CHAPTER 13 ■ AGITATED CHILD LAURA L CHAPMAN, EMILY R KATZ, ERON FRIEDLAENDER, THOMAS H CHUN, JEREMY ESPOSITO INTRODUCTION This chapter presents an approach for the diagnosis of the acutely agitated or aggressive child Additional recommendations for managing the conditions discussed here are found in Chapter 126 Behavioral and Psychiatric Emergencies DIFFERENTIAL DIAGNOSIS A wide variety of medical and psychiatric conditions can lead to significant agitation and aggression These disorders are listed in Table 13.1 and include severe psychiatric disturbances, life-threatening medical conditions, and minor aberrations in the child’s ability to respond to stressful events Medical Conditions Agitation, especially in the presence of disorientation, abnormal vital signs, or decreased level of consciousness, suggests an emergent medical cause until proven otherwise Clinicians should resist the temptation to immediately ascribe agitation or aggression to psychiatric causes, even in children with a pre-existing psychiatric diagnosis These children remain susceptible to medical illness and are at even higher risk than their peers for engaging in substance use and highrisk behaviors The first step in evaluating a child with a chief complaint of sudden personality change or confusion is to rule out any potentially lifethreatening process The history and physical examination can provide direction in differentiating medical from psychiatric illness ( Table 13.2 ) In general, medical causes of agitation have an acute onset and the patient is likely to be disoriented, particularly with regard to time and place Recent memory may be impaired If present, hallucinations may be visual, tactile, or gustatory, rather than auditory in nature (auditory hallucinations are less common) In contrast, psychiatric causes of agitation and confusion typically have a more gradual onset, often following a period of progressive social and emotional withdrawal Hallucinations with psychiatric conditions are most frequently auditory Table 13.3 lists medical conditions that can induce agitation in a child Most of these diagnoses present acutely For example, a patient with closed head trauma