Adolescents in crisis: When to admit for self-harm or aggressive behavior
Assess suicide risk, family support, other factors when considering hospitalization
Table 1
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.
Aggressive behaviors
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
The Child and Adolescent Service Intensity Instrument can be used to help determine the level of care an adolescent patient requires ( Box ).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 conditions
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.
