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Aggression and Behavioral Dysregulation

Clinical Pearls Video Series

Video Chapters

Click on the three lines in the upper left corner to see chapter information or reference the chapter table of contents below to navigate to specific chapters.

  • Assessment
    • How do we think about aggressive behavior and how does it present? (0:08–2:33)
    • What risk factors contribute to aggression? (2:35–3:10)
    • What factors should be considered when assessing aggression? (3:11–4:50)
    • How do I effectively communicate to the patient and family about aggression and understand how family dynamics can contribute to aggression risk? (4:52–10:00)
    • How do I conduct an evaluation of youth at risk for aggression? (10:00–14:10)
  • Management
    • How can I partner with schools and community resources in supporting a child who has aggressive behavior? (14:12–16:15)
    • What types of environmental, family, and therapy strategies can I suggest to help stem aggressive behavior?  (16:17–20:25)
    • How and when do I think about using medications to manage aggression? (20:26–25:02)
  • Key Takeaways (25:03–26:12)

Nasuh Malas, M.D., M.P.H., Child & Adolescent Psychiatrist, University of Michigan

Children and adolescents frequently manifest agitation or aggressive behavior that puts themselves or others at risk. Worsening behaviors, agitation, and aggression are one of the most common reasons families seek care in primary care offices and emergency care settings. It is also one of the top reasons a child is removed from the school setting. Nationally, 15% of youth in the emergency room require physical restraint, and as many as 23% of youth with Autism Spectrum Disorders (ASD) treated in the emergency room are restrained or sedated.

If not addressed early and often, agitation can further escalate, leading to delays in care, increased health care utilization, safety concerns, and poor outcomes, while creating an unsafe, distressing care environment for patients, families and staff. This presentation will review key aspects of the assessment and management of escalating behaviors, agitation, and aggression in the pediatric patient.

Resources Mentioned in the Video

Screening Tools

Although there are no validated screening tools for risk of aggression in youth in the primary care setting, there are screeners that may help you identify potential factors contributing to aggression, including:

Other Resources

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. 

Malas N, Spital L, Fischer J, Kawai Y, Cruz D, Keefer P. National Survey on Pediatric Acute Agitation and Behavioral Escalation in Academic Inpatient Pediatric Care Settings. Psychosomatics. 2017;58(3):299-306. 

Gerson R, Malas N, Feuer V, Silver GH, Prasad R, Mroczkowski MM. 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;20(2):409-418. 

Curry A, Malas N, Mroczkowski M, Hong V, Nordstrom K, Terrell C. Updates in the Assessment and Management of Agitation. Focus (Am Psychiatr Publ). 2023;21(1):35-45. 

Connor DF, Newcorn JH, Saylor KE, Amann BH, Scahill L, Robb AS, Jensen PS, Vitiello B, Findling RL, Buitelaar JK. Maladaptive Aggression: With a Focus on Impulsive Aggression in Children and Adolescents. J Child Adolesc Psychopharmacol. 2019;29(8):576-591. 

Test your knowledge with an optional 5-question quiz below. (Note: If you wish to receive a certificate of completion for this MC3 Clinical Pearl, you must receive a passing score of 80%.)


Aggression and Behavioral Dysregulation Quiz

1. Which of the following factors should be the primary driver for the choice of medication to manage agitation or aggression in youth?

2. Which of the following statements is most true about agitation?

3. An adolescent presents to the hospital with a history of insulin-dependent diabetes, psoriasis, mild intermittent asthma and generalized anxiety disorder. At admission, the patient becomes irritable and argumentative and starts refusing treatment. Family notes this behavior is atypical for the patient. Which of the following is the next best step in the care of this patient?

4. What is the primary goal of medication management in the pediatric patient exhibiting aggressive behavior?

5. A child with seizure disorder, needle phobia, and attention deficit hyperactivity disorder presents to outpatient phlebotomy for a blood draw related to valproic acid levels. Upon entering the waiting room of the facility, the child begins to scream, thrash, and use vulgar language and attempts to bolt out into the parking lot. Which of the following is recommended as the best option to address this child’s aggressive behavior?

Your score is