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