Role of pharmacological management for acute behavioural disturbance in children
Managing a patient with acute behavioural disturbance is a detailed flowchart for managing a patient with acute behavioural disturbance.
For advice on the approach to management of acute behavioural disturbance, see here.
If the child has cognitive impairment or communication difficulties, they are more likely to have unmet needs (eg pain, hunger, thirst, toileting needs). Acute behavioural disturbance in a child can often be managed by addressing unmet needs, and by using nonpharmacological management techniques, such as environmental management (adaption), verbal de-escalation and psychological interventions, and risk mitigation.
Pharmacological management is less often required in children than in adults, as the potential risk of significant harm to self or others is lower in children. The effects of psychoactive drugs on developing brains is not without risk and it is better to avoid psychotropics in children up to 18 years of age.
When deciding upon a suitable dose regimen in children 12 years and older, consider the child’s developmental (physical) maturity—developmental maturity can vary between individuals of the same age (eg some 12 year olds are metabolically similar to young children, whereas others are similar to adults).
In a child with communication difficulties (eg suspected cognitive impairment or developmental disability), it can be difficult to distinguish behavioural disturbance related to severe acute pain from behavioural disturbance related to another cause. If unrecognised pain is thought to be a potential precipitant of distress and behavioural disturbance, a trial of analgesia is a reasonable first-line treatment rather than a sedative drug.
If nonpharmacological management techniques (eg environmental management [adaption], verbal de-escalation and psychological intervention, risk mitigation), have not adequately defused or settled the situation, consider pharmacological management with an oral sedative drug. Seek advice from a senior clinician before using sedation in a child.
A Sedation Assessment Tool (SAT) score may assist clinical decision making about whether sedation is required; however, the SAT score has not been validated for use in children. In children and people with developmental disability, if considering using the SAT score, consider the score in the context of the patient’s baseline function and communication style. Managing a patient with acute behavioural disturbance provides an example of a sedation assessment tool.
Continue nonpharmacological management techniques alongside any sedation regimen, both before and after drug administration.
The oral route of sedative drug administration is preferred for children with acute behavioural disturbance when there is low imminent risk of significant harm to the patient or others, the patient’s level of agitation and distress is not severe, and they are accepting of oral medication. The oral route is preferred over parenteral administration for children because:
- generally, children do not pose an imminent risk of significant harm
- it is the least invasive route
- it encourages engagement between the patient and staff
- it allows the patient to feel more in control.
It is rare to use parenteral sedative drugs for a child, though parenteral sedation may be necessary for a child with acute behavioural disturbance associated with substance use or a psychiatric disorder. The intramuscular route of sedative drug administration may be indicated if all of the following apply:
- there is imminent risk of significant harm to self or others
- nonpharmacological management is unsuccessful
- the patient cannot or will not take oral sedative drugs.
Intramuscular sedation for children should only be used in a setting in which staff are trained in the use of intramuscular sedation and its possible complications, and appropriate equipment and expertise to monitor the patient are available.
In community settings (especially in rural and remote areas) intramuscular sedation for children is rarely indicated outside of a life-threatening situation. If the minimum monitoring and equipment requirements are not available a senior clinician needs to make a risk assessment of the situation proportionate to the risk of the sedative drug.
The intravenous route of sedative drug administration is rarely appropriate for children. Intravenous sedation should only be considered for a child with acute severe behavioural disturbance if all of the following apply:
- oral or intramuscular therapy is not possible
- the child already has intravenous access established
- there is imminent risk of significant harm to self or others.
Intravenous sedation for children should only be used in a setting in which staff are trained in the use of intravenous sedation and its possible complications, and appropriate equipment and expertise to monitor the patient are available.
If intravenous sedation is considered appropriate, seek advice from a senior clinician. Most emergency departments and hospitals have protocols for the safe use of parenteral sedation, especially via the intravenous route—follow local protocols or consensus state guidelines where available.