Acute behavioural disturbance and agitation — OSCE communication and management station

Station objectives

1. Make the environment safe and call for help early in a behavioural emergency. [1] [3]
2. Apply verbal de-escalation as the first-line treatment of acute agitation. [5] [1]
3. Climb the least-restrictive ladder correctly and justify each step. [1] [4]
4. Exclude organic causes before and after sedation. [3] [2]
5. Minimise restraint harms and debrief in a trauma-informed way. [6] [5]

Candidate brief

You are the paediatric doctor in the emergency department. You have 8 minutes for Station A (a 14-year-old with autism who is escalating in a noisy department, with his mother present) and 10 minutes for Station B (a deterioration in which he refuses oral medication and the team must decide on the parenteral rung and a restraint decision). Examiners score environmental safety, de-escalation skill, ladder reasoning, organic-cause exclusion, restraint decision-making and the debrief. [1] [3]

Station A — Escalation: de-escalation and organic exclusion

Setup: A 14-year-old with autism is pacing and shouting in a crowded, noisy cubicle. He has not eaten today. His mother is present and distressed. [3] [5]

Expected actions:

• Secure the environment: reduce noise and crowding, open exits, remove hazards, position staff safely, call senior, security and mental-health help early. [1]
• Apply verbal de-escalation: calm single voice, short phrases, respect personal space, identify his wants and feelings, offer choices such as a quieter room, use his communication aids and his mother as a familiar regulator. [5] [1]
• Exclude organic causes in parallel: check capillary glucose because he has not eaten, temperature and oxygen saturation; take collateral from his mother on baseline, triggers, and whether this episode is typical or new. [3] [2]
• Offer oral medication if he engages, citing an oral-first approach grounded in paediatric trial evidence. [4]

Station B — Deterioration: parenteral rung and restraint decision

Setup: He now refuses oral medication and lunges at a nurse. The danger is uncontained. [2] [7]

Expected actions:

• Recognise that the parenteral rung is now appropriate because oral is refused and danger is uncontained; name intramuscular olanzapine or droperidol, with or without midazolam, per local protocol. [2] [7]
• State the mandatory post-dose monitoring: airway, breathing, sedation score, respiratory rate, oxygen saturation, blood pressure, heart rate, and ECG if an antipsychotic was given, with reversal and resuscitation available. [2]
• Treat restraint as a last resort: if unavoidable, team-trained, brief, continuously monitored, never solitary, never prone or with neck pressure; document justification, duration and monitoring. [6] [1]
• Once calm, return to exclude organic causes — a calm, sedated child is not an assessed child. [3] [2]

Marking anchors

Clear pass: makes the environment safe first; calls help early; demonstrates structured de-escalation adapted to autism; checks glucose and saturations in parallel; offers oral medication before parenteral; correct ladder reasoning; recognises the parenteral rung is now appropriate; states full post-dose monitoring; treats restraint as a last resort with asphyxia awareness; returns to organic causes once calm; plans a trauma-informed debrief. [1] [4] [5] Borderline: good rapport but ladder reasoning vague, or organic exclusion omitted, or restraint discussed without acknowledging the asphyxia risk. Fail: reaches for restraint or parenteral medication as a first move; omits de-escalation; fails to exclude organic causes; does not monitor after sedation; or does not debrief. [2] [6] [3]

Debrief pearls

• De-escalation is the first-line treatment; restraint is a last resort and a failure to plan. [5] [6]
• Severity drives the ladder; cause drives the treatment — keep both axes in mind. [1] [3]
• Adapt communication and environment for neurodivergent children; restraint reduction begins with that adaptation. [5] [6]