Table 2.

Hypothetical case vignettes synthesized from several real cases of adolescents referred to PED for aggressive behavior.

Clinical vignette 1

M., a 16-year-old boy, was rushed to the hospital for extreme agitation by a social educator. He had lived in foster care placement since he was expelled from his father's house at the age of 6 for unknow reasons. M. had no prior psychiatric or somatic history. He had had a prior visit to PED a few months earlier but ran away before the clinical assessment. The psychiatric assessment revealed severe delusional and paranoid thoughts which gave rise to feelings of hostility. He was deeply convinced of being victim of an injustice in his receiving home. The routine somatic and paraclinical investigations were normal, including toxicologic evaluation. An antipsychotic treatment with sedative effect was prescribed in PED, and the patient was addressed to a psychiatric pediatric inpatient unit for continuation of care. No physical restraint was used. The probabilistic diagnostic at the discharge of the PED was an acute psychotic episode

Clinical vignette 2

L., a 14-year-old girl, was brought to emergency consultation by her parents for severe aggressive behaviors against them. She is a single girl adopted 3 years previously with her biological family still living in Colombia. She had had few psychiatric consultations at age 11 for an anger-management issue. The parents reported that over the last days L. had a resurgence of the same problematic behaviors as at age 11 (mainly irritable and touchy mood) accompanied by new symptoms (secondary enuresis, loss of interest for school and leisure, and marked social withdrawn). In the emergency room, L. is initially mute, still, huddled up. After repeated consultations, alone and with the parents, she reported a first sexual relation with ambivalent consent 2 weeks earlier. Family consultations helped L. and her parents to make sense of her behavior in a context of preexisting difficulties for sharing emotional distress. We also discussed L.'s reluctance to access ambulatory care despite several emergency consultations (about 10 during the past 2 years). As sharing her inner feeling with adults is specifically her core problem, we discussed alternative treatments (family sessions, physical therapy). The probabilistic diagnosis at the discharge of the ED was adjustment disorder with depressive symptoms in a context of prior reactive attachment disorder

Clinical vignette 3

S., a 16-year-old boy, was brought to PED by a social educator after he threatened to strangle another adult. He had been having a psychiatric follow-up since the age of seven and had received the diagnoses of attention deficit disorder, conduct disorder, post-traumatic stress disorder, and borderline intellectual functioning. He had moved into a new foster care 2 months previously with difficulties adjusting to this new environment, with in particular a history of bullying with sexual assault of other residents, both as victim and as perpetrator. He is described as becoming notably more irritable and hostile over the past few days, staying in his room alone, watching television, and avoiding any social contacts. A contract had been formalized with his consulting psychiatrist to plan a hospitalization in the weeks to come. During clinical assessment aggressive behaviors are often minimized with a tendency to place the blame on others. A phone call to his referent educator told us much about the current situation. Following S.'s temper outbursts several adults were frightened of him, avoiding interactions or minimizing educational requirements, with episodic sudden coercive reactions by threating him of being hospitalized. The patient was also not permitted to phone-call his biological family for vague reasons (in response to his behavior or for a problem of administrative authorization). In this context of escalade of retaliatory measures between the adolescent and the educative team, a very short period of separation (12 h) was helpful to gain insight on the systemic contribution of S.'s problematic behaviors and suggest calming measures. In collaborations with a broad array of partners we suggested that at the discharge of the PED, S. might be oriented to a farmhouse for a break before attending to his inpatient admission. The educators were interested to find out how they could develop more consistent educative responses to his transgressive behaviors