A wide variety of medical and psychiatric conditions can lead to significant agitation and aggression. Clinicians should resist the temptation to immediately ascribe agitation or aggression to psychiatric causes, even in children with a pre-existing psychiatric diagnosis.
Agitation, especially in the presence of disorientation, abnormal vital signs, or decreased level of consciousness, suggests an emergent medical cause until proven otherwise.
The first step in evaluating a child with chief complaint of sudden personality change or confusion is to rule out any potentially life-threatening process.
The first priority when approaching an agitated and/or aggressive patient is to ensure the safety of both the patient and ED staff. Potential pharmacological and non-pharmacological interventions could be used to approach the aggressive children.
The second major area in the ED approach to an agitated or withdrawn child involves assessment of psychiatric manifestations. This involves thorough history of present illness, performing mental status examination of presenting condition and review of the child’s previous level of adjustment, past psychiatric history, and family psychiatric history.
The final priority is emergency evaluation includes assessment of the family and social support system. The physician can assess the degree of parent’s level of concern and coping by the family and potential negligence.
In determining the disposition of a child psychiatric causes in ED, the physician should be guided by the severity of the problem, as well as the ability of the family to manage the child with outpatient and/or school-based supports. The medical causes usually need further stabilization in the ward or intensive care unit, depending on the acuteness of the disease.
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