Psychiatric and behavioral problems combined with limited understanding of what is happening to them and an unfamiliar, overstimulating situation often lead to an uncooperative and at times combative child. The prevalence of major psychiatric disorders and attention deficit disorder is two to three times that of the general population. Stereotypy and self-injurious behavior are seen almost exclusively in the mentally retarded population, with increased incidence in children with the most severe cognitive limitations. Treatment of psychiatric and behavioral disorders is similar to treatment of these disorders in the general population.
The most worrisome problem in the ED is self-injurious behaviors. Self-injurious behavior is chronic, repetitive acts that may result in serious medical consequences. Self-injurious behaviors may include head-banging, chewing, hitting, and picking at various body parts. Behavior management, protective strategies, and pharmacologic intervention have all been used with variable success. When dealing with injuries sustained secondary to self-injurious behavior, use protective strategies immediately. Referral to psychiatric, psychological, or developmental services for behavior management and possible pharmacologic intervention is advised. This may be done on an outpatient basis. For children with known problems who are currently being treated for psychiatric disorders or behavioral problems, the side effects of the medications may become an issue. See Table 131:6 for a list of pharmacologic agents and their side effects.
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