Here is a hypothetical situation that most child psychiatrists have encountered: You’re an attending on a child psychiatric inpatient unit. An 11-year-old boy who was admitted for suicidal ideation just had a difficult meeting with his parents and the social worker.

He wants to go home, but is not yet ready for discharge, and he’s angry about it. He marches up and down the hallway menacingly. He goes into his room and pulls the mattress off his bed and throws it around. Both you and your staff have tried to reason with him in order to de-escalate the situation, but nothing works.

What do you do? Unfortunately, there are no clear answers, since we lack good research on the best ways to calm acutely agitated children. Your approach may likely be slightly different from a colleague’s. In this month’s interview, Ruth Gerson, MD, discusses a variety of verbal de-escalation strategies in child psychiatry emergencies, and we suggest you use these when you can. (See “Practical Tips for Handling Psychiatric Emergencies in Children and Adolescents” Q&A with Ruth Gerson, MD.)

But, as with adults, children can lose behavioral control, putting themselves or others at risk, and in such cases it is our responsibility to figure out how to quickly ensure everybody’s safety—which may include the use of medications, whether voluntary or involuntary. In this article we provide you with some tips and pearls, derived from the literature and from discussions with various child psychiatrists on the front lines.

Typical Situations Requiring Sedation

Situations requiring sedation boil down to potential harm to self or to others, with agitation usually a part of the mix. Common diagnoses leading to these situations include autism spectrum disorders, conduct disorder, depression and other mood disorders, psychotic disorders, and substance abuse. The behaviors will vary depending on age and developmental level, and can include explosive temper tantrums, verbal threats, frank violence towards others or property, and agitation or restlessness.

Pre-Medication Management

We want to avoid medications if possible, and we certainly want to avoid using physical restraints. Why avoid restraints? According to one study, children, especially those with histories of abuse and neglect, perceive restraints to be aggressive and punitive, potentially leading to further mistrust of mental health providers (General Accounting Office, 1999, http://1.usa.gov/17ObU8f).

Behavioral Interventions

If talking has not worked to calm your patient down, try behavioral or environmental changes. You can deploy these in a variety of settings, whether you are working in your office, in an emergency room, on an inpatient ward, or even if you are giving phone advice to panicking parents. (See “Some Guidelines for Working with Agitated Patients” below for more tips.) Some tried and true methods include:

• Separation from the trigger. Put some space between the patient and people who may be aggravating him, such as parents or siblings, specific teachers, hospital staff whom the patient has singled out as “the problem”, or security personnel who may have brought the child in for involuntary treatment.


• Use media as a distractor. Watching a little TV, playing a video game, or listening to some music can be helpful in soothing the cycle of agitation.


• Milk and cookies. Kids like treats, which can serve as a distraction, and the bonus is that they may like you better after you offer them.


• Sports. If available, a game of foosball, ping pong, or basketball can help dissipate the negative energy.


• Relax. Asking the patient to chill out by sitting or lying down in a quiet place can be helpful.

Pharmacologic Management

You’ve tried behavioral remedies, but your 11-year-old patient is still pacing and tearing up his room. Don’t go right to physical restraints. First, see if you can convince your patient to voluntarily take a medication to calm himself down. Getting agitated kids to agree to a sedative is often not difficult, but it requires skill in the art of convincing.

Here are some techniques:

• Normalize the situation by communicating an understanding of their reaction, and saying that you’ve seen it before. For instance, “I understand that being in a hospital can make you pretty stressed out. A lot of kids I’ve seen who get this stressed tell me they feel a lot better after taking a medicine.”


• Give them a sense of control by framing the suggestion as a question. “What would you like to do to calm down? Can I give you something to help?”


• Give them some choices—usually just two is enough. “I can see you’re pretty keyed up now. I have two suggestions—either take a seat on the couch and cool down, or take this medication. Which one do you choose?” Or, if the situation is more dire and teetering toward physical restraints, say, “Here’s the deal. You have two choices. You can either take this medication or we’re going to have to put you in restraints. You decide.”

Medication Options

Although Risperdal and Abilify do have FDA indications for the management of irritability associated with autism spectrum disorders, this evidence is based on standing doses and not when used “prn” or as needed. In fact, there are no FDA-approved medications for managing acute agitation in children, so in the absence of good research you’ll probably settle on a few favorite go-to meds based mainly on your experience.

Benadryl. Benadryl (diphenhydramine), in doses from 12.5 mg to 50 mg, can be sedating and is generally safe when used prn. Potential problems with Benadryl include paradoxical excitation, in which the kid runs around like the Tasmanian devil instead of going to sleep, and its anticholinergic properties, which can lead to confusion if given at high doses too frequently. It is also unclear how much of Benadryl’s sedating effect is due to placebo, since the only double-blind, placebo-controlled study of this agent, which enrolled 21 males between 5 and 13 years old, found prn Benadryl to be no different than placebo for aggression (Vitiello B et al, J Clin Psychiatry 1991;52(12):499–501).

Antipsychotics. Thorazine has an old FDA indication for severe behavioral disorders in children aged 1–12 years and is dosed identically to Benadryl (12.5 mg to 50 mg). It’s a good sedative, though it may rarely cause significant drop in blood pressure, particularly when given as an intramuscular (IM) injection. Other child psychiatrists favor Haldol, finding that very low doses (in the range of 0.5 mg to 2.5 mg) are unlikely to cause dystonia, especially if given with some Benadryl.

Low dose quetiapine is another good choice to use for sedation, though it is more expensive, less studied for this use, and may also cause a dose-related drop in blood pressure. Zyprexa Zydis (olanzapine, at 2.5 mg to 5 mg) is popular among some psychiatrists, because it dissolves in the child’s mouth and reduces the otherwise coercive feeling of having to swallow a pill. Other antipsychotics are available in orally disintegrating tablets, such as Risperdal M-tab (risperidone). Of course, you are free to use any of a number of other antipsychotics to treat agitation. (See the “Medications Used to Sedate Children and Adolescents” below for dosing). Most psychiatrists are conservative when treating children—which means giving preference to medications that have a longer track record of safety.

Benzodiazepines. Lorazepam tends to be the most used benzodiazepine for kids, because it doesn’t have active metabolites that can accumulate and cause prolonged side effects. However, especially in younger kids (up to 14 or so), or those with developmental disorders including autism, it can cause disinhibition with aggressive and impulsive outbursts (Mancuso CE et al, Pharmacotherapy 2004;24(9):1177–1185).

Use a standing med as a prn. Many kids will already be on a medication regimen, and if so, the best strategy may be to use one of these medications as a prn. For example, if a child is taking Risperdal 1 mg twice daily, offer a single 0.5 mg dose for agitation. The advantage is that you know the patient is already tolerating the medication, and so you will likely not cause new side effects.

Injections—voluntary or involuntary. Most tranquilizing medications are available as IM injections as well as pills—and shots work twice as fast. Kids that have been in and out of the mental health system may know that shots work more quickly, and if they are motivated to calm down they may accept an injection voluntarily.

Physical restraints and involuntary medication. Once you are in a physical restraint situation, your goal is to calm your patient as quickly as possible so that you can remove the restraints, and you can accomplish this with IM medications. The typical adult cocktail of Haldol, Ativan, and Cogentin given together is often used with older teens (16 and up) and is an effective rapid sedative. With younger kids, you’ll want to be more conservative, using lower doses of meds such as Thorazine, Haldol, Ativan, or Benadryl.

General Considerations

For suicidal children and adolescents, once the acute presentation has been managed, avoid medications that could be lethal in overdose (tricyclic antidepressants, benzodiazepines, narcotics). If these medications are necessary, provide only a few days’ supply and have a responsible caregiver lock up the supply and directly provide single doses to the child.

The most common side effects of emergency psychiatric medications are respiratory depression and extrapyramidal reactions (EPS). With benzodiazepines in particular, vitals should be monitored, dosing should be limited to recommended ranges, and there should be consideration of other issues that may also affect respiratory or central nervous system (CNS) depression (illicit drugs, alcohol, opiates, apnea). EPS can be managed with Benadryl or Cogentin or by using the antipsychotics less likely to produce EPS.

Dr. Carlat’s Verdict: Avoid meds for agitation if you can—and if you must, try voluntary meds by mouth first. Physical restraints are a last resort.