Aggressive Behavior in Children and Adolescents: Psychiatric Pathology or Pathologic Community?

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Aggressive Behavior in Children and Adolescents
Psychiatric Pathology or Pathologic Community?

• James Chandler MD, FRCPC
• Chief of Psychiatry
• Yarmouth Regional Hospital
• February 15, 2006

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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.

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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.

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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!

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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

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The Aggresion Review of Systems

• What is the aggression directed against?
• Violence against others
• Home- parents, sibs, others
• School
• Public

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Violence directed against the Environment

• Firesetting
• Vandalism

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Violence against self

• Cutting
• hand smashing
• head banging

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Violence against Animals

• Pets
• Livestock
• Wildlife

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What type of Aggresion is it?

• Physical
• With/without weapons
• Verbal
• Sexual

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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

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Cold blood? What was the mood?

• Volcanic anger and irritability/ cool and
  calculating

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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
•          

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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

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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

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   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)

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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

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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

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    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.

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Environmental and cultural factors

•      If the adolescent
•           Lives in an urban area
•           Attends a large urban school that
  serves the very poor

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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

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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

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If you ask-

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

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must be followed with-

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

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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

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Important Diagnostic Considerations

• The Big 4
• Conduct Disorder
• Bipolar Disorder
• Drug Induced Psychosis
• Schizophrenia

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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

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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

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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)

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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

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

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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

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A number of important diagnoses can look like
Conduct Disorder including

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

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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

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• 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.

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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

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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

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• Number symptoms occur three or four times a day
• Duration symptoms occur 4 or more hours a day,
  total, not necessarily contiguous

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Lots of comorbidity

• 87 have ADHD78 have ODD10-25 have Conduct
  Disorder

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Genetics

• Family studies find that if one parent has a
  major affective disorder the risk to the
  offspring is 2530, whereas if both parents have
  an affective disorder the risk to the offspring
  may be as high as 5075.
• Childhood onset bipolar disorder is more genetic
• also more psychosis

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Treatment of Bipolar disorder

• Atypical Antipsychotics that is-
• Zyprexa, Seroquel, and Risperidal
• And if that doesnt work switch or add mood
  stabilizers like-
• Divalproex, Lithium , Carbamazepine
• Schizophrenia

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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

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Who has it?

• Odd strange children who werent always that type
  of a person.
• Engaging in unusual aggressive acts.
• Thought disorder

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Very hard to pick up because?

• Teens dont often talk about hallucinations
  readily
• Comorbid disorders mask it, especially substance
  abuse
• Paranoid people dont go to doctors readily

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What makes it even worse is-

• Only a third who present have a family history of
  Schizophrenia
• One quarter dont even show a prodrome of
  negative symptoms
• As a result, it takes about a year to get
  diagnosed on the average.

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Dont 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!

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Treatment of Schizophrenia

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

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Medical treatment

• Atypical Antipsychotics that is-
• Zyprexa, Seroquel, and Risperidal
• Or Clozapine if that fails
• Look Familiar??

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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
  ..

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Cannabis

• Increases risk of psychosis for all.
• Doubles risk of schizophrenia developing
• Aggravates symptoms of schizophrenia

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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.

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Disassociation

• For the most part, dissociative symptoms result
  from horrible trauma, usually sexual abuse.
• Sexual abuse predicts violence in kids

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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

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But almost never-

• Movie style separation of personalities
• Movie style changes from one personality to
  another
• If these are the case, think factious

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Treatment

• See a Psychiatrist soon
• Emergent use, and sometimes chronic use of
  Atypical Antipsychotics

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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

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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 cant cope and melt down, often even hearing
  voices
• Usually improves over a few weeks
• Occasionally requires short term meds best
  studied is Risperidal

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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

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Common Causes of the Acute Confusional State

• Intoxicationsalcohol prescription,
  over-the-counter, and street drugs solvents
  heavy metals pesticides carbon monoxide
• Withdrawal statesalcohol, sedative-hypnotic
  drugs
• Nutritional deficienciesthiamine (Wernickes
  encephalopathy), vitamin B12 , folate, niacin
• Metabolic disorderselectrolyte and acid-base
  disturbances hepatic, renal, pancreatic disease
• Infectionspneumonia, urinary tract infection,
  sepsis, AIDS
• Endocrinopathieshypo- and hyperthyroidism, hypo-
  and hyperglycemia, hypo- and hyperadrenocorticism
  
• Structural brain diseasetraumatic brain injury,
  seizure disorders, stroke, subarachnoid or
  parenchymal hemorrhage, epidural or subdural
  hematoma, encephalitis, brain abscess
• Postoperative statesanesthesia, electrolyte
  disturbances, fever, hypoxia, analgesics

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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 (Huntingtons
  disease, Wilsons disease)

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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
  (Wilsons, Porphyria)
• Most cases with a medical cause will come with a
  medical history

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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

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In Summary-

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

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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.

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The good news

• It wont be hard to find causes for aggression
• The medical treatment is relatively non-specific
  and easy to remember
• Few Canadians have handguns

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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.

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