What are the appropriate diagnoses for a 10-year-old male presenting to the emergency department (ED) with extreme agitation, violent behavior, and screaming, with no known medical or psychiatric history?

Differential Diagnosis for a 10-Year-Old Male with Acute Agitation, Violence, and Screaming

In a 10-year-old with no prior medical or psychiatric history presenting with extreme agitation and violent behavior, you must immediately rule out medical causes before considering primary psychiatric diagnoses, as pediatric mental health emergencies frequently present with behavioral symptoms that mask underlying organic pathology.

Immediate Medical Causes to Exclude

The first priority is identifying life-threatening or reversible medical conditions that commonly present as acute behavioral disturbance in children 1:

Metabolic and Endocrine Emergencies

• Hypoglycemia - Check fingerstick glucose immediately, as this can cause acute agitation and altered behavior 1
• Electrolyte disturbances (hyponatremia, hypercalcemia) - Obtain basic metabolic panel 1
• Hyperthyroidism - Can present with acute agitation and behavioral changes 2

Neurological Emergencies

• Intracranial pathology - Trauma, hemorrhage, tumor, or increased intracranial pressure can manifest as acute behavioral change 3
• Seizure activity - Post-ictal states or non-convulsive status epilepticus may present with agitation and confusion 2
• Encephalitis or meningitis - Infectious CNS processes frequently present with behavioral symptoms before classic signs 1, 3

Toxic Ingestions and Substance-Related

• Anticholinergic toxicity - Causes agitation, confusion, and combativeness 1
• Sympathomimetic ingestion - Amphetamines, cocaine, or other stimulants cause severe agitation 1
• Alcohol intoxication or withdrawal - Though less common in this age group, must be considered 1
• Illicit drug use - Increasingly common in pediatric populations with varied substances 4

Other Medical Causes

• Hypoxia - Check oxygen saturation and respiratory status 5
• Pain - Unrecognized severe pain can manifest as agitation, particularly in children with communication difficulties 5
• Urinary retention or constipation - Can cause significant distress and behavioral changes 5, 3
• Infection/sepsis - Systemic infections can present with delirium and agitation 3

Primary Psychiatric Diagnoses to Consider

Only after medical causes are excluded should you consider primary psychiatric emergencies 1:

Acute Psychiatric Conditions

• First episode psychosis - New-onset psychotic disorder can present with severe agitation, hallucinations, and violent behavior 1, 6
• Acute mania (bipolar disorder) - Can present with extreme agitation, irritability, and aggressive behavior 2
• Severe anxiety or panic disorder - May manifest as extreme agitation and apparent aggression 1
• Acute stress reaction or post-traumatic stress disorder - Particularly if there is recent trauma exposure 1

Behavioral and Developmental Considerations

• Undiagnosed autism spectrum disorder with acute behavioral crisis - Children with ASD may have severe behavioral dysregulation when overwhelmed 1
• Attention-deficit/hyperactivity disorder with severe impulsivity - Though typically diagnosed earlier, can present acutely 2
• Intermittent explosive disorder - Characterized by episodic aggressive outbursts 2

Trauma and Environmental Factors

• Acute response to abuse or maltreatment - Physical, sexual, or emotional abuse can cause acute behavioral decompensation 1
• Exposure to violence - Witnessing or experiencing violence can trigger acute behavioral crisis 1
• Acute situational crisis - Recent significant stressor or loss 1

Critical Diagnostic Pitfalls to Avoid

The most dangerous error is assuming a psychiatric cause without adequate medical workup 1. Pediatric mental health emergencies are frequently not recognized as such and may initially present as behavioral complaints when the underlying cause is medical 1.

Key Warning Signs of Medical Etiology

• Acute onset with no prodrome (suggests organic cause) 1
• Altered level of consciousness or fluctuating mental status (suggests delirium) 5
• Abnormal vital signs (fever, tachycardia, hypertension, hypoxia) 5
• Focal neurological findings 1
• Visual hallucinations (more common in medical causes than primary psychiatric disorders) 7

Essential Initial Workup

Before labeling this as a psychiatric emergency, obtain 1, 3:

• Vital signs including oxygen saturation and temperature
• Fingerstick glucose immediately
• Detailed history from caregivers about recent illness, trauma, ingestions, medication access, behavioral changes
• Focused physical and neurological examination looking for signs of trauma, infection, or focal deficits
• Basic laboratory studies: Complete blood count, comprehensive metabolic panel, urinalysis
• Toxicology screen (urine drug screen, acetaminophen, salicylate levels)
• Consider neuroimaging if any concern for intracranial pathology or if mental status does not improve with initial management 3

Immediate Management Approach

While conducting your diagnostic evaluation, prioritize safety and de-escalation 1, 8:

1. Ensure environmental safety - Remove potential weapons, provide adequate space, have sufficient staff present 8
2. Attempt verbal de-escalation first - Use calm demeanor, simple language, respect personal space, designate one staff member to interact 5, 8
3. Treat identified medical causes immediately - Correct hypoglycemia, provide oxygen, treat pain 5
4. Reserve pharmacological intervention for situations where the patient poses imminent harm to self or others, or when necessary to complete essential medical evaluation 5, 4

The diagnosis in this case is fundamentally a medical emergency requiring systematic exclusion of organic causes before attributing symptoms to primary psychiatric illness 1.