may be appropriate if the adolescent’s aggressive behavior substantially endangers the patient or others, is increasing in intensity, exceeds the ability to be managed in the home or living environment, and cannot be maintained in available less-restrictive settings.
In addition to the patient’s potential for suicidal or aggressive behavior, consider other aspects of potential harm, such as:
- unintentional harm associated with altered mental status from psychosis or intoxication
- the adolescent’s impulsivity or judgment in situations he or she is likely to encounter
- the patient’s ability to recognize potential threats and take appropriate action for safety
- severely impaired self-care. 14
CASII can help determine appropriate care for teens
The Child and Adolescent Service Intensity Instrument (CASII) can help you determine what level of care is most appropriate for your adolescent patient. This scale—developed by a work group of the American Academy of Child and Adolescent Psychiatry (AACAP)—links clinical assessment with standardized levels of care. It includes scoring in 6 dimensions:
- risk and harm
- functional status
- co-occurrence of conditions
- recovery environment
- resiliency and response to services
- primary caretaker involvement in services.
Scores are combined to generate a recommend level of service intensity from 0 (basic services) to 7 (24-hour psychiatric management—admission to a hospital or locked residential unit).
The AACAP strongly encourages clinicians to receive training to use the CASII and provides 1-and 2-day courses.
Source: Reference 14
Comorbid medical illness, substance use disorders, and cognitive disability are common complications in determining the level of care for an adolescent in crisis. Active or passive noncompliance with treatment for medical conditions can pose an immediate or chronic threat to the individual and may represent a method of self-harm. Medical comorbidities and care requirements frequently preclude quick access to services such as group homes, therapeutic foster programs, and residential treatment. Hospitalization often is required to stabilize psychiatric conditions and medical illness.
CASE REPORT: Multiple comorbidities
Ms. P, age 16, has type 1 diabetes mellitus, posttraumatic stress disorder from early physical and sexual abuse, and an IQ of 49. She presents after repeated arguments and physical confrontations with her mother, with whom she lives. She has been caught hoarding high-sugar foods.
The most recent fight is over Ms. P wanting to consume large amounts of candy. She has been hospitalized twice for diabetic ketoacidosis in the last 6 months. Her most recent blood sugar levels ranged from 250 to 500 mg/dL. Ms. P states she is angry at her mother and will hit her if she tries to control her diet. She says she doesn’t care if she gets sick, but her recognition of medical complications is limited.
Developmental delays may complicate treatment for psychiatric illness or impair an adolescent’s ability to understand the dangerousness of his or her behaviors. 15 Communication barriers make it challenging to assess risk or the patient’s ability to comply with a safety plan. In patients with developmental delay who live in the community, external structure, monitoring, and the ability to manage crises depends on the family/caregivers. Strongly consider hospitalization if an adolescent’s developmental delay has a serious adverse effect on managing the psychiatric condition, causing increased risk of harm to self or others.
Substance use frequently accompanies adolescent psychiatric illness and may pose severe risk by disinhibiting impulse control, exacerbating mood symptoms, altering mental status, or causing intoxication or withdrawal syndromes. Substance use also carries inherent risks, such as contracting human immunodeficiency virus or other blood-borne infections.