Adolescents in crisis: When to admit for self-harm or aggressive behavior
Assess suicide risk, family support, other factors when considering hospitalization
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.
Substance use is well-documented as a severe risk factor for suicide and suicide attempts7,8 and frequently is associated with violence.16 Hospitalization may be the safest way to manage an adolescent who exhibits escalating substance use that complicates management of the psychiatric illness or indicates progressive endangering behavior.
Functional assessment
In addition to exploring risk of self-harm, aggressive behaviors, and medical comorbidities, evaluate the adolescent’s ability to function in interpersonal relationships, self-care, and school. A pattern of severe or worsening functional impairment often indicates illness progression or that management or supports are not meeting the patient’s needs.
Strongly consider hospitalizing patients who demonstrate serious deterioration in interpersonal relationships with peers, adults, or family, as evidenced by escalating threats, episodic violence, or disorganized communication. Additional concerns include severe social withdrawal, neglect of self-care appropriate to developmental level, and inability to perform academically despite appropriate accommodations.
Identify impaired physical functions. When severe medical complications accompany anorexia nervosa or other psychiatric illness, hospitalization is needed to ensure the patient’s safety and to begin appropriate assessment and treatment ( Table 2 ).17
Table 2
Adolescents with eating disorders: Admission criteria
| Heart rate near 40 bpm |
| Orthostasis (pulse change >20 bpm or blood pressure drop of >10 to 20 mm Hg from sitting to standing) |
| Hypotension (blood pressure <80/50 mm Hg) |
| Electrolyte imbalance (hypokalemia, hypophosphatemia, hypomagnesemia) |
| Weight <85% of ideal body weight |
| Acute weight decline with food refusal |
| Suicidal ideation |
| Needs supervision during and after all meals and in bathrooms because of disabling purging |
| Suitability of pediatric vs psychiatric unit depends on level of medical care required and respective units’ ability to manage eating disorders |
| Source: Adapted from reference 17 |
Family and environmental factors
The decision to admit an adolescent to a psychiatric hospital or provide a home treatment plan often hinges on the ability and willingness of the patient’s family/caregivers and support systems to meet the patient’s needs. Consider whether family functioning has been disrupted by a parent’s illness, death, divorce, medical problems, psychiatric illness, substance abuse, or financial stress. If you suspect abuse or violence in the home, observe reporting laws in your jurisdiction and intervene with the family to ensure the adolescent’s safety. Hospitalization may be the best means of providing safety during an investigation.
Determine if the family or primary caregivers are able to meet the adolescent’s developmental, material, and emotional requirements, and if help from treatment or support services or community resources could provide these needs. If not, hospitalization likely is required.
CASE CONTINUED: Risk of physical harm
Ms. P is admitted to the psychiatric hospital because her mother reports that in the past week she and her daughter have had 2 physical altercations—resulting from arguments about her daughter’s dietary intake—that caused injuries. She does not feel she can keep her daughter safe. Ms. P’s mother states she feels she is poorly trained in diabetic care and cannot provide the medical intervention her daughter needs.
