dropping them off at day care Children with obsessive-compulsive disorder (OCD) can become agitated or aggressive when they are kept from carrying out a compulsion Agitation and aggression tend to escalate as the fear of the event or activity draws near and may resolve rather precipitously when the event has passed For example, the child with a school phobia may become increasingly irritable as the weekend draws to a close It may worsen to the point of trying to jump out of a moving school bus However, that same child may then appear perfectly safe and happy within 15 minutes of starting the school day Typically, children whose anxiety leads to severe irritability or aggression will have a longstanding history of anxiety symptoms, and the patient or their parents are usually able to give a clear history of precipitating events In the absence of such a history or a clear precipitating event, suspicion for an organic contribution should be raised Trauma Children and adolescents who have been victims of past or ongoing physical or sexual abuse or other severe trauma may develop acute agitation brought on by PTSD The symptoms of this disorder include fluctuating behavior with episodes of excitement, fearfulness, or irritability; recurrent nightmares or flashbacks; and lack of involvement in usual friendships or activities Children who experience posttraumatic reactions often avoid or refuse to talk about the trauma, and thus, parents may be confused about the reasons for the child’s disturbed behavior If parents are aware of the traumatic event, they may be upset or feel guilty about its occurrence Alternatively, one or more of the child’s parents may be the perpetrators of the trauma Parents and children should thus be asked about trauma separately, as part of the diagnostic assessment Children who are upset about a previous trauma may be particularly difficult to evaluate They may appear frightened, behave erratically, and be uncomfortable with discussing past events A quiet environment and gentle support from the physician may help these children express their thoughts and fears ADHD and Disruptive, Impulse Control, and Conduct Disorders Disorders including attention-deficit/hyperactivity disorder, oppositional defiant disorder, intermittent explosive disorder, and conduct disorder are discussed in greater length in Chapter 126 Behavioral and Psychiatric Emergencies Children with each of these disorders may present with out-of-control, agitated, and/or violent behavior Acute agitation or aggression that requires an ED visit often results from some consequences of the child’s difficulties at school or at home Usually their presenting symptoms fit into a long-standing pattern of similar behaviors Children with these disorders are at increased risk for substance abuse and suffering trauma-related injuries Therefore, any acute change in behaviors, especially if accompanied by any physical symptoms or abnormal vital signs, should raise suspicion of a medical contribution to the patient’s presentation Adjustment Disorders Adjustment disorder is characterized by a deterioration of functioning from a previously higher level The decline in function occurs in the presence of some precipitating event or situation that leads to significant emotional or behavioral distress or a symptomatic response in excess of what would be expected given the specific stressor At times, the precipitant may be a developmental event, such as enrollment in a new school, increased peer pressure, or the emergence of secondary sexual characteristics during puberty The precipitant also may be an acute event such as the loss of a parent through death or divorce Children with adjustment reactions can present with anxiety, depressed mood, and/or behavioral disturbances The child with an adjustment reaction is oriented and usually can explain his or her problems well, although those who present with behavioral disturbances may be quite angry and difficult to engage In order for a diagnosis of adjustment disorder to be made, the patient’s symptoms must not meet criteria for any other major psychiatric disorder The agitation and aggression of an adjustment reaction can be as dangerous and require similar intensive intervention as other psychiatric disorders As such, patients with adjustment reactions need to be screened for suicidality, homicidality, and safety to return home Autism Spectrum Disorder and Other Developmental Disabilities These disorders are discussed in greater length in Chapter 126 Behavioral and Psychiatric Emergencies Children with autism spectrum disorders (ASDs) or other developmental disabilities who present with agitation or aggression can pose a significant diagnostic and treatment challenge The range of causes of such behavior is extremely broad, and the patient’s ability to report his or her current symptoms can be severely impaired Clinicians should pay special attention to questioning caregivers about any recent changes in the patient’s life or behaviors, no matter how insignificant they may initially appear Small changes in the patient’s routine or apparently minor medical ailments such as constipation can lead to severe behavioral disturbances including self-injurious behavior Suspicion for medical causes/contributions to the patient’s presentation must be extremely high and consultation with the patient’s primary clinicians should be sought whenever available While interventions for agitated and aggressive behavior will be discussed in detail later in this chapter and in Chapter 126 Behavioral and Psychiatric Emergencies , it should be noted that special care should be taken with patients with developmental disabilities Caregivers should be consulted in order to ascertain what calming/distracting techniques have been useful for the patient in the past, and clinicians should use caution when dosing sedative medications, as patients with developmental disabilities often require smaller doses than other children and are especially sensitive to medication side effects EVALUATION AND DECISION The emergency assessment of the agitated or withdrawn child or adolescent involves three complementary areas The first is determination of whether the problematic behavior is caused by a medical condition Any potential lifethreatening effects of the identified illness must be recognized and treated Second, the psychiatric manifestations of the presenting condition, whether organic or psychiatric, are assessed Third, the family system and social support for the child are evaluated The collective investigation then allows the physician to make an appropriate decision regarding disposition and further treatment General Approach/Initial Stabilization The first priority when approaching an agitated and/or aggressive patient is to ensure the safety of both the patient and the ED staff Potential pharmacologic and nonpharmacologic interventions are discussed in Chapter 126 Behavioral and Psychiatric Emergencies Medical Conditions First, to determine whether the child’s agitation or withdrawal is organically based, the physician should bear in mind the differential diagnosis of these behaviors, including psychiatric and organic origins ( Table 13.1 ) A complete history of the acute events that led up to the ED visit, including any changes in behavior or functioning of the child, should be obtained The possibility of drug use or ingestions should be explored The child’s medical history should be documented carefully, and any previous episodes of the current behavior should be reviewed In general, organically based problems are acute in onset and are likely to result from an ingestion, an injury, or the worsening of an underlying medical condition The differentiating features of organic psychoses and psychiatric psychoses are listed in Table 13.2 TABLE 13.9 MEDICAL EVALUATION OF THE AGITATED CHILD Baseline evaluation Physical examination including neurologic examination If intoxication suspected Toxicologic screening Specific drug testing Anion/osmolar gap Blood gas If suggested by history or physical examination CBC ESR Urinalysis Electrolytes Blood glucose BUN Ammonia LFTs Pregnancy test Thyroid function tests EKG If trauma or mass lesion suspected Head CT or MRI CBC, complete blood cell count; ESR, erythrocyte sedimentation rate; BUN, blood urea nitrogen; LFTs, liver function tests; EKG, electrocardiogram; CT, computed tomography; MRI, magnetic resonance imaging The medical evaluation of agitation and aggression requires that each child who presents to the ED with these behaviors receive a complete physical examination, including full neurologic evaluation This makes it possible to detect most significant organic illnesses, including neurologic disease of traumatic, infectious, or structural origin Of note, mild incoordination, abnormalities of rapid alternating movements, and impaired tandem gait may be present in children with an attention-deficit disorder In situations in which an acute ... other children and are especially sensitive to medication side effects EVALUATION AND DECISION The emergency assessment of the agitated or withdrawn child or adolescent involves three complementary