Evidence-Based Reviews

Agitation in children and adolescents: Diagnostic and treatment considerations

Current Psychiatry. 2019 June;18(6):19-24,26,32

References

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2. American College of Emergency Physicians. Pediatric mental health emergencies in the emergency department. https://www.acep.org/patient-care/policy-statements/pediatric-mental-health-emergencies-in-the-emergency-medical-services-system/. Revised September 2018. Accessed February 23, 2019.
3. Voepel-Lewis, T, Burke C, Hadden S, et al. Nurses’ diagnoses and treatment decisions regarding care of the agitated child. J Perianesth Nurs. 2005;20(4):239-248.
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8. Pringsheim T, Hirsch L, Gardner D, et al. The pharmacological management of oppositional behaviour, conduct problems, and aggression in children and adolescents with attention-deficit hyperactivity disorder, oppositional defiant disorder, and conduct disorder: a systematic review and meta-analysis. Part 2: antipsychotics and traditional mood stabilizers. Can J Psychiatry. 2015;60(2):52-61.
9. Vareilles D, Bréhin C, Cortey C, et al. Hallucinations: Etiological analysis of children admitted to a pediatric emergency department. Arch Pediatr. 2017;24(5):445-452.
10. Bartlett J. Childhood-onset schizophrenia: what do we really know? Health Psychol Behav Med. 2014;2(1):735-747.
11. Diler RS, Goldstein TR, Hafeman D, et al. Distinguishing bipolar depression from unipolar depression in youth: Preliminary findings. J Child Adolesc Psychopharmacol. 2017;27(4):310-319.
12. Dervic K, Garcia-Amador M, Sudol K, et al. Bipolar I and II versus unipolar depression: clinical differences and impulsivity/aggression traits. Eur Psychiatry. 2015;30(1):106-113.
13. Masi L, Gignac M ADHD and DMDD comorbidities, similarities and distinctions. J Child Adolesc Behav2016;4:325.
14. Kendrick JG, Goldman RD, Carr RR. Pharmacologic management of agitation and aggression in a pediatric emergency department - a retrospective cohort study. J Pediatr Pharmacol Ther. 2018;23(6):455-459.
15. Schieveld JN, Staal M, Voogd L, et al. Refractory agitation as a marker for pediatric delirium in very young infants at a pediatric intensive care unit. Intensive Care Med. 2010;36(11):1982-1983.
16. Traube C, Silver G, Gerber LM, et al. Delirium and mortality in critically ill children: epidemiology and outcomes of pediatric delirium. Crit Care Med. 2017;45(5):891-898.
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35. Douglas JF, Sanders KB, Benneyworth MH, et al. Brief report: retrospective case series of oxcarbazepine for irritability/agitation symptoms in autism spectrum disorder. J Autism Dev Disord. 2013;43(5):1243-1247.
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In a retrospective case series of 30 pediatric patients with autism spectrum disorder who were given oxcarbazepine, Douglas et al³⁵ found that 47% of participants experienced significant improvement in irritability/agitation. However, 23% of patients reported significant adverse effects leading to discontinuation. Insufficient evidence exists for the safety and efficacy of oxcarbazepine in this population.³⁵

Benzodiazepines. The use of benzodiazepines in pediatric patients has been associated with paradoxical disinhibition reactions, particularly in children with autism and other developmental or cognitive disabilities or delays.²¹ There is a lack of data on the safety and efficacy of long-term use of benzodiazepines in children, especially in light of these patients’ developing brains, the risk of cognitive impairment, and the potential for dependence with long-term use. Despite this, some studies show that the use of benzodiazepines is fairly common among pediatric patients who present to the ED with agitation.¹⁴ In a recent retrospective study, Kendrick et al¹⁴ found that among pediatric patients with agitation who were brought to the ED, benzodiazepines were the most commonly prescribed medications.

Other medications. Clonidine and guanfacine have been used off-label to treat agitation in children and adolescents, particularly among those with ADHD or autism. Some small pediatric trials have also shown their benefit in decreasing symptoms of aggression, impulsivity, and hyper-arousal in PTSD.³⁶ In addition to adverse effects that include but are not limited to lowered blood pressure, bradycardia, and risk of atrioventricular block, clinicians need to be vigilant for potentially serious rebound hypertension that may occur if doses of these medications are missed; this risk is greater with clonidine.

Diphenhydramine, in both oral and IM forms, has been used to treat agitation in children,³² but has also been associated with a paradoxical disinhibition reaction in pediatric patients²¹ and therefore should be used only sparingly and with caution. Diphenhydramine has anticholinergic properties, and may worsen delirium.¹⁵Stimulant medications can help aggressive behavior in children and adolescents with ADHD.³⁷

Bottom Line

Agitation among children and adolescents has many possible causes. A combination of a comprehensive assessment and evidence-based, judicious treatment interventions can help prevent and manage agitation in this vulnerable population.

Related Resources

Baker M, Carlson GA. What do we really know about PRN use in agitated children with mental health conditions: a clinical review. Evid Based Ment Health. 2018;21(4):166-170.
Gerson R, Malas N, Mroczkowski MM. Crisis in the emergency department: the evaluation and management of acute agitation in children and adolescents. Child Adolesc Psychiatr Clin N Am. 2018;27(3):367-386.

Drug Brand Names

Amantadine • Symmetrel
Aripiprazole • Abilify
Clonidine • Catapres
Guanfacine • Intuniv, Tenex
Haloperidol • Haldol
Lamotrigine • Lamictal
Levetiracetam • Keppra, Spritam
Olanzapine • Zyprexa
Oxcarbazepine • Trileptal
Quetiapine • Seroquel
Topiramate • Topamax
Risperidone • Risperdal
Valproate • Depakene
Ziprasidone • Geodon

References

Weight-based teasing may mean further weight gain in children

Agitation in children and adolescents: Diagnostic and treatment considerations

References

Bottom Line

Related Resources

Drug Brand Names

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