20.2 Pediatric Behavioral & Mental Health Emergencies: Suicidality, Acute Agitation & Psychosis
Key Takeaways
Assess attention, vital signs, neurologic findings and medication or substance exposure before attributing new behavior to a primary psychiatric cause.
An acute positive ASQ needs immediate protection and emergency evaluation. A non-acute positive usually needs a brief suicide safety assessment to guide disposition.
Use trauma-informed de-escalation and cause-directed medication. Avoid concomitant IM olanzapine and parenteral benzodiazepines and reassess cardiorespiratory status after medication.
Use violent restraint only for immediate physical safety. Follow one-hour face-to-face evaluation and age-based order limits, and release as soon as safely possible.
New catatonia with dyskinesia and autonomic instability warrants evaluation for encephalitis. Serotonergic exposure with clonus and hyperreflexia suggests serotonin toxicity.
Pediatric Behavioral Emergencies: Suicidality, Agitation and Psychosis
Quick Answer: Stabilize physiologic threats and use the history, examination and clinical course to select tests. Distinguish a positive suicide screen from imminent risk. Keep a child with imminent risk under direct observation in a safe setting and obtain an emergency mental health evaluation. For agitation, reduce stimulation and choose treatment for the likely cause. Use the least restrictive effective safety measure and reassess frequently.
Evaluate medical and psychiatric causes in parallel
Obtain vital signs, oxygen saturation and a focused physical and neurologic examination. Assess attention, level of consciousness, pain, medication changes, exposures and developmental baseline. Ask the child and caregiver what changed and when. Treat injuries, ingestion and unstable chronic illness. Check bedside glucose promptly with altered consciousness or an otherwise unexplained behavioral change. Consider electrolytes, pregnancy testing in a pubertal patient who could be pregnant, or toxicology testing when the history and intended management warrant them. A routine laboratory panel or negative urine drug screen cannot establish readiness for psychiatric disposition. AAP and ACEP pediatric emergency report
| Presentation | Clinical reasoning |
|---|---|
| Acute, fluctuating attention or awareness | Suspect delirium. Evaluate hypoxia, infection, pain, medication effects, withdrawal and metabolic causes. Select an age- and development-appropriate tool, such as CAPD or pCAM-ICU, when applicable. |
| Agitation with abnormal vital signs or exposure | Sweating with mydriasis and hyperthermia supports a sympathomimetic pattern. Dry skin and mucosa with urinary retention suggest antimuscarinic toxicity. Assess glucose, ECG and targeted tests as indicated. |
| First psychotic symptoms with focal signs, fever, seizures, altered consciousness or new movements | Evaluate neurologic and infectious causes. Select imaging, EEG and lumbar puncture with the team based on the presentation and procedural safety. Start indicated empiric treatment for suspected CNS infection without waiting for an unsafe or delayed lumbar puncture. |
| New psychosis with mutism, dyskinesia or autonomic instability | Consider anti-NMDA receptor encephalitis. Seek urgent neurology and critical care evaluation. Evaluate with MRI, EEG, infectious testing and neuronal antibodies in CSF and serum when safe. A normal MRI does not exclude it. Include early age- and sex-appropriate tumor screening, including ovarian teratoma in adolescent girls. |
The content or sensory modality of hallucinations can help frame the differential. Onset, attention, associated signs and the trajectory determine how much weight to give it. SCCM pediatric PANDEM guidance · Pediatric autoimmune encephalitis diagnosis · Pediatric NMDAR encephalitis consensus
Screen, assess and determine disposition
- Know the setting. The AAP Blueprint recommends universal screening at preventive visits from age 12 and screening ages 8–11 when clinically indicated. In younger children with warning signs, assess directly using developmental judgment. The Joint Commission hospital standard effective January 2026, NPG.08.01.01, requires validated screening from age 12 when a behavioral health condition is the primary reason for care. ED and medical inpatient programs can implement broader age and presentation criteria. The NIMH youth ASQ materials cover ages 8–24, while the original ED validation enrolled ages 10–21.
- Use the tool and check acuity. In the NIMH ASQ, any yes to the first four items triggers the acuity question about current thoughts of killing oneself. A yes to the acuity question calls for immediate precautions and an emergency evaluation. A no after a positive screen usually calls for a brief suicide safety assessment to guide disposition. NIMH allows an exception for a remote attempt more than one year earlier as the only positive response when a brief assessment has already been documented since that attempt. A youth who refuses the screen follows the non-acute positive pathway in the NIMH tool unless other findings warrant greater precautions. The Columbia-Suicide Severity Rating Scale (C-SSRS) assesses ideation and behavior. Follow the chosen tool's protocol, and use clinical judgment when a negative screen conflicts with observed risk.
- Match precautions to risk. A youth with current intent, a recent dangerous attempt or other evidence of imminent risk needs prompt clinician notification, protection from self-harm, and emergency evaluation. In units with ligature or other safety risks, the Joint Commission requires continuous 1:1 observation by qualified staff who can intervene immediately for high-risk patients. Reduce access to hazards while preserving necessary medical equipment. Use safe transport and handoff. In a ligature-resistant psychiatric unit, follow the unit's high-risk observation policy. A non-acute positive screen alone does not require 1:1 observation under the NIMH pathway.
- Assess and plan the transition. Ask privately when feasible about current thoughts, plan, intent, access to means and past attempts. Seek caregiver collateral and assess available supervision and support. For discharge after assessment, collaborate on a written safety plan with warning signs, coping strategies, places or people for distraction, trusted supports, clinical and crisis contacts, and steps to reduce access to lethal means. Ask caregivers to explain how they will secure medications and remove or securely store firearms. Arrange follow-up based on risk. A safety plan or promise of safety cannot replace urgent evaluation when risk is imminent.
A youth who reports an attempt last month and denies current thoughts needs a brief suicide safety assessment. Clarify the attempt, current supports and access to means before deciding disposition. A youth who reports current suicidal thoughts needs immediate protection and an emergency evaluation, even while medical treatment continues.
AAP Blueprint clinical pathways · NIMH ASQ toolkit · NIMH current ASQ screening tool · C-SSRS initial validation · Joint Commission hospital suicide standards and resources · Joint Commission monitoring FAQ · Stanley–Brown safety planning
Treat acute agitation and preserve safety
Reduce noise and the number of people giving instructions. Use a calm speaker, personal space, simple choices, and a trusted caregiver or sensory supports when they help. Address pain, hunger and unmet communication needs. Offer an oral option if the child can safely take it. When danger precludes waiting, use the pediatric emergency pathway and mobilize trained staff. Review recent drugs, dose, route and response before repeating medication. Pediatric ED BETA consensus
| Likely cause | Medication and monitoring decision |
|---|---|
| Stimulant toxicity or alcohol/sedative withdrawal | A benzodiazepine may address the cause. The BETA consensus lists lorazepam 0.05–0.1 mg/kg per dose in a 0.5–2 mg range, with route and dose selected for the child and setting. Monitor breathing and consciousness, especially with another CNS depressant. |
| Severe primary mania or psychosis | A pathway-directed antipsychotic may be appropriate. Choose by route, prior exposure, hypotension, QT risk and extrapyramidal effects. Short-acting IM olanzapine for pediatric agitation is off-label. The U.S. label advises against concomitant IM olanzapine and a parenteral benzodiazepine due to excessive sedation and cardiorespiratory depression. BETA advises avoiding close administration within one hour. Use local policy and monitoring. An elapsed interval does not establish safety. |
| Delirium or possible catatonia | Treat the cause first. Benzodiazepines can worsen many forms of delirium, with exceptions such as sedative withdrawal and a monitored catatonia challenge. Avoid anticholinergic sedatives in delirium. Specialist-directed medication may be needed if severe symptoms threaten safety. |
For example, a pathway dose of lorazepam 0.05 mg/kg for a 30-kg child is 1.5 mg. Check what was already given and reassess before redosing. Reassess airway, work of breathing, oxygenation, consciousness and hemodynamics after medication. Obtain ECG monitoring as appropriate for agent, risk and urgency. Oculogyric crisis, torticollis or tongue spasm after dopamine blockade can be acute dystonia. Assess the airway urgently with stridor or respiratory compromise, stop the culprit and give a rapid-acting treatment such as parenteral diphenhydramine. Benztropine is an alternative when age and contraindications permit. U.S. olanzapine labeling · Pediatric extrapyramidal reaction recommendations
Violent or self-destructive restraint and seclusion
In U.S. hospitals subject to CMS requirements, use these measures only for immediate physical safety when less restrictive measures are ineffective. A physician or authorized licensed practitioner orders restraint or seclusion. For violent or self-destructive behavior, a qualified physician, other licensed practitioner or appropriately trained RN performs a face-to-face medical and behavioral assessment within one hour. An RN who performs it consults the responsible physician or licensed practitioner as soon as possible afterward. Orders are time-limited and cannot be standing or PRN. Federal maximum order and renewal intervals are one hour under age nine, two hours from nine to 17, and four hours for adults, with a new practitioner assessment required before another order after 24 hours. Follow more restrictive state or hospital rules.
Use trained staff, avoid prone positioning and any compromise of breathing, and reassess respiratory status, circulation, skin, distress and ongoing need at the intervals required by hospital policy. Simultaneous restraint and seclusion require continuous monitoring under the federal rule. Document alternatives, indication, examination, response and the reason for any continuation. Release at the earliest safe time, even if the order has time remaining. 42 CFR § 482.13 · AAP and ACEP pediatric emergency report
Distinguish catatonia from drug-related emergencies
| Syndrome | Findings that guide action | Immediate response |
|---|---|---|
| Catatonia | New mutism, immobility, posturing, waxy flexibility or echo phenomena. Compare with baseline, particularly in neurodevelopmental conditions. Use a structured tool such as the Pediatric Catatonia Rating Scale. | Investigate psychiatric and medical causes. A monitored lorazepam challenge can support the diagnosis. A negative or incomplete response does not exclude it. Seek urgent consultation for autonomic instability or possible malignant catatonia, and avoid reflexive dopamine blockade. |
| Neuroleptic malignant syndrome | Recent dopamine blockade or withdrawal of a dopamine agonist, rigidity, fever, altered mental status and autonomic instability. CK may rise and kidney injury can follow. | Stop the implicated dopamine antagonist, support vital functions, cool and treat complications. Discuss agents such as bromocriptine or dantrolene with specialists in severe cases. |
| Serotonin toxicity | Serotonergic exposure with rapid onset of clonus, hyperreflexia, agitation or diaphoresis. Severe rigidity may obscure clonus. | Stop the offending drugs, support airway and circulation, use benzodiazepines and cool actively when hyperthermic. Severe hyperthermia or rigidity requires critical care. Cyproheptadine is a possible toxicologist-directed adjunct for persistent symptoms. |
BAP catatonia guideline · Pediatric lorazepam challenge cohort · NMS international consensus · Hunter criteria derivation · Pediatric serotonin toxicity guideline
Involuntary evaluation, who can authorize it, and duties to warn or protect depend on state law. Document objective risk and use the facility's emergency process. For a credible threat, take immediate safety measures and involve the responsible clinical and legal team. HIPAA permits certain necessary disclosures to people who can lessen a serious and imminent threat, consistent with law and ethical standards. Coordinate caregiver involvement when safe and use required reporting and safeguarding pathways if a caregiver may be the source of harm. AAP adolescent confidentiality policy · 45 CFR § 164.512
A 15-year-old with bipolar mania threatens staff and throws furniture. De-escalation has been ineffective and he refuses oral medication. The team considers short-acting IM olanzapine under the pediatric ED pathway. A clinician proposes adding IM lorazepam at the same time. Which response is appropriate?
Give both at once at separate injection sites and reassess after the child falls asleep.
Give lorazepam immediately followed by olanzapine, since giving the drugs sequentially avoids the interaction.
Avoid concurrent treatment. Select one pathway-directed agent based on the suspected cause and monitor breathing, consciousness and circulation.
Defer reassessment while a standing six-hour restraint order runs, then consider medication.
A 14-year-old with no prior psychiatric diagnosis has 10 days of progressive paranoia and disorganized speech, then develops episodes of mutism and waxy flexibility, involuntary orofacial movements, and labile heart rate and blood pressure. Which next approach best addresses the findings?
Start high-dose haloperidol for first-episode schizophrenia and defer neurologic assessment.
Treat isolated dystonia with diphenhydramine and reassess for discharge if the movements improve.
Use a negative urine drug screen to select outpatient psychiatric follow-up.
Stabilize and seek urgent evaluation for encephalitis with catatonic features. Assess for infectious and autoimmune causes and consider a monitored lorazepam challenge.
A 16-year-old taking fluoxetine develops agitation, diaphoresis, temperature 39.3°C, ocular and inducible ankle clonus, and marked lower-extremity hyperreflexia within six hours of starting linezolid. Which diagnosis and initial care fit this presentation?
Neuroleptic malignant syndrome. Give bromocriptine before reviewing the medication exposure.
Serotonin toxicity. Stop the implicated drugs, provide supportive care, give benzodiazepines and cool actively.
Acute dystonia. Give benztropine and continue linezolid while monitoring temperature.
Antimuscarinic toxicity. Give physostigmine to reverse the diaphoresis and clonus.
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