Approach to Children with Aggressive Behavior for General Pediatricians and Hospitalists: Part 1—Epidemiology and Etiology

Abstract

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.]

The agitated pediatric patient located in the emergency department: The APPLIED observational study

“…Acute agitation is multifactorial in origin 3 – 5 . Typically, it is a reactionary response to an acute stressor resulting from a complex interplay of personal, physical, and environmental factors 3 .…”

“… 3 – 5 Typically, it is a reactionary response to an acute stressor resulting from a complex interplay of personal, physical, and environmental factors. 3 Best practice guidelines for evaluation and treatment recommend a collaborative multimodal approach involving anticipation and proactiveness on the part of the ED provider, rapid risk assessment with ongoing re‐evaluations, strategic reduction of environmental triggers, mitigation of modifiable risk factors, and proactiveness in diffusing early signs of agitation through non‐pharmacologic de‐escalation strategies followed by individualized care that addresses the specific needs of the child. 4 , 6 , 16 , 25 Early and skillful use of non‐pharmacologic de‐escalation strategies has significantly reduced the need for pharmacologic and physical restraints.…”

“…Acute agitation is a common and challenging behavioral health emergency seen in the acute care setting. 1 , 2 , 3 The agitated child or adolescent poses a significant risk to self, staff, parent(s), and others. 4 , 5 Acute agitation can result in significant care disruption, property destruction, and unnecessary resource use.…”

“…Acute agitation is a common and challenging behavioral health emergency seen in the acute care setting 1–3 . The agitated child or adolescent poses a significant risk to self, staff, parent(s), and others 4,5 .…”

Case of Treatment-Resistant Aggression in the Context of a Medically Underserved Community

“…The development of conflict resolution techniques without the use of aggression is key as a child becomes a member of society [ 1 ]. Despite this, maladaptive aggression patterns can develop if children are exposed to consistent negative stimuli such as ongoing toxic stress, inconsistent and poor parenting, peers who consistently break rules, and adverse childhood experiences (ACEs) [ 3 ]. Furthermore, aggression is a shared feature among several psychiatric conditions, especially those involving poor impulse control.…”