Aggression and Behavioral Dysregulation

The correct answer is the underlying etiology driving presentation.

Although all of these are important considerations in the medication management of agitation or aggression in youth, the underlying etiologic factors that are driving the agitation are most important. Managing these factors will mitigate progression of the behavior,and also address the underlying cause of the escalation in the behavior.

The correct answer is it occurs along a spectrum of cognitive, emotional, and behavioral changes.

Agitation often has many precipitating factors that cause a child or adolescent to go from a calm state to an agitated state. Agitation can be screened for and monitored over time.  Commonly, these patients are managed by primary care providers, school personnel, and other non-mental professionals, with only a small proportion being directly managed by mental health professionals. Effective preventative measures and early intervention may include the use of environmental modification, behavioral planning and other psychotherapeutic interventions, which can mitigate the use of medications or avoid the use of medications altogether. Agitation does occur along a spectrum, with thoughts, emotions, and resulting behaviors being quite varied from patient to patient.

The correct answer is that you should obtain laboratory investigation.

This case highlights how physical health may impact cognition, emotional regulation, and behavior in an adolescent with diabetes. Although many of these interventions may be needed, initially, it is important to understand the patient’s physical health status. The presentation of diabetic ketoacidosis, or another physical health factor contributing to changes in behavior may be a harbinger for clinical decompensation and can be an acute safety concern. Rapid physical health evaluation is needed in this case and should not be delayed.

The correct answer is tranquilization.

The primary goal of medication management in the pediatric patient exhibiting aggressive behavior is tranquilization, or calming of the patient, without sedation. This allows for the ongoing evaluation and management of underlying clinical factors influencing the presentation of aggression. Sedation is not the primary goal, and it can be harmful to the patient while limiting further assessment. It should be avoided when possible. Chemical restraint, or restricting an individual's freedom of movement through medications, is also potentially harmful, limits assessment, and should be avoided. Limit setting and other behavioral interventions are often achieved non-pharmacologically. The use of medications to delay the worsening of behavior may be a secondary goal or a consideration in the management of aggression but should not be the primary focus because it may result in delays in care and the use of more invasive or restrictive means of managing the patient’s aggression.

The correct is to provide the child a tablet with their favorite programming.

Providing the child with a soothing strategy is preferred, particularly one that will be enjoyable to the patient and distract them from the task at hand. The other options may worsen the behavior, carry more risk, be traumatic for the patient, or reinforce the behavior in the phlebotomy setting. Leaving the office may not result in a change in behavior, and may delay the needed testing. It can also reinforce the use of aggression to avoid being in the office, therefore strengthening the behavior. Suggesting that the child will not have “a shot” may engender mistrust and be traumatic. Expediting the process with restraint may be unsafe and further distress the patient the next time they attempt to get a blood draw. The use of a medication, while it might be needed in the future, is not the best next step in this situation. Thoughtful use of non-pharmacologic and environmental interventions may be more effective for this patient.