CHPR: Dr. Feuer, please tell us about yourself.

Dr. Feuer: I did child and adolescent fellowship training at Zucker School of Medicine at Hofstra/Northwell Health, and I have remained here ever since. For the past 10 years I’ve worked in the emergency department (ED) focusing on kids, and we’ve opened a behavioral urgent care center in the hospital and three additional ones in the community that partner with 26 school districts in Nassau County and Suffolk County.

CHPR: You’ve done a lot to address kids’ mental health needs. Let’s start by reviewing key points we should know about how to best help kids when they arrive in the ED in crisis. 

Dr. Feuer: First and foremost, we must keep developmental stages in mind. The ability to regulate emotions and behaviors continues to develop well into early adulthood, so the younger the kids are, the harder it will be for them to manage their behavioral dyscontrol. In many cases, we can de-escalate kids with behavioral techniques and environmental changes. In the ED or in the hospital, that often means moving them to a quiet, uncrowded space where there are no harsh lights. If this is not possible, we try to remove as many sources of stimulation as possible, like noisy machines and extremes of temperature. We speak at the patient’s eye level, using clear, simple language. Family members can help us identify what helps the child feel calmer and what triggers the child; it’s also helpful for them to bring comforting items from home. We also use snacks and other rewards in our de-escalation efforts. We joke that Goldfish crackers and M&Ms are our favorite PRNs.

CHPR: What do you do for kids who are in state custody/foster care rather than with their families? How about kids whose family members aren’t really engaged or are outright abusive?

Dr. Feuer: We approach these kids from a trauma-informed perspective. These children have had many difficult experiences, often leaving them even more sensitive and reactive to situations where they experience a loss of control or need to put their trust in strange adults. We can approach them by validating these feelings, offering them choices, and supporting them through their hospital experience. At times we also must protect them by removing them from abusive family members and engaging family members without the child present. 

CHPR: Those are good tips. Do you have any others?

Dr. Feuer: We also set firm limits for unacceptable behaviors and praise appropriate behaviors. By making reflective statements and validating what they’re feeling, we not only help children and adolescents feel understood, but we also help promote problem solving. 

CHPR: Can you give us examples of what you might say?

Dr. Feuer: We might say “I know you are really angry about being here and I am going to do my best to help you,” or “I really liked the way you started to explain what happened. Can we sit down so you can tell me more?”

CHPR: Right. We want to make every effort to de-escalate kids with verbal or other nonpharmacologic strategies.

Dr. Feuer: And it’s important to understand what’s driving the kid’s agitation so you can choose the right approach to treatment. Of the many causes of agitation in kids, only some are due to a psychiatric illness and are treatable with medication. 

CHPR: You have a very useful algorithm in your article, “Best Practices for Evaluation and Treatment of Agitated Children and Adolescents,” that lists different management approaches depending on the cause of the agitation (Gerson R et al, Western J Emerg Med 2019;20(2):409–418).

Dr. Feuer: Right, we list the five main etiologies of agitation in children and adolescents: 1) psychiatric diagnoses; 2) substance use or withdrawal; 3) developmental delay/autism; 4) delirium; and 5) unknown. The algorithm dictates the workup and medications to use for each etiology.

CHPR: When we do use medications for kids, are there any general principles we should follow?

Dr. Feuer: There are three important principles. First, use an etiology-based algorithm. The goal is not to just sedate the patient, except in those rare cases when we have no information available and they are actively hurting themselves and others. But more commonly, when kids present with agitation, they are not acutely dangerous, and we typically have time to start our evaluation and obtain collateral information that can guide us in determining the etiology. Second, whenever possible, use monotherapy—although there are times that multiple medications or combinations of medications may still be appropriate, such as when the agitation is severe. And third, see if there is a home medication that they are already on that we can use. If a kid takes olanzapine at home, for example, we might provide a rapidly dissolvable tablet as an additional dose to help with the acute agitation instead of introducing a new medication, which might produce new side effects and chances for drug interactions. 

CHPR: Is there any medication that works best or that we should try to avoid in kids?

Dr. Feuer: There is no clear evidence that any one medication works best, but we generally like to use diphenhydramine for younger children and children with anxiety or agitation if there’s no clear psychiatric history and they’re generally healthy. Diphenhydramine has the advantage of being calming, and families are ­familiar with it. Benzodiazepines are another option for these kids. But both diphenhydramine and benzos should be avoided in cases of delirium or if there’s a concern for paradoxical agitation, such as in younger or developmentally delayed youth (Editor’s note: For ED dosing recommendations for children and adolescents, see: www.thecarlatreport.com/ed-dosing).

CHPR: When would you choose other medications?

Dr. Feuer: We use antipsychotic agents in cases of severe agitation—most often olanzapine since it’s more sedating than many other agents, like haloperidol. We generally don’t recommend ziprasidone since it can be activating, can prolong the QT interval, and needs to be taken with food when it’s given by mouth. But choice of medication should also consider a patient’s past experiences, of course (Editor’s note: See www.thecarlatreport.com/ed-dosing).

CHPR: And it’s important to remember that children are more vulnerable to some medication side effects.

Dr. Feuer: Right. They tolerate cardiac side effects better, which is sometimes why we go to chlorpromazine (Thorazine) because it’s more sedating. But by and large, they are more sensitive to side effects; they are more sensitive to neuroleptic malignant syndrome and to dystonia, and with certain medications like diphenhydramine or benzodiazepines, kids with developmental delay/autism can get disinhibited.

CHPR: Autistic kids can be quite challenging to manage in EDs. Do you have any other tips for working with these kids? 

Dr. Feuer: Awareness of the kid’s developmental age is crucial. If we see a full-grown 16-year-old adolescent in front of us, it’s easy to forget that their developmental level and communication skills are not at a typical 16-year-old’s level. In our hospital we have a program called Bee Mindful. We place a bee sticker on the medical record and on the door signaling “Here’s somebody who needs a different approach where we need to rely on the parents or the guardians to tell us about what things trigger them, what things soothe them.” 

CHPR: Are any medications FDA approved for behavioral problems associated with autism?

Dr. Feuer: Aripiprazole and risperidone are FDA approved for the management of irritability associated with autism. Our algorithm also recommends others, such as clonidine, diphenhydramine, chlorpromazine, and olanzapine (Editor’s note: See www.thecarlatreport.com/ed-dosing).

CHPR: What do you do when it’s not safe for these kids to go home and they must stay in an ED? 

Dr. Feuer: The key is to quickly establish a new routine. We use visual schedules with icons so that the kids understand what to expect next. We use cards that have “if-then” statements like “If you take your medicine, then you get your iPad.” The sooner we can get them into a new routine, the less they are going to experience behavioral dyscontrol and the less they will require medications. This is especially important because 1) these kids are more sensitive to medication side effects and polypharmacy than other patients might be; and 2) experiences of getting restrained or medicated are especially traumatic for kids because they don’t have the language and the skills to process the event and understand why it’s happening.

CHPR: How do you handle situations when kids remain in EDs for lengthy periods of time because there are no hospital beds available for them? In our ED, kids are sometimes boarded for days.

Dr. Feuer: In some places, kids are boarded for longer, even weeks. We are working on a paper outlining guidelines for how to manage kids boarding in EDs and medical floors (Feuer and Mooneyham et al, J Acad Consult Liaison Psychiatry submitted). The most crucial point is that you should not wait until a kid is admitted to a hospital to start treatment. If you think treatment is indicated, start it in the ED. You might be able to get the child well enough to go home instead of continuing to wait. And every day there needs to be meaningful engagement and reassessment. The child may have needed an admission on Thursday, but we started treatment and they had time to talk to their family, and now it’s Monday and maybe they’re safe to go home. 

CHPR: For those kids who do end up staying for many days, how do you keep them engaged in treatment?

Dr. Feuer: If you have an already vulnerable youth in crisis, just having them wait endlessly on a stretcher is sure to make them feel worse. So, while we are all stretched for resources, we encourage people to get creative and come up with activities for the kids. The Emergency Nurses Association (www.ena.org/quality-and-safety/behavioral-health) recommends using a visual block schedule. At the very least, tell the kids what their day is going to look like. Tell them when they can call their family or visit with them. Tell them when they are going to take their medicine and when they’re going to meet with someone from occupational therapy or child life (whatever resources you have). And don’t underestimate the power of sitters: ED techs, nursing assistants, and nurses sitting on safety 1:1s. They need to be empowered and trained to engage these kids. That’s not to say that they should be engaged in doing therapy, but even playing a game of Uno can be therapeutic. A little creativity can really help these kids and these families. 

CHPR: How do you handle consent (which for children would be assent)? What rights do children have to refuse medications? 

Dr. Feuer: We use education and motivational interviewing to obtain a child’s or teenager’s assent, so they’ll agree to take medication and the parents must provide the consent. We sometimes encounter cases where a parent wants treatment and a child is adamantly against it. And parents will ask us “Is it OK for us to still give the medicine or put it in food without our child knowing?” But we try to follow the ethical principle that the child or adolescent has a right to know what they’re putting in their body. So, we explain to the parents that their kids must assent and agree to the treatment. Ultimately, they can refuse medication.

CHPR: What about the opposite situation, where a parent doesn’t want their adolescent to take a medication but the teenager feels they would benefit from it?

Dr. Feuer: That can be even trickier because adolescents have the legal right to make decisions about their treatment. Rules vary from state to state, but most states allow adolescents some jurisdiction over making treatment decisions around mental health, sexual health, reproductive health, and substance use treatment. Sometimes we seek guidance from risk management, but our guiding principle is that if it is in the best interest of the child, if it is indicated, and if we think it is important, then we can prescribe the treatment. But then we often get into logistical difficulties with insurance coverage and payment for the treatment. If parents don’t want their child to have the treatment they’ll say “I’m not going to pay the bill,” or if the child is on their insurance they’ll say “I’m not giving you the insurance information.” We’ve sometimes needed to get guidance from legal avenues and have even taken some cases to court to obtain authorization for medications over the parents’ objections.

CHPR: Wow, it gets tricky. Finally, EMS workers often see kids when their agitation is at its most extreme. Do you have any tips for EMS workers? 

Dr. Feuer: We are working in New York state with EMS and prehospital providers to educate them on this, and we are convening a new expert group to create a modified algorithm for EMS providers. Ambulances typically have a limited number of medicines that are available to them in the field, so we are making recommendations specific to what they have available. One topic we address is the use of ketamine, which is often used in the field by prehospital providers because it can be given intranasally and is quickly effective. But it comes with its own risks, especially for kids, and the risks are even higher with IM administration. We strongly feel that in many cases, there are other more appropriate medications to try beforehand. So, we are trying to use these guidelines and recommendations to help guide the prehospital practice toward these etiologic-driven medications as opposed to chemical restraint. 

CHPR: When will those guidelines be available?

Dr. Feuer: We presented them to the New York State Committee in April 2022, and the state included them in their Collaborative Advanced Life Support Adult and Pediatric Patient Care Protocols in February 2023 (www.tinyurl.com/mubrnujd). 

CHPR: Thank you, Dr. Feuer.