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Children and Adolescents With Acute Alcohol Intoxication/Self-poisoning Presenting to the Emergency Department
Sue Woolfenden, MBBS, MPH, FRACP;
David Dossetor, FRCP, FRCPsych, MD;
Katrina Williams, MBBS, MSc, FRACP, FAFPHM
Arch Pediatr Adolesc Med. 2002;156:345-348.
ABSTRACT
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Objective To describe the presentations, characteristics, and follow-up care of
children and adolescents aged 10 to 18 years who present to emergency departments
(EDs) with acute alcohol intoxication/self-poisoning.
Design Retrospective medical record review.
Setting Five EDs in Western Sydney, Australia.
Participants Patients aged 10 to 18 years who presented to EDs with acute alcohol
intoxication/self-poisoning between January 1, 1996, and December 31, 2000.
Main Outcome Measures Frequency of presentations; presentation characteristics; psychosocial
characteristics; and presence or absence of follow-up.
Results Two hundred twelve children and adolescents presented to EDs 216 times.
Of the 212 patients, 49 (23%) were 14 years or younger, and the youngest was
aged 10 years. The majority (82%) came after hours and were brought in by
emergency services (77%). In 13% of presentations, verbal and/or physical
aggression was present, and a threat of self-harm was present in 2% of cases.
A mental health worker was consulted about the child or adolescent in only
6% of presentations. Most children and adolescents (85%) were discharged from
the ED. Of concern, in 56% of presentations, a follow-up plan was not recorded.
There was documentation of mental health follow-up in only 14% of presentations
and follow-up from drug and alcohol services in only 1%. Forensic history,
school functioning, and a history of past mental health problems were not
documented in more than 60% of the medical records examined.
Conclusions When children or adolescents present to an ED with acute alcohol intoxication/self-poisoning,
their risk factors for psychosocial dysfunction appear to be inadequately
assessed, documented, and followed up. Clear guidelines for assessment and
referral pathways must be established in EDs.
INTRODUCTION
ALCOHOL USE and abuse are common in the teenage years. In Australia,
90% of teenagers aged 15 to 16 years report having consumed more than 2 alcoholic
drinks in their lifetime, and 29% describe drinking to the point of intoxication.1 Of concern, data from the United States suggest that
children of an increasingly younger age are using alcohol, and up to 32% of
adolescents have difficulties with alcohol intoxication/self-poisoning or
dependence.2-4
Alcohol abuse and dependence have been shown to play a role in motor
vehicle accidents and other injuries and are associated with an increased
risk of suicide, delinquent behavior, high-risk sex, and problems with school
functioning in adolescents.2-3,5-7
Associated comorbid psychiatric disorders include conduct disorder, oppositional
defiant disorder, attention-deficit/hyperactivity disorder, major depression,
and posttraumatic stress disorder.2, 4, 8
In addition, children and adolescents with alcohol abuse or dependence may
have problems with substance use disorders and comorbid psychiatric disorders
as adults.6-8
Health professionals need to be able to identify children or adolescents
who are having difficulties with alcohol. This problem may come to their attention
when a child or adolescent with acute alcohol intoxication/self-poisoning
presents to an emergency department (ED). Current American pediatric and psychiatric
literature recommends that once the child or adolescent presenting to the
ED with acute alcohol intoxication/self-poisoning is medically stable, mental
health and drug and alcohol issues be explored and appropriate follow-up arranged.3, 9 However, scant data are available on
what actually happens when these children and adolescents present to EDs,
including assessment of their psychosocial risk factors and whether follow-up
is arranged. The purpose of this study was to describe the presentations,
characteristics, and follow-up treatment of children and adolescents aged
10 to 18 years who present with acute alcohol intoxication/self-poisoning
to EDs in Western Sydney, Australia. This research was part of a larger retrospective
medical record review examining children and adolescents who present to EDs
with aggression, self-harm, and substance abuse.
PARTICIPANTS AND METHODS
We conducted a retrospective medical record review of children and adolescents
who presented with aggression, self-harm, and substance abuse to 5 EDs in
Western Sydney from January 1, 1996, to December 31, 2000. A subgroup of children
and adolescents was identified using International Classification
of Diseases, Ninth Revision (ICD-9), and International
Classification of Diseases, Tenth Revision (ICD-10)10-11
codes for "alcohol intoxication" and "self-poisoning, alcohol" based on documented
history, clinical assessment, and/or blood alcohol levels. Subjects were excluded
if their presentation with acute alcohol intoxication/self-poisoning occurred
in the context of an overdose of other substances (eg, paracetamol) or other
forms of deliberate self-harm (eg, self-laceration). Medical records were
then manually searched to confirm that the child or adolescent had indeed
presented with "acute alcohol intoxication/self-poisoning."
As part of the larger study, 2 data collection forms were designed and
piloted on the medical records of 5 eligible subjects then adjusted accordingly.
The first form was used to collect social and demographic data. The second
was used to collect data on details of presentations and follow-up plans.
Data were manually collected from ED records and from the medical records
of those admitted to the ward from the ED. The data for 4 of the EDs were
collected only by the principal investigator (S.W.). At the remaining ED,
a clinical nurse consultant in psychiatry helped the principal investigator
with data collection.
Data were entered in an Access database, and Excel pilot tables were
used to analyze frequency data (Microsoft, Redmond, Wash). Ethics approval
was given by the Children's Hospital at Westmead and the Human Research Ethics
Committee, Western Sydney Area Health Service.
RESULTS
PRESENTATION CHARACTERISTICS
During the 5-year study period, 212 children and adolescents with acute
alcohol intoxication/self-poisoning made 216 visits to the 5 EDs in Western
Sydney. This equates to one presentation every 9 days in Western Sydney. Presentation
characteristics are outlined in Table 1. The majority (82%) of presentations for acute alcohol intoxication/self-poisoning
were made "after hours" (ie, after 5 PM and before 9 AM or on weekends) to
local hospital EDs. The most presentations were seen on Saturday (25%), followed
by Sunday (21%) and Friday (18%).
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Table 1. Presentation Characteristics*
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One hundred sixty-six children and adolescents (77%) were brought in
by emergency services (eg, ambulance or police). On presentation to the ED,
14 subjects (6%) were triaged as needing to be seen immediately by medical
staff, 35 (16%) as needing to be seen within 15 minutes, and 92 (43%) as needing
to be seen within half an hour.
In 4 presentations (2%), self-harm was documented as having been threatened.
Verbal and/or physical aggression was displayed in 28 presentations (13%)
and in 4% of presentations, physical restraint of the child or adolescent
was required in the ED. Of note, although all the children and adolescents
were seen by ED medical staff, in only 12 presentations (6%) was a mental
health professional consulted by the ED. In none of the cases was drug and
alcohol services consulted at the acute presentation.
DEMOGRAPHIC AND PSYCHOSOCIAL CHARACTERISTICS
Of the 212 subjects, 53% were boys, and 47% were girls. The median age
was 16 years. Forty-nine subjects (23%) were 14 or younger, and the youngest
child was aged 10 years.
In general, the current psychosocial characteristics and relevant history
of the children and adolescents were poorly documented in their medical records. Table 2 shows the number of children and
adolescents with this information documented in their records. When this information
was documented, a high proportion of psychosocial dysfunction was present.
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Table 2. Psychosocial Characteristics in 212 Children and Adolescents*
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DISCHARGE AND FOLLOW-UP
The majority of children and adolescents (85%) were discharged. A mental
health follow-up plan was documented in only 30 records (14%), and a drug
and alcohol services follow-up plan was present in only 2 records. Of concern,
in 121 medical records (56%), no follow-up plan was documented.
For 58 children and adolescents (27%), a history of mental health problems,
abuse, and/or a family history of mental health or substance use problems
was documented in their medical records. Only 31% of these subjects had a
mental health follow-up plan documented, and 34% had no follow-up plan documented.
COMMENT
At least every 9 days, a child or adolescent with acute alcohol intoxication/self-poisoning
presents to an ED in Western Sydney. Of concern, 49 children and adolescents
in this study were 14 or younger, and the youngest child was aged 10 years.
Evidence and consensus-based guidelines for assessment and treatment
have been developed for children and adolescents with suspected substance
use disorders, including alcohol abuse and dependence. These guidelines recommend
comprehensive assessment of alcohol and drug history, psychosocial risk factors,
and treatment history.4, 12 The
combination of alcohol abuse and disruptive disorders, previous self-harm,
a history of physical abuse, and a family history of mental health/substance
use problems has been found to be associated with an increased risk of completed
suicide among adolescents.6 Adolescents with
alcohol abuse or dependence are also 6 to 12 times more likely to have a history
of physical abuse and 18 to 21 times more likely to have a history of sexual
abuse than control adolescents.13 Therefore,
the identification and documentation of these risk factors through comprehensive
assessment when children and adolescents present to EDs with acute alcohol
intoxication/self-poisoning has the potential to prevent adverse outcomes,
such as further child abuse, untreated mental health problems, and death.
There is scant evidence from this study that these assessments occur
in EDs. In addition, many of these children and adolescents do not appear
to have a follow-up plan, even when they have a history of risk factors, such
as past mental health problems, child abuse, and family history of substance
use or mental health problems, documented in their medical records.
There are several possible reasons why the recommended approach to assessment
is not followed and follow-up arrangements are not made. The majority of these
presentations occur after hours and are dealt with by emergency staff who
may not have the training or the time to comprehensively assess a child or
adolescent's mental status. In addition, an after-hours presentation is a
barrier for access to specialist child and adolescent mental health and drug
and alcohol services in Western Sydney, acutely and for follow-up, because
these services are only fully staffed and operational during business hours.
There may also be problems in linking after-hours cases with these services
the next day because of staff changes in EDs due to shift work and difficulties
contacting families once they have left the ED.
Another possible reason why mental health or drug and alcohol services
are not consulted by EDs is that some clinicians believe that children and
adolescents who present with acute alcohol intoxication/self-poisoning are
"just experimenting." In this study, most children and adolescents with acute
alcohol intoxication/self-poisoning were clinically ill enough to be brought
to EDs by emergency services and to be triaged as needing to be seen within
half an hour. In addition, 6% of children and adolescents were triaged as
needing to be seen immediately by medical staff, which implies that resuscitation
was required. Threats of self-harm and aggression were present in a small
number of the total sample, as was a history of mental health problems and
child abuse, which implies that at least a subgroup has chronic levels of
psychosocial dysfunction. Scandinavian studies have also found that while
some ED presentations with acute alcohol intoxication/self-poisoning may result
from "normal adolescent experimentation," others may also be an indicator
of psychosocial problems, attempted suicide, and/or continuing alcohol abuse
and dependence.14-15 In other
words, children and adolescents who present to EDs are the "tip of the iceberg"
of alcohol use in young people. It is likely that these children and adolescents
have other reasons for their presentation or that they have used alcohol in
a dangerous situation or dosage.
This study had several limitations. Subject identification relied on
correct ICD-9 and ICD-10
coding of the children and adolescents when they presented to the ED. Incorrect
coding may well have resulted in an underestimate of the true number of children
and adolescents with acute alcohol intoxication/self-poisoning. In addition,
the retrospective nature of this medical record review and poor documentation
in these records limited comprehensive evaluation of psychosocial functioning
and outcomes for this group of children and adolescents. This unsatisfactory
documentation in the medical records has been demonstrated previously for
children and adolescents presenting with self-harm to EDs and raises service
quality and medicolegal issues.16
In conclusion, this study provides a valuable step in collaboratively
tackling the issue of the child or adolescent who presents to the ED with
acute alcohol intoxication/self-poisoning. Clear guidelines on the assessment,
documentation, and follow-up of these children and adolescents must be established
for EDs. These need to be practical, user-friendly, and agreed on by emergency,
pediatric, and mental health professionals. They also need to be based on
current evidence-based practice guidelines to identify those children and
adolescents "at risk" of alcohol dependence, substance use disorders, and
other mental health problems.4, 12
There needs to be discussion among health professionals about the role of
child and adolescent mental health services and drug and alcohol services,
as well as referral pathways to these services. Such guidelines and referral
pathways, once implemented by EDs, then require ongoing evaluation as to whether
they improve the outcomes of this group of children and adolescents.
AUTHOR INFORMATION
Accepted for publication December 13, 2001.
This study was funded by the Centre for Mental Health and a McCaughey
Research Entry Scholarship from the Research and Education Foundation, Royal
Australasian College of Physicians, Sydney.
We thank the Centre for Mental Health; the Centre for the Prevention
of Psychological Problems in Children; the Western Sydney Area Health Service
Child and Adolescent Mental Health Forum; the staff of the emergency, mental
health, pediatric, and medical record departments of the Children's Hospital
at Westmead; Westmead Adult Hospital; Blacktown Hospital; Mount Druitt Hospital;
and Auburn Hospital, Sydney. We also thank Ken Nunn, PhD; Roz Phillips; Rob
Halliday, PhD; Elaine Ford; Ross Jamieson; Shanti Raman; the staff of the
community and mental health teams at Western Sydney Area Health Service; Declan
O'Riordan; Heather Swanston, PhD; Phil Renner, PhD; and Jennifer Peat, PhD.
| What This Study Adds
Health professionals must be able to determine when a child or adolescent
is having difficulties with alcohol abuse or dependence. The problem may come
to their attention through a presentation to an ED by a child or adolescent
with acute alcohol intoxication/self-poisoning.
This retrospective review demonstrates that when a child or adolescent
with acute alcohol intoxication/self-poisoning presents to an ED, comprehensive
assessment and follow-up are either not occurring or not being documented
in the medical record. This study is a valuable step in collaboratively tackling
this issue. Clear guidelines on the assessment, documentation, and follow-up
treatment of these children and adolescents must be established and evaluated
in EDs.
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Corresponding author and reprints: Sue Woolfenden, MBBS, MPH, FRACP,
Department of Psychological Medicine, Children's Hospital at Westmead, Locked
Bag 4001, Westmead 2145, New South Wales, Australia (e-mail: susanw{at}chw.edu.au).
From the Centre for the Prevention of Psychological Problems in Children
(Dr Woolfenden) and the Departments of Psychological Medicine (Drs Woolfenden
and Dossetor) and Paediatrics and Child Health (Dr Williams), Children's Hospital
at Westmead, University of Sydney, Sydney, Australia.
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