Management of Aggression in Emergency Departments is more than just PRNs

Anik Jhonsa, MD

In recent years pediatric emergency departments have seen a dramatic rise in the number of children and families presenting seeking mental health treatment.  As a child and adolescent psychiatrist primarily working in the emergency room, I’m often asked by my Emergency Medicine colleagues to develop an “agitation plan” for patients who are deemed at risk of acting out in an aggressive manner.  Most often these requests tend to focus on the PRN medication plan should a child become aggressive or upset.  However, most successful agitation plans begin well before any medication needs to be administered.

Aggressive behavior is most often a means of communicating something that an individual feels incapable of conveying in any other manner.  Whether it is a child who is retaliating after being bullied or one who has not eaten all day, the act of striking another person is a declaration of displeasure at the current situation.  Understanding the finer details of a child’s past history of aggressive behavior can feel like an arduous task in busy emergency rooms, but the benefits of doing so include reduction in the need for PRN medication, decreased episodes of restraints, and reducing barriers to vital medical care that is being provided.

The best “agitation plans” are not those that deal with aggressive behavior after they happen but those that address a child’s needs before any aggressive behavior has occurred.  Effective history taking combined with practical measures can be extremely effective in stopping aggressive behavior before they start.  Obtaining a complete history should pay special attention to past episodes of aggressive behavior as well as common triggers as these are key in building a plan of care.  For example, a child who is triggered by hunger and needs to be kept NPO to receive anesthesia for an MRI could be scheduled for the first case of the day in order to receive their scan in the morning, as opposed to being kept NPO throughout the entire day.  Communication between staff members regarding a patient’s specific needs is also very important in terms of having those needs met throughout an ER visit.  If a family tells a physician that their child does better when given a warning before anyone approaches them, that information should be passed along to nursing staff prior to their checking the patient’s vital signs.

At The Children’s Hospital of Philadelphia we have developed clinical pathways to optimize patient care from the time they arrive in the emergency room to their discharge.  These pathways primarily focus on a patient’s environment, and emphasizing effective communication and behavioral strategies for managing behaviors before discussing effective PRN usage if those avenues are not successful.  Ultimately successful management of aggressive behavior in an emergency room is a team effort relying on commitment and proactive problem solving from everyone who interacts with a patient and their family throughout their hospital stay.


The Children’s Hospital of Philadelphia ED Pathway for Evaluation/Treatment of Children with

Behavioral Health Issues:


The Children’s Hospital of Philadelphia Pathway for the Approach to Managing Behaviors in Children with Autism Spectrum Disorder (ASD)/Developmental Disorders:


Anik Jhonsa, MD

Children’s Hospital of Philadelphia

Medical Director of Emergency Psychiatric Services

Assistant Training Director Child and Adolescent Psychiatry Fellowship Program

Clinical Associate in Department of Psychiatry Perelman School of Medicine at the University of Pennsylvania

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