Aggressive Behavior in Children and Adolescents: Psychiatric Pathology or P...

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 School Public

8. Violence directed against the Environment Firesetting Vandalism

9. Violence against self Cutting hand smashing head banging

10. Violence against Animals Pets Livestock Wildlife

11. What type of Aggresion is it? Physical With/without weapons Verbal Sexual

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             Male           Between the ages of 15 and 19           Poor           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           Homeless           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)                Conduct disorder                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:           Antisocial parents           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           Homeless status

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:           Income inequality           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 impulsive lots of affect unusual for culture disorganized purposeless

27. Important Diagnostic Considerations The Big 4 Conduct Disorder Bipolar Disorder Drug Induced Psychosis Schizophrenia

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 25% suicidal 55% have mixed mania

36. 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 5. Distractibility 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 Schizophrenia

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. Thought disorder

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 Look Familiar??

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 Poor recall

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 Alcohol withdrawal Drugs (prescription, over-the-counter, street; for example bromocriptine, levodopa, diet pills, amphetamines) Brain infections 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.