Episodes of acute agitation in children and adolescents can range from a state of unrest and anxiety with low frustration tolerance to a state of fear, anger, and/or pain expressed through verbal or physical aggression. An episode of agitation can pose a significant safety risk to the agitated youth, nearby patients, family members, and hospital staff. Thus identifying an episode of acute agitation at its earliest stage is desirable. There are nonpharmacological and pharmacological interventions that can be used to reduce agitation. If there is imminent risk of harm to self and/or others, and there is no less restrictive intervention available to prevent or interrupt harm, medication and/or physical restraints are indicated. This chapter discusses the assessment, management, and prevention of acute agitation in the pediatric population.

ETIOLOGY

Agitation and aggression can have biological and/or psychosocial contributors. Accordingly, a thorough clinical evaluation in the context of both a medical and social history, and treatment of identified contributing factors, is required for all agitated patients.¹

Risk factors for acute agitation include a recent history of agitation, impaired cognitive functioning/brain injury, delirium, recent psychosocial stressors and loss, substance use/withdrawal, specific medication side effects (psychotropic medications, steroids, etc.), a prior history of violence or assault as a victim and/or perpetrator, a prior history of physical restraint, acute medical illness, pain, worsening of a chronic medical condition, and various psychiatric and developmental disorders (Figure 138-1). Agitation can occur in multiple psychiatric conditions, including attention deficit hyperactivity disorder (ADHD), post-traumatic stress disorder (PTSD), bipolar disorder, autism spectrum disorders, agitated unipolar depression, impulse control disorders, disruptive behavior disorders, childhood psychosis, and developmental disorders. Agitation is not a marker for a specific diagnosis; rather, agitation manifests across multiple psychiatric disorders and is often indicative of illness severity. It is unclear whether agitation is the same across psychiatric disorders in quality, cause, and treatment response.²

Multiple studies support the characterization of two subtypes of aggression: impulsive aggression (IA) and planned aggression (PA). Epidemiological research shows differences between IA and PA in both antecedent events and developmental trajectories (IA is associated with poor peer relationships, inadequate problem-solving skills, and a history of physical abuse; PA is associated with aggressive role models who positively value violent behavior). Animal studies indicate that IA and PA are linked to different patterns of brain activation.² The orbitofrontal cortex, medial prefrontal cortex, hypothalamus, and amygdala are proposed brain systems involved in the modulation of aggression and impulsivity. Behavioral and pharmacological interventions can be effective in reducing aggressive behavior, regardless of subtype, although IA is often more amenable to pharmacological interventions.³ Much of the information presented in this chapter relates to the impulsive subtype of aggression, which is referred to as acute agitation.

Agitation consists of a psychological state (anxiety, anger, etc.) and a motoric state (excessive motor activity, restlessness, etc.). Agitation can develop through a series of stages, with each stage characterized by a certain psychological and motoric state. Initial agitation may present as anxiety, noted by an increase or change of behavior, such as rocking, crying, pacing, minimal eye contact, tense posturing, excessive worry, and ruminative fear. Anxiety may evolve into a state of defensiveness, oppositionality, verbal intimidation, and aggressive posturing. At this stage, the patient often challenges limits and authority, refuses initial attempts at redirection, makes excessive and unrealistic demands, uses inappropriate language, and begins to loose rational control. With further escalation, the agitated patient may act out through physical assaultiveness, property destruction, and self-injury.

Aggression is defined as behavior that has the potential (and often the intention) to damage an inanimate object or harm a living being.⁴ As noted above, aggression has been divided into two subtypes. IA is unplanned, overt, and often reactive aggression in which the aggressor perceives the outcome of the aggressive act as negative with negative accompanying emotions, such as guilt, regret, and fear. PA is covert, often deliberate, “predatory” or instrumental aggression in which the aggressor perceives the outcome of the aggressive act as positive, with positive accompanying emotions such as heightened interest, satisfaction, and happiness.²

Youth with aggressive behaviors require systemic diagnostic evaluation and thorough review of medical, family, social, and psychiatric history. Agitation may present in many types of central nervous system (CNS) disorders, including epilepsy (particularly temporal lobe seizures), delirium/encephalopathy, brain injury, and CNS infections and tumors. Certain endocrinologic diseases, including diabetes and hyperthyroidism, are also associated with aggressive behavior. Substance intoxication and withdrawal, and side effects of certain medications, including corticosteroids, antihistamines, benzodiazepines, antidepressants, and antipsychotics, can induce episodes of agitation. Pain can precipitate agitation in children and adolescents.⁵

As previously discussed, aggression is a common phenotype in multiple psychiatric disorders. Aggression is most frequently seen in disruptive behavior disorders, including oppositional defiant disorder (ODD), ADHD, and conduct disorder. In psychiatric disorders, aggression can occur from cognitive and perceptual disturbances, as seen in psychotic and autism spectrum disorders, and mental retardation; from affective states, witnessed in mania and mixed bipolar disorder, unipolar depression, trauma disorders, and ADHD; and from premeditated aggression to achieve an acquired goal or effect, noted in conduct disorder, narcissistic personality disorder, and antisocial personality disorder.⁵

Developmental disorders, including mental retardation and autism spectrum disorders, increase risk of agitation in youth. This increased risk is related to primary deficits in planning, impulse control, and affective regulation and secondary factors related to frequent psychiatric comorbidities and increased vulnerability to CNS insults related to metabolic, infectious, and medication side effects, and other organic and iatrogenic causes.

For all patient encounters, risk factors for acute agitation should be assessed. If multiple risk factors are identified, especially a history of violence in a similar situational or illness-related context, a preventative behavioral response plan should be devised. A behavioral response plan should identify potential triggers for agitation, effective behavioral interventions, and effects of previous medications on agitation, both effective and adverse. Figure 138-1 details a useful assessment checklist for determining agitation risk in a new patient encounter.