Patient is an 8 yr old that has a history of disruptive behaviors at school and at home. She has a history of PTSD ADHD reactive attachment disorder and is on quite a few meds for behavioral health. Apparently she did not sleep well last night and woke up this morning threatening to kill her family members and herself. She continued to escalate at home to the point where mom called psychiatry and they recommended that she come to the ED. She arrives in ED out of control hitting, biting, kicking, and screaming. Mom states that this type of behavior for her has happened frequently in the past but has not had an episode like this for a year or two. She apparently is doing quite well in school and has not had any recent issues. Mom states that when she has these outbursts or crisis that this is typical where she has just a sudden change in her behavior and becomes violent at home. She has not missed any of her medications. Mom denies fever, no recent cough no abdominal pain no nausea vomiting or other recent infections. Mom states that in the remote past she has had a UTI with high fever but typically infections have not caused behavior issues. Patient has an established psychiatrist and has had numerous hopitalizations regarding same issues. Started having visual hallucination yesterday, medication adjustment decreased (risperdal) decreased a couple of months ago with the thoughts that this may be contributing. Biological mother has history of bipolar disorder and grandmother and cousin has history affective schizoid disorder. For the past week her behaviors have been escalating and has been getting harder and harder to negotiate with child. She has threatened to kill her 3 yr old brother and mom concerned for safety of other children in the home.