Aggressive Behavior in Children and Adolescents: Psychiatric Pathology or Pathologic

Community?James Chandler MD, FRCPC

Chief of Psychiatry

Yarmouth Regional Hospital

February 15, 2006

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.

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.

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!”

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

The Aggresion Review of SystemsWhat is the aggression directed against?

• Violence against others

– Home- parents, sibs, others

– School

– Public

Violence directed against the Environment• Firesetting

• Vandalism

Violence against self

• Cutting

• hand smashing

• head banging

Violence against Animals

• Pets

• Livestock

• Wildlife

What type of Aggresion is it?• Physical

• With/without weapons

• Verbal

• Sexual

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

Cold blood? What was the mood?• Volcanic anger and irritability/ cool

and calculating

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

•          

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

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

   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)

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

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

    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.

Environmental and cultural factors

•

•     If the adolescent:

•           Lives in an urban area

•           Attends a large urban school that serves the very poor

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

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

If you ask-

• “Have you ever ended up losing your temper and hit your brother or parents?”

must be followed with-

• “Have your parents ever lost their temper with you and ended up hitting you?”

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

Important Diagnostic Considerations • The Big 4

– Conduct Disorder

– Bipolar Disorder

– Drug Induced Psychosis

– Schizophrenia

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:

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

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)

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

• B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning

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

A number of important diagnoses can look like Conduct Disorder including:

Bipolar IllnessPsychosisHigh Functioning Autism with stressorsDrug induced psychosisTrauma related disorders- Dissociative Disorder

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

–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.

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

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

• Number: symptoms occur three or four times a day

• Duration: symptoms occur 4 or more hours a day, total, not necessarily contiguous

Lots of comorbidity

•87% have ADHD78% have ODD10-25% have Conduct Disorder

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

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

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

Who has it?

• Odd strange children who weren’t always that type of a person.

• Engaging in unusual aggressive acts.

• Thought disorder

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

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.

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!

Treatment of Schizophrenia

• The more severe the illness, the more the risk/benefit ratio favors treatment

Medical treatment

• Atypical Antipsychotics – that is-

• Zyprexa, Seroquel, and Risperidal

• Or Clozapine if that fails

• Look Familiar??

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 …..

Cannabis

• Increases risk of psychosis for all.

• Doubles risk of schizophrenia developing

• Aggravates symptoms of schizophrenia

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.

Disassociation

• For the most part, dissociative symptoms result from horrible trauma, usually sexual abuse.

• Sexual abuse predicts violence in kids

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

But almost never-

• Movie style separation of personalities

• Movie style changes from one personality to another

• If these are the case, think factious

Treatment

• See a Psychiatrist soon

• Emergent use, and sometimes chronic use of Atypical Antipsychotics

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

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

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

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

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)

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

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

In Summary-

• Aggression can be a symptom of a disintegrating society

• Aggression can be a symptom of a medical (including psychiatric) problem

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….

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

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.