What is the best medication and dose for agitation in an autistic child in the emergency department (ED)?

Best Medication for Agitation in Autistic Children in the Emergency Department

For agitation in autistic children in the emergency department, risperidone is the most effective medication, with a recommended starting dose of 0.25 mg/day for children <20 kg and 0.5 mg/day for children ≥20 kg, titrated to clinical response. 1, 2

Initial Assessment and Approach

• Before administering medication, attempt verbal de-escalation techniques and create a calming environment with decreased sensory stimulation 1
• Identify and modify triggers of agitation (e.g., long wait times, argumentative family members) 1
• Consider involving a child life specialist to help calm the agitated child 1

Medication Selection Algorithm

First-line: Risperidone (Atypical Antipsychotic)

• Dosing by weight:
  • Children <20 kg: Start at 0.25 mg PO/day 2
  • Children ≥20 kg: Start at 0.5 mg PO/day 2
  • Titrate to clinical response (effective dose range: 0.5-3 mg/day) 2
  • Mean effective dose in clinical trials: 1.9 mg/day (equivalent to 0.06 mg/kg/day) 2
• Evidence: FDA-approved for irritability associated with autism, including aggression, self-injury, and tantrums 2
• Efficacy: Significantly improved scores on the Aberrant Behavior Checklist-Irritability subscale compared to placebo in multiple controlled trials 3
• Response rate: 69% positive response in controlled trials (vs. 12% with placebo) 3

Alternative Options Based on Clinical Scenario:

For Mild to Moderate Agitation:

• Benzodiazepines (e.g., lorazepam):
  • Dose: 0.05-0.1 mg/kg PO/IM/IV 1
  • Onset: 5-15 min IV, 15-30 min IM, 20-30 min PO 1
  • Consider for suspected medical etiology or intoxication 1
  • Caution: May cause paradoxical disinhibition, especially in younger children and those with developmental disabilities 1

For Severe Agitation:

• Combination therapy: Antipsychotic + benzodiazepine 1
  • Example: Risperidone + lorazepam 1
  • This combination may produce more rapid sedation than monotherapy 1

Administration Considerations

• For patients experiencing persistent somnolence, consider:
  • Administering half the daily dose twice daily 2
  • Administering the dose at bedtime 2
• Oral disintegrating tablets may be useful for children who have difficulty swallowing pills 1
• Monitor vital signs closely after administration 1

Potential Side Effects and Monitoring

• Common side effects of risperidone:
  • Increased appetite and weight gain (2.7 kg vs 0.8 kg with placebo over 8 weeks) 3
  • Fatigue, drowsiness, dizziness, and drooling 3
• Monitoring needed:
  • Vital signs (especially respiratory status)
  • Level of sedation
  • Extrapyramidal symptoms (less common with risperidone than first-generation antipsychotics) 1

Special Considerations

• Benzodiazepines are preferred for agitation with suspected medical etiology or intoxication 1
• Antipsychotics may worsen the condition of patients with anticholinergic delirium or intoxication from drugs with anticholinergic properties 1
• For patients with respiratory compromise, use benzodiazepines with caution 1
• Two-thirds of children with a positive response to risperidone maintain benefit at six months 3

Emerging Alternatives

• Dexmedetomidine continuous infusion has shown promise for maintaining sedation in aggressive adolescents with ASD in the emergency department setting 4
• Intravenous valproate has been reported as effective in case studies for treatment-resistant agitation in children with ASD 5

Remember that medication should be used after verbal de-escalation techniques have failed, and the choice should be guided by the suspected etiology of agitation, severity of symptoms, and patient characteristics.