See also

Autism and developmental disability: Management of distress/ agitation

Key points

1. Management should focus on verbal and non-verbal de-escalation; emphasise the child's safety and use existing behaviour or communication plans where appropriate
2. Consider if the child has an underlying neurodevelopmental condition or history of adverse childhood experiences
3. Consider and exclude organic causes including pain, encephalopathy or delirium
4. Pharmacological treatment may be required to ensure the safety of the child and staff
5. Physical restraint is a last resort, only used to facilitate rapidly effective pharmacological treatment by appropriately trained staff

Background

• Behavioural distress and its underlying causes are different in children compared to adults
• The most important initial action is to reduce the child’s distress to reduce the behaviour and risk of harm
• Once the distress has been addressed, further assessment and specific management of the underlying cause should occur
• Behavioural distress can present and progress in a variety of ways. There are many predisposing, precipitating and perpetuating factors to consider in de-escalation strategies

Assessment

History

• Previous episodes and what constructive management was used
• Underlying neurodevelopmental conditions, intellectual disability, communication barriers or any mental health concerns
• Pre-existing behaviour management plans, communication aids or sensory considerations
• History of adverse childhood experiences which may impact on the flight-fight-freeze response. Children may appear calm when in a frozen or dissociated state
• Details of the current episode eg recent health, triggers, life changes or precipitating events
• Consider if the child is in pain
• Current and previous medications and any adverse reactions
• Consider intoxication with alcohol, illicit drugs or prescribed medication

Examination

• Briefly exclude obvious focal neurology, acute pain, altered conscious state or evidence of a toxidrome
• A more comprehensive examination should occur once level of distress is reduced

Management

Investigations

Investigations are not routine but may be necessary to exclude organic causes of altered conscious state

Treatment

Providing a safe environment to calmly de-escalate a child without the use of physical restraint is the priority

Possible need for sedation

Consider oral or intramuscular sedation only if de-escalation strategies are unsuccessful or there are concerns for safety

Consent

• Obtain consent (ideally from child and/or guardians) for any medical procedures, including sedation, wherever possible
• Common law recognises that a young person can give consent if they have capacity 
• In an unsafe situation, when the child is a danger to themselves or others, no consent is necessary, but clinicians should be aware of the relevant duty of care and Mental Health Act in their jurisdiction (see Additional notes below)

After appropriate assessment, a child who does not need acute medical or psychiatric care should be discharged from the hospital to a safe environment, rather than be chemically or physically restrained

Acute behavioural disturbance medication flowchart

For use when non-pharmacological management has been ineffective 
A stepwise approach should be used if pharmacological treatment is required, but always consider child and staff safety, and whether more rapid escalation is needed

Medication Adverse Reaction Table

*Paradoxical reactions, such as increased agitation and anxiety, may occur in children with autism or developmental delay
** Do not give to child taking frequent or long-term benzodiazepines or to a child who may have taken substances associated with causing seizures. Always involve senior staff 

Post-sedation monitoring

• Monitoring should be performed in a safe environment within the clinical setting, assessing for side-effects as listed above
• Do not unnecessarily wake or irritate the child further to permit sufficient rest
• Consider using an appropriate local sedation assessment scale
• An alert child should have 30 minutely observations for 2 hours post sedation medication
• An agitated child needs continuous clinical observation and regular vital signs
• A child with altered conscious state should have 1:1 clinical support, continuous pulse oximetry and regular medical review
• Following medication, the child must undergo a medical and mental health assessment to guide subsequent management

Code response 

If de-escalation strategies (above) are unsuccessful or there are any safety concerns, a Code Response may be required with an appropriately trained team. See local guidelines

Documentation 

Include:

• Reasons for sedation
• Medications used, dose and route
• Which interventions (including non-pharmacological) were used, which were effective and which were unsuccessful
• Additional documentation may be required to address:
  • Code Response
  • Patient safety/local risk incident reporting system
  • Staff safety/OHS
  • Consent
  • Mental Health Act (see Additional notes below)
  • Restraint Register (NSW)

Defusing and debriefing

• The management of a behaviourally distressed child can be extremely difficult for staff involved
• A critical incident stress debriefing session is encouraged
• Support child and family following the event to build an ongoing therapeutic relationship and prevent future distress 

Consider consultation with local paediatric team when

• The child requires admission for treatment of a medical problem causing behavioural disturbance, or for observation until drug toxicity has resolved
• Local mental health clinicians are involved in the ongoing care of behaviourally distressed children

Consider transfer when

• The child requires a tertiary inpatient mental health facility or ongoing care (to be facilitated by local mental health clinicians)
• There are complications from sedation
• The care required is beyond the comfort level of the hospital

For emergency advice and paediatric transfers, see Retrieval Services

Consider discharge when

• Behavioural distress has reduced or resolved
• Significant medical or psychiatric illness is excluded and/or addressed
• Any identified underlying cause has been treated
• Carers are capable of and willing to take the child home; consider crisis care where required
• A clear plan for medical and/or mental health follow-up is in place

Parent information

Challenging behaviour – school aged children

Challenging behaviour – teenagers

Disruptive disorders in children. What we should know as parents

Mental health – adolescents

Additional notes

Restraint in Mental Health Acts Across Australia
Restraint in Australian and New Zealand Mental Health Acts

Interstate guides to informed consent and the Mental Health Acts:
NSW
Mental Health Act 2007 No 8
Children and Young Persons (Care and Protection) Act 1998 No 157

Queensland
About the Mental Health Act 2016 – Queensland Health
Guide to Informed Decision-making in Health Care 2nd Edition – Queensland Health

South Australia
Mental Health Act 2009

Victoria
Mental Health and Wellbeing Act 2022 Handbook
Chief Psychiatrist’s guidelines regarding restrictive intervention
Informed consent

Western Australia
WALW - Mental Health Act 2014
Chief Psychiatrist’s Guideline on the Use of Detention and Restraint in Non-Authorised Healthcare Settings, Chief Psychiatrist Government of Western Australia
Chief Psychiatrist, Government of Western Australia

Last updated December 2024