Pediatric Annals

Special Issue Article 

Approach to Children with Aggressive Behavior for General Pediatricians and Hospitalists: Part 2—Evaluation, Tests, and Treatment

Sara Haidar-Elatrache, MD, MPH, FAAP; Marlisa Wolf, MD; Noelle Andrea V. Fabie, MD; Shashi Sahai, MD

Abstract

After reviewing the various etiologies that can contribute to a presentation of aggressive behavior in a child (see part 1), a physician should conduct a thorough history and physical examination. The history should be obtained from the patient and caregivers, both together and separately in adolescents. A good physical examination starts with assessment and interpretation of vital signs, followed by a head-to-toe examination focusing on the skin, eyes, and thyroid, and then a neurologic examination. The testing and observation should be tailored to the individual patient, including laboratory results, imaging, and specialist consultation. Management of aggressive behavior can often be achieved through a combination of environmental modifications and verbal techniques, with special consideration given to children with neurodevelopmental problems such as autism. Pharmacologic agents are a good next step, and physical restraints can be used as a last resort. Evaluation of suicidality with thorough and complete questioning as well as assessment of a safety plan can aid in determining patient disposition such as need for admission to a psychiatric facility. [Pediatr Ann. 2018;47(10):e408–e412.]

Abstract

After reviewing the various etiologies that can contribute to a presentation of aggressive behavior in a child (see part 1), a physician should conduct a thorough history and physical examination. The history should be obtained from the patient and caregivers, both together and separately in adolescents. A good physical examination starts with assessment and interpretation of vital signs, followed by a head-to-toe examination focusing on the skin, eyes, and thyroid, and then a neurologic examination. The testing and observation should be tailored to the individual patient, including laboratory results, imaging, and specialist consultation. Management of aggressive behavior can often be achieved through a combination of environmental modifications and verbal techniques, with special consideration given to children with neurodevelopmental problems such as autism. Pharmacologic agents are a good next step, and physical restraints can be used as a last resort. Evaluation of suicidality with thorough and complete questioning as well as assessment of a safety plan can aid in determining patient disposition such as need for admission to a psychiatric facility. [Pediatr Ann. 2018;47(10):e408–e412.]

Pediatricians, emergency department physicians, and hospitalists are increasingly finding themselves in situations where they are evaluating children with aggressive behavior. It is important to first consider a medical organic etiology in the diagnosis of a child who presents with aggressive behavior.1 In a stable patient, the first step is taking a good history and performing a thorough physical examination.

The Interview

The interview can be divided into three parts—an interview of the patient alone if an adolescent, the family alone, and the patient and family together. This is important so that no historical details are missed and for direct observation of the caregiver–child dynamic. Interviewing the family can give the physician insight into the gravity of the patient's actions or his or her intentions that otherwise may be minimized by the patient. Similarly, the child may report incidents concerning for physical or verbal abuse, the use of illicit substances in the home, or other stressful events that the parent may neglect to mention and that the patient may feel compelled to omit in the presence of the parent. The physician should ask questions directly relevant to the patient's current presentation, including events and symptoms leading up to it. Depending on the child's age, different psychosocial stressors may be present. Family conflict is a more likely stressor in a young child, whereas a romantic break-up or peer conflict is more likely in a teenager. In addition, academics, bullying, and disciplinary or legal actions are other possible areas of stress. Pertinent medical or family history may include psychiatric diagnoses such as depression, mania, anxiety, aggression, impulsivity, psychosis, or a prior suicide attempt.2

Two additional integral questions also need to be asked, and these are about suicidality and a safety plan, as patients with aggressive behavior may also be suicidal. Physicians should ask directly about suicidality (prior attempts, current intent) regardless of the perceived seriousness of the committed act. For instance, an intentional ingestion of a small amount of medication may not cause significant clinical effects, but if the patient states he or she took it in a suicide attempt then the clinical outcome becomes a moot point.2 The National Institute of Mental Health has a useful suicide screening tool, the “Ask Suicide-Screening Questions” available online ( https://www.nimh.nih.gov/news/science-news/ask-suicide-screening-questions-asq.shtml).3

Asking what method the patient would use if they had a plan to commit suicide, and assessing for the presence of lethal weapons, medications, or drugs in the home is also of utmost importance. Not infrequently, patients (particularly adolescents) have poor judgment about the dangerousness of their act; they may state they were not thinking, that they wanted to get high, or wanted a break from their feelings. Physicians should be careful not to simply accept such explanations and should look for any signs of ambivalence. Did the patient think there was any possibility they may not wake up, or that the act may endanger his or her life? If so, would they have cared if they never woke up? Did they plan the act or was it impulsive? Did they know they would get caught or did they try to avoid discovery?2 As one can see, the question of suicidality is not answered adequately by a simple “yes or no.” One should be careful to ask all of these detailed questions so that every patient is risk-stratified appropriately, transferred to an inpatient psychiatric unit if needed, and never discharged home in the presence of suicidality, which may not be easy to identify. Last but not least, the physician should ask what the patient would do if they had suicidal thoughts: do they have access to a responsible adult who can help them, perhaps a parent, teacher, or therapist? The physician should discuss feasible options that would work should the situation arise.2

Physical Examination

Vital signs are an important first part of any examination, particularly in an agitated patient. Tachycardia may be present in anxiety but may also be one sign of a serious medical problem or perhaps a toxidrome. Waxing and waning mental status or delirium generally has an underlying medical etiology. The physician should examine the head for obvious trauma, hydrocephalus, or nuchal rigidity, and the eyes and pupils for any evidence supportive of a toxic ingestion (dilation, constriction, or conjunctival injection). The patient's skin may be dry, diaphoretic, or flushed. There may be signs of physical abuse or trauma, or markers of self-inflicted injuries such as cutting. Examination of the thyroid is important in case of nodules or goiters, as is a thorough neurologic examination to assess for any deficits. A complete physical examination also necessitates a cardiac, lung, and abdominal examination.4,5 The physician should cautiously approach a child with autism or intellectual disabilities, ensuring they are calm and prepared before starting the examination. In patients who are better at visual communication, drawing a picture or using illustrations may help. Giving the patient breaks and distracting with sensory toys and snacks may be useful as well. Parents and caregivers can guide the physician to what works best for their child.4,5

Laboratory testing is guided by the individual presentation of the child. The following text discusses the suggested tests for initial presentation of aggressive behavior in a child (Table 1).

Choice of Tests and Rationale

Table 1:

Choice of Tests and Rationale

Neuroimaging and Cerebrospinal Fluid Studies

The use of neuroimaging studies particularly, magnetic resonance imaging, in the assessment of aggressive behavior is significant. Images may be of value especially if vascular stroke or the presence of space occupying lesions, cerebritis, or focal encephalitis is suspected. Cerebrospinal fluid studies may be considered if an inflammatory process secondary to an acute infection or autoimmune disease is strongly considered.

Specialist Consults

Involvement of psychiatry and neurology specialists may be important to guide treatments of children who are aggressive. Other consultations from metabolic and genetic specialists, toxicology, and endocrinology services may be needed based on the suspected medical diagnosis.

Behavior Management

At the time of presentation, perhaps even before initiating testing, it is important to ensure patient and provider staff safety. A variety of techniques can be effective in that regard, starting with the least restrictive and coercive methods so as to avoid the use of physical restraints.4

Environmental modifications. Ensuring the safety of the patient, family, and staff is of utmost importance. Patients should undergo a person-and-belongings search and change into an examination gown. They should be placed in an area with no access to medical equipment and served meals with no metal or plastic utensils, both of which can be used to inflict harm. If possible, patients should be in areas with natural light as this may have a calming effect (this is particularly important if prolonged length of stay is anticipated). Those at risk for suicide should also have a constant trained observer at bedside. The presence of family or loved ones can also be calming, although in some cases they may worsen the patient's agitation (if so, they should be asked to temporarily leave the room).2

It is always important to consider the cognitive and social developmental level of a child before planning any intervention. For example, children with autism may exhibit aggression when faced with strange surroundings. Taking a family-centered approach in managing their aggression would be important. The family may be able to advise the team on calming strategies for their child. In addition, autistic children may benefit from tactile stimulation such as a weighted blanket, a leaded vest, or a “bean-bag” chair that may be available from vendors or child life specialists. A rocking chair or toy may also be helpful; thus, collaboration with caregivers is imperative to identify the most suitable environment for their child.2

Verbal techniques. Nonpharmacologic methods should be employed as a de-escalation strategy. Physicians and staff should get trained in verbal restraint techniques. These techniques are listed in Table 2.

List of Verbal Restraint Techniques

Table 2:

List of Verbal Restraint Techniques

Pharmacologic agents. The use of antipsychotics and benzodiazepines for agitated adults has been well studied but few children have been included in these studies and there are no high-quality pediatric trials. Nevertheless, these medications remain the most efficacious and safe for use in an acute setting. It is important to note that younger patients and those with autism may have atypical responses to benzodiazepines, becoming more agitated rather than calm. When first-generation antipsychotics are used, they should be given with diphenhydramine or benztropine to prevent an acute dystonic reaction.4 The recommended medications and their pharmacokinetic profiles are listed in Table 3. Oral medications should be offered before intramuscular injections, as children approached with an injection may become more agitated.4 Diphenhydramine is a good alternative for younger children because it has a calming anxiolytic effect and is well tolerated. For anxious adolescents presenting with agitation, a benzodiazepine such as lorazepam or lower-potency antipsychotic such as chlorpromazine may be effective, whereas a manic or psychotic patient would likely need a higher-potency antipsychotic such as haloperidol. Note that olanzapine and ziprasidone should be used with caution as the former can cause respiratory depression when combined with a benzodiazepine and the latter may be dangerous in patients with cardiac arrhythmias.4

Medications for Pediatric Chemical Restraint

Table 3:

Medications for Pediatric Chemical Restraint

Restraints. These include physical (by staff) and mechanical (cloth or leather cuffs) restraints. There is little research on restraints in pediatric patients in acute settings, so their use should be limited to preventing injury to the patient or others. They should be avoided in patients with a history of abuse or trauma and should never be employed as punishment or for staff convenience. Furthermore, restraint orders are limited by federal regulation to 1 hour in children younger than age 9 years and to 2 hours in children between ages 9 and 17 years.6 State and local regulations may have more stringent regulations. A new order for continuation of restraints is required after each period or restraint.4

After initial stabilization and testing of the agitated patient, it is important to determine the level of care needed. Referral for an inpatient psychiatric admission is necessary in the circumstances listed in Table 4.

Circumstances that Require a Referral for Inpatient Psychiatric Admission

Table 4:

Circumstances that Require a Referral for Inpatient Psychiatric Admission

Conclusion

Psychiatric emergencies as well as nonemergent behavior health problems represent a significant proportion of emergency department and acute care visits as well as hospital admissions. The shortage of community resources as well as pediatric psychiatric services makes it important for emergency physicians, hospitalists, and general pediatricians alike to take a thorough and careful approach to stabilize, diagnose, and treat a patient presenting with aggressive behavior.

The etiology of aggression includes organic causes that can stem from almost every organ system, from rare genetic disorders to relatively common seizure disorders and obstructive sleep apnea, or from primary psychologic and psychiatric causes. It is crucial to keep a broad differential diagnosis and approach every case individually when choosing laboratory tests, imaging, and consult services.

Safety comes first when initially assessing a combative or aggressive patient, and this includes removal of objects that may be used by the patient to harm himself or herself, caretakers, or members of the medical staff. De-escalation techniques should include verbal methods, which may often suffice, then pharmacological methods, and use of restraints as a last resort. If a sedative drug is necessary, the physician should treat young patients differently than teenagers or adults. Oral formulations should be offered first before intravenous or intramuscular. Patients with developmental delay, autism, or intellectual disabilities represent a unique population that requires a thoughtful approach to create a calming environment that will allow the physician to examine and treat the patient.

A thorough history needs to precede decisions on laboratory testing and disposition. Interviewing the patient and family members separately and together is ideal, with emphasis on suicidality and a safety plan. The Ask Suicide-Screening Questions is one tool available for clinicians in assessing suicide risk, and ultimately the patient's disposition and need for inpatient versus outpatient treatment. A thorough physical examination starts with assessment of vital signs that can give clues as to the cause of the patient's aggression. Laboratory testing may lead to a diagnosis relatively quickly or it may take days before the correct etiology is identified. Even with the correct diagnosis, return of the patient to their baseline mental status and nonaggressive state may take hours to months depending on the underlying cause. Family members and caregivers should be kept informed at all times about expected recovery and outcomes of organic causes of aggressive behavior.

References

  1. Haidar-Elatrache S, Wolf M, Fabie NA, Sahai S. Approach to children with aggressive behavior for general pediatricians and hospitalists: part 1—epidemiology and etiology. Pediatr Ann. 2018;47(10):e402–e407.
  2. Chun TH, Katz ER, Duffy SJ, Gerson RS. Challenges of managing pediatric mental health crises in the emergency department. Child Adolesc Psychiatr Clin N Am. 2015;24(1):21–40. doi:. doi:10.1016/j.chc.2014.09.003 [CrossRef]
  3. Horowitz LM, Bridge JA, Teach SJ, Ballard E, et al. Ask Suicide-Screening Questions (ASQ): a brief instrument for the pediatric emergency department. Arch Pediatr Adolesc Med.2012;166(12):1170–1176. doi:. doi:10.1001/archpediatrics.2012.1276 [CrossRef]
  4. Santillanes G, Gerson RS. Special considerations in the pediatric psychiatric population. Psychiatr Clin North Am. 2017;40(3):463–473. doi:. doi:10.1016/j.psc.2017.05.009 [CrossRef]
  5. Feuer V, Rocker J, Saggu BM, Andrus JM. Best practices in managing child and adolescent behavioral health emergencies. Pediatr Emerg Med Pract. 2018;15(1):1–28.
  6. Centers for Medicare & Medicaid Services (CMS), DHHS. Medicare and Medicaid programs; hospital conditions of participation: patients' rights. Final rule. Fed Regist. 2006;71(236):71377–71428.

Choice of Tests and Rationale

Test Rationale
CBC with differential May indicate underlying anemia, vitamin deficiencies, presence of infection, cytopenia
CRP and ESR Markers of inflammation for infections and autoimmune disorders like lupus and CNS vasculitis
Electrolytes May indicate renal and endocrine disorders in the presence of dyselctrolytemia and/or acidosis, may point to toxins
Liver enzymes May point to liver dysfunction
Ammonia Partial OTC deficiency and liver failure
Serum and urine copper Wilson disease
TSH Thyrotoxicosis
Urine and serum drug screens, GCMS Toxidromes, to capture a wider range of medications and toxins
Pregnancy test/hCG Increased prevalence of psychiatric disorders
Lead level Lead toxicity
CT/MRI brain Tumors, cerebritis, vasculitic changes
EEG To rule out seizures
CSF studies May be necessary if CNS infection and autoimmune diseases are under consideration
CSF studies for antibodies responsible for autoimmune encephalitis NMDA receptor encephalitis

List of Verbal Restraint Techniques

<list-item>

Introduce self

</list-item><list-item>

Prepare patient for what will happen

</list-item><list-item>

Respect patient autonomy

</list-item><list-item>

Offer food and liquids

</list-item><list-item>

Empathetic listening

</list-item><list-item>

Ask about patient requests/preferences

</list-item><list-item>

Honor reasonable requests

</list-item><list-item>

Nonpunitive limit setting

</list-item><list-item>

Simple direct language, soft voice

</list-item><list-item>

Decrease environmental stimulation

</list-item><list-item>

Allow patient to walk/move in room

</list-item><list-item>

Reassure patient that they will be safe

</list-item><list-item>

Offer distraction (eg, toy, books, movie)

</list-item><list-item>

Nonthreatening movement/posture

</list-item>

Medications for Pediatric Chemical Restraint

Medication Initial Dose Onset (minutes) Half-Life (hours)
Diphenydramine 1.25 mg/kg 20–30 (PO) 2–8
Teen: 50 mg 5–15 (IM)
Lorazepam 0.05–0.1 mg/kg 20–30 (PO) 12
Teen: 24 mg 5–15 (IM)
Midazolam 0.05–0.15 mg/kg 20–30 (PO) 3–4
Teen: 2–4 mg 5–15 (IM)
Haloperidol 0.1 mg/kg 30–60 (PO) 21
Teen: 2–4 mg 15–30 (IM)
Risperidone <12 y: 0.5 mg 45–60 (PO) 20
Teen: 1 mg
Olanzapine <12 y: 2.5 mg 45–60 (PO) 30
Teen: 5–10 mg 30–60 (IM)
Ziprasidone <12 y: 5 mg 60 (PO) 2–7
Teen: 10–20 mg 30–60 (IM)
Aripiprazole <12 y: 1–2 mg 60–180 (PO) 75
Teen: 2–5 mg 30–120 (IM)

Circumstances that Require a Referral for Inpatient Psychiatric Admission

<list-item>

Continued desire to die

</list-item><list-item>

Severe hopelessness

</list-item><list-item>

Ongoing agitation

</list-item><list-item>

Inability to engage in a discussion around safety planning

</list-item><list-item>

Inadequate support system/ability for adequate monitoring and follow up

</list-item><list-item>

High-lethality attempt or an attempt with clear expectation of death

</list-item>
Authors

Sara Haidar-Elatrache, MD, MPH, FAAP, is a Pediatric Hospitalist, Carman and Ann Adams Department of Pediatrics, Children's Hospital of Michigan; an Assistant Professor, Wayne State University School of Medicine; and an Assistant Professor, Michigan State University College of Human Medicine. Marlisa Wolf, MD, is a Pediatric Resident, Children's Hospital of Michigan. Noelle Andrea V. Fabie, MD, is a Medical Biochemical Genetics Fellow, Children's Hospital of Michigan. Shashi Sahai, MD, is a Pediatric Hospitalist, Beaumont Children's Hospital; and an Associate Professor of Pediatrics, William Beaumont Oakland University School of Medicine.

Address correspondence to Sara Haidar-Elatrache, MD, MPH, FAAP, Children's Hospital of Michigan, 3901 Beaubien Street, Detroit, MI 48201; email: shaidar@dmc.org.

Grant: N.A.V.F. reports a grant from the American College of Medical Genetics and Genomics Foundation.

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

10.3928/19382359-20180919-02

Sign up to receive

Journal E-contents