Acute Behavioural Disturbance: Assessment and verbal de-escalation


  • Statewide logo

    This guideline has been adapted for statewide use with the support of the Victorian Paediatric Clinical Network

  • See also: 

    Acute behavioural disturbance: Acute Management

    Acute Behavioural Disturbance: Code Grey

    Key Points

    1. Management should emphasise the child's safety and non-pharmacological strategies in the first instance, and parental involvement where appropriate.
    2. If pharmacological treatment is required, a step-wise approach should be taken, depending upon the level of agitation.
    3. Once behaviour is controlled, a thorough history and examination are required.

    Background

    The most important initial action is to control the behaviour to reduce distress, and to reduce the risk of harm.

    Once the behaviour is controlled, further assessment and specific management of the underlying cause should occur.

    Consider

    • Intoxication with alcohol, illicit drugs or prescribed medication.
    • Pain
    • Severe anxiety
    • Underlying medical or psychiatric illness, including autism and ADHD.

    Assessment

    History

    Focus on "What has worked in the past?" and "Why has this episode occurred?"

    Past History

    • Any formal diagnosis? (Autism, ASD, psychosis, anxiety)
      • Behaviour support plans
      • Communication plans / aides
      • Sensory considerations
      • Previous episodes – what has worked in this situation before?

    Medications

    • Current medications and dose
    • What medication has been used previously in this situation, and did it work?

    Allergies

    This episode

    • What has been happening today? Any "trigger"?
    • Recent health – any intercurrent illness?
    • Collateral history from family, carers, service providers

    Social history

    • Who is responsible for the child?
      • DHS / Guardian
    • Who do they live with?
    • Any recent stressors / changes?

    Examination

    • Assess the level of agitation
    • Brief assessment (while ensuring staff and child safety at all times) for
      • Obvious focal neurology
      • Evidence of toxidrome / intoxication
      • Acutely painful condition
    • A comprehensive examination should occur once the behaviour is controlled
    • Consider assessment for weapons and/or other sources of self-harm.

    Investigations

    No investigations are required emergently.

    • A blood glucose level should be considered once the child's behaviour is controlled.
    • Breathalyser blood alcohol assessment if appropriate
    • Further investigations can then be used to exclude any possible organic causes.

    Management

    If pharmacological treatment is required, a step-wise approach should be taken, depending upon the level of agitation. See Acute behavioural disturbance: acute management.

    Verbal de-escalation requires attention to:

    Environment

    • Private location, remove other children, visitors and staff
    • 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.
    • Limit noise. One senior staff member communicates with the child and family.

    Staff / Self

    • Introduce yourself; emphasise collaboration
    • Calm, confident, non-judgemental approach
    • Be interested and concerned in the child's and family member's point of view
    • Calm, quiet voice; clear, brief sentences.
    • Focus on one idea at a time
    • Provide an opportunity for child to regain control of emotions
    • Set clear limits on behaviour for child and family.
    • Offer choices and negotiate realistic options.
    • Maintain professionalism at all times; ignore insults / challenging questions

    Child

    • Allow adequate personal space
    • Check for any child alerts and familiarise yourself with the child's history (e.g. previous incidents of agitation, known medical, developmental or behavioural issues)
    • Consider child's individual needs (i.e. based on culture, language, age, religion, gender, sexuality, physical health, cognitive abilities, trauma history and vulnerabilities)
    • Involve the child's carer/family wherever possible to provide advice and assistance in de-escalation.
    • 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.
    • Ensure any painful condition has been appropriately treated.

    Consider consultation with local paediatric team when:

    Have a low threshold for involving local mental health clinicians in the ongoing care of behaviourally disturbed children, to assist in determining whether acute psychiatric admission would be beneficial, and to ensure appropriate community follow-up.

    Some children may require medical admission for stabilisation of a medical cause for their behavioural disturbance, or for observation until resolution of drug toxicity and should be referred to the local paediatric team if this is thought to be likely.

    Consider transfer when:

    Once the behavioural disturbance is controlled, some children will require transfer to a tertiary psychiatric centre. This can be facilitated following an assessment by local mental health clinicians.

    Complications from chemical sedation -respiratory depression, hypotension, extrapyramidal reactions.

    Child requiring care beyond the comfort level of the hospital.

    For emergency advice and paediatric or neonatal ICU transfers, call the Paediatric Infant Perinatal Emergency Retrieval (PIPER) Service: 1300 137 650.

    Consider discharge when: 

    Before discharge, all children with acute behavioural disturbance should have:

    • Resolution of behavioural disturbance
    • Exclusion of significant medical or psychiatric illness
    • Treatment of any identified underlying cause
    • Carers capable of and willing to take the child home
    • A clear plan for medical and/or psychiatric follow-up.

    Information specific to RCH

    RCH intranet links

    Last updated July, 2017