From the Guidelines
Treatment for acute aggression in children should prioritize a combination of immediate de-escalation techniques and longer-term interventions, with a focus on ensuring safety, using verbal de-escalation, and considering medication only when necessary, as supported by 1. For immediate management, the first step is ensuring safety by removing dangerous objects and creating a calm environment. Verbal de-escalation using a calm, non-threatening tone while maintaining appropriate distance is essential. If medication is necessary for severe cases, first-line options include risperidone (0.25-0.5mg for younger children, 0.5-1mg for adolescents) or aripiprazole (2.5-5mg), as suggested by 1 and 1. These medications can help reduce aggression by targeting dopamine and serotonin receptors. For very severe aggression requiring rapid control, lorazepam (0.5-2mg depending on age/weight) may be considered under medical supervision. Beyond immediate management, a comprehensive approach should include:
- Identifying triggers
- Implementing behavioral strategies like positive reinforcement
- Teaching coping skills such as deep breathing and counting techniques
- Parent training in behavior management, which is crucial for long-term success, as emphasized by 1 and 1 Physical restraint should only be used as a last resort when there is imminent danger of harm. It's essential to follow up with a thorough evaluation to identify underlying causes such as ADHD, autism, trauma, or mood disorders, as treating these conditions often reduces aggressive behavior, as noted in 1 and 1.
From the FDA Drug Label
RISPERIDONE is indicated for the treatment of irritability associated with autistic disorder, including symptoms of aggression towards others, deliberate self-injuriousness, temper tantrums, and quickly changing moods Efficacy was established in 3 short-term trials in children and adolescents (ages 5 to 17 years)
The treatment for acute aggression in children is Risperidone (PO), which is indicated for the treatment of irritability associated with autistic disorder, including symptoms of aggression towards others. The recommended dosage is:
- Initial dose: 0.25 mg (body weight less than 20 kg) or 0.5 mg (body weight greater than or equal to 20 kg)
- Target dose: 0.5 mg (body weight less than 20 kg) or 1 mg (body weight greater than or equal to 20 kg)
- Effective dose range: 0.5 to 3 mg 2
From the Research
Treatment Approaches for Acute Aggression in Children
- Non-pharmacological approaches to de-escalation, including the use of restraint, are considered in the management of acutely agitated pediatric patients with aggressive behaviors 3
- A multimodal approach to managing agitation in the emergency department (ED) is recommended, with the etiology of agitation driving the choice of treatment 4
- Pharmacological agents, such as pro re nata (prn) oral immediate-release (IR) quetiapine, haloperidol, loxapine, and chlorpromazine, have been used to manage acute agitation or aggression in pediatric patients 5
Medication Options for Aggression in Children
- Medication classes with positive evidence for treating aggression in youth include:
- Psychostimulants and α-2 agonists (in the presence of attention-deficit/hyperactivity disorder [ADHD] and/or disruptive behavior disorders) 6
- Mood stabilizing agents
- Atypical antipsychotics
- Quetiapine appears to be a viable agent for managing acute agitation and aggression in the pediatric ED with low rates of extrapyramidal side effects (EPS) 5
Considerations for Treatment
- The underlying disorder should be identified, when possible, to guide treatment selection 6
- Systematic and adequate trials of medications in sequential order are recommended to optimize response and minimize polypharmacy 6
- Guidelines for safety monitoring are available for many of the medications used for aggression in youth 6