Acute behavioural disturbance and agitation — formative SAQs

SAQ 1 — The least-restrictive ladder (10 marks)

A 13-year-old boy with autism is brought to the emergency department by his mother after he became distressed and aggressive at school. He is pacing, shouting and hitting the cubicle wall. His mother says he has not eaten today and the department is loud and crowded. ^{[3] [1]}

Questions

1. Outline the stepped least-restrictive ladder you would use to manage this episode, and justify why each rung comes in that order. (6 marks) ^[1]
2. Describe the verbal de-escalation skills you would apply first, and state what you would do in parallel to exclude an organic cause. (4 marks) ^[7]

Model answer

The ladder (6). The least-restrictive ladder runs from least to most restrictive: zero is safety and triage, with stimulus reduction, a single staff voice, removal of the audience, and an early call to a senior, security and the mental-health team. The first rung is verbal de-escalation, the first-line treatment of acute agitation. The second rung is offering oral medication if the child will engage — oral midazolam or oral olanzapine plus or minus diazepam, per the PEAChY-O trial. The third rung is parenteral medication if oral is refused and the danger remains uncontained. The fourth rung is physical restraint as a last resort only, team-trained, brief and continuously monitored. The order matters because each rung above de-escalation carries its own harms — over-sedation, respiratory depression, QTc prolongation, injury and retraumatisation — so you escalate one step at a time only when the step below has genuinely failed, and you justify, time-limit and document every step. ^{[1] [5]}

De-escalation and organic exclusion (4). I would respect personal space, keep a calm single voice, use short simple phrases, identify his wants and feelings, listen, set clear limits, offer realistic choices such as a quieter room, and remove the audience and reduce the noise — adapting to his autism by using his own communication aids and his mother as a familiar regulator. In parallel I would check a capillary glucose because he has not eaten, his temperature and his oxygen saturation, and take a rapid collateral history from his mother on his baseline, his triggers and whether this episode is typical or new, because a new episode in a settled child raises the possibility of an organic cause that sedation would mask. ^{[7] [3]}