Articles
Vaccination Referrals from ED Paediatric Antimicrobial Guidance Children’s Services Resolution and Escalation Protocol Blunt Chest Wall Trauma/Rib Fractures Information for Parents Carers of Children Having Investigations in Relation to Unexplained Injuries + Consent form Bruising and Injuries in Babies and Children – Parents Leaflet Multi-Agency Protocol for Injuries to Non-Mobile Children Flowchart for children attending Galloway Community Hospital (GCH) for NAI Follow Up Skeletal Survey Flowchart for children attending DGRI for NAI Follow-Up Skeletal Survey Cognitive Function Conscious Level Kidney Biopsy Complications Parenteral Iron for Non-HD CKD Patients Fracture Management Guidelines (Paediatric) Fracture Management Guidelines (Adult) Management of Hypertension in Acute Stroke Prescribing for CAU Patients Still in ED Hypothermia Deactivation of Implantable Cardioverter Defibrillator Myeloma Croup Care Of Burns In Scotland (COBIS) Paediatric Guidance Management of Epistaxis Sore Throat Differential Diagnosis Dizziness Differential Diagnosis Peritonsillar Abscess/Quinsy Acute Tonsillitis Acute Mastoiditis Otitis Media Otitis Externa Extravasation of IV Amiodarone WoS Paediatric Drooling and Aspiration Guideline Palliative Care – How to Refer Eating Disorders Stroke Care Warfarin Anticoagulation for AF, DVT and PE Molnupiravir MyPsych Foundation Doctors Toolkit Paediatric Febrile Neutropenia Guidance PAEDIATRIC HYPOGLYCAEMIA MANAGEMENT in NON DIABETIC CHILDREN   Paediatric Diabetic Ketoacidosis (DKA) Guideline Child Protection Policies and Procedures (D&G) Management of Acute Behavioural Challenges in Adolescents and Young People presenting to Secondary Care Cancer of Unknown Primary Patients Returning from Interventional Cardiac Procedure Treatment of Malaria Discharging Patients on High Dose Steroids Sotrovimab Paediatric Ketone Correction Guideline Insulin Correction Factor Table (Paediatrics) Management of uncomplicated Henoch-Schonlein Purpura (HSP) in under 16s Management of Hypoglycaemia in Children with Type 1 Diabetes Newly diagnosed diabetic – not in DKA (Walking wounded) Proton Pump Inhibitor Guideline for Neonatal and Paediatrics Stroke – Post Thrombolysis Neonatal Guidelines Gentamicin Prescribing (Paediatrics) Management of Anaphylaxis (Paediatrics) Management of Prolonged Seizures (Convulsive Status Epilepticus) in Children Bronchiolitis Acute Wheeze or Asthma in Paediatrics Conscious Proning Covid-19 Basics Remdesivir Thromboprophylaxis Identifying Patients in the Highest Risk Groups Steroids for Patients with Covid-19 Infection IL-6 Inhibitors – Tocilizumab or Sarilumab Baricitinib Paxlovid (Nirmatrelvir/Ritonavir) Influenza A Inhalers for Adults with Asthma Standard Operating Procedure for AMU Trigger Finger/Thumb Osteoarthritis of the Hand/Thumb Mallet Finger Ganglion Dupuytren’s Contracture De Quervain’s Tenosynovitis Carpal Tunnel Syndrome Prescribing Advice on Admission – Clozapine Prescribing Advice on Admission – Methadone/Buprenorphine Prescribing Advice on Admission – Corticosteroids Prescribing Advice on Admission – Items Not Prescribed by GP Prescribing Advice on Admission – Patients on Chemotherapy Regimes Prescribing Advice on Admission – Medication for Parkinson’s Disease Prescribing Advice on Admission – Insulin Prescribing Advice on Admission Medical Emergencies in Eating Disorders (MEED) Gentamicin & Vancomycin HIV Testing Guidelines Metabolic Syndrome Associated Fatty Liver Disease (MAFLD) Greener Inhaler Prescribing C4 Predischarge Beds Handover Safe and Secure Handling of Medicines Blood Glucose & Steroids IV Fentanyl & Morphine for Acute Pain in Adults Assessment & Management of Acute Pain Hospitalised and Has Coronavirus19 Infection (No suspected Viral Pneumonia Syndrome) Hospitalised Due to Coronavirus19 with Likely Viral Pneumonia Bi-Level NIV S/T Guidelines for CCU Phase Bi-Level NIV S/T Guidelines for ED Phase Adults With Incapacity Premenstrual Syndrome Pelvic USS Boarding Coeliac diagnosis pathway (Adults) Voice clinic Ear Wax Dermatology Squamous Cell Carcinoma (SCC) Malignant Melanoma Basal Cell Carcinoma (BCC) Nipple Discharge Early Cancer Diagnostic Clinic (ECDC) Genetics Referrals Breast Infections Breast Pain Primary Care Prescribing Guidelines Emergency Department Anaesthetics and Chronic Pain Team Respiratory Referrals Chronic Cough Pathway GP Clinical Handbook Test Paediatric Bronchiolitis Early Cancer Diagnosis Clinic (ECDC) Obstetrics & Gynaecology/Medicine Admission Agreement Idiopathic Intrancranial Hypertension Urology Out of Hours Urology Out of Hours Sengstaken/Minnesota Tube for Bleeding Varices Eradication of Helicobacter pylori Transfer from Galloway Community Hospital Repatriation of Patients from Tertiary Hospitals THROMBOPROPHYLAXIS IN PREGNANCY – Appendix 1, Risk factors THROMBOPROPHYLAXIS IN PREGNANCY – Appendix 3, Postnatal assessment & management THROMBOPROPHYLAXIS IN PREGNANCY – Appendix 4 THROMBOPROPHYLAXIS IN PREGNANCY – Appendix 2, Management of women with previous VTE THROMBOPROPHYLAXIS IN PREGNANCY, LABOUR AND THE PUERPERIUM Orthopaedic VTE Risk Assessment Sodium Glucose Transporter 2 Inhibitors (SGLT2i) Cardiology Referrals Vascular Referrals ‘Watershed’ Conditions Myasthenia Gravis Gentamicin in Renal Replacement Therapy Vancomycin in Renal Replacement Therapy REDMAP Poster Realistic Conversations Summary Plan for Deteriorating Health Treatment Escalation Plans Ambulatory Care for Blood and/or Iron Infusion Principles for Light Touch Patients – B2 Clostridiodes difficile Infection Post Astra Zeneca Vaccine Headache Blood Culture Rhabdomyolysis Analgesia Acute Appendicitis Small Bowel Obstruction Elective Admission – Colorectal Surgery Trauma Admissions Post-operative Care Gallstone Disease Vasopressors and Inotropes/Chronotropes Shock Elective Admission – ERCP Elective Admission – Orthopaedics Laxatives Fat Embolism Compartment Syndrome Surgical Post-operative Complications Stoma Diverticular Disease High Dose Steroid Pre-Treatment Checklist Acute Surgical Admissions Level 1 CCU Medical Area Acute Oncology STEMI Thrombolysis Protocol Haemolytic Anaemia Conversion Charts Anticipatory ‘As Required’ Medications Syringe Driver Chart Scottish Palliative Care Guidelines Covid-19 Sick Day Rules for Patients with Primary Adrenal Insufficiency Diabetic Retinopathy Coming Off Benzodiazepines and “Z” Drugs Dental Abscess Facial Trauma – Mandibular Fractures Facial Trauma – Orbital Fractures Facial Trauma – Zygoma Platelet Transfusion Death Certification Parenteral Iron in Adults >18 Years OPAT SBAR (Complex Infections) Mental Health Liaison Team Referrals STEMI Admitting Patients with Tracheostomy/Laryngectomy to DGRI Emergency Laryngectomy Management Emergency Tracheostomy Management Safe Transfer of Patients with Tracheostomy/Laryngectomy within DGRI Other Tracheostomy Documents Systemic Anticancer Therapy Toxicity Haemodialysis Medication Prescribing Breaking Bad News by Telephone End of Life Diabetes Care Adrenal Insufficiency Serotonin Syndrome DGRI Referrals Confirmation of Death Neuroleptic Malignant Syndrome Pulmonary Embolism Deep Vein Thrombosis of Lower Extremities Exacerbation of COPD Contrast Associated AKI Acute Kidney Injury – Introduction Paracetamol Hypertensive Emergencies Staphylococcus aureus Bacteraemia (SAB) Rate Control in AF Common Scenarios Acute Severe Ulcerative Colitis IV Fluid Prescription in Adults Chronic Obstructive Pulmonary Disease Legionnaires Disease Septic Arthritis Guillain-Barré Syndrome Back Pain Anaesthetics – Unscheduled Procedures Requests Hyperglycaemia & Steroids Variable Rate Insulin Infusion Decompensated Liver Disease Fast Atrial Fibrillation – ACP Hyperkalaemia Contraindications to MRI Magnetic Resonance Imaging Bleeding with Other Antithrombotics In-patient Hyperglycaemia Management Anaemia (Management) – ACP Suspected NSTEMI – ACP Guidance on Chaperones Compulsory Admission and Treatment Radiology Immediate Discharge Letter Alcohol Withdrawal Fentanyl Patches in the Last Days of Life Care in the Last Days of Life Low Molecular Weight Heparin Interstitial Lung Disease Haematinic Testing Thromboprophylaxis for Non-Covid Patients Lung Cancer Osteoporosis Heart Failure Fluid Replacement in AKI Death & The Procurator Fiscal Thrombophilia Screening Neutropenic Sepsis Acute Vertigo Aortic Dissection Antithrombotics in Hip Fracture Transient Global Amnesia Hypomagnesaemia Hypophosphataemia Oxygen Therapy Falls – ACP Falls Acute Asthma Oncology Contact Details & General Advice Reversal of Warfarin Lumbar Puncture, Antiplatelet & Anticoagulant Drugs Antithrombotics & Surgery Non ST Elevation MI (NSTEMI) Suspected Acute Coronary Syndrome Antibiotics and the Kidney Acute Upper GI Bleeding (AUGIB) Pericardiocentesis Pleural Effusion Spontaneous Pneumothorax Acute Diarrhoea Iron Deficiency Anaemia Hyperthyroidism Gout Giant Cell Arteritis Pacemakers Clinical Suspicion PE – ACP Community Acquired Pneumonia (CAP) Management of Urinary Symptoms Management of Acute Kidney Injury SSRI Poisoning Immobility Autopsies Indications for Echocardiography Bradycardia Suspected Meningitis Hypernatraemia Diarrhoea – ACP Suspected Meningitis – ACP Blood Transfusion Brain Tumours Newer Antidiabetic Drugs Parkinson’s Disease Major Haemorrhage Protocols (DGRI & GCH) Major Haemorrhage Stroke Thrombolysis Heart Failure – ACP Suspected Anaphylaxis Anaphylaxis – ACP The AMB Score – ACP Transient Loss of Consciousness (TLOC) – ACP Bell’s Palsy – ACP Suspected Sepsis Lumbar Puncture Hypokalaemia Gentamicin Dosing Transient Loss of Consciousness Urinary Tract Infection Urethral Catheterisation Vancomycin Dosing Hyponatraemia Narrow Complex Tachycardia Hypocalcaemia New Onset Type 1 Diabetes – ACP Paracentesis for Tense Ascites – ACP Idiopathic Intracranial Hypertension – ACP Other Funny Turns Hypoglycaemia Hypoglycaemia – ACP Management of Transfusion Reactions Hypercalcaemia Haematemesis – ACP Anti-Platelet Therapy in Coronary Heart Disease Unfractionated Heparin Infusion Anaemia (Investigation) – ACP Delirium Suspected Seizure – ACP Headache – ACP Community Acquired Pneumonia – ACP Cellulitis Dyspepsia Management of Acute AF Rhythm Control in AF Atrial Fibrillation Renal Transplants Massive Pulmonary Embolism Head and Neck Injury Diabetic Ketoacidosis Switching from VRII Insulin Pumps Diabetes Mellitus Aspirin Digoxin Poisoning Tricyclic Antidepressants Opiates Benzodiazepines Gut Decontamination Deliberate Self Harm Acute Liver Failure Asymptomatic Raised Transaminases (ALT & AST) Nutritional Support in Adults Refeeding Syndrome Parenteral Nutrition Crohn’s Disease Acute Pancreatitis Abdominal Aortic Aneurysms Malignant Spinal Cord Compression Post Splenectomy Sepsis Ascites in Cirrhosis Alcohol Related Liver Disease Hepatitis C Symptom Control Suspected Variceal Bleeding Severe Headache Status Epilepsy in Adults Lower Gastrointestinal Bleeding Functional & Social Assessment Breathlessness with Abnormal CXR Polymyalgia Rheumatica Rheumatoid Arthritis Ureteric Colic & Renal Stones Intravascular Catheter Related Blood Stream Infection Care of Vascular Access Urinary Incontinence Peritoneal Dialysis Related Peritonitis The First Seizure Hypertension Ventricular Tachycardia Cardiogenic Shock Complicating Acute Coronary Syndrome Telemetry The Diabetic Foot Subcutaneous Insulin Diabetes and Acute Coronary Syndrome Hyperosmolar Hyperglycaemic State Multiple Sclerosis Coma
 
 
In this section Close
Home | Articles | Mental Heath | Management of Acute Behavioural Challenges in Adolescents and Young People presenting to Secondary Care

Management of Acute Behavioural Challenges in Adolescents and Young People presenting to Secondary Care

Last updated 1st June 2023

Background

The management of adolescents/young people (YP) presenting with acute behavioural disturbance can pose many challenges in health and social care and for families involved.  The purpose of this document is to provide support for staff with the management of this patient group within NHS D&G.

The Royal College of Paediatric and Child Health (RCPCH), 2021 recognise the pandemic has exacerbated already existing pressures on services caring for children and young people presenting with mental ill health. They recommend regardless of where children and young people present to care or what their specific health needs are, we must work together to ensure they receive the highest quality care, from qualified clinicians, as quickly as possible. A joint position statement from RCPCH, the Royal College of Emergency Medicine (RCEM) and the Royal College of Psychiatrists (RCPsych) in Dec 2021 recommends that services work together to meet the mental health needs of children and young people so they receive the right treatment, in the right place, at the right time.

Managing the complexities, risks and other departmental activities can be challenging and it is recognised that it may have a direct and/or indirect impact on other patients and families.  This guide aims to support staff with managing these challenges but recognises each individual situation to be unique.

Presentation

If the YP is posing an active risk to themselves or others due to related mental health and/or behavioural issues all attempts should be made to de-escalate presenting behaviours. It is recognised that a trauma informed approach is desirable and it is recommended that all staff who may come into contact with such YP complete Trauma Informed Practice 1 training via https://learn.nes.nhs.scot/.

Key Points

  1. Management should focus on verbal and non-verbal de-escalation and emphasise the child’s safety with carer involvement and existing behaviour or communication plans where appropriate.
  2. Consider underlying neurodevelopment diagnoses such as ADHD and Autism, any drugs or alcohol taken or a history of adverse childhood experiences.
  3. A stepwise approach should be used if pharmacological treatment is required.  Physical restraint should be an absolute last resort but may be required to facilitate sedation and keep the child safe.

The most important initial action is to reduce the distress to reduce the behaviour, and to reduce the risk of harm. Once the distress is reduced, further assessment and specific management of the underlying cause should occur. Behavioural distress can present and progress in a variety of ways. There are often many predisposing, precipitating and perpetuating factors that need to be considered in de-escalation strategies.

Management

Approach to De-escalating Behavioural Disturbance
AimsVerbal and non-verbal de-escalation is first line intervention Treat the underlying cause Debrief the child/family and staff Involve senior staff early
EnvironmentPrivate location, remove other children, visitors and staff A calming space: quiet room, soft/decreased lighting, eliminate triggers for agitation, keep the room simple and uncluttered Family member presence: on case-by-case basis Safety: remove weapons, obstacles; be aware of exit to avoid further escalation and ensure your own safety One senior staff member communicates with the child and family  
ChildThe most important initial action is to reduce the behaviour to minimise distress and any possible risk of harm Listen,  talk in a calm manner and keep communication simple Respect personal space Check for any child alerts and familiarise yourself with the child’s history (eg previous incidents of agitation, known medical, developmental or behavioural issues)Consider child’s individual needs including language, cognitive ability or trauma history Consider the use, where appropriate, of: age-appropriate distraction techniques, familiar toys and objects. Take guidance from any accompanying adult offers of food, drink, icy-pole, or attention to physical needs Crisis prevention: anticipate and identify early irritable behaviour, consider past history and involve mental health expertise early for assistance if appropriate Offer planned ‘collaborative’ sedation (eg ask the child if they would take some oral medication).  
 StaffIntroduce yourself, emphasise collaboration Minimise behaviours and/or interventions that the patient may find provocative Be interested and concerned in the child’s and family member’s point of view Calm, quiet voice; clear, concise non-judgemental language and expectations focus on one idea at a time active listening, especially regarding the patient’s goals Provide an opportunity for child to regain control of emotions Set clear limits on behaviour for child and family Offer clear choices and negotiate realistic options, avoid ‘bargaining’ Maintain professionalism at all times; ignore insults / challenging questions Consider if any investigations are required to exclude underlying cause Remember a child who has experienced abuse may find a “hands on approach” triggering.

De-escalation Pathway

If the situation is successfully de-escalated and the young person requires an urgent Mental Health triage prior to discharge CAMHS Intensive Therapy Service (CITS) should be contacted in working hours which are Monday – Friday 9-5pm on 01387 244262. 

If the young person presents who is known to CAMHS or would meet CAMHS criteria after hours, the Mental Health Crisis Team (if in ED) and/or the Mental Health Liaison Nursing Team (if in ward) can be contacted for triage advice via hospital switchboard.

We would expect regardless of presenting factors the paediatric team to co-ordinate care until a suitable mental health plan is agreed.

Complex Management        

**Sedation should be last resort**

Sedation of a young person should only be considered by most senior doctor on duty, if not a consultant in all instances.

When all de-escalation interventions have been exhausted with insufficient impact or improvement, or there is a significant concern for safety, sedation and restraint may be considered. Police should be notified of the situation and consider if social work intervention is appropriate.

As soon as sedation is being considered careful thought is required with regards to patient placement, observation and on-going management.

To ensure a co-ordinated approach a senior huddle should be convened during day time hours  to discuss exceptional pathway criteria.  The Duty Consultant paediatrician should co-ordinate an urgent discussion via Microsoft Teams which should include:

Directorate GM / Duty General Manager

SCN or Nurse in Charge of receiving ward plus Nominated Hospital Lead (NHL) Midpark if required.

Duty Consultant Psychiatrist

Hospital Bed Manager

Consider Duty Consultant Anaesthetist

Consider Nurse in Charge Children’s Ward

Clinical Nurse Manager, Paediatrics

Health and Safety Manager

CAMHS/crisis or liaison team representation

***Most clinicians will feel uncomfortable having to sedate a YP as a result of behavioural issues.

Consent

Consent for any medical procedures, including giving sedation, should be sought wherever possible.  Consent should be ideally sought from the child and/or guardians.

In an emergency, essential treatment can be delivered under Common Law – i.e. you can treat a patient without their consent – this is the Principle of Necessity.  This could apply if the patient is unable to consent (e.g. unconscious) or lacks capacity to consent (e.g. when acutely mentally ill, or in some cases where so distressed that they cannot engage in a meaningful discussion about their clinical situation, the risks, and the treatment options), and is at significant risk of harm (or poses a significant risk to the safety of others) without treatment. 

The Mental Welfare Commission for Scotland says:

Under common law, it is reasonable in an emergency to take necessary action to safeguard a person who is unable to consent and without treatment would come to significant harm. For example, a person who is knocked unconscious in an accident may be treated for their injuries if any delay to that treatment would risk the person’s life or be a serious risk to the person’s health. The treating physician may argue that the consent was implied, i.e. if the person were conscious the person would want their life saved….

“This is equally true of someone who is incapable of consenting through mental illness, if the nature of their physical injury is such that any delay in treatment would lead to a significant risk to their health.What is important in invoking the principle of necessity under common law as the basis on which to proceed is that the clinician should only do what is necessary and not undertake any other procedures because it is convenient to do so at that time. If a procedure is not urgent and informed consent might be obtained later- it would be prudent to wait.

The Mental Welfare Commission has guidance on this issue which might be helpful to consider outwith an urgent clinical situation. 

https://www.mwcscot.org.uk/sites/default/files/2022-02/RightToTreat-Guide_February2022_0.pdf

The link below may assist further with compulsory detention and treatment should it be required.

https://www.nhsdghandbook.co.uk/medical-handbook/compulsory-admission-and-treatment/

Important points to note and consider

  • A sedated YP cannot be sent back to usual care location immediately.
  • If considering sedating a YP, paediatricians should be involved in this decision (Appendix 2).
  • De-escalation and trauma informed approach is desirable.
  • The sedation score will determine placement of YP (Appendix 2).

Appendix 1 Young Person Presenting with Challenging Behaviour

Appendix-2-SedationGuide.docx

Appendix-3 Checklist for admission to Midpark.docx

Appendix-4 ICP <16 exceptional circumstances requiring MH assessment.docx