This article presents recommendations developed in 2001 by a committee of the Maryland Department of Health and Mental Hygiene that are used for managing acute aggressive behavior of youths in residential and inpatient treatment facilities in Maryland. The recommendations are highly similar to practice parameters published by the American Academy of Child and Adolescent Psychiatry, although they were developed independently. The recommendations are not prescriptive, nor are they based on an algorithm. Rather, they are based on a therapeutic process and designed to acknowledge the importance of professional and patient autonomy. The first step in the therapeutic process is to define the problem by addressing three issues: the target symptoms, the severity of those symptoms, and possible precipitants of the aggressive behavior. The next two steps are to select the goals of the intervention and to choose among three levels of immediate intervention, from least to most restrictive. The recommendations describe specific interventions, including medications that can be used at each level. The authors caution that the recommendations should be used in accordance with current regulations of the Center for Medicaid and Medicare Services and the Joint Commission on Accreditation of Healthcare Organizations.