Ethical and Legal Foundations of PMHNP Care (discussion)

e293

SPECIAL ISSUE ARTICLE

Andrea L. Dean, MD; and Jason V. Lambrese, MD

Treating Children and Adolescents with Aggressive Behaviors in the Inpatient Setting

ABSTRACT The mental health crisis in children and adolescents presents a unique challenge for

pediatric providers in the inpatient setting. Patients are presenting to the emergency

department in acute psychiatric crises, but the increased need for behavioral health ser-

vices is met with an already limited supply of behavioral health services and facilities. As

such, these patients are hospitalized on acute care floors, which can serve to exacerbate

symptoms of aggression regardless of cause and complicates treatment and harm pre-

vention strategies. We present a comprehensive management approach to the acutely

agitated pediatric patient with aggressive behaviors, including prevention of symptoms

in patients with risk factors; nonpharmacological approaches to de-escalation, including

the use of restraint; and common oral and parenteral psychopharmacological agents.

Such strategies are considered from a medical, ethical, and legal standpoint with the goal

of maintaining safety and minimizing harm to patients, families, and staff. [Pediatr Ann.

2024;53(8):e293–e298.]

Andrea L. Dean, MD, is an Associate Professor of Pediatrics, Division of Pediatric Hospital Medicine,

Department of Pediatrics, Baylor College of Medicine/Texas Children’s Hospital. Jason V. Lambrese, MD,

is an Assistant Professor of Psychiatry, Department of Psychiatry and Psychology, Cleveland Clinic Le-

rner College of Medicine of Case Western Reserve University.

Address correspondence to Andrea L. Dean, MD, Pediatric Hospital Medicine, Texas Children’s Hospi-

tal, 1102 Bates Street, Suite FC 1860, Houston, TX 77030; email: [email protected].

Disclaimer: This article does not contain discussion of an unapproved/investigative use of a com-

mercial product/device.

Disclosure: The authors have no relevant financial relationships to disclose.

doi:10.3928/19382359-20240605-06

Agitation in pediatric patients is a state of excitement or rest- lessness with difficulty calming.

Alternatively, aggression is character- ized by behaviors that are intended to harm another person or damage physi- cal property, including verbal threats or combative behavior. Commonly, the terms agitation and aggression are used interchangeably or are thought of as a continuum; however, given the rise of

behavioral health concerns among chil- dren and adolescents,1-4 differentiating the generalized state of agitation versus the directed nature of aggression may help to clarify management discussions.

While guidance has been published on the management of children with aggressive behaviors in the emergency department (ED),5-7 little has been pub- lished about the complexity of caring for these children in the acute care setting

to prevent distress and harm to patients, families, and staff.5,8 As such, the follow- ing review presents a comprehensive ap- proach to the aggressive child or adoles- cent in the inpatient medical setting with attention to medical, legal, and ethical principles.

IDENTIFYING THE CAUSE While agitation is a manifestation of

several medical conditions common in inpatient pediatric medicine, the pres- ence of true aggressive behavior may be more specific to certain medical and psychiatric conditions; however, the cur- rent medical literature does little to dif- ferentiate these symptoms. As such, we recommend approaching aggressive be- havior with a broad differential diagno- sis encompassing medical disease, psy- chiatric disorders, neurodevelopmental conditions, and environmental stressors (Table A). Obtaining an initial history, including a thorough review of systems, that addresses chronic as well as acute concerns, psychiatric interview with mental status examination, and physical examination will narrow the differential diagnosis and guide further evaluation.

In many hospitalized children and adolescents, the cause of acute aggres- sion will be multifactorial. For example, in patients with neurodevelopmental conditions, such as developmental de- lay or autism spectrum disorder (ASD), aggression is a maladaptive behavior in response to communication difficulties,

PEDIATRIC ANNALS • Vol. 53, No. 8, 2024

e294 Copyright © SLACK Incorporated

SPECIAL ISSUE ARTICLE

anxiety, or impulsivity.9 Such patients are more likely to manifest aggressive behavior in response to pain associated with an acute illness, the stress of a new environment, or medication side effects. Hospitalized patients could also develop delirium, which may exacerbate under- lying conditions and increase aggressive behaviors. The complexity of determin- ing the underlying etiology of aggression suggests that all patients with risk factors for aggression benefit from a generalized nonpharmacologic approach as well as pharmacological measures for symp- tomatic relief of aggression, which can be targeted when the underlying etiol- ogy is known or suspected.

DECISION TO HOSPITALIZE Patients may require inpatient hospi-

talization for further medical evaluation, treatment of disease, or prevention of harm while awaiting treatment in a psy- chiatric facility (ie, “holding”).10 Howev- er, a decision to hospitalize in the absence of medical need must consider elements of the inpatient setting that worsen agi- tation and aggressive behaviors, includ- ing monitors, bright lighting, noise from hospital staff and other patients, and safety protocols that confine patients to restricted spaces. Moreover, acute care units are often unlocked, rooms are not designed with safety features, and staff often lack behavioral health training, which increases the risk of harm to the patient or staff. Therefore, if medically appropriate, arranging safe disposition to home should be considered.

Indications for care in a locked psy- chiatric facility include risk to self, acute danger to others, psychiatric diagnoses that cause inability to communicate re- garding safety, impulsivity that limits identification of triggers, and failure of less restrictive treatment plans. The goals of inpatient psychiatric hospital- ization for safety are protection of the

patient and others during the period of acute aggression, stabilization of behav- iors through psychological and phar- macological therapy, safety planning with the family, and development of an outpatient follow-up plan. If psychiat- ric hospitalization is deemed necessary, patients with aggressive behaviors, es- pecially those with comorbidities such as ASD, may wait longer for psychiat- ric placement due to the reverse tri- age effect, where inpatient psychiatric units select lower-acuity patients for their limited beds.10 Therefore, if hold- ing becomes necessary, it is essential that the psychiatric care of patients is progressed during the acute care hospi- talization and regular reassessments of disposition take place.

NONPHARMACOLOGICAL INTERVENTIONS Environmental

Though understudied in pediatrics, evidence from dementia research may be helpful for hospitals looking to de- sign or alter clinical environments to accommodate the growing population of behavioral health patients. Sound- absorbing materials can be used to re- duce noise levels, adjustable lighting should be available, and space should be arranged to prevent crowding to re- duce sensory stimuli.11 Hospital proto- cols should aim to room patients with risk factors for agitation away from gathering spaces and should allow pro- viders to initiate a room transfer if a recurring trigger is identified for an in- dividual patient, such as a crying infant in a neighboring room. The use of mu- sic, white noise, aromatherapy, social- ization, regular physical activity, and avoidance of boredom have been found to be effective in calming hospitalized adults.11

The Behavioral Health Design Guide incorporates Joint Commission guide-

lines in the safe design of behavioral health rooms and is a helpful reference to providers looking to optimize situ- ational awareness when caring for such patients.12,13 Each provider interacting with the patient is responsible for the regular and continuous assessment of the patient’s space, including but not limited to ligature points, non-shatterproof ma- terials, unanchored fixtures, areas where the patient cannot be monitored, and the presence of obstacles between the patient and staff.

Early Recognition Recognizing early signs of agitation

and aggression is essential to prevent harm to property, the patient, and oth- ers, and to minimize use of restrictive measures. Signs of agitation include fidgeting, pacing, handwringing, in- somnia, crying, and excessive motor or verbal activity. Initial and subsequent history as well as observation of an in- dividual patient’s specific behaviors dur- ing admission should be gathered and provided to bedside staff to promote early recognition of these signs. When agitation is present, underlying causes should be addressed, nonpharmacologi- cal de-escalation techniques should be attempted, and pharmacological agents can be utilized, if necessary.

Unlike agitation, aggression is direct- ed, threatens the immediate safety of the patient and others, and may occur spon- taneously or as a progression from agita- tion. Establishing language for grading a patient’s level of aggression promotes effective communication among the health care team and efficient treatment decisions. There is no universally agreed upon acute episodes of aggression scale for clinical use in children and adoles- cents in the ED or acute care setting. A model is provided that can be adapted to suit the needs of individual providers and institutions (Figure 1). Nonpharmaco-

e295

SPECIAL ISSUE ARTICLE

logical attempts at de-escalation should occur at any level; however, once aggres- sion is identified, medications should be accessible. Medication regimens can be designed to reflect the aggression score with the goal of promoting early use of appropriate oral medication and avoid- ing injectable medications and use of restraint.

De-Escalation Techniques De-escalation is defined by The Joint

Commission as “the first line response to potential violence and aggression in the healthcare setting… to reduce risk of harm to patients and caregivers and to decrease use of restraints or seclu- sion.”14 De-escalation is not a singular event, but a continuous effort to avert harm that begins from the time a patient comes into care (Figure 2). It starts with primary prevention by maximizing en- vironmental conditions and progresses to secondary prevention, which includes avoiding triggers, effective communica- tion, distraction, and redirection. While there are several models of de-escala- tion, each emphasizes recognizing signs of agitation, verbal and nonverbal com- munication skills, giving choices and maintaining a patient’s dignity, and reas- sessment of patient’s response.15,16

All health care staff regularly inter- acting with behavioral health patients, including physicians who are respon- sible for leading the medical team, should undergo formal training in de- escalation and crisis intervention. While these trainings have not been proven to decrease harm to patients or staff, they have been shown to improve knowledge and confidence of participants.17 All health care providers expected to em- ploy de-escalation strategies must have consistent access to protective equip- ment determined by the behaviors of the individual patient, including bite-resis- tant sleeves or face shields.

Physical Restraint Behavioral restraints are any method,

material, or device that immobilizes or reduces the ability of a patient to move any part of their body freely, with the goal of preventing injury to self or oth- ers.18 This includes physical holding by staff, mechanical restraints, and se- clusion. Physical restraint poses risks of asphyxia, aspiration, blunt trauma, rhabdomyolysis, thrombosis, and death, as well as psychological trauma to both the patient and medical staff.19 There is evidence of bias in the use of restraint in hospital settings.20,21 As such, each decision to use restraint requires a care- ful consideration of ethical principles of beneficence, nonmaleficence, autonomy, and justice.

Accordingly, The Joint Commission has set forth strict regulations for the use of restraint, starting with the prem- ise that it should only be used to ensure the immediate physical safety of the pa- tient, staff members, or others, and only when alterative, less restrictive measures have been ineffective.14 When mechani- cal restraint is applied, there are strict guidelines determined by the patient’s age for timing of face-to-face evaluation, frequent documentation and re-order- ing, constant monitoring, using the least restrictive effective type of restraint, and removal of restraints as soon as the risk of immediate danger passes.14 Any pro- vider responsible for determination of

the need for physical restraint and lead- ing the medical teams caring for these patients must be highly knowledge- able of ethical principles as well as Joint Commission regulations, as well as any other relevant state laws or hospital poli- cies that are in place.

Multidisciplinary Team Involvement A multidisciplinary team should be

utilized for any child or adolescent ad- mitted with aggression. If available, psy- chiatry should be consulted early, not just for medication recommendations, but to provide brief therapy sessions, as- sist in the creation of behavioral health plans, and repeat safety and disposition assessments.22,23 Psychologists can pro- vide individual supportive psychother- apy, family education, and recommen- dations for the most appropriate type of outpatient psychotherapy. Child life spe- cialists and occupational therapists can provide developmentally appropriate play and conversation for distraction and therapeutic purposes, build schedules to promote routine, practice coping skills, and practice age-appropriate activities of daily living for patients who need this support. Social workers have training in risk assessment, individual and family therapy, and engagement with systems of care.23 Incorporating caregivers into the treatment process is crucial for long- term success and their buy-in to the plan is a necessary criterion for eventual dis-

PEDIATRIC ANNALS • Vol. 53, No. 8, 2024

Figure 1. Sample aggression scoring scale to facilitate communication among medical team members and promote early recognition and addressing of agitation and aggression.

e296 Copyright © SLACK Incorporated

SPECIAL ISSUE ARTICLE

charge. This comprehensive approach should be undertaken early in the ad- mission, with regular evaluation of the patient’s response to treatment.

PHARMACOLOGICAL INTERVENTIONS

Pharmacological interventions play a pivotal role in managing acute agita- tion and aggression. These interventions should consider the individual patient’s clinical presentation, comorbidities, and potential side effects (Table B). The on- set of action and route of delivery are key factors to consider when choosing a medication or combination of medica- tions for acute agitation (Figure 3).

In acute aggressive episodes, medi- cations should always be used concur- rently with other attempts to de-escalate a patient and in doses appropriate for calming;15 the goal of pharmacotherapy is to mitigate the patient’s symptoms enough for them to participate in their treatment plan. When medications are used out of convenience or in doses intended to sedate a patient, this is re- ferred to as chemical restraint, which is subject to legal regulations and ethical considerations, and is illegal in some states. Care should be taken to differen- tiate between therapeutic medications given on an as needed basis and chemi- cal restraints.

Alpha-2 Agonists Alpha-2 adrenoceptor agonists, in-

cluding clonidine and guanfacine, treat agitation and mild aggression by reduc- ing sympathetic hyperactivity. They are often only used orally for this indication, so the patient must be amenable to tak- ing medication.

Alpha-2 agonists are frequently used as maintenance treatment for attention- deficit/hyperactivity disorder (ADHD), and, therefore, can be used acutely for children whose agitation stems from ADHD. Maintenance doses of these medications should be continued in the hospital barring a contraindication, such as systemic hypotension or bradycardia, as stopping these medications abruptly can cause rebound hypertension as well as increased risk of agitation and impul- sivity during the hospitalization.

Antihistamines Due to their favorable safety profile,

antihistamines such as diphenhydr- amine and hydroxyzine are frequently used in children and adolescents with acute anxiety, agitation, and aggression, either alone or in combination with other medications. Hydroxyzine and diphenhydramine are available in both oral and intramuscular (IM) prepara- tions, though only diphenhydramine is available for intravenous (IV) admin-

istration. While onset of action is rapid for oral and IV dosing, IM onset is not as well established, which limits its reliability.

Side effects include QTc prolongation and delirium. Additionally, paradoxical reactions will occur in 1% to 2% of the population and present as crying, agita- tion, restlessness, inconsolability, and, sometimes, aggression. The risk is high- est in patients with developmental delay or ASD, with history of aggressive behav- ior, at extremes of age (<3 years old), and when substance use is present. The cause of paradoxical reactions is unknown but may represent disinhibition versus true paradoxical excitation resulting from a variation of metabolites in some individ- uals. Treatment is supportive and future use of antihistamines should be avoided.

If acute side effects are not present, antihistamines are safe to use on a long- term basis as a part of a patient’s treat- ment plan after discharge, including as a standing or on demand medication for anxiety, agitation, aggression, or insomnia.

Benzodiazepines While chronic use of benzodiaz-

epines poses the risk for development of tolerance and abuse, benzodiazepines are a staple in the treatment of acute agi- tation and aggression in the ED and in- patient setting. Benzodiazepines are in- dicated in alcohol withdrawal, stimulant intoxication, and neurological disease, such as encephalitis, and, therefore, are often used when the exact cause is un- determined.

Lorazepam is preferred in behavioral health situations due to its short onset of action with a relatively short half-life. Conversely, the short duration of action of midazolam does not allow concurrent use of nonpharmacological de-escalation measures during its period of effective- ness. Acutely, side effects include hypo-

Figure 2. Conceptualization of the de-escalation continuum. If a patient demonstrates progressive aggression, they will require strategies moving toward the left of the figure, but all strategies should be undertaken concurrently.

e297

SPECIAL ISSUE ARTICLE

tension and respiratory depression. Like antihistamines, paradoxical reaction can occur but is rarer (<1% of the popula- tion) and may reflect disinhibition.

Typical Antipsychotics Antipsychotic medications can be

categorized as typical (first generation) and atypical (second generation). Typi- cal antipsychotics, including haloperidol and chlorpromazine, are used for acute agitation due to their effects on the do- pamine D2 receptor; both are available orally and IM. Haloperidol is the recom- mended treatment for aggression due to psychosis, intoxication due to unknown substance, and patients with neurodevel- opmental comorbidities. IV use should be avoided due to the elevated risk of arrhythmia. Chlorpromazine is recom- mended for patients with acute psycho- sis, neurodevelopment disorders, or al- cohol/benzodiazepine intoxication.

Typical antipsychotics can cause ex- trapyramidal symptoms, including acute dystonia, akathisia, Parkinsonism, and tardive dyskinesia. Haloperidol has a higher potency at the D2 receptor and, therefore, a greater risk of extrapyra- midal symptoms. As a result, IM halo- peridol should always be administered concurrently with an anticholinergic medication (benztropine or diphenhydr- amine). Other side effects include ortho- static hypotension, QTc prolongation, and neuroleptic malignant syndrome.

Atypical Antipsychotics Atypical antipsychotics target symp-

toms like aggression, irritability, and psychosis by modulating dopamine and serotonin receptors in the brain. They can be used for acute agitation related to psychiatric disorders, neurodevel- opmental comorbidities, and intensive care unit (ICU) and post-ICU delirium. They are frequently used as maintenance medications in certain psychiatric and

neurodevelopmental disorders. This class of medications includes olanzap- ine, risperidone, quetiapine, and zipra- sidone. Both olanzapine and ziprasidone are available as short-acting IM medica- tions and can be used for acute agitation. Fast-acting oral medications include olanzapine, risperidone, and quetiapine.

Acute side effects include hypoten- sion and QTc prolongation, and long- term side effects include weight gain and metabolic syndrome. Of note, IM olanzapine must not be given within 2 hours of a parenteral benzodiazepine, as this has been associated with sudden hemodynamic collapse and death.

Adjunctive Medications Additional medications may be used

to target the underlying etiology of a patient’s aggression. For instance, pa- tients with ADHD may benefit from starting a stimulant in the hospital to address impulsivity and irritability. In addition, patients with bipolar disorder may require mood stabilizers such as lithium and valproic acid, which require frequent blood monitoring. Due to the nature of the hospital, many patients struggle with acute insomnia and ben- efit from pharmacological intervention to promote sleep and improve mood the next day; in these cases, medica- tions such as melatonin, diphenhydr- amine, or trazodone can be considered.

Many patients will be admitted to the hospital with an outpatient psy- chiatric treatment plan in place. Until psychiatry consultation is available, and barring any acute contraindications, patients should be given their home medications to avoid psychiatric de- compensation during ED or acute care hospitalizations.

Tailoring Treatment Plans Treatment plans should be individu-

alized, considering factors such as age,

comorbid conditions, and previous treatment responses. In the inpatient setting, medications must often be tri- aled and adjusted based on response, which reflects the individualized nature of aggression as a symptom. Response to medication should be reviewed and regimens should be adjusted routinely as part of de-briefing behavioral events in the acute care setting.

Combining medications from differ- ent classes can be helpful at maximizing effect while avoiding adverse effects and is often required when moderate or se- vere aggression is present. In designing medication regimens, we recommend anticipating the progression of aggres- sion from mild to severe and, therefore, ensuring each medication can be safely given in a stepwise fashion if neces- sary. Acute aggression regimens should also account for doses that will be giv- en in addition to the patient’s regular medication.

CONCLUSION The management of the aggressive

child or adolescent in the acute care set- ting presents a unique challenge given

PEDIATRIC ANNALS • Vol. 53, No. 8, 2024

Figure 3. Medications by route with (expected time to onset, expected time to peak action). These times can be considered in monitoring response and making decisions for stepwise measures or redosing.

e298 Copyright © SLACK Incorporated

SPECIAL ISSUE ARTICLE

that hospitalization itself can exacerbate the symptom. Therefore, as behavioral health admissions become more com- mon, providers and hospitals must be prepared to institute a multifaceted ap- proach that anticipates risk, avoids trig- gers, addresses early signs of agitation, and equips staff to manage dangerous or violent behavior. Nonpharmacologic and pharmacologic interventions, ad- ministered in accordance with medical, ethical, and legal principles throughout the course of a patient’s hospitalization, are essential in the prevention of harm to the patient or others.

REFERENCES 1. Whitney DG, Peterson MD. US National and

state-level prevalence of mental health disor- ders and disparities of mental health care use in children. JAMA Pediatr. 2019;173(4):389- 391. https://doi.org/10.1001/jamapediat- rics.2018.5399 PMID:30742204

2. Centers for Disease Control and Preven- tion. Youth Behavior Risk Survey: Data Sum- mary and Trends Report. https://www.cdc. gov/healthyyouth/data/yrbs/pdf/yrbs_data- summary-trends_report2023_508.pdf

3. Cutler GJ, Rodean J, Zima BT, et al. Trends in pediatric emergency department vis- its for mental health conditions and dis- position by presence of a psychiatric unit. Acad Pediatr. 2019;19(8):948-955. https://doi.org/10.1016/j.acap.2019.05.132 PMID:31175994

4. Arakelyan M, Freyleue S, Avula D, McLar- en JL, O’Malley AJ, Leyenaar JK. Pedi- atric mental health hospitalizations at acute care hospitals in the US, 2009- 2019. JAMA. 2023;329(12):1000-1011. https://doi.org/10.1001/jama.2023.1992 PMID:36976279

5. Gerson R, Malas N, Feuer V, Silver GH, Prasad R, Mroczkowski MM. Best practices for evaluation and treatment of agitated children and adolescents (BETA) in the emergency department: consensus state-

ment of the American Association for Emer- gency Psychiatry. Focus Am Psychiatr Publ. 2023;21(1):80-88. https://doi.org/10.1176/ appi.focus.23022005 PMID:37205041

6. Hoffmann JA, Pergjika A, Konicek CE, Reynolds SL. Pharmacologic management of acute agitation in youth in the emer- gency department. Pediatr Emerg Care. 2021;37(8):417-422. https://doi.org/10.1097/ PEC.0000000000002510 PMID:34397677

7. Hoffmann JA, Pergjika A, Liu L, et al. Stan- dardizing and improving care for pediatric ag- itation management in the emergency depart- ment. Pediatrics. 2023;152(1):e2022059586. https://doi.org/10.1542/peds.2022-059586 PMID:37317809

8. Malas N, Spital L, Fischer J, Kawai Y, Cruz D, Keefer P. National survey on pediatric acute agitation and behavioral escalation in academic inpatient pediatric care set- tings. Psychosomatics. 2017;58(3):299-306. https://doi.org/10.1016/j.psym.2017.01.009 PMID:28365002

9. Towbin KE. Strategies for pharmacologic treatment of high functioning autism and Asperger syndrome. Child Adolesc Psychi- atr Clin N Am. 2003;12(1):23-45. https:// doi.org/10.1016/S1056-4993(02)00049-4 PMID:12512397

10. McEnany FB, Ojugbele O, Doherty JR, McLaren JL, Leyenaar JK. Pediatric men- tal health boarding. Pediatrics. 2020;146(4). https://doi.org/10.1542/peds.2020-1174

11. Carrarini C, Russo M, Dono F, et al. Agita- tion and dementia: prevention and treat- ment strategies in acute and chronic con- ditions. Front Neurol. 2021;12:644317. https://doi.org/10.3389/fneur.2021.644317 PMID:33935943

12. The Joint Commission. R3 report: require- ment, rationale, reference. Updated Novem- ber 20, 2019. Accessed June 12, 2024. https:// www.jointcommission.org/-/media/tjc/ documents/standards/r3-reports/r3_18_sui- cide_prevention_hap_bhc_cah_11_4_19_fi- nal1.pdf

13. Hunt JM, Sine DM. Behavioral health design guide. 7.3 ed: Behavioral Health Facility Con- sulting, LC; 2018.

14. The Joint Commission. Quick safety issue 47: De-escalation in health care. January 28, 2019. Accessed June 12, 2024. https://www.joint- commission.org/resources/news-and-multi- media/newsletters/newsletters/quick-safety/

quick-safety-47-deescalation-in-health-care/ 15. Du M, Wang X, Yin S, et al. De-escalation

techniques for psychosis-induced aggres- sion or agitation. Cochrane Database Syst Rev. 2017;4(4):CD009922. https://doi. org/10.1002/14651858.CD009922.pub2 PMID:28368091

16. Price O, Baker J. Key components of de- escalation techniques: a thematic synthesis. Int J Ment Health Nurs. 2012;21(4):310- 319. https://doi.org/10.1111/j.1447- 0349.2011.00793.x PMID:22340073

17. Price O, Baker J, Bee P, Lovell K. Learning and performance outcomes of mental health staff training in de-escalation techniques for the management of violence and aggres- sion. Br J Psychiatry. 2015;206(6):447-455. https://doi.org/10.1192/bjp.bp.114.144576 PMID:26034178

18. Centers for Medicare & Medicaid Services. State Operations Manual: Appendix A—Sur- vey Protocol, Regulations and Interpretive Guidelines for Hospitals. Updated 2023. Ac- cessed June 12, 2024. https://www.cms.gov/ regulations-and-guidance/guidance/manu- als/downloads/som107ap_a_hospitals.pdf

19. Mohr WK, Petti TA, Mohr BD. Adverse ef- fects associated with physical restraint. Can J Psychiatry. 2003;48(5):330-337. https:// doi.org/10.1177/070674370304800509 PMID:12866339

20. Nash KA, Tolliver DG, Taylor RA, et al. Racial and ethnic disparities in physical restraint use for pediatric patients in the emergency de- partment. JAMA Pediatr. 2021;175(12):1283- 1285. https://doi.org/10.1001/jamapediat- rics.2021.3348 PMID:34515764

21. Foster AA, Porter JJ, Monuteaux MC, et al. Disparities in pharmacologic restraint use in pediatric emergency departments. Pediatrics. 2023;151(1):e2022056667. https://doi.org/10.1542/peds.2022-056667 PMID:36530158

22. Becker JE, Smith JR, Hazen EP. Pediatric consultation-liaison psychiatry: an update and review. Psychosomatics. 2020;61(5):467- 480. https://doi.org/10.1016/j. psym.2020.04.015 PMID:32482345

23. Gallagher KAS, Bujoreanu IS, Cheung P, et al. Psychiatric boarding in the pediatric inpatient medical setting: a retrospective analysis. Hosp Pediatr. 2017;7(8):444-450. https://doi.org/10.1542/hpeds.2017-0005 PMID:28716803

Table A Etiologies of agitation and aggressive behavior which will direct evaluation, targeted medical treatment as well as psychopharmacologic choices in some cases

Category Etiologies Examples Notes

Neuro- developmental Disorders

Developmental disorders

Developmental Delay, Autism Spectrum Disorder

Maladaptive behavior in response to communication difficulties, anxiety, or poor impulse control

Disruptive behavior disorders

Attention-Deficit/Hyperactivity Disorder, Oppositional Defiant Disorder, Conduct Disorder

Hyperactivity, impulsivity, irritability, and poor frustration tolerance can lead to aggressive outbursts

Genetic syndromes

Cri du chat, Smith-Magenis, Prader-Willi, Angelman, Fragile X

Often associated with developmental delay

Psychiatric Diagnoses

Mood disorders Major Depressive Disorder (MDD), Bipolar Disorder

• MDD can present with irritability • Mania/hypomania can present

with Irritability, impulsive decision making, grandiosity, and rapid speech, which may appear as aggressive behavior

Acute psychosis Schizophrenia, Schizoaffective Disorder Hallucinations, delusions, paranoia, and disorganization can result in aggression

Anxiety disorders

Generalized Anxiety Disorder, Panic Disorder Irritability, meltdowns, combativeness, aggression when triggered

Trauma-Related disorders

Post-Traumatic Stress Disorder, Acute Stress Disorder

Constant state of hyperarousal and hypervigilance readily triggered by acute stressors

Neurological Disorders

Encephalitis Autoimmune, infectious, paraneoplastic Psychiatric/behavioral changes can be sole/earliest manifestation, especially in anti-N- methyl-D-aspartate (NMDA) encephalitis

Seizure disorder Preitcal, ictal, postical agitation Newer literature refutes strong association of epilepsy and directed aggressive behavior

CNS injury, structural or degenerative Disease

Frontal lobe tumor or mass, traumatic brain injury, neurodegenerative diseases, CNS vasculitis

Likely with concurrent symptoms

Encephalopathy Uremic, hepatic, hypertensive, post-stroke Can persist after initial insult resolves

Intoxication and Drug Effects

Substance intoxication

Alcohol, cannabis, synthetic marijuana, cocaine, phencyclidine, ketamine, amphetamines including methamphetamine or 3,4-methylenedioxy-methamphetamine (MDMA), tryptamines (LSD)

Alterations in mood and cognition plus disinhibition contribute to unpredictable and aggressive behavior

Toxidromes Anticholinergic toxicity, serotonin syndrome, neuroleptic malignant syndrome, malignant hyperthermia, lead toxicity

Concurrent symptoms will be present

Side effects/adverse reactions

Paradoxical reactions to sedatives, high-dose corticosteroids, anabolic-androgenic steroids, psychotropic medications

Symptoms may increase with increasing dosing of medication

Substance withdrawal

Opioids, GABA-receptor agonists (alcohol and benzodiazepines), cannabinoids, alpha- agonists, baclofen

Symptoms, including aggression, can be severe and necessitate inpatient management for detoxification

Other Medical Causes

Endocrinological Hypo- or hyperglycemia, hypercalcemia, thyroid disorders, adrenal disorders

More research needed to differentiate which present with symptoms of agitation vs true aggression

Metabolic Some under- or untreated inborn errors of metabolism, electrolytes imbalances

Nutritional B12 deficiency, thiamine deficiency

Pain Gastrointestinal pain, dental caries, hypoxia, etc

Table B Preferred medications for acute aggression by etiology

Category Diagnosis Recommended Medication

Neuro- developmental

ASD/DD

• Clonidine • Chlorpromazine • Avoid antihistamines due to risk of paradoxical

reaction

ADHD • Clonidine • Risperidone

Psychiatric

Anxiety • Diphenhydramine or hydroxyzine • Lorazepam

ODD/CD • Chlorpromazine or olanzapine • +/- Lorazepam

PTSD/Trauma reaction • Clonidine • Lorazepam

Mania, Psychosis • Chlorpromazine or olanzapine • Haloperidol + diphenhydramine • +/- Lorazepam

Catatonia • Lorazepam

Drug-related

Alcohol/Benzodiazepine withdrawal

• Lorazepam • + haloperidol if hallucinating

Alcohol/Benzodiazepine intoxication

• Haloperidol • Chlorpromazine

Opiate withdrawal • Clonidine • Opiate replacement

PCP • Lorazepam

UDS is negative/unknown substance

• Lorazepam +/- haloperidol • Chlorpromazine

Neurologic Encephalitis (autoimmune)

• Lorazepam • Avoid antipsychotics (risk of worsening disease

symptoms, catatonia-like effects or NMS)

Copyright of Pediatric Annals is the property of SLACK Incorporated and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.