Management of Agitation and Aggression in Children and Adolescents

Regulatory Guidelines and Recommendations

The American Academy of Child and Adolescent Psychiatry states that PRN use of chemical restraints is prohibited, and JCAHO considers such use an inappropriate use of medication needing to be addressed as part of the facility's performance improvement process 1, 2, 3
The American Academy of Child and Adolescent Psychiatry recommends that risperidone is the best-evidenced medication for irritability and aggression in children and adolescents, but should be used as scheduled treatment after nonpharmacological interventions have been attempted 4, 5, 6

Risperidone reduces aggression scores by a clinically significant amount, with effects typically starting within 2 weeks, and should only be considered after addressing potential contributors to aggression through nonpharmacological means 4, 5, 6
Haloperidol has been used in pediatric populations for emergency use, though with risk of extrapyramidal symptoms and dystonic reactions 1, 7, 8
Lorazepam has been used for acute agitation, though carries risk of paradoxical rage reactions that cannot be predicted unless previously documented 1, 7, 2

Continuous monitoring by trained nursing personnel until patient is awake and ambulatory is required when medications are given emergently 1
Physician review of rationale for single versus multiple medications and drug interactions must be documented 1
Parental approval should be obtained in advance when possible 1
Oral route should be offered first before intramuscular administration 1
Monitoring for allergic reactions, paradoxical reactions, dystonias, extrapyramidal side effects, and neuroleptic malignant syndrome is essential 1, 8, 2

Benzodiazepines are not recommended for chronic anxiety in children with intellectual disabilities due to heightened sensitivity to behavioral side effects such as disinhibition 4
Droperidol raises concerns due to its amnestic effect and obligatory IM administration, which may induce trauma 1, 8
Low-potency neuroleptics have anticholinergic effects that may be contraindicated in patients with asthma or other conditions 1, 2

Nonpharmacological interventions should be implemented first, including de-escalation, environmental modifications, 1:1 staffing, and time-out settings 1, 7
If scheduled medication is needed, risperidone should be considered as standing treatment after comprehensive assessment, starting conservatively given increased sensitivity to side effects in pediatric populations 4, 5, 6
If emergency medication is required, it should be administered on a stat/emergency basis only, with preference for oral quetiapine or haloperidol depending on clinical context and prior response history 1, 7, 2