Pediatric agitation in the Emergency Department is one of those presentations that can escalate quickly and leave even experienced clinicians feeling on edge. It is high-risk, resource-intensive, and often unfolds in an already overstimulating environment where small missteps can make things worse. At the same time, agitation is not a diagnosis, it is a clinical presentation that may reflect anything from psychiatric illness to delirium, intoxication, trauma, or simply a child overwhelmed by the ED itself. So how do we approach these patients in a way that is safe, systematic, and effective?

In this episode with guest experts, Dr. Susan Duffy and Dr. Thomas Chun, we tackle the questions that come up at the bedside: How do we rapidly distinguish mild, moderate, and severe agitation in a way that actually changes what we do next? Which patients are most likely to escalate, and how can we intervene early to prevent that? When should we be worried about a medical or toxicologic cause rather than assuming this is “behavioural”? What does effective verbal de-escalation actually look like in a busy ED, and why does it so often fail? When is a “code white” for emergency security measures truly indicated, and how do we avoid turning it into an escalation trigger? How should we be thinking about medications: what to choose, when to give them, and how to avoid over-sedation? And once the patient is finally calm, how do we make sure we aren’t missing the underlying diagnosis? and many more…

Podcast production, sound design & editing by Anton Helman; Voice editing by Braedon Paul

Written Summary and blog post by Sara Brade, edited by Anton Helman April 2026

Cite this podcast as: Helman, A. Duffy, S. Chun, T. Ep 217 Pediatric Agitation: Assessment and Management. Emergency Medicine Cases. April 2026. https://emergencymedicinecases.com/pediatric-agitation-assessment-and-management. Accessed May 24, 2026

The first task is to determine whether the agitation is mild, moderate, or severe, because this classification drives almost everything that follows: where the patient is placed, who needs to be involved, how closely the patient must be observed, whether urgent intervention is required, and what pharmacologic options are appropriate. Our experts emphasize that this categorization is not merely descriptive: it’s operational. It creates a shared mental model for the team so everyone can share the same level of concern and the same urgency of response.

In practical terms:

There are clinical tools such as the Aggressive Behaviour Assessment Risk Tool (ABRAT) and the Brief Rating of Aggression by Children and Adolescents (BRACHA) to guide assessment; however, our experts emphasize that clinical judgement is paramount in these cases.

Our best tool for managing pediatric agitation in the ED is prevention. This starts at triage. Even when a child appears calm on first encounter, the team should identify red flags that suggest a higher likelihood of escalation during the ED visit.

The most predictive factor is a prior history of aggression. This is particularly important when the child has presented because of aggression at home, school, or in the community, even if they appear settled on arrival. Other important risk factors include:

These factors influence how patients perceive the ED environment as they may be sensitive to noise, authority figures, unpredictability, and loss of control. Identification of these risk factors should trigger preventative communication and environmental modification strategies.

Children with agitation often have prior experiences that affect how they respond to the ED. A trauma-informed approach means recognizing that what may look like “bad behaviour” can actually represent fear, loss of control, sensory overload, or a learned protective response.

Key early prevention interventions include:

Pearl: Do not ignore these patients. Lack of engagement and long waits increase agitation. Regular team check-ins reduce escalation risk.

Once agitation is present, the clinician’s job is not simply to calm the child down. The more important task is to determine whether this is primarily a psychiatric or behavioral presentation, or whether there is an underlying medical cause that requires urgent treatment.

Red flags that suggest a medical or toxicological cause of agitation include:

Some EDs choose critical care or high-observation areas for severely agitated pediatric patients because they are often undifferentiated and may require urgent medical assessment and monitoring.

Verbal de-escalation is a structured and team-based intervention that begins the moment the patient enters the ED and should continue throughout the entire encounter.

The foundational elements of de-escalation include:

Useful de-escalation language includes:

Calling a “code white” or emergency security response is one of the most consequential decisions in agitation management. This response should be reserved for cases with concern for imminent harm to self or others. It is not a response to mere non-compliance, verbal hostility, or frustration if the patient is still redirectable and not yet physically threatening.

Indications for calling a “code white”/emergency security response include:

If staff are becoming increasingly concerned for safety, it is better to communicate calmly and transparently: “We’re worried about safety. We want to avoid restraints. How can we work together to keep everyone safe?” That keeps the focus on collaboration and preserves the possibility of de-escalation even as staff prepare for escalation.

Pitfall: Calling a “code white”/emergency security response is a safety response, not a disciplinary tactic. The most important pitfall is using a code white as a threat. “If you don’t cooperate, we’ll call security and hold you down” is counterproductive and often escalates the situation further. A code white should never be framed as punishment or coercion.

If physical restraint becomes necessary, it should be used only as a last resort, for the shortest possible duration, and almost always as a bridge to calming medication.

Important safety principles of physical restraints:

Some pediatric centers also use structured papoose-style restraints for selected neurodevelopmental patients, or specially designed chair restraints in behavioural settings.

Pitfall: A common pitfall is prolonged and/or inappropriate use of physical restraints. Restraints are not treatment. They are a temporary safety measure while definitive calming measures take effect. The overarching principle is to use the least harmful method that safely contains the patient, and discontinue it as soon as possible.

When medications are needed, the goal is to calm the patient, not over-sedate them. The ideal medication choice depends on the likely cause of agitation, the urgency of the situation, the patient’s age and co-morbidities, prior medication response, and practical issues such as route and onset of action.

Key principles of medication management of the agitate pediatric patient in the ED:

For the undifferentiated severely agitated child, a second-generation antipsychotic such as olanzapine is our experts’ go-to agent, with some clinicians using a combination of olanzapine and lorazepam depending on the situation. There are no robust RCTs to guide calming medication choices for pediatric agitation. A truly undifferentiated patient is uncommon; usually, some information about psychiatric history, developmental condition, substance exposure, or prior medication response can be obtained and should guide medication choice.

The oral route is preferred when possible, IM is used when danger is imminent, and IV is rarely needed.

Pearl: Even highly agitated children sometimes accept oral medication if it is presented as a meaningful choice. A child who seems to be heading toward IM treatment may still say, “I’ll take the oral medication.” That moment of choice can preserve dignity and reduce the need for force.

After the patient has settled, the work is not done. The ED remains a high-risk environment for re-escalation. Our experts emphasize that ongoing management of the room and the care process is one of the most important determinants of whether the patient stays calm.

Helpful ongoing strategies include:

Other practical examples include: using guided imagery, weighted blankets, sensory tools, headphones, puzzles, and comfort items; allowing a preferred caregiver to remain present; and even maintaining a dedicated “autism closet” or activity closet to improve environmental support.

Once initial safety is restored, the clinician should return to the underlying cause. The adult EM Cases approach is especially helpful here: after calming medications take effect, clinicians should actively pursue immediate life threats and the diagnosis beneath the agitation.

Reassess for:

Children with developmental disorders, autism, acute psychosis, intoxication, or trauma-related dysregulation may all look superficially “agitated,” but their optimal management differs. The more clearly the clinician identifies the driver, the safer and more effective the care becomes.

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