David Pressel, MD, PhD, FAAP, FHM

Introduction

Child abuse and neglect (hereafter described using the single term “maltreatment”) refer to the physical, sexual or psychological maltreatment of children by a caregiver or other adult. Maltreatment results in harm and/or risk of harm that may impact a child’s mental and physical health outcomes into adulthood. Annually, child protective services agencies investigate more than 3 million reports of suspected child maltreatment; approximately 1 million children per year are victims of maltreatment, resulting in nearly 2000 fatalities per year. Children may require hospitalization to manage problems directly related to potential maltreatment or discovery of an abusive or high-risk situation may occur when they are hospitalized for another reason. Pediatric hospitalists are in a unique position to identify and/or prevent and participate in treatment plans for these victims of child maltreatment.

Pediatric Hospitalists should be able to:

• Discuss the role of pediatric hospitalists in recognition/detection of maltreatment, evaluation and treatment of maltreatment-related injuries or medical conditions, coordination of subspecialty care, and reporting to child welfare authorities in centers with and without child maltreatment pediatric experts.
• Describe the role of consultants who may be involved in evaluation of suspected maltreatment, including hospital child protection team, trauma/surgical team, radiology, neurosurgery, ophthalmology, orthopedics, social work, child protective services/social services, law enforcement, psychiatry/psychology, forensic nursing/sexual assault examiners, and others.
• Describe the aspects of the history that raise concern for abusive trauma, including either no or vague explanation for a significant injury; explanation inconsistent with the pattern, age, or severity of injury; explanation inconsistent with the child’s physical and/or developmental capabilities; unexplained/unexpected notable delay in seeking medical care; or other.
• Describe circumstances, characteristics, and risk factors that may be associated with child maltreatment, including child-related factors (physical or developmental disabilities, prematurity, chronic illness, and others), caregiver-related factors (substance abuse, mental illness, unrealistic expectations of child development, and others), and environmental factors (poverty, unemployment, intimate partner violence, and others).
• Discuss how developmental status impacts the likelihood of accidental injury.
• Describe aspects of the physical examination that should prompt an evaluation for abusive trauma, such as patterned injuries, injuries to non-bony or other unusual locations (torso, ear, head, face, neck, or genitals), bruises and unusual bruising patterns, fractures, intraoral injuries, any injury to young, pre-ambulatory infants, and others.
• Compare and contrast key history and exam features that may discriminate between a victim of child maltreatment and other diagnoses for infants presenting with conditions such as failure to thrive or BRUE (Brief Resolved Unexplained Event), attending to both medical and behavioral features.
• Compare and contrast key history and exam feature that may discriminate between a victim of child maltreatment and other diagnoses for children and adolescents presenting with conditions such as abdominal pain or genital complaints, attending to both medical and behavioral features.
• Review common factors found in association with caregiver medical child abuse (formerly Munchausen Syndrome by Proxy), such as inexplicable findings or treatment failures, pursuit of unnecessary medical care or procedures, use of varied providers and/or provider networks, and others.
• Discuss the utility, risks, and benefits of radiologic and laboratory studies in the evaluation of suspected child maltreatment, including non-contrast head CT, MRI, skeletal survey (initial and repeat), coagulation studies, liver function tests, and others.
• List examples of culturally appropriate behaviors, such as coining or cupping, that may result in unusual physical examination findings which may lead to erroneous concern for physical child maltreatment.
• Cite the steps required for reporting of suspected child maltreatment to local child welfare agencies/child protective services and law enforcement.
• Discuss the importance of objective, unbiased, thorough written documentation of findings in the medical record.
• Compare and contrast the role of pediatric hospitalists with expert witnesses in providing court testimony for suspected maltreatment cases.
• List common community resources for caregivers and maltreated children, such as support groups, domestic violence resources, safe houses, parenting classes, foster care, and others.

Pediatric Hospitalists should be able to:

• Elicit a thorough medical history to identify signs consistent with child maltreatment.
• Perform a physical exam to elicit signs consistent with child maltreatment, differentiating it from findings with mimicking conditions.
• Identify genital abnormalities suggestive of sexual trauma.
• Discriminate between physical examination findings such as bruises, burns, and cutaneous findings that may be suggestive of maltreatment from those related to medical conditions, accidental trauma, or cultural healing practices.
• Initiate with efficiency the local processes for suspected maltreatment case evaluation.
• Report suspected maltreatment promptly and communicate concerns for maltreatment to investigative authorities clearly and effectively.
• Communicate concerns about maltreatment to the family/caregivers at the bedside, including discussion regarding reports of suspected maltreatment made to investigative authorities.
• Coordinate care with child maltreatment experts to ensure timely and accurate collection of forensic evidence as appropriate for the local context.
• Select and correctly interpret appropriate diagnostic testing based on risk/benefit assessment to evaluate child maltreatment in collaboration with other subspecialists.
• Engage consultants efficiently and appropriately when indicated.
• Coordinate care with the primary care provider, subspecialists, and child protective services to arrange an appropriate multidisciplinary transition plan for hospital discharge, including determination of the location and responsible party to whom the child will be discharged.
• Educate learners and other healthcare providers on child maltreatment and the role of pediatric hospitalists in early maltreatment detection and intervention.
• Provide accurate court testimony where indicated and within local context.

Pediatric hospitalists should be able to:

• Recognize that child maltreatment and neglect affect all cultures, ethnicities/races, and socioeconomic classes.
• Reflect on the importance of and provide support and education for the family/caregivers of child maltreatment victims.
• Exemplify behaviors that espouse sensitivity, lack of bias, and empathy.
• Communicate effectively with patients, the family/caregivers, other subspecialists, social services, and investigative authorities regarding diagnosis, relevant medical findings, and care plans.
• Realize the importance of post-hospital care and support for victims of child maltreatment and their family/caregivers.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Collaborate with hospital administration and community leaders to advocate for policies/programs that support the family/caregivers and protect children from maltreatment.
• Lead, coordinate, or participate in the development and implementation of evidence-based care pathways to standardize the evaluation and management of hospitalized children with suspected maltreatment concerns.
• Collaborate with hospital administration, community partners, social work, and subspecialty care providers to develop and sustain referral networks for suspected victims of maltreatment that address both immediate and long-term care needs.

Introduction

Child abuse and neglect (hereafter described using the single term “maltreatment”) refer to the physical, sexual or psychological maltreatment of children by a caregiver or other adult. Maltreatment results in harm and/or risk of harm that may impact a child’s mental and physical health outcomes into adulthood. Annually, child protective services agencies investigate more than 3 million reports of suspected child maltreatment; approximately 1 million children per year are victims of maltreatment, resulting in nearly 2000 fatalities per year. Children may require hospitalization to manage problems directly related to potential maltreatment or discovery of an abusive or high-risk situation may occur when they are hospitalized for another reason. Pediatric hospitalists are in a unique position to identify and/or prevent and participate in treatment plans for these victims of child maltreatment.

Pediatric Hospitalists should be able to:

• Discuss the role of pediatric hospitalists in recognition/detection of maltreatment, evaluation and treatment of maltreatment-related injuries or medical conditions, coordination of subspecialty care, and reporting to child welfare authorities in centers with and without child maltreatment pediatric experts.
• Describe the role of consultants who may be involved in evaluation of suspected maltreatment, including hospital child protection team, trauma/surgical team, radiology, neurosurgery, ophthalmology, orthopedics, social work, child protective services/social services, law enforcement, psychiatry/psychology, forensic nursing/sexual assault examiners, and others.
• Describe the aspects of the history that raise concern for abusive trauma, including either no or vague explanation for a significant injury; explanation inconsistent with the pattern, age, or severity of injury; explanation inconsistent with the child’s physical and/or developmental capabilities; unexplained/unexpected notable delay in seeking medical care; or other.
• Describe circumstances, characteristics, and risk factors that may be associated with child maltreatment, including child-related factors (physical or developmental disabilities, prematurity, chronic illness, and others), caregiver-related factors (substance abuse, mental illness, unrealistic expectations of child development, and others), and environmental factors (poverty, unemployment, intimate partner violence, and others).
• Discuss how developmental status impacts the likelihood of accidental injury.
• Describe aspects of the physical examination that should prompt an evaluation for abusive trauma, such as patterned injuries, injuries to non-bony or other unusual locations (torso, ear, head, face, neck, or genitals), bruises and unusual bruising patterns, fractures, intraoral injuries, any injury to young, pre-ambulatory infants, and others.
• Compare and contrast key history and exam features that may discriminate between a victim of child maltreatment and other diagnoses for infants presenting with conditions such as failure to thrive or BRUE (Brief Resolved Unexplained Event), attending to both medical and behavioral features.
• Compare and contrast key history and exam feature that may discriminate between a victim of child maltreatment and other diagnoses for children and adolescents presenting with conditions such as abdominal pain or genital complaints, attending to both medical and behavioral features.
• Review common factors found in association with caregiver medical child abuse (formerly Munchausen Syndrome by Proxy), such as inexplicable findings or treatment failures, pursuit of unnecessary medical care or procedures, use of varied providers and/or provider networks, and others.
• Discuss the utility, risks, and benefits of radiologic and laboratory studies in the evaluation of suspected child maltreatment, including non-contrast head CT, MRI, skeletal survey (initial and repeat), coagulation studies, liver function tests, and others.
• List examples of culturally appropriate behaviors, such as coining or cupping, that may result in unusual physical examination findings which may lead to erroneous concern for physical child maltreatment.
• Cite the steps required for reporting of suspected child maltreatment to local child welfare agencies/child protective services and law enforcement.
• Discuss the importance of objective, unbiased, thorough written documentation of findings in the medical record.
• Compare and contrast the role of pediatric hospitalists with expert witnesses in providing court testimony for suspected maltreatment cases.
• List common community resources for caregivers and maltreated children, such as support groups, domestic violence resources, safe houses, parenting classes, foster care, and others.

Pediatric Hospitalists should be able to:

• Elicit a thorough medical history to identify signs consistent with child maltreatment.
• Perform a physical exam to elicit signs consistent with child maltreatment, differentiating it from findings with mimicking conditions.
• Identify genital abnormalities suggestive of sexual trauma.
• Discriminate between physical examination findings such as bruises, burns, and cutaneous findings that may be suggestive of maltreatment from those related to medical conditions, accidental trauma, or cultural healing practices.
• Initiate with efficiency the local processes for suspected maltreatment case evaluation.
• Report suspected maltreatment promptly and communicate concerns for maltreatment to investigative authorities clearly and effectively.
• Communicate concerns about maltreatment to the family/caregivers at the bedside, including discussion regarding reports of suspected maltreatment made to investigative authorities.
• Coordinate care with child maltreatment experts to ensure timely and accurate collection of forensic evidence as appropriate for the local context.
• Select and correctly interpret appropriate diagnostic testing based on risk/benefit assessment to evaluate child maltreatment in collaboration with other subspecialists.
• Engage consultants efficiently and appropriately when indicated.
• Coordinate care with the primary care provider, subspecialists, and child protective services to arrange an appropriate multidisciplinary transition plan for hospital discharge, including determination of the location and responsible party to whom the child will be discharged.
• Educate learners and other healthcare providers on child maltreatment and the role of pediatric hospitalists in early maltreatment detection and intervention.
• Provide accurate court testimony where indicated and within local context.

Pediatric hospitalists should be able to:

• Recognize that child maltreatment and neglect affect all cultures, ethnicities/races, and socioeconomic classes.
• Reflect on the importance of and provide support and education for the family/caregivers of child maltreatment victims.
• Exemplify behaviors that espouse sensitivity, lack of bias, and empathy.
• Communicate effectively with patients, the family/caregivers, other subspecialists, social services, and investigative authorities regarding diagnosis, relevant medical findings, and care plans.
• Realize the importance of post-hospital care and support for victims of child maltreatment and their family/caregivers.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Collaborate with hospital administration and community leaders to advocate for policies/programs that support the family/caregivers and protect children from maltreatment.
• Lead, coordinate, or participate in the development and implementation of evidence-based care pathways to standardize the evaluation and management of hospitalized children with suspected maltreatment concerns.
• Collaborate with hospital administration, community partners, social work, and subspecialty care providers to develop and sustain referral networks for suspected victims of maltreatment that address both immediate and long-term care needs.

Introduction

Child abuse and neglect (hereafter described using the single term “maltreatment”) refer to the physical, sexual or psychological maltreatment of children by a caregiver or other adult. Maltreatment results in harm and/or risk of harm that may impact a child’s mental and physical health outcomes into adulthood. Annually, child protective services agencies investigate more than 3 million reports of suspected child maltreatment; approximately 1 million children per year are victims of maltreatment, resulting in nearly 2000 fatalities per year. Children may require hospitalization to manage problems directly related to potential maltreatment or discovery of an abusive or high-risk situation may occur when they are hospitalized for another reason. Pediatric hospitalists are in a unique position to identify and/or prevent and participate in treatment plans for these victims of child maltreatment.

Pediatric Hospitalists should be able to:

• Discuss the role of pediatric hospitalists in recognition/detection of maltreatment, evaluation and treatment of maltreatment-related injuries or medical conditions, coordination of subspecialty care, and reporting to child welfare authorities in centers with and without child maltreatment pediatric experts.
• Describe the role of consultants who may be involved in evaluation of suspected maltreatment, including hospital child protection team, trauma/surgical team, radiology, neurosurgery, ophthalmology, orthopedics, social work, child protective services/social services, law enforcement, psychiatry/psychology, forensic nursing/sexual assault examiners, and others.
• Describe the aspects of the history that raise concern for abusive trauma, including either no or vague explanation for a significant injury; explanation inconsistent with the pattern, age, or severity of injury; explanation inconsistent with the child’s physical and/or developmental capabilities; unexplained/unexpected notable delay in seeking medical care; or other.
• Describe circumstances, characteristics, and risk factors that may be associated with child maltreatment, including child-related factors (physical or developmental disabilities, prematurity, chronic illness, and others), caregiver-related factors (substance abuse, mental illness, unrealistic expectations of child development, and others), and environmental factors (poverty, unemployment, intimate partner violence, and others).
• Discuss how developmental status impacts the likelihood of accidental injury.
• Describe aspects of the physical examination that should prompt an evaluation for abusive trauma, such as patterned injuries, injuries to non-bony or other unusual locations (torso, ear, head, face, neck, or genitals), bruises and unusual bruising patterns, fractures, intraoral injuries, any injury to young, pre-ambulatory infants, and others.
• Compare and contrast key history and exam features that may discriminate between a victim of child maltreatment and other diagnoses for infants presenting with conditions such as failure to thrive or BRUE (Brief Resolved Unexplained Event), attending to both medical and behavioral features.
• Compare and contrast key history and exam feature that may discriminate between a victim of child maltreatment and other diagnoses for children and adolescents presenting with conditions such as abdominal pain or genital complaints, attending to both medical and behavioral features.
• Review common factors found in association with caregiver medical child abuse (formerly Munchausen Syndrome by Proxy), such as inexplicable findings or treatment failures, pursuit of unnecessary medical care or procedures, use of varied providers and/or provider networks, and others.
• Discuss the utility, risks, and benefits of radiologic and laboratory studies in the evaluation of suspected child maltreatment, including non-contrast head CT, MRI, skeletal survey (initial and repeat), coagulation studies, liver function tests, and others.
• List examples of culturally appropriate behaviors, such as coining or cupping, that may result in unusual physical examination findings which may lead to erroneous concern for physical child maltreatment.
• Cite the steps required for reporting of suspected child maltreatment to local child welfare agencies/child protective services and law enforcement.
• Discuss the importance of objective, unbiased, thorough written documentation of findings in the medical record.
• Compare and contrast the role of pediatric hospitalists with expert witnesses in providing court testimony for suspected maltreatment cases.
• List common community resources for caregivers and maltreated children, such as support groups, domestic violence resources, safe houses, parenting classes, foster care, and others.

Pediatric Hospitalists should be able to:

• Elicit a thorough medical history to identify signs consistent with child maltreatment.
• Perform a physical exam to elicit signs consistent with child maltreatment, differentiating it from findings with mimicking conditions.
• Identify genital abnormalities suggestive of sexual trauma.
• Discriminate between physical examination findings such as bruises, burns, and cutaneous findings that may be suggestive of maltreatment from those related to medical conditions, accidental trauma, or cultural healing practices.
• Initiate with efficiency the local processes for suspected maltreatment case evaluation.
• Report suspected maltreatment promptly and communicate concerns for maltreatment to investigative authorities clearly and effectively.
• Communicate concerns about maltreatment to the family/caregivers at the bedside, including discussion regarding reports of suspected maltreatment made to investigative authorities.
• Coordinate care with child maltreatment experts to ensure timely and accurate collection of forensic evidence as appropriate for the local context.
• Select and correctly interpret appropriate diagnostic testing based on risk/benefit assessment to evaluate child maltreatment in collaboration with other subspecialists.
• Engage consultants efficiently and appropriately when indicated.
• Coordinate care with the primary care provider, subspecialists, and child protective services to arrange an appropriate multidisciplinary transition plan for hospital discharge, including determination of the location and responsible party to whom the child will be discharged.
• Educate learners and other healthcare providers on child maltreatment and the role of pediatric hospitalists in early maltreatment detection and intervention.
• Provide accurate court testimony where indicated and within local context.

Pediatric hospitalists should be able to:

• Recognize that child maltreatment and neglect affect all cultures, ethnicities/races, and socioeconomic classes.
• Reflect on the importance of and provide support and education for the family/caregivers of child maltreatment victims.
• Exemplify behaviors that espouse sensitivity, lack of bias, and empathy.
• Communicate effectively with patients, the family/caregivers, other subspecialists, social services, and investigative authorities regarding diagnosis, relevant medical findings, and care plans.
• Realize the importance of post-hospital care and support for victims of child maltreatment and their family/caregivers.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Collaborate with hospital administration and community leaders to advocate for policies/programs that support the family/caregivers and protect children from maltreatment.
• Lead, coordinate, or participate in the development and implementation of evidence-based care pathways to standardize the evaluation and management of hospitalized children with suspected maltreatment concerns.
• Collaborate with hospital administration, community partners, social work, and subspecialty care providers to develop and sustain referral networks for suspected victims of maltreatment that address both immediate and long-term care needs.

Introduction

Over the past several years, the number of children with acute behavioral and psychiatric conditions who require admission to the hospital has grown. Over the past decade, due to reductions in available psychiatric beds nationally, coupled with increases in children and young adults seeking and referred for acute mental health issues, the numbers of patients who require care by pediatric hospitalists while awaiting psychiatric disposition has risen dramatically. Pediatric hospitalists working in both university/children’s and community hospitals often encounter patients with acute behavioral or psychiatric illnesses. Patients may present with acute behavioral or psychiatric issues due to acute effects such as intoxication, medical illness, or suicide attempt, or for an acute change in an underlying behavioral, developmental, or psychiatric disorder. Pediatric patients with aggressive or agitated presentations are particularly challenging to care for in the hospital setting. In collaboration with mental health specialists, the hospitalist should know how to approach the diagnosis and initiate best treatment for these patients, while optimizing safety for the patients, the family/caregivers, and hospital staff.

Pediatric hospitalists should be able to:

• State the most common groups of underlying conditions that occur in children that manifest with acute behavioral concerns, attending to medication effects (accidental or intentional misuse or withdrawal from prescription or non-prescription drugs), abuse, endocrine/metabolic/rheumatologic disorders, encephalitidies, primary central nervous system disorders, new onset psychiatric disorders, and others.
• Compare and contrast the role of pediatric hospitalists with other subspecialists in management of these patients as it relates to diagnosis and treatment.
• Discuss the role of diagnostic testing for patient presenting with acute behavioral concerns.
• State indications for intra- or interfacility transfer, attending to local context and resource needs.
• Summarize potentially dangerous environmental hazards in the acute care hospital setting and cite methods that can be used to safeguard the patient, family, and healthcare providers.
• Define somatoform and conversion disorders and describe the relationship between somatic symptoms and depression or other mental illness.
• Define delirium and list examples of potential causes in the pediatric population for patients newly admitted and those developing delirium during the hospital stay.
• Distinguish agitation from aggression and review how patients may be acutely agitated secondary to an underlying medical condition, psychiatric illness, developmental disorder, change in environment, or loss of sensory abilities such as hearing or sight.
• Review common acute behavioral concerns that may occur in children with autism or developmental delays.
• Describe the approach toward an aggressive patient, including environmental changes, use of sitters, use of medications, and application of restraints.
• Summarize the Joint Commission requirements for patients placed in Violent Restraints (previously called Behavioral Restraints).
• List medications commonly used to stabilize pediatric patients with acute behavioral or psychiatric crises, and discuss associated adverse effects, overdose effects, potential drug-drug interactions, contraindications, and potential risks of repeated use.
• Review the use and value of commonly used screening tools for suicide and depression and describe use in local context.
• Explain the approach toward management of the acutely suicidal patient in the hospital environment, attending to issues such as safe eating utensils, room choice, and engagement of appropriate psychiatric consultants.
• Discuss the approach toward a successful interdisciplinary family meeting for this population.

Pediatric hospitalists should be able to:

• Diagnose the source of an acute behavioral condition by performing a history and physical exam, determining if key features of varied etiologies are present.
• Order appropriate studies and arrange needed consultation to further assess and address the underlying medical, psychiatric, or environmental/social problem resulting in the altered behavior.
• Order monitoring and environmental safeguards appropriate for the witnessed behavior and potential etiology.
• Prescribe appropriate, evidence-based medications indicated for acute behavioral or psychiatric crises using the safest route, dosing, frequency, and duration of treatment to stabilize the patient.
• Engage consultants such as Poison Control Center staff or toxicology experts to help manage patients with acute intoxication.
• Consult and engage psychiatric specialists and associated medical and mental health professionals (including developmental pediatricians, neurologists, therapists, and others) in ongoing care of hospitalized patients with acute behavior issues, within local context.
• Demonstrate basic skills in de-escalating aggression in patients.
• Document according to Joint Commission requirements for patients placed in Violent Restraints (previously called Behavioral Restraints).
• Demonstrate communication skills that diffuse anxiety and fears for patients, the family/caregivers, and healthcare providers.
• Demonstrate skills in maintaining confidentiality, empathy, and respect for the patient, family/caregivers, and staff.
• Coordinate the timing and frequency of care delivery with other healthcare providers in order to reduce unnecessary stimulation for patients with acute behavioral and psychiatric conditions.
• Create a comprehensive discharge plan that is interdisciplinary, engaging patients and the family/caregivers in shared decision-making for next steps in care.

Pediatric hospitalists should be able to:

• Recognize the need for empathy and sensitivity in the care of these patients, including awareness of the potential negative effects of varied treatment modalities.
• Reflect on the importance of maintaining a calm focus while leading the healthcare team caring for these patients with challenging needs.
• Appreciate the significant role that communication with the family/caregivers plays in allaying fears and reducing anxiety associated with the child’s illness.
• Realize that anxiety and other stress behaviors demonstrated by the family/caregivers may contribute to the child’s symptoms.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Work with hospital administration and medical staff leaders to ensure access to experts in behavioral and psychiatric medicine within referral networks.
• Lead, coordinate, or participate in development of education and training of teams regarding safe response to patients who exhibit aggressive behaviors.
• Promote an environment that embraces the importance of confidentiality in evaluating and treating patients with behavioral or psychiatric illness.
• Collaborate with an interdisciplinary team to develop and sustain a system of review of events that resulted in physical restraint or medication usage to control aggressive behavior.
• Collaborate with or lead an interdisciplinary team ensuring the security and safety of patients with aggressive or self-injurious behaviors.

Introduction

Over the past several years, the number of children with acute behavioral and psychiatric conditions who require admission to the hospital has grown. Over the past decade, due to reductions in available psychiatric beds nationally, coupled with increases in children and young adults seeking and referred for acute mental health issues, the numbers of patients who require care by pediatric hospitalists while awaiting psychiatric disposition has risen dramatically. Pediatric hospitalists working in both university/children’s and community hospitals often encounter patients with acute behavioral or psychiatric illnesses. Patients may present with acute behavioral or psychiatric issues due to acute effects such as intoxication, medical illness, or suicide attempt, or for an acute change in an underlying behavioral, developmental, or psychiatric disorder. Pediatric patients with aggressive or agitated presentations are particularly challenging to care for in the hospital setting. In collaboration with mental health specialists, the hospitalist should know how to approach the diagnosis and initiate best treatment for these patients, while optimizing safety for the patients, the family/caregivers, and hospital staff.

Pediatric hospitalists should be able to:

• State the most common groups of underlying conditions that occur in children that manifest with acute behavioral concerns, attending to medication effects (accidental or intentional misuse or withdrawal from prescription or non-prescription drugs), abuse, endocrine/metabolic/rheumatologic disorders, encephalitidies, primary central nervous system disorders, new onset psychiatric disorders, and others.
• Compare and contrast the role of pediatric hospitalists with other subspecialists in management of these patients as it relates to diagnosis and treatment.
• Discuss the role of diagnostic testing for patient presenting with acute behavioral concerns.
• State indications for intra- or interfacility transfer, attending to local context and resource needs.
• Summarize potentially dangerous environmental hazards in the acute care hospital setting and cite methods that can be used to safeguard the patient, family, and healthcare providers.
• Define somatoform and conversion disorders and describe the relationship between somatic symptoms and depression or other mental illness.
• Define delirium and list examples of potential causes in the pediatric population for patients newly admitted and those developing delirium during the hospital stay.
• Distinguish agitation from aggression and review how patients may be acutely agitated secondary to an underlying medical condition, psychiatric illness, developmental disorder, change in environment, or loss of sensory abilities such as hearing or sight.
• Review common acute behavioral concerns that may occur in children with autism or developmental delays.
• Describe the approach toward an aggressive patient, including environmental changes, use of sitters, use of medications, and application of restraints.
• Summarize the Joint Commission requirements for patients placed in Violent Restraints (previously called Behavioral Restraints).
• List medications commonly used to stabilize pediatric patients with acute behavioral or psychiatric crises, and discuss associated adverse effects, overdose effects, potential drug-drug interactions, contraindications, and potential risks of repeated use.
• Review the use and value of commonly used screening tools for suicide and depression and describe use in local context.
• Explain the approach toward management of the acutely suicidal patient in the hospital environment, attending to issues such as safe eating utensils, room choice, and engagement of appropriate psychiatric consultants.
• Discuss the approach toward a successful interdisciplinary family meeting for this population.

Pediatric hospitalists should be able to:

• Diagnose the source of an acute behavioral condition by performing a history and physical exam, determining if key features of varied etiologies are present.
• Order appropriate studies and arrange needed consultation to further assess and address the underlying medical, psychiatric, or environmental/social problem resulting in the altered behavior.
• Order monitoring and environmental safeguards appropriate for the witnessed behavior and potential etiology.
• Prescribe appropriate, evidence-based medications indicated for acute behavioral or psychiatric crises using the safest route, dosing, frequency, and duration of treatment to stabilize the patient.
• Engage consultants such as Poison Control Center staff or toxicology experts to help manage patients with acute intoxication.
• Consult and engage psychiatric specialists and associated medical and mental health professionals (including developmental pediatricians, neurologists, therapists, and others) in ongoing care of hospitalized patients with acute behavior issues, within local context.
• Demonstrate basic skills in de-escalating aggression in patients.
• Document according to Joint Commission requirements for patients placed in Violent Restraints (previously called Behavioral Restraints).
• Demonstrate communication skills that diffuse anxiety and fears for patients, the family/caregivers, and healthcare providers.
• Demonstrate skills in maintaining confidentiality, empathy, and respect for the patient, family/caregivers, and staff.
• Coordinate the timing and frequency of care delivery with other healthcare providers in order to reduce unnecessary stimulation for patients with acute behavioral and psychiatric conditions.
• Create a comprehensive discharge plan that is interdisciplinary, engaging patients and the family/caregivers in shared decision-making for next steps in care.

Pediatric hospitalists should be able to:

• Recognize the need for empathy and sensitivity in the care of these patients, including awareness of the potential negative effects of varied treatment modalities.
• Reflect on the importance of maintaining a calm focus while leading the healthcare team caring for these patients with challenging needs.
• Appreciate the significant role that communication with the family/caregivers plays in allaying fears and reducing anxiety associated with the child’s illness.
• Realize that anxiety and other stress behaviors demonstrated by the family/caregivers may contribute to the child’s symptoms.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Work with hospital administration and medical staff leaders to ensure access to experts in behavioral and psychiatric medicine within referral networks.
• Lead, coordinate, or participate in development of education and training of teams regarding safe response to patients who exhibit aggressive behaviors.
• Promote an environment that embraces the importance of confidentiality in evaluating and treating patients with behavioral or psychiatric illness.
• Collaborate with an interdisciplinary team to develop and sustain a system of review of events that resulted in physical restraint or medication usage to control aggressive behavior.
• Collaborate with or lead an interdisciplinary team ensuring the security and safety of patients with aggressive or self-injurious behaviors.

Introduction

Over the past several years, the number of children with acute behavioral and psychiatric conditions who require admission to the hospital has grown. Over the past decade, due to reductions in available psychiatric beds nationally, coupled with increases in children and young adults seeking and referred for acute mental health issues, the numbers of patients who require care by pediatric hospitalists while awaiting psychiatric disposition has risen dramatically. Pediatric hospitalists working in both university/children’s and community hospitals often encounter patients with acute behavioral or psychiatric illnesses. Patients may present with acute behavioral or psychiatric issues due to acute effects such as intoxication, medical illness, or suicide attempt, or for an acute change in an underlying behavioral, developmental, or psychiatric disorder. Pediatric patients with aggressive or agitated presentations are particularly challenging to care for in the hospital setting. In collaboration with mental health specialists, the hospitalist should know how to approach the diagnosis and initiate best treatment for these patients, while optimizing safety for the patients, the family/caregivers, and hospital staff.

Pediatric hospitalists should be able to:

• State the most common groups of underlying conditions that occur in children that manifest with acute behavioral concerns, attending to medication effects (accidental or intentional misuse or withdrawal from prescription or non-prescription drugs), abuse, endocrine/metabolic/rheumatologic disorders, encephalitidies, primary central nervous system disorders, new onset psychiatric disorders, and others.
• Compare and contrast the role of pediatric hospitalists with other subspecialists in management of these patients as it relates to diagnosis and treatment.
• Discuss the role of diagnostic testing for patient presenting with acute behavioral concerns.
• State indications for intra- or interfacility transfer, attending to local context and resource needs.
• Summarize potentially dangerous environmental hazards in the acute care hospital setting and cite methods that can be used to safeguard the patient, family, and healthcare providers.
• Define somatoform and conversion disorders and describe the relationship between somatic symptoms and depression or other mental illness.
• Define delirium and list examples of potential causes in the pediatric population for patients newly admitted and those developing delirium during the hospital stay.
• Distinguish agitation from aggression and review how patients may be acutely agitated secondary to an underlying medical condition, psychiatric illness, developmental disorder, change in environment, or loss of sensory abilities such as hearing or sight.
• Review common acute behavioral concerns that may occur in children with autism or developmental delays.
• Describe the approach toward an aggressive patient, including environmental changes, use of sitters, use of medications, and application of restraints.
• Summarize the Joint Commission requirements for patients placed in Violent Restraints (previously called Behavioral Restraints).
• List medications commonly used to stabilize pediatric patients with acute behavioral or psychiatric crises, and discuss associated adverse effects, overdose effects, potential drug-drug interactions, contraindications, and potential risks of repeated use.
• Review the use and value of commonly used screening tools for suicide and depression and describe use in local context.
• Explain the approach toward management of the acutely suicidal patient in the hospital environment, attending to issues such as safe eating utensils, room choice, and engagement of appropriate psychiatric consultants.
• Discuss the approach toward a successful interdisciplinary family meeting for this population.

Pediatric hospitalists should be able to:

• Diagnose the source of an acute behavioral condition by performing a history and physical exam, determining if key features of varied etiologies are present.
• Order appropriate studies and arrange needed consultation to further assess and address the underlying medical, psychiatric, or environmental/social problem resulting in the altered behavior.
• Order monitoring and environmental safeguards appropriate for the witnessed behavior and potential etiology.
• Prescribe appropriate, evidence-based medications indicated for acute behavioral or psychiatric crises using the safest route, dosing, frequency, and duration of treatment to stabilize the patient.
• Engage consultants such as Poison Control Center staff or toxicology experts to help manage patients with acute intoxication.
• Consult and engage psychiatric specialists and associated medical and mental health professionals (including developmental pediatricians, neurologists, therapists, and others) in ongoing care of hospitalized patients with acute behavior issues, within local context.
• Demonstrate basic skills in de-escalating aggression in patients.
• Document according to Joint Commission requirements for patients placed in Violent Restraints (previously called Behavioral Restraints).
• Demonstrate communication skills that diffuse anxiety and fears for patients, the family/caregivers, and healthcare providers.
• Demonstrate skills in maintaining confidentiality, empathy, and respect for the patient, family/caregivers, and staff.
• Coordinate the timing and frequency of care delivery with other healthcare providers in order to reduce unnecessary stimulation for patients with acute behavioral and psychiatric conditions.
• Create a comprehensive discharge plan that is interdisciplinary, engaging patients and the family/caregivers in shared decision-making for next steps in care.

Pediatric hospitalists should be able to:

• Recognize the need for empathy and sensitivity in the care of these patients, including awareness of the potential negative effects of varied treatment modalities.
• Reflect on the importance of maintaining a calm focus while leading the healthcare team caring for these patients with challenging needs.
• Appreciate the significant role that communication with the family/caregivers plays in allaying fears and reducing anxiety associated with the child’s illness.
• Realize that anxiety and other stress behaviors demonstrated by the family/caregivers may contribute to the child’s symptoms.

In order to improve efficiency and quality within their organizations, pediatric hospitalists should:

• Work with hospital administration and medical staff leaders to ensure access to experts in behavioral and psychiatric medicine within referral networks.
• Lead, coordinate, or participate in development of education and training of teams regarding safe response to patients who exhibit aggressive behaviors.
• Promote an environment that embraces the importance of confidentiality in evaluating and treating patients with behavioral or psychiatric illness.
• Collaborate with an interdisciplinary team to develop and sustain a system of review of events that resulted in physical restraint or medication usage to control aggressive behavior.
• Collaborate with or lead an interdisciplinary team ensuring the security and safety of patients with aggressive or self-injurious behaviors.

Presenter: Kyung E. Rhee, MD, MSc, MA

Summary: Eating disorders (ED) are common and have significant morbidity and mortality. EDs are the third most common psychiatric disorder of adolescents with a prevalence of 0.5-2% for anorexia and 0.9-3% for bulimia; 90% of patients are female. Mortality rate can be as high as 10% for anorexia and 1% for bulimia. Diagnosis is formally guided by DSM 5 criteria, but the mnemonic SCOFF can be useful:

1. Do you feel or make yourself SICK when eating?
2. Do you feel you’ve lost CONTROL of your eating?
3. Have you lost one STONE (14 lbs. developed by the British) of weight?
4. Do you feel FAT?
5. Does FOOD dominate your life?

A detailed history is needed as patients with ED may engage in secretive behaviors to hide their illness. After diagnosis, treatment may be outpatient or inpatient. Medical issues hospitalists are likely to see with inpatients include re-feeding syndrome, various metabolic disturbances, secondary amenorrhea, sleep disturbances, and for patients with bulimia, evidence of dental or esophageal trauma from purging. Differential diagnoses include: IBD, thyroid disease, celiac, diabetes, and Addison’s disease.

Hospitalists’ role in treatment is as part of a multidisciplinary group to manage the medical complications. Inpatient management includes individual and group therapy, monitored group meals, daily blind weights, bathroom visits, and focused lab studies. There is no “cure” and only ~50% of patients are free of ongoing symptoms after treatment.

Key Takeaways

• Eating disorders are common in adolescent females and have significant morbidity and mortality.
• Hospitalists’ role is diagnosis via careful history and management of medical complications with an eating disorder team. TH

Dr. Pressel is a pediatric hospitalist and inpatient medical director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a member of Team Hospitalist.

Presenter: Kyung E. Rhee, MD, MSc, MA

Summary: Eating disorders (ED) are common and have significant morbidity and mortality. EDs are the third most common psychiatric disorder of adolescents with a prevalence of 0.5-2% for anorexia and 0.9-3% for bulimia; 90% of patients are female. Mortality rate can be as high as 10% for anorexia and 1% for bulimia. Diagnosis is formally guided by DSM 5 criteria, but the mnemonic SCOFF can be useful:

1. Do you feel or make yourself SICK when eating?
2. Do you feel you’ve lost CONTROL of your eating?
3. Have you lost one STONE (14 lbs. developed by the British) of weight?
4. Do you feel FAT?
5. Does FOOD dominate your life?

A detailed history is needed as patients with ED may engage in secretive behaviors to hide their illness. After diagnosis, treatment may be outpatient or inpatient. Medical issues hospitalists are likely to see with inpatients include re-feeding syndrome, various metabolic disturbances, secondary amenorrhea, sleep disturbances, and for patients with bulimia, evidence of dental or esophageal trauma from purging. Differential diagnoses include: IBD, thyroid disease, celiac, diabetes, and Addison’s disease.

Hospitalists’ role in treatment is as part of a multidisciplinary group to manage the medical complications. Inpatient management includes individual and group therapy, monitored group meals, daily blind weights, bathroom visits, and focused lab studies. There is no “cure” and only ~50% of patients are free of ongoing symptoms after treatment.

Key Takeaways

• Eating disorders are common in adolescent females and have significant morbidity and mortality.
• Hospitalists’ role is diagnosis via careful history and management of medical complications with an eating disorder team. TH

Dr. Pressel is a pediatric hospitalist and inpatient medical director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a member of Team Hospitalist.

Presenter: Kyung E. Rhee, MD, MSc, MA

Summary: Eating disorders (ED) are common and have significant morbidity and mortality. EDs are the third most common psychiatric disorder of adolescents with a prevalence of 0.5-2% for anorexia and 0.9-3% for bulimia; 90% of patients are female. Mortality rate can be as high as 10% for anorexia and 1% for bulimia. Diagnosis is formally guided by DSM 5 criteria, but the mnemonic SCOFF can be useful:

1. Do you feel or make yourself SICK when eating?
2. Do you feel you’ve lost CONTROL of your eating?
3. Have you lost one STONE (14 lbs. developed by the British) of weight?
4. Do you feel FAT?
5. Does FOOD dominate your life?

A detailed history is needed as patients with ED may engage in secretive behaviors to hide their illness. After diagnosis, treatment may be outpatient or inpatient. Medical issues hospitalists are likely to see with inpatients include re-feeding syndrome, various metabolic disturbances, secondary amenorrhea, sleep disturbances, and for patients with bulimia, evidence of dental or esophageal trauma from purging. Differential diagnoses include: IBD, thyroid disease, celiac, diabetes, and Addison’s disease.

Hospitalists’ role in treatment is as part of a multidisciplinary group to manage the medical complications. Inpatient management includes individual and group therapy, monitored group meals, daily blind weights, bathroom visits, and focused lab studies. There is no “cure” and only ~50% of patients are free of ongoing symptoms after treatment.

Key Takeaways

• Eating disorders are common in adolescent females and have significant morbidity and mortality.
• Hospitalists’ role is diagnosis via careful history and management of medical complications with an eating disorder team. TH

Dr. Pressel is a pediatric hospitalist and inpatient medical director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a member of Team Hospitalist.

Presenter: Matthew Grossman, MD, FAAP

Summary: Treating Neonatal Abstinence Syndrome (NAS) traditionally has followed a standardized approach using the Finnegan Scoring System in which if there were three consecutive scores > 8 or two scores > 12, medications would be started. Common medications included tincture of opium or morphine. Medication doses would be adjusted or weaned, typically every other day, by Finnegan scoring.

A better approach is indicated with the 2012 AAP guidelines that indicate the first-line approach to NAS should be nonpharmacological. The approach should be that used for any crying baby, i.e., holding, swaddling, on-demand feeding, and parents rooming in with the infant. NAS infants without significant other medical problems are best cared for in a regular nursery or hospital unit rather than a NICU. With these simple interventions, some NAS infants may not need medications, and if they do, may be weaned sooner.

Additionally, medication management can be more successful if using combinations of a narcotic plus an additional agent such as clonidine or phenobarbital. Medications may be safely weaned more quickly than every other day. Using such a combined approach, the Yale New Haven Hospital has significantly reduced NAS infant LOS, total narcotic dose, and cost while increasing rates of breast feeding.

Key Takeaways

1. Treat NAS first by providing high quality nursing care with infants out of an ICU, swaddled, fed and held when first exhibiting withdrawal symptoms.
2. Use combination narcotic and other medication if pharmacologic treatment is needed.
3. Wean aggressively by symptoms. TH

Dr. Pressel is a pediatric hospitalist and inpatient medical director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a member of Team Hospitalist.

Presenter: Matthew Grossman, MD, FAAP

Summary: Treating Neonatal Abstinence Syndrome (NAS) traditionally has followed a standardized approach using the Finnegan Scoring System in which if there were three consecutive scores > 8 or two scores > 12, medications would be started. Common medications included tincture of opium or morphine. Medication doses would be adjusted or weaned, typically every other day, by Finnegan scoring.

A better approach is indicated with the 2012 AAP guidelines that indicate the first-line approach to NAS should be nonpharmacological. The approach should be that used for any crying baby, i.e., holding, swaddling, on-demand feeding, and parents rooming in with the infant. NAS infants without significant other medical problems are best cared for in a regular nursery or hospital unit rather than a NICU. With these simple interventions, some NAS infants may not need medications, and if they do, may be weaned sooner.

Additionally, medication management can be more successful if using combinations of a narcotic plus an additional agent such as clonidine or phenobarbital. Medications may be safely weaned more quickly than every other day. Using such a combined approach, the Yale New Haven Hospital has significantly reduced NAS infant LOS, total narcotic dose, and cost while increasing rates of breast feeding.

Key Takeaways

1. Treat NAS first by providing high quality nursing care with infants out of an ICU, swaddled, fed and held when first exhibiting withdrawal symptoms.
2. Use combination narcotic and other medication if pharmacologic treatment is needed.
3. Wean aggressively by symptoms. TH

Dr. Pressel is a pediatric hospitalist and inpatient medical director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a member of Team Hospitalist.

Presenter: Matthew Grossman, MD, FAAP

Summary: Treating Neonatal Abstinence Syndrome (NAS) traditionally has followed a standardized approach using the Finnegan Scoring System in which if there were three consecutive scores > 8 or two scores > 12, medications would be started. Common medications included tincture of opium or morphine. Medication doses would be adjusted or weaned, typically every other day, by Finnegan scoring.

A better approach is indicated with the 2012 AAP guidelines that indicate the first-line approach to NAS should be nonpharmacological. The approach should be that used for any crying baby, i.e., holding, swaddling, on-demand feeding, and parents rooming in with the infant. NAS infants without significant other medical problems are best cared for in a regular nursery or hospital unit rather than a NICU. With these simple interventions, some NAS infants may not need medications, and if they do, may be weaned sooner.

Additionally, medication management can be more successful if using combinations of a narcotic plus an additional agent such as clonidine or phenobarbital. Medications may be safely weaned more quickly than every other day. Using such a combined approach, the Yale New Haven Hospital has significantly reduced NAS infant LOS, total narcotic dose, and cost while increasing rates of breast feeding.

Key Takeaways

1. Treat NAS first by providing high quality nursing care with infants out of an ICU, swaddled, fed and held when first exhibiting withdrawal symptoms.
2. Use combination narcotic and other medication if pharmacologic treatment is needed.
3. Wean aggressively by symptoms. TH

Dr. Pressel is a pediatric hospitalist and inpatient medical director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a member of Team Hospitalist.

Presenters: David Pressel, MD, PhD, FAAP, FHM, Emily Fingado, MD, FAAP, and Jessica Tomaszewski, MD, FAAP

Summary: Patients may engage in violent behaviors that pose a danger to themselves or others. Behavioral emergencies may be rare, can be dangerous, and staff may feel ill-trained to respond appropriately. Patients with ingestions, or underlying psychiatric or developmental difficulties, are at highest risk for developing a behavioral emergency.

The first strategy in handling a potentially violent patient is de-escalation, i.e., trying to identify and rectify the behavioral trigger. If de-escalation is not successful, personal safety is paramount. Get away from the patient and get help. If a patient needs to be physically restrained, minimally there should be one staff member per limb. Various physical devices, including soft restraints, four-point leathers, hand mittens, and spit hoods may be used to control a violent patient. A violent restraint is characterized by the indication, not the device. Medications may be used to treat the underlying mental health issue and should not be used as PRN chemical restraints.

After a violent patient is safely restrained, further steps need to be taken, including notification of the attending or legal guardian if a minor; documentation of the event, including a debrief of what occurred; a room sweep to ensure securing any dangerous items (metal eating utensils); and modification of the care plan to strategize on removal of the restraints as soon as is safe.

Hospitals should view behavioral emergencies similarly to a Code Blue. Have a specialized team that responds and undergoes regular training.

Key Takeaways

1. Behavioral emergencies occur when a patient becomes violent.
2. De-escalation is the best response.
3. If not successful, maintain personal safety, control and medicate the patient as appropriate, and document clearly. TH

Dr. Pressel is a pediatric hospitalist and inpatient medical director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a member of Team Hospitalist.

Presenters: David Pressel, MD, PhD, FAAP, FHM, Emily Fingado, MD, FAAP, and Jessica Tomaszewski, MD, FAAP

Summary: Patients may engage in violent behaviors that pose a danger to themselves or others. Behavioral emergencies may be rare, can be dangerous, and staff may feel ill-trained to respond appropriately. Patients with ingestions, or underlying psychiatric or developmental difficulties, are at highest risk for developing a behavioral emergency.

The first strategy in handling a potentially violent patient is de-escalation, i.e., trying to identify and rectify the behavioral trigger. If de-escalation is not successful, personal safety is paramount. Get away from the patient and get help. If a patient needs to be physically restrained, minimally there should be one staff member per limb. Various physical devices, including soft restraints, four-point leathers, hand mittens, and spit hoods may be used to control a violent patient. A violent restraint is characterized by the indication, not the device. Medications may be used to treat the underlying mental health issue and should not be used as PRN chemical restraints.

After a violent patient is safely restrained, further steps need to be taken, including notification of the attending or legal guardian if a minor; documentation of the event, including a debrief of what occurred; a room sweep to ensure securing any dangerous items (metal eating utensils); and modification of the care plan to strategize on removal of the restraints as soon as is safe.

Hospitals should view behavioral emergencies similarly to a Code Blue. Have a specialized team that responds and undergoes regular training.

Key Takeaways

1. Behavioral emergencies occur when a patient becomes violent.
2. De-escalation is the best response.
3. If not successful, maintain personal safety, control and medicate the patient as appropriate, and document clearly. TH

Dr. Pressel is a pediatric hospitalist and inpatient medical director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a member of Team Hospitalist.

Presenters: David Pressel, MD, PhD, FAAP, FHM, Emily Fingado, MD, FAAP, and Jessica Tomaszewski, MD, FAAP

Summary: Patients may engage in violent behaviors that pose a danger to themselves or others. Behavioral emergencies may be rare, can be dangerous, and staff may feel ill-trained to respond appropriately. Patients with ingestions, or underlying psychiatric or developmental difficulties, are at highest risk for developing a behavioral emergency.

The first strategy in handling a potentially violent patient is de-escalation, i.e., trying to identify and rectify the behavioral trigger. If de-escalation is not successful, personal safety is paramount. Get away from the patient and get help. If a patient needs to be physically restrained, minimally there should be one staff member per limb. Various physical devices, including soft restraints, four-point leathers, hand mittens, and spit hoods may be used to control a violent patient. A violent restraint is characterized by the indication, not the device. Medications may be used to treat the underlying mental health issue and should not be used as PRN chemical restraints.

After a violent patient is safely restrained, further steps need to be taken, including notification of the attending or legal guardian if a minor; documentation of the event, including a debrief of what occurred; a room sweep to ensure securing any dangerous items (metal eating utensils); and modification of the care plan to strategize on removal of the restraints as soon as is safe.

Hospitals should view behavioral emergencies similarly to a Code Blue. Have a specialized team that responds and undergoes regular training.

Key Takeaways

1. Behavioral emergencies occur when a patient becomes violent.
2. De-escalation is the best response.
3. If not successful, maintain personal safety, control and medicate the patient as appropriate, and document clearly. TH

Dr. Pressel is a pediatric hospitalist and inpatient medical director at Nemours/Alfred I. duPont Hospital for Children in Wilmington, Del., and a member of Team Hospitalist.