See also
Acute Behavioural Response: Code response
Autism and developmental disability: Management of distress/ agitation
Key points
- Management should focus on verbal and non-verbal de-escalation and emphasise the child's safety with carer involvement and existing behaviour or communication plans where appropriate
- Consider underlying neurodevelopmental diagnoses (autism, ADHD) or a history of adverse childhood experiences
- A stepwise approach should be used if pharmacological treatment is required. Physical restraint should be a last resort, only to facilitate rapidly effective pharmacological treatment
Background
The most important initial action is to reduce the distress to reduce the behaviour, and to reduce the risk of harm
Once the distress is reduced, further assessment and specific management of the underlying cause should occur
Behavioural distress can present and progress in a variety of ways. There are often many predisposing, precipitating and perpetuating factors that need to be considered in de-escalation strategies. Behavioural distress and its underlying causes are distinct in children as compared to adults
Assessment
History
- Are there any underlying neurodevelopmental conditions such as autism, ADHD, receptive or expressive language delay, intellectual disability or any mental health issues such as anxiety or depression?
- Are there supports already in place: communication tools/aides, behaviour management plans, sensory considerations? What has worked in the past?
- Is there a history of adverse childhood experiences or
psychosocial difficulties which may impact on the flight-fight-freeze response? Children may appear calm when they are actually in a frozen or dissociated phase.
- History of episode: recent health/triggers/changes, what has happened today, what has worked in the past?
- Current medications and past adverse reactions. Is there access to medications/toxins? Consider intoxication with alcohol, illicit drugs or prescribed medication
- Could the child be in pain?
Examination
- Brief assessment to exclude obvious focal neurology, acutely painful condition or evidence of a
toxidrome
- A comprehensive examination should occur once distress has been reduced
Management
| Approach to De-escalating Behavioural Disturbance
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Aims
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- Verbal and non-verbal de-escalation is first line intervention
- Treat the underlying cause
- Debrief the child/family and staff
- Involve senior staff early
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Environment |
- Private location, remove other children, visitors and staff
- A calming space: quiet room, soft/decreased lighting, eliminate triggers for agitation
- Family member presence: on case-by-case basis
- Safety: remove weapons, obstacles; be aware of exit to avoid further escalation and ensure your own safety
- One senior staff member communicates with the child and family
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Child |
- The most important initial action is to reduce the behaviour to minimise distress and any possible risk of harm
- Listen and talk simply and in a calm manner
- Respect personal space
- Check for any child alerts and familiarise yourself with the child's history (eg previous incidents of agitation, known medical, developmental or behavioural issues)
- Consider child's individual needs including language, cognitive ability or trauma history
- Consider the use, where appropriate, of:
- age-appropriate distraction techniques, familiar toys and objects
- offers of food, drink, icy-pole, or attention to physical needs
- Crisis prevention: anticipate and identify early irritable behaviour, consider past history and involve mental health expertise early for assistance if appropriate
- Offer planned 'collaborative' sedation (eg ask the child if they would take some oral medication)
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| Staff/Self |
- Introduce yourself, emphasise collaboration
- Minimise behaviours and/or interventions that the patient may find provocative
- Be interested and concerned in the child's and family member's point of view
- Calm, quiet voice; clear, concise non-judgemental language and expectations
- focus on one idea at a time
- active listening, especially regarding the patient's goals
- Provide an opportunity for child to regain control of emotions
- Set clear limits on behaviour for child and family
- Offer clear choices and negotiate realistic options, avoid 'bargaining'
- Maintain professionalism at all times; ignore insults / challenging questions
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Investigations
- Investigations may be necessary to exclude underlying cause
- Blood alcohol assessment or urine drug screen if appropriate
Code response
If
de-escalation strategies (see table below) are unsuccessful or there are any safety concerns, a
Code Response may be required with appropriate leadership and allocation of roles
Possible need for sedation
If
de-escalation strategies are unsuccessful or there are any concerns for safety, oral or intramuscular sedation may need to be considered. A stepwise approach should be taken depending on level of agitation
Consent
- Obtaining consent for any medical procedures, including giving sedation, should be sought at all times, even in unsafe situations, wherever possible
- Consent should be ideally sought from the child and/or guardians
-
Common law recognises that adolescents can give consent if they have capacity
- In an unsafe situation when the child or adolescent 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 blow)
Acute Behavioural Disturbance Management Flowchart
Medication Adverse Effects
Side-effect |
Medication association |
Management |
Respiratory depression |
Common with benzodiazepines, but also olanzapine or rapid administration of ketamine
Droperidol can potentiate respiratory depression if used with opioids or other sedative medications |
Reversible with flumazenil if caused by benzodiazepines |
Extrapyramidal reactions |
Common with droperidol but can be seen with olanzapine, risperidone and quetiapine |
Reversible with benzatropine |
Neuroleptic Malignant Syndrome |
Seen with antipsychotics |
MET/ICU
Check for elevated CK |
Paradoxical reactions |
Can be seen particularly in children with autism, developmental delay or history of escalating behaviour – benzodiazepines can result in increased agitation and anxiety |
|
Post-sedation monitoring
- Appropriate sedation monitoring should be performed in a safe environment within the clinical setting and assessing for side-effects as listed above
- Do not unnecessarily wake or irritate the child further to permit sufficient rest
- Alert child should have 30 minutely observations for 2 hours post sedation medication
- Agitated children need continuous clinical observation
- The child with a low level of consciousness should have appropriate 1:1 support and regular medical review
- Follow local hospital protocols for post-sedation monitoring
- Following medication, the child must undergo a medical and mental health assessment to guide subsequent management
Principles of possible need for restraint
- Physical restraint may need to be considered if behaviour poses an imminent risk of harm to self, others or property
- As physical restraint and sedation deprives the child of autonomy, it should only be contemplated as a last resort
- A child who is 'acting out' and who does not need acute medical or psychiatric care should be discharged from the hospital to a safe environment rather than be restrained or sedated
Documentation
Include:
- Reasons for sedation (in medical notes)
- Medications used: dose and route
- What worked? What was unsuccessful?
- As applicable, additional documentation may be required to address:
- Code Response
- Patient safety / Local risk incident reporting system
- Staff safety / OHS
-
Consent (in investigations section above)
-
Mental Health Act (in Additional notes below)
- Restraint Register (NSW)
- Staff safety / OHS
Consider consultation with local paediatric team when
- Needing assistance in determining whether acute mental health admission would be beneficial
- Ongoing care of behaviourally disturbed child is required and to ensure appropriate community follow-up
- A child may require admission for treatment of a medical problem causing behavioural disturbance, or for observation until drug toxicity has resolved
Consider transferring care when
- Behavioural disturbance is reduced, and child requires transfer to a tertiary mental health centre (to be facilitated by local mental health clinicians)
- Complications from sedation medication
- Child requires care beyond the comfort level of the hospital
For emergency advice and paediatric or neonatal ICU transfers, see Retrieval Services
Consider discharge when
- Behavioural distress has reduced or resolved
- Significant medical or psychiatric illness is excluded
- Any identified underlying cause treated
- Carers are capable of and willing to take the child home
- A clear plan for medical and/or mental health follow-up is in place
Parent information
Kids Health Info Fact Sheets (VIC):
Challenging behaviour – school aged children
Challenging behaviour – teenagers
Mental health – adolescents
NSW Children's Hospital Fact Sheets:
Disruptive Behaviours in Children – what parents should know
Additional Notes
The polyvagal theory of response
Adapted from Missimer (2020)
Guides to informed consent and the Mental Health Act
Restraint in Mental Health Acts Across Australia
Restraint in Australian and New Zealand 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
Extrapyramidal effects post Droperidol
Victoria
Mental Health Act 2014
Informed consent
Last updated September 2020