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1. Aggressive Behavior in Children and Adolescents: Psychiatric Pathology or Pathologic Community?
James Chandler MD, FRCPC
Chief of Psychiatry
Yarmouth Regional Hospital
February 15, 2006
2. Examples of Aggression 11 y.o. white male referred for fighting. Amongst other details of his violence, it is revealed that he has taken a cat, put its head in a vice, and sawed off the head.
3. More! 12 y.o. white male referred for fighting. For no apparent reason, he flattens one of his classmates, giving him a black eye and stitches.
4. And last week... 7 y.o. male will not go to school. RCMP is called to come and talk with him. The boy swears at the RCMP and then attacks them. The mounties comment? “That kid needs to be on meds!”
5. Accurate Diagnosis of Aggression depends on: Determining the type, frequency, and severity of the episodes
Considering the big 4 treatable causes
Understanding that violence begets violence
Realizing that a single etiology for Aggression is the exception
7. The Aggresion Review of Systems What is the aggression directed against?
Violence against others
Home- parents, sibs, others
8. Violence directed against the Environment Firesetting
9. Violence against self Cutting
10. Violence against Animals Pets
11. What type of Aggresion is it? Physical
12. How Crazy was this? Well thought out/totally impulsive
Bullies attacking weak child who refuses to pay protection/ breaking up windows in broad daylight
Has some point/ totally disorganized
Throwing rocks at RCMP house/Hitting self, doors, neighbors, and cat
Culturally understandable/ out of character for culture
Burning tires in the road on Halloween/ carrying handguns to school
13. Cold blood? What was the mood? Volcanic anger and irritability/ cool and calculating
14. Determine the Risk Factors Individual factors for Aggressive Behavior
Between the ages of 15 and 19
A racial or ethnic minority
A member of a violent family
15. More Individual Risk Factors Dating
Angry after experiencing a violent trauma
Involved in serious criminal behavior
A runaway from home
Using/abusing alcohol or legal/illegal drug
16. If the child or adolescent has:
History of early aggressive behavior
A comorbid psychiatric diagnosis of
Attention-deficit hyperactivity disorder (predominately hyperactive type)
Multiple personality disorder
A low obtained (IQ) on standardized intellectual tests
17. If the child or adolescent:
Uses or abuses substances
Believes violence is effective for resolving conflicts
Accepts that violence or aggression is normal
Carries a weapon
Engages in antisocial behavior and hostile talk with other males about females
Threatens others (infrequently or frequently)
18. If the Child has- Poor academic performance
A learning disability
A history of physical or sexual abuse
Peers who are violent
Associates with delinquent peers
Access to a weapon
19. Family factors
If the child or adolescent has:
Physically aggressive parents
Parents who use harsh physical Punishment to discipline
Poor supervision by parents
A mother was parent at an early age
A Family with low socioeconomic status
A parent who abuses alcohol or other substances
20. If the child or adolescent experiences:
Parental conflict in early childhood
A low level of attachment with parents
Parental separation or divorce when child or adolescent is at a young age
A low level of family cohesion.
21. Environmental and cultural factors
If the adolescent:
Lives in an urban area
Attends a large urban school that serves the very poor
22. Social, political, and cultural factors
If the adolescent lives in an area or region where there is:
Rapid demographic changes in the youth population, urbanization
A culture does not provide nonviolent alternative for resolving conflicts
23. The other side of the coin Few aggressive children are born that way, most have been the victims of violence themselves.
If you ask a child whether or not he has been involved in a violent act as the aggressor, you must also ask if he has been the victim
24. If you ask- “Have you ever ended up losing your temper and hit your brother or parents?”
25. must be followed with- “Have your parents ever lost their temper with you and ended up hitting you?”
26. Putting it all together (so far) When is a psychiatric cause other than Conduct Disorder most likely?
Few Risk factors
lots of affect
unusual for culture
27. Important Diagnostic Considerations The Big 4
Drug Induced Psychosis
28. Conduct Disorder DSM-IV diagnostic criteria for conduct disorder are:
A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past 6 months:
29. Aggression to people and animals (1) often bullies, threatens, or intimidates others(2) often initiates physical fights(3) has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun)(4) has been physically cruel to people(5) has been physically cruel to animals(6) has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery)(7) has forced someone into sexual activity
30. Destruction of property (8) has deliberately engaged in fire setting with the intention of causing serious damage(9) has deliberately destroyed others' property (other than by fire setting)Deceitfulness or theft(10) has broken into someone else's house, building, or car(11) often lies to obtain goods or favors or to avoid obligations (i.e., "cons" others)(12) has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery)
31. Serious violations of rules (13) often stays out at night despite parental prohibitions, beginning before age 13 years(14) has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period)(15) is often truant from school, beginning before age 13 years
32. B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning
33. Not exactly a specific diagnosis. Children with major conduct disorder at age 8 will have increased rates of every psychiatric disorder by early adulthood, not just antisocial PD
34. A number of important diagnoses can look like Conduct Disorder including: Bipolar IllnessPsychosisHigh Functioning Autism with stressorsDrug induced psychosisTrauma related disorders- Dissociative Disorder
35. Bipolar Disorder looks different in children than adults 77% have at least daily mood swings, often 3-5 times a day
age of onset is about 6-10 years old
episode length is forever- averaging 1-2 years
55% have mixed mania
An elevated, expansive, or irritable mood, lasting at least 1 week. This mood is also accompanied by at least three (four if mood is only irritable) of the following:
1. Inflated self -esteem or grandiosity
2. Decreased need for sleep
3. Increased talkativeness or pressure to keep talking
4. Racing thoughts or flight of ideas
6. Increased Activity or psychomotor agitation
7. Excessive involvement in pleasurable activities that have a high potential for painful consequences.
The disturbance should be so severe that hospitalization is required to avoid harming themselves or others.
37. Symptom Thresholds
When ascertaining the presence or absence of manic symptoms, we recommend that clinicians use the FIND (frequency, intensity, number, and duration) strategy to make this determination. FIND guidelines for the diagnosis of BPD include
38. Frequency: symptoms occur most days in a week Intensity: symptoms are severe enough to cause extreme disturbance in one domain or moderate disturbance in two or more domains
39. Number: symptoms occur three or four times a day
Duration: symptoms occur 4 or more hours a day, total, not necessarily contiguous
40. Lots of comorbidity 87% have ADHD78% have ODD10-25% have Conduct Disorder
41. Genetics Family studies find that if one parent has a major affective disorder the risk to the offspring is 25–30%, whereas if both parents have an affective disorder the risk to the offspring may be as high as 50–75%.
Childhood onset bipolar disorder is more genetic
also more psychosis
42. Treatment of Bipolar disorder
Atypical Antipsychotics – that is-
Zyprexa, Seroquel, and Risperidal
And if that doesn’t work switch or add mood stabilizers like-
Divalproex, Lithium , Carbamazepine
43. Schizophrenia Remember-
This is not a common disease
Only .5% of population have this.
Onset before age 10 is almost impossible
Onset before age 13 is quite rare
BUT, late teenage onset is common
44. Who has it? Odd strange children who weren’t always that type of a person.
Engaging in unusual aggressive acts.
45. Very hard to pick up because? Teens don’t often talk about hallucinations readily
Comorbid disorders mask it, especially substance abuse
Paranoid people don’t go to doctors readily
46. What makes it even worse is- Only a third who present have a family history of Schizophrenia
One quarter don’t even show a prodrome of negative symptoms
As a result, it takes about a year to get diagnosed on the average.
47. Don’t Worry- The treatment in 2006 of Aggression in-
early onset Schizophrenia, Bipolar Disorder, Severe Conduct Disorder, Drug-induced Psychosis, and Aggression from Fetal Alcohol Syndrome, Head Trauma, Epilepsy, …..
IS ALL THE SAME!
48. Treatment of Schizophrenia The more severe the illness, the more the risk/benefit ratio favors treatment
49. Medical treatment Atypical Antipsychotics – that is-
Zyprexa, Seroquel, and Risperidal
Or Clozapine if that fails
50. Drug induced psychosis In our area, biggest culprits are-
marijuana, Acid, Cocaine, and mushrooms.
Plus many minor players including:
PCP, Ecstasy, other amphetamines, embalming fluid …..
51. Cannabis Increases risk of psychosis for all.
Doubles risk of schizophrenia developing
Aggravates symptoms of schizophrenia
52. Other drugs Of the many drugs now available that cause psychosis, few are measured in our urine drug screens-
Many are very cheap
Cocaine, LSD, PCP, Mushrooms, Ectasy, Emballming fluid all have been implicated in psychosis in my practice in the last year.
53. Disassociation For the most part, dissociative symptoms result from horrible trauma, usually sexual abuse.
Sexual abuse predicts violence in kids
54. Aggression from Disassociation usually includes a picture of Self harm
Totally out of control behavior
Totally out of control emotions
Totally out of character (sometimes)
Sudden onset and offset
55. But almost never- Movie style separation of personalities
Movie style changes from one personality to another
If these are the case, think factious
56. Treatment See a Psychiatrist soon
Emergent use, and sometimes chronic use of Atypical Antipsychotics
57. Agitation in Autistic Spectrum Disorder People with Autism have
Poor social skills
Poor language skills
Restricted range of interest
Which usually means few coping mechanisms for stress
58. So if you put them in a stress full environment Physically-lots of pain
Emotionally- lots of teasing of family problems
Personally- take away their activities
They can’t cope and melt down, often even hearing voices
Usually improves over a few weeks
Occasionally requires short term meds – best studied is Risperidal
59. The many other causes of violence in children Is this an acute Confusional state?
Aggression with pronounced flucuations in consciousness
Hard to pick out sometimes in population with 10+ risk factors for aggression
60. Common Causes of the Acute Confusional State
Intoxications—alcohol; prescription, over-the-counter, and street drugs; solvents; heavy metals; pesticides; carbon monoxide
Withdrawal states—alcohol, sedative-hypnotic drugs
Nutritional deficiencies—thiamine (Wernicke’s encephalopathy), vitamin B12 , folate, niacin
Metabolic disorders—electrolyte and acid-base disturbances; hepatic, renal, pancreatic disease
Infections—pneumonia, urinary tract infection, sepsis, AIDS
Endocrinopathies—hypo- and hyperthyroidism, hypo- and hyperglycemia, hypo- and hyperadrenocorticism
Structural brain disease—traumatic brain injury, seizure disorders, stroke, subarachnoid or parenchymal hemorrhage, epidural or subdural hematoma, encephalitis, brain abscess
Postoperative states—anesthesia, electrolyte disturbances, fever, hypoxia, analgesics
61. Disorders Associated with Secondary Psychosis
Complex partial seizures
Traumatic brain injury and Stroke
Drugs (prescription, over-the-counter, street; for example bromocriptine, levodopa, diet pills, amphetamines)
Metabolic disorders (hepatic, renal, thyroid disease; vitamin deficiencies) Brain neoplasms
Multiple sclerosis Dementia (Huntington’s disease, Wilson’s disease)
62. However Recall that: Uncommon diseases are extremely uncommon in Pediatrics
An atypical presentation of a common illness (bipolar disorder) is still much more common than a classic presentation of a rare disorder (Wilson’s, Porphyria)
Most cases with a medical cause will come with a medical history
63. When to Worry Aggression with no risk factors
Aggression with no family history of mood disorder or psychosis
Few factors, but multiple volumes of non-psychiatric charts
64. In Summary- Aggression can be a symptom of a disintegrating society
Aggression can be a symptom of a medical (including psychiatric) problem
65. The interaction of the two- Many events that occur in a disintegrating society increase the likelihood of certain disorders which have Aggression as a symptoms such as:
Trauma, Drugs and Alcohol in utero, trauma, poverty, malnutrition….
66. The good news It won’t be hard to find causes for aggression
The medical treatment is relatively non-specific and easy to remember
Few Canadians have handguns
67. The bad news
Trying to treat aggression as a physician in our society is like going to ( your choice of country) after a disaster and treating diarrhea with antibiotics.