Do you know how to de-escalate children?

You may be familiar with pediatric advanced life support training, child abuse screening, and ensuring accurate medication dosages for children. But do you know how to de-escalate children with psychiatric emergencies?

If not, obtain additional training now, advises Joe Novak, PsyD, director of the Mental Health Network at Northwest Community Hospital in Arlington Heights, IL. "We have seen a significant increase in psychiatric patients coming to the ED, and that is true across the country," he reports.

As an ED nurse, you must be comfortable providing appropriate interventions for children with serious emotional disturbances, says Novak. "The No. 1 issue is safety, for both patients and staff," he emphasizes.

To de-escalate children with psychiatric emergencies, use these strategies that work:

Limit the number of staff who have direct contact with the child.

Take steps to ensure that children with psychiatric issues receive as little stimulation as possible, says Shirley Berman, RN, ED nurse manager at Children’s Hospital Medical Center of Akron (OH).

"This can help prevent outbursts or out-of-control behavior," says Berman, adding that the number of psychiatric patients in her ED has almost doubled in the last few years.

When children present with a psychiatric problem, the primary assessment is done at triage, and they are placed in a private room, says Berman. "If the social worker is available, the nurse does not need to see the patient at that time unless they need medication," she says.

Usually the only staff the child interacts with are the social worker and the physician, unless they become combative or are a threat to themselves or others, says Berman. "If they are in the ED for a prolonged time, the nurses will reassess at least once an hour," she explains.

If the child is being admitted, a nurse from the psychiatric unit comes down to explain the process to the family, Berman says. "The child is meeting someone they will see on the inpatient unit, and that seems to makes them more comfortable," she says.

Be trained in verbal interventions.

Most children with psychiatric emergencies do not require restraints, says Richard Westgate, RN, manager of pediatric emergency services at Wellstar Health System in Marietta, GA. "Many can be de-escalated with verbal interventions," he says.

ED staff at his facility receive training in verbal de-escalation skills, with an eight-hour nonviolent crisis intervention training course taught by a consultant with a law enforcement background, he says. The training is offered twice a year to any staff member, says Westgate. (See "Resources," at end of article, for information on crisis intervention training.)

You must recognize that verbal threats are not physical attempts and should be met only with verbal interventions, he says. Westgate recommends making contracts with your patients for short-term goals.

"For example, if your patients will contract with you not to make any verbal threats against staff, you will contract to spend 15 minutes with them talking," he says.

Ensure your own safety.

At Northwest Community Hospital, all ED nurses are required to have crisis prevention training, which covers safety assessment, nonverbal communication, and restraint and seclusion, says Novak.

"Safety education includes procedures to follow consistently, for patients identified as falling into the psychiatric category," he says.

For example, nurses are taught that if a situation becomes physical and restraints are needed, proper procedures with a team approach should be followed, so no one is at risk of getting hurt, he says.

Nurses also are taught to enter a room always facing the patient and with their backs to the door, says Novak. "This allows staff to observe a patient and have the exit right behind them," he says.

Not every psychiatric patient is violent, but you may not know exactly what you’re dealing with, says Novak. "You need to take into account the reason they came to the ED in the first place," he says. "If substances are involved, there is unpredictability. The patient may be calm at the moment, but that may not continue."

If you determine a child is suicidal or combative, you should move the patient to a safe area, he says. "The area should be low risk in terms of tools available to them," says Novak. You also should help the patient into a gown immediately, so that any contraband can be secured rapidly, he adds.

Don’t allow children to wait for hours in the ED.

Children with psychiatric emergencies may come to your ED in the middle of the night, which means that the resources you normally rely on will be closed, says Novak.

"These situations don’t always happen at 11 a.m.; they can happen at 2 a.m.," he says. "We’ve seen a significant increase in all hours of the day, which is a major change for us."

You need to know which crisis workers can be reached at any hour of the day, says Novak. "If you don’t know that, you will have a kid sitting in the ED for hours," he says. "This poses a risk, because the longer the patient has to sit there without intervention, the more risk there is of them escalating."


For additional information about de-escalating pediatric psychiatric patients, contact:

Shirley Berman, RN, Children’s Hospital Medical Center of Akron, One Perkins Square, Akron, OH 44308-1062. Telephone: (330) 543-8583. Fax: (330) 543-3761. E-mail:

Joseph J. Novak, PsyD, Director, Mental Health Network, Northwest Community Hospital, 800 W. Central Road, Arlington Heights, IL 60005. Telephone: (847) 618-4075. Fax: (847) 618-4129. E-mail:

Richard Westgate, RN, Manager, Pediatric Emergency Services, Wellstar Health System, Kennestone Office, 677 Church St., Marietta, GA 30060. Telephone: (770) 793-5580. E-mail:

The Crisis Prevention Institute offers nonviolent crisis intervention programs with one or two workshops including training in use of verbal and nonverbal techniques, appropriate use of physical intervention, team intervention strategies, and how to debrief after a crisis. For more information, contact:

Crisis Prevention Institute, 3315-K N. 124th St., Brookfield, WI 53005. Telephone: (800) 558-8976 or (262) 783-5787. Fax: (262) 783-5906. E-mail: Web: