(iii) the child is not actively suicidal or psychotic; (iv) the child can earnestly engage in safety planning; (v) the family can take responsibility for safely managing the child until formal psychiatric treatment is begun; and (vi) adequate means restriction can be carried out Before sending a family home, the family should formulate an acceptable, concrete plan for how they will manage the child Parents should be given guidelines for the prevention of suicide ( Table 126.20 ) and instruction in the early warning signs ( Table 126.21 ) TABLE 126.18 AREAS TO ASSESS FOLLOWING A SUICIDE ATTEMPT Social set Intent Method History Stress Mental status Support TABLE 126.19 INDICATIONS FOR PSYCHIATRIC HOSPITALIZATION FOLLOWING CHILDHOOD/ADOLESCENT SUICIDE ATTEMPT Failure of rapport among physician, child, and family Serious suicide attempt (lethality and intent) Continuing active suicidality Inability to engage in safety planning Psychosis of child Divisive/disturbed family, incapable of support and supervision Denial of significance of suicide attempt TABLE 126.20 PREVENTION OF CHILDHOOD AND ADOLESCENT SUICIDE: GUIDELINES FOR PARENTS Understand nature of parent—child dilemma during adolescence Maintain physical contact—be around, combat tendency toward isolation Maintain emotional contact—stay involved, show positive regard Listen to child before responding—promote safety in talking Respond to child once child has finished—take child seriously, not dismiss or attack Encourage choices by adolescent Acknowledge child and provide respect Restrict means to suicide (such as firearms, knives, drugs/alcohol, motor vehicles, toxins) as indicated TABLE 126.21 PREVENTION OF CHILDHOOD AND ADOLESCENT SUICIDE: WARNING SIGNS FOR PARENTS Withdrawal (peers, parents, siblings) Somatic complaints Irritability Crying Diminished school performance Sad or anxious appearance Significant loss (rejection by peer group, breakup of romance, poor grades, failure to achieve important goal) Major event or change within family Casual mention of suicide or being “better off dead” Explicit suicide threat Giving away of possessions Abrupt improvement in mood (which may represent relief upon deciding to carry out suicidal act) Minor, seemingly unimportant suicide “gestures” Apparent “accidents” Other unusual behavior pattern—housebound behavior, breaking curfew, running away, drug or alcohol abuse, bizarre or antisocial actions DEPRESSION Goals of Treatment The goals of emergency treatment of the depressed pediatric patient are to establish a safe and appropriate disposition plan and to provide brief psychoeducational and therapeutic interventions to the patient and their family CLINICAL PEARLS AND PITFALLS Depression in pediatric patients may present with either sad or irritable mood as its predominant symptom Unlike depressed adults, who tend to be consistently down or sad, depressed pediatric patients will often have moments in which they seem happy—often when they are engaged in a preferred activity Clinicians should not rule out depression based on these moments of what is referred to as mood reactivity Clinical Considerations Depression involves a pervasive sad or irritable mood, accompanied frequently by self-deprecation and suicidal ideation Depression also implies a change in functioning from an earlier state of relatively good adjustment The depressed child typically experiences a profound sense of helplessness, feeling unable to improve an unsatisfactory situation The prevalence of depression in children and adolescents is around 3% It is higher in children with anxiety and/or behavioral or significant medical problems Most children with depression present to the ED with other chief complaints (somatic symptoms, school or behavior problems); the ED clinicians must consider the possibility of depression in all children seen with recurrent or vague somatic complaints A large body of evidence suggests that a genetic predisposition exists for depression, particularly severe depression Depression manifests differently, depending on the stage of development In infancy, depression is usually the result of loss of important attachments and/or nurturance and is seen as a global interference of normal growth and physiologic functioning, including apathy, listlessness, staring, hypoactivity, poor feeding and weight loss, and increased susceptibility to infection In school-aged children key features include dysphoric mood, irritability, and self-deprecatory ideation Dysphoric mood is manifested by looking or feeling sad and forlorn, being moody and irritable, and crying easily Selfdeprecatory thoughts are reflected by low self-esteem, feelings of worthlessness, and suicidal ideation Depression in this age can also appear as other common symptoms, including multiple somatic complaints, school avoidance, or underachievement, including learning disabilities or ADHD, angry outbursts, runaway behavior, phobias, and fire setting ... abuse, bizarre or antisocial actions DEPRESSION Goals of Treatment The goals of emergency treatment of the depressed pediatric patient are to establish a safe and appropriate disposition plan and... Depression in pediatric patients may present with either sad or irritable mood as its predominant symptom Unlike depressed adults, who tend to be consistently down or sad, depressed pediatric patients