Here is a hypothetical situation that most child psychiatrists have encountered: You’re an attending on a child psychiatric inpatient unit. An 11-year-old boy who was admitted for suicidal ideation just had a difficult meeting with his parents and the social worker.
He wants to go home, but is not yet ready for discharge, and he’s angry about it. He marches up and down the hallway menacingly. He goes into his room and pulls the mattress off his bed and throws it around. Both you and your staff have tried to reason with him in order to de-escalate the situation, but nothing works.
What do you do? Unfortunately, there are no clear answers, since we lack good research on the best ways to calm acutely agitated children. Your approach may likely be slightly different from a colleague’s. In this month’s interview, Ruth Gerson, MD, discusses a variety of verbal de-escalation strategies in child psychiatry emergencies, and we suggest you use these when you can. (See “Practical Tips for Handling Psychiatric Emergencies in Children and Adolescents” on p. 1.)
But, as with adults, children can lose behavioral control, putting themselves or others at risk, and in such cases it is our responsibility to figure out how to quickly ensure everybody’s safety—which may include the use of medications, whether voluntary or involuntary. In this article we provide you with some tips and pearls, derived from the literature and from discussions with various child psychiatrists on the front lines.
Typical Situations Requiring Sedation
Situations requiring sedation boil down to potential harm to self or to others, with agitation usually a part of the mix. Common diagnoses leading to these situations include autism spectrum disorders, conduct disorder, depression and other mood disorders, psychotic disorders, and substance abuse. The behaviors will vary depending on age and developmental level, and can include explosive temper tantrums, verbal threats, frank violence towards others or property, and agitation or restlessness.
We want to avoid medications if possible, and we certainly want to avoid using physical restraints. Why avoid restraints? According to one study, children, especially those with histories of abuse and neglect, perceive restraints to be aggressive and punitive, potentially leading to further mistrust of mental health providers (General Accounting Office, 1999, http://Lusa.gov/17ObU8f).
If talking has not worked to calm your patient down, try behavioral or environmental changes. You can deploy these in a variety of settings, whether you are working in your office, in an emergency room, on an inpatient ward, or even if you are giving phone advice to panicking parents. (See “Some Guidelines for Working with Agitated Patients” on p. 3 for more tips.) Some tried and true methods include:
• Separation from the trigger. Put some space between the patient and people who may be aggravating him, such as parents or siblings, specific teachers, hospital staff whom the patient has singled out as “the problem”, or security personnel who may have brought the child in for involuntary treatment.
• Use media as a distractor. Watching a little TV, playing a video game, or listening to some music can be helpful in soothing the cycle of agitation.
• Milk and cookies. Kids like treats, which can serve as a distraction, and the bonus is that they may like you better after you offer them.
• Sports. If available, a game of foos- ball, ping pong, or basketball can help dissipate the negative energy.
• Relax. Asking the patient to chill out by sitting or lying down in a quiet place can be helpful.
You’ve tried behavioral remedies, but your 11-year-old patient is still pacing and tearing up his room. Don’t go right to physical restraints. First, see if you can convince your patient to voluntarily take a medication to calm himself down. Getting agitated kids to agree to a sedative is often not difficult, but it requires skill in the art of convincing. Here are some techniques:
• Normalize the situation by communicating an understanding of their reaction, and saying that you’ve seen it before. For instance, “I understand that being in a hospital can make you pretty stressed out. A lot of kids I’ve seen who get this stressed tell me they feel a lot better after taking a medicine.”
• Give them a sense of control by framing the suggestion as a question. “What would you like to do to calm down? Can I give you something to help?”
• Give them some choices—usually just two is enough. “I can see you’re pretty keyed up now. I have two suggestions—either take a seat on the couch and cool down, or take this medication. Which one do you choose?” Or, if the situation is more dire and teetering toward physical restraints, say, “Here’s the deal. You have two choices. You can either take this medication or we’re going to have to put you in restraints. You decide.
Although Risperdal and Abilify do have FDA indications for the management of irritability associated with autism spectrum disorders, this evidence is based on standing doses and not when used “prn” or as needed. In fact, there are no FDA-approved medications for managing acute agitation in children, so in the absence of good research you’ll probably settle on a few favorite go-to meds based mainly on your experience.