What do we really know about PRN use in agitated children with mental health conditions: a clinical review

Abstract

What is the evidence that ‘pro re nata’ (PRN) medication is effective for ending agitated outbursts in children and adolescents in psychiatric emergency rooms or inpatient units? Literature search was performed for studies of PRN medication use in children and adolescents that included an outcome measure. One randomised controlled trial, three prospective studies and six retrospective studies that included some outcome measure were identified. Outcome measures were heterogeneous, and frequently did not use standardised metrics assessing agitation level to measure effectiveness. The single small Randomized Controlled Trial (RTC) does not find a difference between placebo and medication, and outcomes of other studies do not control for potential placebo effect of the intervention itself as opposed to the medication. There is insufficient evidence to support the common practice of PRN medications for the management of acute agitation, and no data with which to inform clinical practice, such as which medicines and doses are helpful for specific populations or situations. Psychiatrists have no evidence-based medication interventions for acutely managing agitated outbursts in children and adolescents.

Presidential Address: Emotion Dysregulation in Children and Adolescents

“…For a practice as widespread as PRN use, there are no randomized controlled trials demonstrating the effectiveness of this practice, and very little data with usable outcomes even documented. 25 This should not be surprising: oral drugs don't even start to work within the time frame needed to shorten the duration of a 45-minute outburst! I hope I've made a case for the seriousness of the problem of dysregulated behavior in children.…”

Nurses' responses to adolescent distress in an acute child and adolescent mental health inpatient unit: A qualitative interpretive descriptive study

“…The use of prn medication is another common intervention in C&A inpatient units (Baker & Carlson, 2018), with guidelines on the appropriate use and the clinical effectiveness of this intervention lacking. Due to insufficient evidence, clinical expertise often guides nurses in their use of prn medication as an intervention (Baker & Carlson, 2018).…”

“…Research regarding nursing interventions on acute child and adolescent inpatient units include those that report on prn medication, and coercive interventions such as seclusion and physical restraint (Azeem et al, 2017; Baker & Carlson, 2018). Nurses attend specific aggression minimization training that guides them in their physical restraint practices, however, these programs focus on the physical skills and do not incorporate other important interventions such as sensory modulation, or how to develop individualized, unit‐based behavior management plans that are likely to prevent aggression (Price & Price, 2019).…”

Debate: Putting psychiatric hospitalization for children and adolescents in its place: it is time to create a system of care that works

“…Although an inpatient unit would seem to be the safest place to explore reducing medication burden, the short duration of stays and crisis stabilization nature of treatment predictably results in more not less. Further, as needed (PRN) medications are often a main focus of behavioral management, despite the fact that there is no evidence that the use of PRNs improves outcomes (Baker & Carlson, 2018). Encouraging youth with poor impulse control who are at risk for substance abuse to take a pill in order to act and feel better is probably not the best therapeutic strategy.…”