12.4 Behavioral & Psychosocial Care

Abuse, Neglect, and Maltreatment Recognition

Critical care nurses are mandated reporters. Physical abuse, sexual abuse, emotional abuse, and neglect may present as the primary reason for PICU admission or as an incidental discovery during trauma, burn, ingestion, or unexplained coma workups. Your role is to stabilize physiology, document facts without bias, protect the child, and activate social work/child protection pathways — not to determine guilt at the bedside.

High-concern physical findings include bruises on the torso, ears, or neck, any bruise in a non-mobile infant (often summarized in teaching tools such as TEN-4), patterned injuries (loop marks, cigarette burns), immersion burn lines, frenulum tears in non-ambulatory infants, retinal hemorrhages in appropriate clinical context, and fractures as discussed in the musculoskeletal section. Neglect may appear as severe malnutrition, untreated medical conditions, profound diaper dermatosis, or supervisory failure leading to preventable trauma or ingestion.

Communication and documentation

Use quotation marks for caregiver statements, record exact times, and describe injuries by location, size, color, and pattern without pejorative language. If histories conflict between caregivers or change substantially, document each version. Separate the child from the alleged perpetrator when safety requires it, following hospital security and legal guidance. Sexual abuse evaluations need specialized teams (child advocacy centers) whenever possible; limit repeated interviews.

Cultural practices and osteogenesis imperfecta/bleeding disorders can mimic abuse — evaluate medically while still protecting the child if concern remains.

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Mood, Anxiety, and Suicidality in the PICU

Adolescents increasingly enter the PICU after intentional ingestion, hanging, or self-injury. Younger children may show anxiety, regression, or agitation related to delirium, pain, or trauma. Differentiate delirium (acute fluctuating attention, medical cause) from primary psychiatric disease, recognizing they can coexist.

For suicidality or intentional harm:

• Place the patient on institutional suicide precautions immediately.
• Remove ligature risks, sharps, medications at bedside, and unsecured tubing when feasible; follow continuous observation policies.
• Screen with validated tools when the child can participate; involve psychiatry/psychology early.
• Treat medical toxicologic and traumatic injuries first, but never defer safety planning.
• Engage caregivers in means restriction teaching before discharge (locked meds, firearms removed from home).

Anxiety and acute stress reactions are common in both patients and parents. Developmentally appropriate explanation, child life presence, nonpharmacologic calming, sleep protection, and judicious anxiolysis improve cooperation and reduce PTSD risk. Avoid shaming language about "attention-seeking"; self-harm is a signal of distress requiring skilled care.

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Pediatric Post-Intensive Care Syndrome (PICS-p)

PICS describes new or worsening impairments in physical, cognitive, or mental health after critical illness. In pediatrics (PICS-p), effects may include weakness, feeding regression, sleep disruption, attention problems, anxiety, depression, and post-traumatic stress. Family PICS is equally important: parents may experience PTSD, depression, complicated grief risk, and financial strain that later undermine adherence and recovery.

Prevention starts in the PICU

Evidence-informed bundles emphasize the pediatric adaptation of ICU liberation concepts:

• Minimize deep sedation when safe; target comfort and wakefulness.
• Screen for and treat delirium.
• Mobilize early with PT/OT.
• Protect sleep (cluster care, light/noise control).
• Facilitate family presence and caregiving roles.
• Provide clear daily goals communication.
• Arrange follow-up clinics and school re-entry planning before discharge when possible.

Document baseline function on admission when possible so later changes are measurable. Normalize that recovery continues for months and that seeking mental health care is part of critical illness recovery, not a failure.

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Medical Non-Adherence

Non-adherence (also called non-compliance in older literature) contributes to PICU readmissions in asthma, diabetes DKA, epilepsy, transplant rejection, and technology-dependent care. Framing the problem solely as willful defiance misses the real drivers: health literacy gaps, adolescent identity and risk-taking, depression, chaotic households, transportation and insurance barriers, distrust after prior adverse events, and regimen complexity.

Productive PICU approach

1. Stabilize the acute decompensation without humiliation.
2. Use teach-back on medications, devices, and warning signs.
3. Screen for depression, substance use, food insecurity, and housing instability.
4. Simplify regimens with the primary specialty team when possible.
5. Involve social work, case management, school nurses, and outpatient partners before discharge.
6. For adolescents, negotiate shared goals and privacy boundaries while keeping safety non-negotiable.

In transplant and diabetes populations, recurrent preventable crises should trigger a structured adherence and safety plan, sometimes including closer outpatient touchpoints or protective services if neglect is suspected. Distinguish inability (no access to insulin) from unwillingness (refusing despite access) — interventions differ, and many families experience both.

Putting behavioral care into every neuro/MSK admission

A child with meningitis, stroke, spinal fusion, or crush injury is not only a pathophysiology case. Pain, immobility, isolation from peers, and parental fear all shape recovery. Integrate child life, psychology, chaplaincy as desired, and consistent nurse communication. When maltreatment, suicidality, PICS risk, or adherence barriers are present, escalate early — these issues determine whether the physiologic save becomes a durable recovery.