Children and adolescents are increasingly presenting to the hospital and emergency department with aggressive behavior and psychiatric emergencies. The rise in pediatric mental health problems, coupled with a lack of much needed resources, necessitates that pediatricians safely diagnose and treat patients presenting with aggressive behavior. In this article, we discuss the broad differential diagnosis that should be considered when initially evaluating a patient presenting with aggression or altered mental status; underlying causes include predisposing factors, comorbid conditions, and acute organic causes involving almost every organ system. Emergency and hospital physicians should tailor their examination and testing individually based on the patient's history and presentation. [ Pediatr Ann. 2018;47(10):e402–e407.]

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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.]