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Children present in increasing numbers to the emergency department with psychiatric-related complaints. An estimated 21% of children aged 9-17 years have an identifiable mental health disorder. There are several drivers behind the increase in psychiatric cases presenting to the emergency department, including increased demand for pediatric psychiatric services unable to be met in the outpatient arena, decreased comfort by primary care physicians with psychiatric conditions, decreased practitioners of child and adolescent psychiatry, and various cultural phenomena. The increase in children presenting with psychiatric disorders is also leading to an increase in children admitted for mental health reasons.

Many children who present to the emergency department live in environments with risk factors for poor mental health. These include poverty, single parenthood, witnessed domestic abuse, parental mental illness, and substance abuse in the home. As primary care physicians are increasingly less comfortable with psychiatric complaints and the pool of child/adolescent psychiatrists has not been able to match demand, the emergency department is increasingly viewed as the patient’s access point to the mental health system.

Because emergency department physicians are thrust into the role of evaluating children with psychiatric needs, it is imperative that they have the proper knowledge to screen children appropriately for organic causes of their symptoms and identify psychiatric illness when it presents. Indications that an organic disorder may be causing a patient’s symptoms include a relatively new onset of symptoms, substance use/abuse, and abnormal vital signs or physical examination findings.

A key aspect of the history and physical examination of the pediatric psychiatric patient is the mental status examination (Table 48–1).

Table 48–1.Essential elements of the mental status examination.

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