The Assignment

Respond to at least two of your colleagues by recommending at least one additional way you would treat a child or adolescent client differently than you would an adult and at least one additional way you would address the legal and ethical issues involved. Support your responses with evidence-based literature with at least two references in each colleague’s response with proper citation in APA Format. 

Colleagues Response # 1

Wk 6- Adult vs. Pediatric Emergencies

            Adults presenting for psychiatric emergencies are often handled quite different than children.  The decision-making rights of an adult is one of the most basic human rights that must be respected whenever possible (Mental Health America [MHA], 2015).  However, children and adolescents presenting for psychiatric emergencies also have rights, but these rights are sometimes different because of their inability to make some independent decisions as a result of them not being of age to grant legal consent.  Take for example, Sara, a 41-year-old female presenting to the emergency department after a domestic violence dispute with her husband.  Sara’s husband has been physically and emotionally abusive for years.  The most recent physical assault resulted in her needing stitches in her forehead and multiple bruises are visible on her face and body.  Sara was treated for her injuries, a police report was filed, and she was provided information of shelters for victims of domestic violence.  However, Sara declined all offers and asked to be released from the hospital so that she could go bail her husband out of jail.  This case is unfortunate, but not uncommon, with many women choosing to return to their abusive partners. 

            In contrast, consider a child presenting to the emergency department with similar injuries inflicted by the parents.  However, this case is less obvious with the parents saying the injuries were “an accident”.  When the nurse attempts to evaluate the child, without the parent in the room, the parent refuses to leave, thereby making the nurse suspicious of child abuse.  This situation is quite different in that the child’s physical injuries and suspected abuse must be reported.  The provider that suspects or discovers child abuse is considered a mandatory reporter and are required, by law, to report suspected child abuse (Child Welfare Information Getaway, 2019).  Mandatory reporting of suspected child abuse is both a legal and moral requirement for psychiatric providers.  We must advocate for our young clients and psychiatric providers have a legal and ethical duty to continually evaluate their safety in the home environment (Sadock et al., 2014).  Based on this concern, I would call the police and Child Protective Service (CPS) to assist with evaluating the safety of this child’s home environment.

          The child’s safety at home and mandatory reporting is quite different from that of Sara, the adult victim of domestic violence.  Despite the blatant lack of safety within Sara’s home, she can return to her abuser regardless of risk for her safety.  This is quite different when it comes to child abuse.  Regardless of a child’s wishes to return to an abusive household, providers determine safety first, with the child’s requests often being ignored if safety is a problem.  The big difference between Sara and a child being that I cannot prevent Sara’s return to her abuser, but for a child, law enforcement and CPS can step in and assume custody of a child that is in an unsafe home environment. 

Legal and Ethical Issues

         Legal and ethical issues surround the reporting of abuse for adults and children.  Although I am required to report Sara’s abuse to law enforcement, she may refuse to press charges and elect to return to her abuser.  For a child victim of abuse, this outcome is often quite different.  Providers are mandated by law to report the abuse and removal from the home may occur regardless of the child’s wishes (Sadock et al., 2014). 

References

Child Welfare Information Getaway. (2019). Mandatory reporters of child abuse and neglect – child welfare information gateway. Retrieved October 5, 2020, from https://www.childwelfare.gov/topics/systemwide/laws-policies/statutes/manda/

Mental Health America. (2015, March 7). Position statement 22: Involuntary mental health treatment. Retrieved October 5, 2020, from https://www.mhanational.org/issues/position-statement-22-involuntary-mental-health-treatment

Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.

Colleagues Response # 2

Treatment of psychiatric emergencies in children versus adults

           A previous case I experienced involved a 22-year-old female. She was being seen by a therapist for weekly psychotherapy due to generalized anxiety disorder and major depressive disorder. She had difficulty with transitioning from home to college and felt hopeless. She began to isolate from her family and friends and developed worsening anxiety, isolation, and depressive symptoms. During a weekly therapy session, she disclosed that she had suicidal thoughts, a plan to overdose on her medication, and intention to do so. She could not contract for safety with the therapist. The therapist talked to her about going to an inpatient psychiatric facility because of these thoughts and the client was receptive to this information. The therapist called the facility to set up an evaluation and the client stated that she would drive there and voluntarily admit herself to the hospital. We saw the client after she was released from the hospital and she thanked the therapist for helping her through a “dark period in her life.” She denied any ongoing suicidal thoughts and felt safe in her living environment.

Differences with Children

Children are treated differently than adults during psychiatric emergencies. Children are minors and cannot admit themselves to a hospital. A parent or guardian needs to sign them in for them to be admitted, in most cases. Technically, children are voluntarily admitted because their parents have taken them to the hospital and signed them in. However, many children do not want to go to the hospital so are personally involuntary. I often see this in my work as a pediatric psychiatric nurse in an inpatient unit. Kids are often upset and angry about coming to the hospital despite being ‘voluntary’ admissions.

The practitioner must assess the minor and determine if suicidal thoughts or other emergencies require hospitalization. Psychiatric admission is required if the client is ambivalent about suicidal thoughts and is a harm to themselves or others (Sadock et al., 2014). This practice is similar to adults but with children and adolescents, parents or guardians are also involved in the decision and treatment.

Legal and Ethical Issues

One major ethical and legal consideration with children and adolescents is involuntary commitment. This issue is complex because the child may disagree with the decision of the parents and the practitioner (American Academy, 2020). The practitioner must consider the best interest of the child and their developmental level when making the decision for them to be treated in an inpatient facility (American Academy, 2020). In addition to this, a parent may want to have their child discharged after they have been admitted to an inpatient facility. Under the involuntary treatment act, the minor can be held for 72 hours and then the court will need to petition for the minor to be involuntarily committed for an additional 14 days (American Academy, 2020). In my experience, this becomes especially upsetting and disruptive. An example of this occurred when an adolescent’s parents were strongly encouraged to have their child admitted to the facility. After three days they wanted the child to be discharged but the psychiatrist did not think the child was safe to go home. The parents signed a 3-day document and the legal system became involved. Ultimately, the court sided with the psychiatrist and the patient was held against his and his parent’s will. The parents and patient were very upset and were especially angry with the nursing staff and hospital for the events. These situations must be carefully considered and ultimately the patient’s safety and best interest must be the center of decision making.

           Another ethical and legal consideration when working with minors in emergency cases is physical and chemical restraints. Restraints affect the child’s safety and autonomy and must be carefully considered. Restraints should be used as a very last resort for a child who is an immediate danger to themselves or others (Carubia et al., 2016). It is especially important that the practitioner examines the state of the child and thoroughly determines if the child will be a threat to themselves or others before restraint is applied.

References

American Academy of Child & Adolescent Psychiatry. (2020). Ethical issues in clinical practice.

Retrieved from https://www.aacap.org/AACAP/Member_Resources/ Ethics/Ethics_Committee/Ethical_Issues_in_Clinical_Practice.aspx

Carubia, B., Becker, A., & Levine, B. H. (2016). Child psychiatric emergencies: Updates on

trends, clinical care, and practice changes. Current Psychiatry Reports, 18(41). https://doi.org/10.1007/s11920-016-0670-9

Sadock, B. J., Sadock, V.A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry:

           Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.

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