Paeds · mental-behavioural-and-psychosomatic
Acute behavioural disturbance and agitation
Also known as Acute behavioural disturbance · Acute agitation · Behavioural emergency · Paediatric agitation management · Rapid tranquillisation in young people · Least-restrictive behavioural management
A fellowship approach to the acutely behaviourally disturbed or agitated child and adolescent: secure the environment and call help early, apply verbal de-escalation as first-line treatment, climb a stepped least-restrictive ladder from de-escalation to oral then parenteral medication to physical restraint as a last resort, exclude organic causes before and after sedation, and minimise and recover from restraint — grounded in the BETA consensus and the PEAChY trials across ANZ, UK, US and Canada.
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Target exams
Red flags
- Imminent risk of serious harm to self, others or the environment — a behavioural emergency, not a waiting-room problem
- Agitated delirium with hyperthermia, sweating or rigidity — excited delirium is a physiological emergency
- Suspicion of an organic cause (hypoglycaemia, hypoxia, sepsis, head injury, post-ictal) driving the agitation
- Respiratory depression, airway compromise or over-sedation after parenteral medication
- Prolonged physical restraint, especially prone or with pressure on the neck — asphyxia risk
- Intoxication with stimulants or alcohol driving both the agitation and the medical risk
Life stages
Care settings
Clinical exam formats
Board mappings
- General and Community Paediatrics
- Emergency presentations: acute behavioural disturbance and agitation — safety, de-escalation and the least-restrictive ladder
- Current 2026 PREP curriculum — Learning Objective 1.2.1: Communicate with a child or young person in a way which is appropriate to the position of that child within their own culture
- Renewed curriculum for first-year trainees from 2027 — Learning goal 15: Essential general paediatrics
- Acute behavioural disturbance and agitation — stepped least-restrictive management
- Clinical Applications
- Behavioural emergencies: acute behavioural disturbance and agitation
- Long Cases
- Short Cases
- Communication stations
- 8. Safeguarding and social paediatrics
- 11. Adolescent health
- 10. Mental health and behavioural problems
- General Paediatrics: Manages acute behavioural disturbance using de-escalation and the least-restrictive ladder, excludes organic causes, and minimises restraint
- Foundation of Practice (FOP)
- Applied Knowledge in Practice (AKP)
- Mental health, safeguarding and emergency behavioural management
- Communication
- History
- Clinical
- Development
- General Pediatrics Content Outline — Domain 6: Behavioral and Mental Health
- General Pediatrics Content Outline — Domain 9: Emergency Medicine
- General Pediatrics EPA 3: Assessing and managing mental health concerns including acute behavioural emergencies
- Patient Care 5: Patient Management
- Interpersonal and Communication Skills 1: Patient- and Family-Centered Communication
- Systems-Based Practice 3: System Navigation for Patient Centered Care - Coordination of Care
- Professionalism 1: Professional Behavior and Ethical Principles
- Communicator
- Collaborator
- Leader
- Pediatrics: Foundations EPA — Managing acute behavioural disturbance and agitation in children and adolescents using de-escalation and least-restrictive care
Overview & Definition
A 14-year-old in the emergency department waiting room is pacing, shouting, and squaring up to security. A nine-year-old with autism has flown into distress in a noisy cubicle and is hitting out at anyone who comes near. A 16-year-old brought in intoxicated is kicking the cubicle wall and threatening staff. These are everyday behavioural emergencies, and the skill they test is acute behavioural disturbance and agitation management. [1] [3]
Acute behavioural disturbance is a state of severe psychomotor agitation, distress or uncontained behaviour that places the child or those around them at immediate risk. It is not a diagnosis. It is a signal that arousal has outrun the child's capacity to regulate it, and that something — psychiatric, organic, toxicological, neurodevelopmental or environmental — has pushed them past their threshold. [1] [4]
The episode becomes a behavioural emergency when the risk of imminent harm to the child, to others, or to the environment is real and uncontained. At that point the task is to reduce danger first and understand the cause second, while never forgetting that the cause will decide the definitive treatment. [2] [11]
Two principles govern everything that follows. The first is the least-restrictive principle: you intervene with the least force and the least medication that will restore safety, escalating one rung at a time only when the rung below has genuinely failed. The second is cause-seeking: sedation is not assessment, and a settled child still needs glucose checked, intoxication considered, and the underlying driver identified. [1] [3]
References14ShowHide
- [1]Gerson R Best Practices for Evaluation and Treatment of Agitated Children and Adolescents (BETA) in the Emergency Department: Consensus Statement of the American Association for Emergency Psychiatry. West J Emerg Med, 2019.PMID 30881565
- [2]Hoffmann JA Pharmacologic Management of Acute Agitation in Youth in the Emergency Department. Pediatr Emerg Care, 2021.PMID 34397677
- [3]Foster AA Approach to acute agitation in the pediatric emergency department. Curr Opin Pediatr, 2024.PMID 38299972
- [4]Mills KP Pharmacotherapy considerations for pediatric acute agitation management in the emergency department. Am J Health Syst Pharm, 2024.PMID 39008306
- [5]Bourke EM Pharmacological emergency management of agitation in children and young people: protocol for a randomised controlled trial of oral medication (PEAChY-O). BMJ Open, 2023.PMID 36997250
- [6]Bourke EM Pharmacological Emergency management of Agitation in Children and Young people: protocol for a randomised controlled trial of intraMuscular medication (PEAChY-M). BMJ Open, 2023.PMID 36997241
- [7]Bourke EM PEAChY-O: Pharmacological Emergency Management of Agitation in Children and Young People: A Randomized Controlled Trial of Oral Medication. Ann Emerg Med, 2025.PMID 39955661
- [8]Klein K Non-pharmacological de-escalation techniques used to manage acute severe behavioural disturbance in children and adolescents presenting to emergency departments: secondary analysis of a randomised controlled trial. Arch Dis Child, 2026.PMID 41015487
- [9]Perers C Methods and Strategies for Reducing Seclusion and Restraint in Child and Adolescent Psychiatric Inpatient Care. Psychiatr Q, 2022.PMID 33629229
- [10]Bourke EM Emergency mental health presentations in children with autism spectrum disorder and attention deficit hyperactivity disorder. J Paediatr Child Health, 2021.PMID 33963626
- [11]Bourke EM Acute Severe Behavioral Disturbance Requiring Parenteral Sedation in Pediatric Mental Health Presentations to Emergency Medical Services: A Retrospective Chart Review. Ann Emerg Med, 2023.PMID 37389492
- [12]Smith HAB 2022 Society of Critical Care Medicine Clinical Practice Guidelines on Prevention and Management of Pain, Agitation, Neuromuscular Blockade, and Delirium in Critically Ill Pediatric Patients With Consideration of the ICU Environment and Early Mobility. Pediatr Crit Care Med, 2022.PMID 35119438
- [13]Taylor DM Midazolam-Droperidol, Droperidol, or Olanzapine for Acute Agitation: A Randomized Clinical Trial. Ann Emerg Med, 2017.PMID 27745766
- [14]Valenkamp M Reducing seclusion and restraint during child and adolescent inpatient treatment: still an underdeveloped area of research. J Child Adolesc Psychiatr Nurs, 2014.PMID 25100241