Review of Suicide by Security Blanket,and Other Stories from the Child Psychiatry Emergency Service,by Laura M. Prager,and Abigail L. Donovan

Prager and Donovan take the reader into the emergency room (ER) at Massachusetts General Hospital (MGH) and introduce them to children/adolescents brought to the ER, and to the challenges of assessment and decision making. Suicide by Security Blanket and other stores from the Child Psychiatry Emergency Service allows the reader to join 12 children, adolescents, and their families as they enter the ER and to walk through the assessment alongside the resident or child psychiatry fellow. The children are described in detail, making the reader want to know more and care about them. Readers go through the differential diagnosis with the evaluator, reassess it as more information presents itself, and determine what tests and collateral contacts are needed.

Several key questions are asked and answered: “Who comes to their ER?” “Why is this child/ family coming now?” “What led to them to present in the manner they did?” “What can be done?” The book's children have some of more common problems seen in ERs. In addition, the book introduces the reader to the many people who work in the ER: Nurses, social workers, certified nursing assistants (CNAs), security staff, junior and senior residents, and the attending, and the importance of each member of the team. The authors approach this topic from the unique situation at MGH, where there is a psychiatrist on duty 24 hours a day, which is rare in most ERs where children are seen. It highlights the problems, common in many ERs, of an overcrowded waiting area where children and adults may sit together for a long time waiting to be seen, and where there is limited time to do the assessment, and limited resources to make the best disposition. In each chapter, we learn tidbits about child development and medical illnesses that present with psychiatric symptoms, we learn how to approach the assessment of children/ adolescents of different ages, we learn about different educational and social service systems and the role of how and where a patient lives, and about how a patient's insurance can have an impact on what happens next.

The first chapter, titled “Safe to Return to School?”, is about the many children referred from school with concerns about whether certain children can safely return to school, or are still too dangerous to either themselves or other children/ staff at school. With the many school shootings and other violence that occur, schools are scared, and look to ERs to help keep them safe. There is often a request for a note guaranteeing safety, even though the ability to predict future dangerousness is not possible, and no meaningful guarantee can be given. Any ER assessment is brief, and only reflects a particular point in time and not a full picture. Gabriel, age 8, had drawn pictures of himself impaling his teacher with a knife. The school wanted to know if they would be safe if he returns. Gabriel had learning problems, and when pushed to perform a reading assignment beyond what he was capable of doing by a teacher he was unfamiliar with, he got upset and drew his feelings. Pictures are often the way to enter into a child's world and feelings. Helena, another child, with her intricate squiggles on her arm and her inner thighs, reveals another challenge for child psychiatry staff working in an ER who have to try to figure out what is happening, why, what it means, and what needs to be done.

Prager and Donovan remind us again that the ER assessment is just the start of the process and must continue with additional assessments. The cases of Gabriel and Helena take the reader through the thought process that the resident struggles with. Who made the drawings? Why? What does it represent? Is the child safe? Is the child being abused? It shows that an ER is only the start of the process of clarifying what is going on, and that it must team with schools, family, and pediatricians. The ER's main role is to decide the immediate next step in the assessment and treatment process. Major questions answered there are: Is the child safe to go home? Does the child need an admission? Does the child need immediate further assessment by a pediatrician, immediate laboratory tests, neurology consultation, or radiology assessments? What treatments can be coordinated?

Other common problems covered were children who were bullied; had tantrums; exhibited psychosis caused by drugs; had delirium secondary to anticholinergic drugs; and had primary psychiatric problems such as depression, obsessive-compulsive disorder (OCD), anxiety disorders, psychosis, oppositional defiant disorder (ODD), and attention-deficit/hyperactivity disorder (ADHD). A chapter entitled “The Whirling Dervish” is a good review of the perils and difficulty of treating an out-of-control child, and the need to sometimes medicate and use restraints.

The book is a fun, easy read, and an educational introduction into child psychiatry assessments and how thinking evolves as the ER assessment progress. What the book does not do is present a comprehensive picture of ER assessments outside of MGH. It does not give sufficient information on the numbers of children/adolescents who present to psychiatric ERs or to pediatric ERs with mental health problems, the frequency of presenting problems, or the difficulties in conducting these assessments, especially with a limited number of well-trained child staff. It does not cover the use of risk assessment tools that might help with the assessment process. It does not discuss the particular problems in our nation's ERs where there are no trained child specialists. It does not cover issues of children who are abandoned in ERs because their parents either cannot get enough help in the community or are too tired to use the help offered when it has been unsuccessful in the past. There are also families who do not come to the ER voluntarily, but are forced to by state agencies or schools, and there are special issues in working with them. Further, many people use ERs because they cannot get a timely appointment with a specialist in the community who takes their insurance or find a provider one who accepts uninsured children. The breadth of this problem was mentioned, but it was not adequately addressed. The special features of assessing and structuring treatment plans for the developmentally disabled, the child who commits crimes, or the conduct disordered child not yet in the juvenile justice system were not discussed in enough detail. Also, the role of medicating children in the ER is only partially addressed.

The book is best for getting the reader excited about working with youth and families, and is most appropriate for clinicians new to working with children and adolescents. However, it is not a resource for understanding the complex issues in working with children and adolescents in an ER.