In this section
Acute behavioural disturbance: Acute ManagementAcute Behavioural Disturbance: Assessment and verbal de-escalation
Acute Behavioural Disturbance: Code GreyCode Grey procedure (RCH intranet)High dependency and special nursing care guideline
This aim of this guideline is to provide clinical practice tips for the inpatient management of anxiety, and agitation in young people with developmental disabilities (including autism) who may require medical or surgical care at RCH.
Studies show that children and teenagers with autism spectrum disorders (ASD) and other developmental disabilities are 10 times more likely to be admitted to hospital for medical illnesses and complaints. (Lokhandwala 2012, Leonard 2005)
Behaviour and communication difficulties act as significant barriers to these children accessing hospital care. Children with Autism with intellectual disability (ID) have a higher incidence of behavioural problems compared with children with ID without Autism (Scarpinato 2010).
These children are varied in their levels and types of developmental problems, in their psychomotor skills, communication needs and in the presentations of their behaviours and emotional distress.
Children and teenagers with autism spectrum disorder, intellectual and other developmental disabilities have the same rights of access to health care as the general population. These children and young people often have additional undiagnosed or poorly treated medical and psychiatric conditions. They should be treated with the same dignity, respect and understanding that is shown to typically
To ensure a successful inpatient experience for the patient and family, a high quality preadmission or at admission assessment is vital. At RCH, preadmission can occur in several ways, either by the allied health or nursing staff through the admitting
medical or surgical team and through consultation with the departments of Developmental Medicine, General Medicine and Mental Health.
The ultimate responsibility for collating this information (that may obtained by medical, nursing and allied health staff) rests with the resident or registrar of the admitting team. As appropriate, information must then be shared with nursing and allied health
Referrals to Educational Play Therapy (for assistance in planning procedural support) and Speech Pathology (to assess and plan for communication assistance) should be considered.
A history of the young person’s level of intellectual and physical disability (if any), their functional capacity, skills and abilities and relevant past history must be carefully taken. Information from the family and their local allied health team provides important information on the child/adolescent’s presentation and how best to manage their
communication and behaviour over their inpatient stay.
How does the individual express their needs/desires?
How does the individual say yes/no?
How does the individual express pain?
How does the individual generally comprehend communication – verbal/non-verbal/visual?
How does the individual understand new information or instructions?
How does the individual understand the passage of time?
Use of augmented communication aids such as Picture Exchange Communication System (PECS), communication book/board or communication Apps on iPad must be ascertained. Parents should be reminded to bring a child’s augmented communication system to hospital.
If a young person’s mode/method of communication is unable to be ascertained, or established assistive or augmentative communicative devices cannot be accessed, a referral should be considered to Speech Pathology for assessment and management.
Individuals who have communication impairment are at risk of interaction and behavioural difficulties due to failure in communication. Consider their capacities of comprehension and expression in what may be stressful environments and interactions.
Routines enable young people with developmental disabilities to manage their internal states of distress. They can experience significant distress upon changes to these routines. This may lead to the young person being seen as uncooperative or difficult. They might, for instance, become very anxious and disruptive when plans are changed or if they are required to wait for procedures.
Some children will develop intense interests, which they prefer to engage with most of the time and can become distressed if interrupted. Ascertain what the young person does during leisure periods, what they enjoy doing and accommodate what is possible within an acute
Sensory sensitivities to sounds, light, colours, textures, loud volume, unexpected noises, smells or and touch are common. Patients may be hyper-sensitive or hypo-sensitive to these stimuli. These may trigger agitation but knowledge of the sensitivities may help also to allow preventative measures
to be put in place. This information can be gained from their parents or community occupational therapist. If the child/adolescent is an inpatient and difficulties arise in regard to their behaviour in regard to sensory inputs, the RCH OT department can provide consultation to promote
a supportive physical and sensory environment.Past history of agitation or aggression
Enquire about past history of agitation, aggression, or self-harm, including triggers and helpful measures used in the past. Seek history of other disruptive behaviours such as head banging, screaming, rocking, flapping, hand wringing or repetitive self-stimulating vocalisations.
Find out if there is an existing behaviour management plan and obtain a copy.
Review the past history of behaviours during hospitalisations or visits to outpatient clinics, emergency departments, to the GP. This will include checking previous RCH history on the electronic medical record.
Look for variations in the behaviours between the home, school and other settings such as respite care. What strategies are used to manage at home and school? Ask which individual has the most calming influence and facilitate their involvement in helping
the young person settle into hospital.
Find out what the young person has been told about coming to hospital and their level of understanding of the same.
(The Autism Intervention Centre at the Rady Hospital San Diego USA (Schwartz N 2013))
A useful guide to the young person’s comprehension level is to ask his/her parents: “From past experience how would you let the young person know they need to get ready for any activity/procedure?”
Young people with developmental problems have a right to information about their care and treatment presented in a way that they can understand or make adequate sense. This has to be weighed against the need to avoid harm from avoidable emotional distress. Discuss
with a child’s parents/guardians their expectations regarding this communication during your admission assessment.
The young person’s Developmental Physician or General Paediatrician and nursing care manager must be contacted to get additional information and be involved in important meetings to maintain a sense of consistency and familiarity to the young person
and their carers/family.
Carers can suggest useful strategies for the individual which can include:
Psychotropic medication use in non-acute preemptive management of agitation
anxiety during hospital
visits or before procedures during an inpatient
When considering the type of medication consider the following:
It is recommended that the selected anxiolytic medication be trialled by the family at home prior to the day of the visit to hospital or by the team in the hospital prior to the day of the procedure so as to assess appropriate timing of dose and to observe for possible adverse effects. The lowest possible
therapeutic dose of the anxiolytic medication used is preferred to avoid adverse effects
For the pre-emptive management of anxiety and agitation
The lowest possible therapeutic dose of the anxiolytic medication used is preferred to avoid
0.5 mg, 1 mg
Orally disintegrating tablet:
0.125 mg, 0.25 mg, 0.5
mg, 1 m
< 10 yrs: 0.125 mg
to 0.5 mg
≥ 10 yrs: 0.5 mg to
0.5 mg, 1 mg, 2 mg Liquid:
> 13 years of age
0.02 to 0.05 mg/kg (max dose 2 mg)
0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg
≥ 5 years of age:
15 to 20 kg: 0.25 mg
≥ 20 kg: 0.5 mg
<5 years of age:
No dosing recommendations available, use with caution
Courtesy: Best Evidence Statement Cincinnatti Children’s Hospital, Pre procedural Anxiolytic Guideline 2011
Patients with developmental disabilities may require much lower or larger doses than commonly prescribed.
Emergency restraint and sedation – code grey CPG
After any acute incidence of aggression, review the incident carefully to identify potential triggers and minimise them for the future. Complete VHIMS report. Debrief staff where necessary involving the Employee Assistance Program (EAP).
Written June 2015. For review March 2018.
Authors: Chidambaram Prakash; Gabrielle Hart; Ric Haslam (RCH Mental Health)
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Acknowledgements: Prof Katrina Williams (RCH Developmental Medicine), Robyn Clark (RCH Social Work), Bernadette O’Connor (Allied Health), Lisa Vale (Occupational Therapy), Fiona Zandt and Frances Saunders (RCH Mental Health Specialist Autism Assessment
Team), Helen Codman RN and Bec McGrath RN Clinical Support Nurses Sugar Glider ward, Jess Ellis RN Clinical Support Nurse Cockatoo Ward, Stacey Richards RN Clinical Support Nurse Platypus ward and the RCH Educational Play Therapy department.