Pediatric emergency medicine trisk 0385 0385
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dropping them off at day care. Children with obsessive-compulsive disorder
(OCD) can become agitated or aggressive when they are kept from carrying out a
compulsion. Agitation and aggression tend to escalate as the fear of the event or
activity draws near and may resolve rather precipitously when the event has
passed. For example, the child with a school phobia may become increasingly
irritable as the weekend draws to a close. It may worsen to the point of trying to
jump out of a moving school bus. However, that same child may then appear
perfectly safe and happy within 15 minutes of starting the school day. Typically,
children whose anxiety leads to severe irritability or aggression will have a longstanding history of anxiety symptoms, and the patient or their parents are usually
able to give a clear history of precipitating events. In the absence of such a history
or a clear precipitating event, suspicion for an organic contribution should be
raised.
Trauma
Children and adolescents who have been victims of past or ongoing physical or
sexual abuse or other severe trauma may develop acute agitation brought on by
PTSD. The symptoms of this disorder include fluctuating behavior with episodes
of excitement, fearfulness, or irritability; recurrent nightmares or flashbacks; and
lack of involvement in usual friendships or activities. Children who experience
posttraumatic reactions often avoid or refuse to talk about the trauma, and thus,
parents may be confused about the reasons for the child’s disturbed behavior. If
parents are aware of the traumatic event, they may be upset or feel guilty about its
occurrence.
Alternatively, one or more of the child’s parents may be the perpetrators of the
trauma. Parents and children should thus be asked about trauma separately, as part
of the diagnostic assessment. Children who are upset about a previous trauma
may be particularly difficult to evaluate. They may appear frightened, behave
erratically, and be uncomfortable with discussing past events. A quiet
environment and gentle support from the physician may help these children
express their thoughts and fears.
ADHD and Disruptive, Impulse Control, and Conduct Disorders
Disorders including attention-deficit/hyperactivity disorder, oppositional defiant
disorder, intermittent explosive disorder, and conduct disorder are discussed in
greater length in Chapter 126 Behavioral and Psychiatric Emergencies . Children
with each of these disorders may present with out-of-control, agitated, and/or
violent behavior. Acute agitation or aggression that requires an ED visit often
