Evidence-Based Reviews

Agitation in children and adolescents: Diagnostic and treatment considerations

Author and Disclosure Information

 

References

In a retrospective case series of 30 pedi­atric patients with autism spectrum disorder who were given oxcarbazepine, Douglas et al35 found that 47% of participants experienced significant improvement in irritability/agitation. However, 23% of patients reported significant adverse effects leading to discontinuation. Insufficient evidence exists for the safety and efficacy of oxcarbazepine in this population.35

Benzodiazepines. The use of benzodiazepines in pediatric patients has been associated with paradoxical disinhibition reactions, particularly in children with autism and other developmental or cognitive disabilities or delays.21 There is a lack of data on the safety and efficacy of long-term use of benzodiazepines in children, especially in light of these patients’ developing brains, the risk of cognitive impairment, and the potential for dependence with long-term use. Despite this, some studies show that the use of benzodiazepines is fairly common among pediatric patients who present to the ED with agitation.14 In a recent retrospective study, Kendrick et al14 found that among pediatric patients with agitation who were brought to the ED, benzodiazepines were the most commonly prescribed medications.

Other medications. Clonidine and guanfacine have been used off-label to treat agitation in children and adolescents, particularly among those with ADHD or autism. Some small pediatric trials have also shown their benefit in decreasing symptoms of aggression, impulsivity, and hyper-arousal in PTSD.36 In addition to adverse effects that include but are not limited to lowered blood pressure, bradycardia, and risk of atrioventricular block, clinicians need to be vigilant for potentially serious rebound hypertension that may occur if doses of these medications are missed; this risk is greater with clonidine.

Diphenhydramine, in both oral and IM forms, has been used to treat agitation in children,32 but has also been associated with a paradoxical disinhibition reaction in pediatric patients21 and therefore should be used only sparingly and with caution. Diphenhydramine has anticholinergic properties, and may worsen delirium.15 Stimulant medications can help aggressive behavior in children and adolescents with ADHD.37

Bottom Line

Agitation among children and adolescents has many possible causes. A combination of a comprehensive assessment and evidence-based, judicious treatment interventions can help prevent and manage agitation in this vulnerable population.

Related Resources

  • Baker M, Carlson GA. What do we really know about PRN use in agitated children with mental health conditions: a clinical review. Evid Based Ment Health. 2018;21(4):166-170.
  • Gerson R, Malas N, Mroczkowski MM. Crisis in the emergency department: the evaluation and management of acute agitation in children and adolescents. Child Adolesc Psychiatr Clin N Am. 2018;27(3):367-386.

Drug Brand Names

Amantadine • Symmetrel
Aripiprazole • Abilify
Clonidine • Catapres
Guanfacine • Intuniv, Tenex
Haloperidol • Haldol
Lamotrigine • Lamictal
Levetiracetam • Keppra, Spritam
Olanzapine • Zyprexa
Oxcarbazepine • Trileptal
Quetiapine • Seroquel
Topiramate • Topamax
Risperidone • Risperdal
Valproate • Depakene
Ziprasidone • Geodon

Pages

Recommended Reading

Malpractice: Diagnostic errors top allegation involving children
MDedge Psychiatry
Neurodevelopmental concerns may emerge later in Zika-exposed infants
MDedge Psychiatry
Early childhood infections tied to psychosis risk
MDedge Psychiatry
Comorbid depression worsens many pediatric hospital outcomes
MDedge Psychiatry
Youth suicide: Rates rising more rapidly in girls
MDedge Psychiatry
The effects persist for children who witnessed 9/11
MDedge Psychiatry
Risk of suicide attempt is higher in children of opioid users
MDedge Psychiatry
Team sports may mitigate tough childhoods
MDedge Psychiatry
Pediatric lung disease plus nighttime screen time impact sleep quality
MDedge Psychiatry
Weight-based teasing may mean further weight gain in children
MDedge Psychiatry