Who does this guideline apply to?

This guideline applies to adults, adolescents and children

Who is the audience for this guideline?

This guideline is for bystanders, first aiders and first aid training providers

Summary of Recommendations

The Australian and New Zealand Committee on Resuscitation (ANZCOR) makes the following recommendations [all Good Practice Statements]:

1. Ensure your safety and the safety of others; send for help early.
2. Attempt de-escalation strategies/techniques if experienced in these techniques.
3. Identify and treat any medical conditions and/or injuries when safe to do so.
4. Avoid physical restraint for an aggressive, agitated/behaviourally disturbed person.

First aiders and first aid providers may encounter persons presenting with abnormal behaviour including agitation, aggression and abnormal thinking or thoughts.  Behavioural disturbances can range from mild to life threatening.  Professional healthcare assessment is needed to determine the most likely cause of the abnormal behaviour to guide appropriate treatment. 

The immediate goals of first aid for the agitated/behaviourally disturbed person is keeping yourself, others and the person safe from harm.

Severe behavioural disturbance is behaviour that puts the disturbed person or others at immediate risk of serious harm and may include threatening or aggressive behaviour, extreme distress, and serious self-harm which could cause major injury or death.¹

Agitation or behavioural disturbance can have many causes and may or may not be related to a mental health disorder or other illness. There are many causes of agitation/behavioural disturbance including:

• Medical conditions: e.g., head injury, hypoxia (low oxygen levels in blood), severe infections/sepsis (e.g., meningitis), seizures, metabolic derangements (e.g., low blood sugar, electrolyte disturbance), organ failures (e.g., liver & kidney), dementia and delirium.
• Intoxication/withdrawal: e.g., alcohol, hallucinogens, stimulants (e.g., amphetamine type substances, cocaine), cannabis, synthetic drugs, opioids, sedatives.
• Mental health conditions: psychotic disorders (e.g., schizophrenia), anxiety disorders, and personality disorders.
• Others: developmental disorders e.g., intellectual disability, autism spectrum disorders, grief, situational stress, and pain.

These causes may be applicable to the person requiring first aid and/or others at the scene such as a parent, friend, partner or family member.  The first aid management of agitation/behavioural disturbance may apply to one or more people at the same time.²

Agitation/behavioural disturbance encompasses a variety of symptoms and signs alone or in combination. Diagnosis is largely based on history and physical findings. Symptoms and signs are highly variable but include:

• increased arousal (e.g., agitation, excitation, restlessness, pacing, tearful, wringing hands, screaming, yelling, frightened, frantic)
• a rigid body language (an indicator of an intense effort to control themselves)
• abnormal or unusual thinking, perception, or ideas (e.g. hallucinations)
• inappropriate clothing for the climate or context
• altered conscious state
• aggressive/violent/argumentative/bizarre behaviour.

A severe and potentially life-threatening form of behavioural disturbance is present when the person has:

• an elevated body temperature, is hot to touch or is sweating profusely
• insensitivity to pain (e.g., may be walking with a broken leg or severe injury)
• a rapid respiratory rate and rapid pulse rate
• extreme arousal with aggression or violence.

The initial approach to a person with agitation/behavioural disturbance should be focused on staying safe and seeking help. If you are unsure or feel threatened in any way, remove yourself from the situation and seek a safe space. Be aware of the danger and ensure safety of first aiders, others and the agitated person.

For those trained and experienced (e.g. first responders at events) attempts should be made to de-escalate the behaviour through the use of specific de-escalation techniques and engagement of the person in conversation [see below all Good Practice Statements].

• To ensure safety, seek help early by calling the emergency services number (e.g. ambulance, or police if weapons present or an immediate threat to safety).
• Seek advice or assessment from a healthcare professional if appropriate.
• Be calm and, if trained, engage with the person using de-escalation strategies (listed below).
• Enlist parents, friends, partners, family members if the agitated person is calmed by their presence.
• Manage life threatening injuries as soon as possible and prevent further injury.
• If the person deteriorates or becomes unconscious manage the person according to ANZCOR Guideline 3.
• If the person becomes unresponsive and not breathing normally, give resuscitation following the Basic Life Support Flowchart (Refer to ANZCOR Guideline 8).

Staying safe is a priority. Be aware of the potential danger and ensure safety of first aiders, others and the behaviourally disturbed person. If you are unsure or feel threatened in any way, remove yourself and others from the situation, seek a safe space and send for appropriate support and assistance by calling the emergency services number (000 in Australia; 111 in New Zealand).  The following is from Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup [all Good Practice Statements].⁴

• Avoid being alone with the person and when possible keep at least two arm lengths away.
• Always face the person, maintain visual contact and never turn your back.
• Be vigilant for signs of violence or escalation.
• Make sure there is access to two exits if possible and avoid blocking exits.
• Remove any object that could be used as weapons.
• People who are calming may be of assistance but try to keep conflict partners away from the person.
• It is helpful to find someone the person knows and trusts to help with their care, but do not leave the scene to find that person.
• Be aware the person may act on a delusion or hallucination, and this may not make sense to the first aider.
• If a person does become violent or you feel unsafe; stop managing them, move to safety and send for help by calling the emergency services number.
• Watch for decreasing level of consciousness.

Recommended de-escalation strategies for health professionals, first responders, mental health first aiders and those trained in de-escalation techniques. It is recommended that these skills be practiced annually through role playing with non-agitated persons acting out as difficult and not conforming to what is expected and accepted behaviour.⁴

Remain calm and non-confrontational [all Good Practice Statements].

• Speak softly, slowly and politely with a gentle, caring tone of voice.
• Maintain a non-threatening body language and do not argue with the person.
• Avoid raising your voice or talking too fast.
• Avoid prolonged eye contact with the person and respect their personal space.
• Listen closely and non-judgementally to what the person is saying and feeling.
• Reassure, empathise, agree with the person’s position when possible and help them feel safe.
• Consider inviting the person to sit down if they are standing.

Manage the situation/environment [all Good Practice Statements].

• Do not allow the person to be crowded by friends/family or bystanders (a support person may be helpful).
• If safe to do so, move the person to a quiet area and place in a comfortable position.
• Reduce external stimuli such as noise, odour, light, and background movement.
• Handle gently and touch only when necessary or with permission.
• Be clear and specific about what is acceptable behaviour– use words the person will understand.
• Consider taking a break from the conversation to allow the person to calm down.
• Be aware of the person’s cultural background to avoid words or actions that are taboo or could shame the person.
• Offer choices/alternatives for the person to stay in control without aggression or violence.

The effective management of behavioural disturbance in children is difficult and requires specialised training and extensive experience, increasing the need to seek appropriate support and assistance early.  The same general principles of management apply as described above modified to the child’s age and needs. 

The initial focus of management should be on your safety, the safety of others and the safety of the child. Involvement of the child’s family/carer (if available and appropriate) will generally be helpful in the first aid setting.  The child’s family/carer will be able to provide advice and assistance to determine the most likely effective de-escalation strategies such as age-appropriate distraction techniques (e.g. toys) [Good Practice Statement].

Physical restraint is associated with potential harm to both the aggressive or agitated/behaviourally disturbed person and the care provider.  The risks of physical restraint typically outweigh the benefits.  Restraint can escalate violence or result in physical injury to both parties.  ANZCOR recommends avoiding the physical restraint of aggressive, agitated/behaviourally disturbed persons by bystanders/first aiders and first aid providers [Good Practice Statement].

1. Health NSW: Management of patients with Acute Severe Behavioural Disturbance in Emergency Departments. Volume Viewed October 2024. Edited by Health. health.nsw.gov.au; 2015.
2. Iroku-Malize T, Grisson M: The agitated patient: Steps to take, how to stay safe. The Journal of Family Practice. 2018, 67:136-147.
3. Rozel J, Stowell K, Thorkelson G: The Diagnosis and management of Agitation. Cambridge University Press; 2017.
4. Richmond J, Berlin J, Fishkind A, et al.: Verbal De-escalation of the Agitated Patient: Consensus Statement of the American Association for Emergency Psychiatry Project BETA De-escalation Workgroup. West J Emerg Med. 2012, 13:17-25. 10.5811/westjem.2011.9.6864
5. Kitchener B, Jorm A, Kelly C: Mental health first aid manual (Red Cross). 2017.
6. Langlands R, Jorn A, Kelly C, Kitchener B: First aid recommendations for psychosis: using the Delphi method to gain consensus between mental health consumers, carers, and clinicians. Schizophren Bull. 2008, 34:435-443. 10.1093/schbul/sbm099

• ANZCOR Guideline 2 - Managing an emergency
• ANZCOR Guideline 8 - Cardiopulmonary Resuscitation
• ANZCOR Guideline 9.5.1 - Emergency management of a person who has been poisoned
• Kitchener BA, Jorm AF, Kelly CM. Mental Health First Aid Manual. 4^th Melbourne: Mental Health First Aid Australia; 2017, reprinted 2023.

When citing the ANZCOR Guidelines we recommend:

ANZCOR, 2025, Guideline 9.2.11 – First Aid Management of The Agitated Person, accessed 31 July 2025, https://www.anzcor.org/home/new-guideline-page-2/guideline-9-2-11-first-aid-management-of-the-agitated-person