Management of Acute Behavioural Challenges in Adolescents and Young People presenting to Secondary Care
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
- 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.
- Consider underlying neurodevelopment diagnoses such as ADHD and Autism, any drugs or alcohol taken or a history of adverse childhood experiences.
- 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 | |
| Aims | Verbal and non-verbal de-escalation is first line intervention Treat the underlying cause Debrief the child/family and staff Involve senior staff early |
| Environment | Private 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 |
| Child | The 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). |
| Staff | Introduce 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-Sedation–Guide.docx
Appendix-3 Checklist for admission to Midpark.docx
Appendix-4 ICP <16 exceptional circumstances requiring MH assessment.docx