Aggressive Disruptive Behaviour in Children and Adolescents
General measures Medicine Treatment ICD-10 code: R45.1/R45.4-6 As with adults, agitation among children and adolescents may escalate to overt aggression and violence. However, aggression may also occur suddenly, without warning signs, particularly in children with neurodevelopmental conditions such as intellectual disability and autism spectrum disorder. All children and adolescents should be tre
ICD-10 code: R45.1/R45.4-6
As with adults, agitation among children and adolescents may escalate to overt aggression and violence. However, aggression may also occur suddenly, without warning signs, particularly in children with neurodevelopmental conditions such as intellectual disability and autism spectrum disorder. All children and adolescents should be treated respectfully and calmly, especially if seen in a busy, noisy clinic environment.
Possible causes for aggressive, disruptive behaviour include:
- Physical: epilepsy (pre-, intra-, and post-ictal), acute medical (e.g. encephalopathy, infection, metabolic disease, medication adverse effects) or surgical conditions, injuries (including traumatic brain injury).
- Neuropsychiatric: severe anxiety, distress, and/or acute or chronic traumatic stress, especially in children with neurodevelopmental disorders (which may be mild and missed clinically; See: Special considerations: Intellectual disability).
- Substance use: alcohol, cannabis, methaqualone (mandrax) intoxication or withdrawal, stimulant (cocaine, methamphetamine [tik], methcaninone [cat]) intoxication or withdrawal.
- Psychological factors: high levels of impulsivity and antagonism, hypersensitivity to rejection or insult, and poor frustration tolerance may contribute to aggression and rage.
CAUTION
- An unsafe home, school, or community environment must always be considered.
- Children who have been abused, and/or have a neurodevelopmental or other psychiatric condition may also have medical conditions, trauma, and substance misuse.
- Do not assume that aggressive behaviour is due to abuse, mental illness or psychological factors.
General Measures
- Be prepared – have in place:
- a step-wise protocol to ensure safety and protection of the child or adolescent aligned with the Children’s Act No. 38 of 2005 and the national Policy Guidelines on Child and Adolescent Mental Health (available from https://www.gov.za/documents/policy-guidelines-child-and-adolescent-mental-health).
- clear roles for all staff members. - a triage plan for children and adolescents at high risk of aggression.
- a designated calming area – suitable for regular monitoring.
- De-escalate and contain:
- Be calm, confident, kind and reassuring.
- Maintain a submissive posture with open hands; do NOT turn your back.
- Limit the number of the people attending the child, limit noise levels.
- Do NOT attempt to touch the patient unnecessarily.
- Do NOT confront, argue, or smother with kindness.
- Try and discern the child’s/adolescent’s wishes and attend to them immediately.
- Examine for delirium, medical, and other causes while calming the patient.
- Mechanical restraint:
- Only use when absolutely necessary to protect the patient and others in an acute setting for as short a period of time as possible.
- Beware of using excessive force, especially if the child/adolescent fights back.
- Type, sites, and duration of any restraints used must be documented, with 15-minute monitoring of vital signs, mental state, restraint sites, and reasons for use.
- For people managed under the MHCA, complete and submit MHCA Form 48, along with reports of any injuries or death incurred, to the Mental Health Review Board and health facility quality assurance department.
Medicine Treatment
For children < 6 years of age:
- Sedation with psychotropic agents should only be considered in extreme cases and only after consultation with a specialist.
For children ≥ 6 years of age and adolescents:
- Benzodiazepines, e.g.: (Doctor prescribed)
- Midazolam, IM, 0.1–0.15 mg/kg/dose immediately as a single dose.
- Onset of action: within 5 minutes.
If sedation with benzodiazepines is inadequate: See Hospital Paediatric STGs: SEDATION OF AN ACUTELY DISTURBED CHILD OR ADOLESCENT for further medicine management.
CAUTION
- Always consult with a doctor, preferably a psychiatrist where possible, when prescribing antipsychotic medication to children and adolescents.
- Rapid tranquillisation may cause cardiovascular collapse, respiratory depression, neuroleptic malignant syndrome (See: Neuroleptic malignant syndrome), and acute dystonic reactions (See: Extra-pyramidal side effects).
- The elderly, children, intellectually disabled, and those with comorbid medical conditions and substance use are at highest risk.
- An emergency trolley, airway, bag, oxygen and intravenous line equipment must be available.
Standard Treatment Guidelines and Essential Medicines List for South Africa Primary Healthcare Level_Chapter 16: Mental Health Conditions_NEMLC Recommendations for Medicine Amendments 2020_2023