Aggressive behaviors not manageable at home, school, or in other community settings constitute one of the major reasons for psychiatric hospitalization of children, but reduction and prevention of such behaviors in inpatient settings remain elusive goals. Strategies with varying degrees of success have ranged from reliance on therapeutic milieu as a positive treatment agent in and of itself to psychotherapeutic, behavioral, and psychopharmacological approaches targeted to specific disorders.¹ Challenges include the diverse biologic, psychological, familial, environmental, and diagnostic factors that may be associated with aggressive episodes²; limitations in adapting evidence-based, disorder-specific treatments developed in non-inpatient or specialized settings (for example, for individuals with autism spectrum disorder and other developmental disabilities) to the contingencies of 24-hour care in general inpatient units; and implementation of interventions such as time-outs, manual holds, and PRN and STAT medications for agitation in the context of current Joint Commission standards for seclusion, restraint (physical and chemical), and behavior management.³ Point and level systems that are integral components of behavior modification programs (BMPs) on child inpatient units have been the subject of criticism based on limited empirical support and concerns as to whether such systems take adequate account of the needs of individual patients.⁴ Opportunities for demonstration of relative effectiveness of BMPs in comparison to other milieu-based programs in acute care settings are limited owing to practical issues in implementation of differing interventions requiring round-the-clock staff participation and methodological issues in comparison of findings between studies.