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

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[Author Affiliation]Lenore Engel. Child Comprehensive Psychiatry Emergency Program ( CPEP) Team New York City Health and Human Services Corporation- Kings County Hospital Center, Brooklyn, New York.ISBN: 978-0313399497. Santa Barbara, CA: Praeger, 2012, 115 pages. Prager, 2012.Address correspondence to: Lenore Engel, MD, Child Comprehensive Psychiatry Emergency Program (CPEP) Team, New York City Health and Human Services Corporation, Kings County Hospital Center, Brooklyn, NY 11203, E-mail: lengelmd@aol.comPrager 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. …