Title: Aggressive Behavior in Children and Adolescents: Psychiatric Pathology or Pathologic Community
1Aggressive Behavior in Children and Adolescents
Psychiatric Pathology or Pathologic Community?
- James Chandler MD, FRCPC
- Chief of Psychiatry
- Yarmouth Regional Hospital
- February 15, 2006
2Examples 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.
3More!
- 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.
4And 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!
5Accurate 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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7The Aggresion Review of Systems
- What is the aggression directed against?
- Violence against others
- Home- parents, sibs, others
- School
- Public
8Violence directed against the Environment
9Violence against self
- Cutting
- hand smashing
- head banging
10Violence against Animals
11What type of Aggresion is it?
- Physical
- With/without weapons
- Verbal
- Sexual
12How 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
13Cold blood? What was the mood?
- Volcanic anger and irritability/ cool and
calculating
14Determine 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
-
15More 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 -
16If 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)
18If 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
19Family 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.
-
21Environmental and cultural factors
-
- If the adolescent
- Lives in an urban area
- Attends a large urban school that
serves the very poor
22Social, 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
23The 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
24If you ask-
- Have you ever ended up losing your temper and
hit your brother or parents?
25must be followed with-
- Have your parents ever lost their temper with
you and ended up hitting you?
26Putting 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
27Important Diagnostic Considerations
- The Big 4
- Conduct Disorder
- Bipolar Disorder
- Drug Induced Psychosis
- Schizophrenia
28Conduct 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
29Aggression 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
30Destruction 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)
31Serious 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
33Not 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
34A number of important diagnoses can look like
Conduct Disorder including
- Bipolar IllnessPsychosisHigh Functioning
Autism with stressorsDrug induced
psychosisTrauma related disorders- Dissociative
Disorder
35Bipolar 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.
37Symptom 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
38Frequency 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
40Lots of comorbidity
- 87 have ADHD78 have ODD10-25 have Conduct
Disorder
41Genetics
- 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
42Treatment 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
43Schizophrenia
- 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
44Who has it?
- Odd strange children who werent always that type
of a person. - Engaging in unusual aggressive acts.
- Thought disorder
45Very 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
46What 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.
47Dont 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!
48Treatment of Schizophrenia
- The more severe the illness, the more the
risk/benefit ratio favors treatment
49Medical treatment
- Atypical Antipsychotics that is-
- Zyprexa, Seroquel, and Risperidal
- Or Clozapine if that fails
- Look Familiar??
50Drug induced psychosis
- In our area, biggest culprits are-
- marijuana, Acid, Cocaine, and mushrooms.
- Plus many minor players including
- PCP, Ecstasy, other amphetamines, embalming fluid
..
51Cannabis
- Increases risk of psychosis for all.
- Doubles risk of schizophrenia developing
- Aggravates symptoms of schizophrenia
52Other 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.
53Disassociation
- For the most part, dissociative symptoms result
from horrible trauma, usually sexual abuse. - Sexual abuse predicts violence in kids
54Aggression 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
55But almost never-
- Movie style separation of personalities
- Movie style changes from one personality to
another - If these are the case, think factious
56Treatment
- See a Psychiatrist soon
- Emergent use, and sometimes chronic use of
Atypical Antipsychotics
57Agitation 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
58So 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
59The 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
60Common 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
61Disorders 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)
62However 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
63When 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
64In Summary-
- Aggression can be a symptom of a disintegrating
society - Aggression can be a symptom of a medical
(including psychiatric) problem
65The 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.
66The 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
67The 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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