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Acute behavioural disturbance: Acute management


  • Statewide logo

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

  • See also 

    Acute Behavioural Response: Code response
    Autism and developmental disability: Management of distress/ agitation

    Key Points

    1. 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 
    2. Consider underlying neurodevelopmental diagnoses (autism, ADHD) or a history of adverse childhood experiences
    3. 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

    Aims

    • Verbal and non-verbal de-escalation is first line intervention
    • Treat the underlying cause
    • Debrief the child/family and staff
    • Involve senior staff early

    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

    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)
    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 

    Investigations

    • Investigations may be necessary to exclude underlying cause
    • Blood alcohol assessment or urine drug screen if appropriate

    Code response 

    If de-escalation strategies 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

    Acute Behavioural Disturbance Management Flowchart

    Acute Behavioural Distress 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
      • Mental Health Act
      • 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

    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