Behavioural Disturbance

Many episodes of behavioural disturbance in children and young people coming for treatment can be minimized or prevented by clear, careful communication with the child and their family/whanau. In line with ADHB's Restraint Minimisation & Safe Practice policy (located in the ADHB policies and guidelines library), all staff who work in frontline situations need training in de-escalation so that behavioural disturbance can be reduced.

Behaviour problems in children and adolescents presenting to clinical services are common and are usually misguided strategies for coping with fear, pain etc. Mostly these can be managed by parents and staff working together using reassurance, clear communication and warm, firm communication suitable for developmental stage.

Some children and adolescents have a more established pattern of problem behaviour which worsens in a stressful situation such as hospitalisation. If the above strategies don't work and the behaviour can be safely ignored, this is often the best approach since difficult behaviour in children often increases in response to attention.

Staff need to:

• Gather history of previous behaviours to decide whether this is a new response or whether there are pre-existing behaviour problems which might need a different approach.

• Ensure that family/whanau members who know the child and can help manage the behaviour are present, and gain their views on the best approaches with their child.

• Clearly explain the clinical issue and proposed treatment in a developmentally appropriate manner

• Offer limited choice where appropriate (e.g. about site of IV, examination process etc)

• Advise calmly and firmly about allowed and not allowed behaviour

If these approaches don't help, the first issue is safety of the child and others. Limiting the area that the child has access to (e.g. a safe room, not wandering through the ED), removing potentially dangerous objects and ensuring lots of family members are present are important.

Endeavour to calm the patient or talk them down; explain to them what is going on and address any concerns they have, irrespective of how unreasonable they may seem.

If a clinical encounter is planned with a child whose behaviour has caused concern previously, try to problem-solve in advance with the family/whanau about the best family/whanau member to be present & ways to encourage the child's cooperation. Organise adequate staff coverage, particularly support staff (e.g. play therapists or kai atawhai).

For children with really difficult behaviour, especially if this is interfering with their medical treatment, contact the Consult Liaison Team. After hours, contact the on call psychiatric registrar or child psychiatry consultant, particularly if restraint is needed and issues of the Mental Health Act need to be addressed.

At the time of contact, the psychiatric registrar or consultant can advise about medication for sedation, if it is needed.

This behavioural disturbance guidance is not intended for procedural sedation for children (eg for anxiety reduction with medical procedures). See Sedation in children guideline