the aggressive child:

The Aggressive The Aggressive Child:Child:

Oppositional Defiant and Oppositional Defiant and Conduct DisordersConduct Disorders

Michael Kisicki, M.D.Seattle Children’s Hospital

Echo Glen Children’s CenterUniversity of Washington, Department of Psychiatry

PAL ProgramPAL Program

Main Points Main Points

SafetySafety

Assess and treat comorbid conditionsAssess and treat comorbid conditions

Address risk factors and bolster strengthsAddress risk factors and bolster strengths

Behavioral interventions firstBehavioral interventions first

Medications secondary and adjunctiveMedications secondary and adjunctive


Nature of AggressionNature of Aggression

Development of contrary and aggressive Development of contrary and aggressive behaviorbehavior

Psychological factorsPsychological factors

Environmental factorsEnvironmental factors

Physiological factorsPhysiological factors

Determining pathologicDetermining pathologic


Developmental TrajectoryDevelopmental Trajectory

From “Developmental Origins of Aggression” by Tremblay, Hartup and Archer (2005)PAL ProgramPAL Program

DevelopmentDevelopment

Infants promote bonding with behaviorInfants promote bonding with behavior

Anger expression by age 6 monthsAnger expression by age 6 months

Toddlers show defiance as they individuateToddlers show defiance as they individuate

Tantrums diminish in school age childrenTantrums diminish in school age children

Social conformity progresses in elementarySocial conformity progresses in elementary

Testing limits, debating, experimenting in Testing limits, debating, experimenting in early teensearly teens


PhysiologyPhysiology

GeneticsGenetics

Autonomic nervous systemAutonomic nervous system

EndocrineEndocrine

NeuroanatomyNeuroanatomy

SerotoninSerotonin

ToxinsToxins


Nature - NurtureNature - Nurture

Caspi, et al 2002PAL ProgramPAL Program

NeuroanatomyNeuroanatomy

Orbito/frontal: reactive Orbito/frontal: reactive aggression, negative aggression, negative affective style, affective style, impulsivityimpulsivity

Temporal: Temporal: unprovoked unprovoked aggressionaggression

Amygdala: Amygdala: interpretation of social interpretation of social cuescues


Distinguishing PathologicDistinguishing Pathologic

SafetySafety

Variety of symptoms and settingsVariety of symptoms and settings

Proactive aggression and crueltyProactive aggression and cruelty

Use of weaponUse of weapon

Contrary to social groupContrary to social group

Behavior atypical for ageBehavior atypical for age


AssessmentAssessment


SAFETYSAFETYAbuse, neglectAbuse, neglect

Presence of weaponPresence of weapon

Past behaviorPast behavior

Use of drugs/alcoholUse of drugs/alcohol

Acute psychiatric illness (mania, psychosis)Acute psychiatric illness (mania, psychosis)

Suicide Suicide


Treatment Focused HistoryTreatment Focused History

When, how, what,? Focusing on modifiable variablesWhen, how, what,? Focusing on modifiable variables

Hot or cold?Hot or cold?

Time course, association with stressor?Time course, association with stressor?

Risk factorsRisk factors

StrengthsStrengths

Information from multiple sources Information from multiple sources

Measures, scales (Vanderbilts, OAS)Measures, scales (Vanderbilts, OAS)


Individual FactorsIndividual Factors

Family history (ADHD, DBD, PDD, mood)Family history (ADHD, DBD, PDD, mood)

Temperament, affect dysregulationTemperament, affect dysregulation

Reading, speech/languageReading, speech/language

Social skillsSocial skills

Prenatal, environmental toxic exposurePrenatal, environmental toxic exposure


ParentingParenting

Parental mental illnessParental mental illness

Low involvementLow involvement

High conflictHigh conflict

Poor monitoringPoor monitoring

Harsh inconsistent Harsh inconsistent disciplinediscipline

Physical punishmentPhysical punishment

Lack of warmth and Lack of warmth and involvementinvolvement

Parental burn outParental burn outPAL ProgramPAL Program

Child AbuseChild Abuse

Physical abuse and neglect predict APD, Physical abuse and neglect predict APD, criminal behavior, violencecriminal behavior, violence

Abused children have social processing Abused children have social processing deficitsdeficits

Sexual abuse victims of both genders Sexual abuse victims of both genders develop DBD, girls have more internalizingdevelop DBD, girls have more internalizing

Risk reduced when removed Risk reduced when removed


PeersPeers

Rejected and Rejected and reinforced by pro-reinforced by pro-social peerssocial peers

Uneasy affirmation Uneasy affirmation by anti-social by anti-social peerspeers

Females more Females more sensitive to sensitive to rejectionrejection


NeighborhoodNeighborhood

More predictive of DBD More predictive of DBD than any other than any other psychopathologypsychopathology

Public housing Public housing outweighs all protective outweighs all protective factorsfactors

Disorganization, drugs, Disorganization, drugs, adult criminals, racial adult criminals, racial prejudice, poverty, prejudice, poverty, unemploymentunemployment


Oppositional Defiant DisorderOppositional Defiant Disorder

Defiance, anger, quick temper, bullying, Defiance, anger, quick temper, bullying, spitefulness, usually before 8 years of agespitefulness, usually before 8 years of age

Usually resolves, 1/3 develop conduct disorderUsually resolves, 1/3 develop conduct disorder

High rate of comorbidityHigh rate of comorbidity

Irritability is a component (think about when Irritability is a component (think about when considering Bipolar NOS)considering Bipolar NOS)


Conduct DisorderConduct Disorder

Repetitive + persistent, violates basic rights of Repetitive + persistent, violates basic rights of others or societal normsothers or societal norms

Aggression, property destruction, theft, deceit, Aggression, property destruction, theft, deceit, truancytruancy

Prognosis depends on age, aggression and social Prognosis depends on age, aggression and social withdrawal withdrawal

Boys: higher prevalence, more persistence and Boys: higher prevalence, more persistence and aggressionaggression

Girls: less persistent, more covert behavior and Girls: less persistent, more covert behavior and problematic relationshipsproblematic relationships

Less Aggression and more rights violations with Less Aggression and more rights violations with age.age.


PrevalencePrevalence

5% of kids5% of kids

ODD: 2-16% of community, 50% of clinicODD: 2-16% of community, 50% of clinic

CD: 1.5-3.4% of community adolescents, CD: 1.5-3.4% of community adolescents, 30-50% in clinic30-50% in clinic

Usually resolves, 1/3 of ODD develop CDUsually resolves, 1/3 of ODD develop CD

Adult antisocial personality disorder: 2.6%Adult antisocial personality disorder: 2.6%

Boys >> girls, unless you consider Boys >> girls, unless you consider relational aggressionrelational aggression


Comorbid DisordersComorbid Disorders

ADHD, 10x the prevalence; inattention, ADHD, 10x the prevalence; inattention, impulsivity, hyperactivity. Vanderbilts.impulsivity, hyperactivity. Vanderbilts.

MDD, 7x the prevalence; mood MDD, 7x the prevalence; mood complaints, neurovegative symptoms. complaints, neurovegative symptoms. SMFQ.SMFQ.Substance abuse, 4x the prevalence; by Substance abuse, 4x the prevalence; by history, UA. CRAFFT history, UA. CRAFFT (car, relax, alone, forget, friends, trouble)(car, relax, alone, forget, friends, trouble)

PTSD, Autism, BipolarPTSD, Autism, Bipolar


Treatment MenuTreatment Menu

EducationEducation

Treat co-morbid medical and Treat co-morbid medical and psychiatric conditionspsychiatric conditions

Parenting supportParenting support

PsychotherapyPsychotherapy

Community/Multimodal servicesCommunity/Multimodal services

MedicationMedication


Acute AgitationAcute Agitation

Attention to your own demeanor, Attention to your own demeanor, environmentenvironment

Provide some sense of control, choicesProvide some sense of control, choices

Distractions, foodDistractions, food

Medications (oral, risperidone liquid/Mtab)Medications (oral, risperidone liquid/Mtab)

Careful with benzos and BenadrylCareful with benzos and Benadryl


EducationEducation

Drugs, toxinsDrugs, toxins

Parenting/abuseParenting/abuse

Parent mental healthParent mental health

Learning problemsLearning problems

Peers, communityPeers, community

Safety precautionsSafety precautions

Available resourcesAvailable resources

CommunicationCommunication


Expert OpinionExpert Opinion

46 leading experts surveyed46 leading experts surveyed

10 years of “ballooning” off-label use of 10 years of “ballooning” off-label use of antipsychoticsantipsychotics

Decline in psychosocial interventionsDecline in psychosocial interventions

Mismatch between research and clinical Mismatch between research and clinical practicepractice

Martin & Leslie, 2003


ComorbidityComorbidity

ADHD: medication and parenting ADHD: medication and parenting support +/- behavioral therapysupport +/- behavioral therapy

Substance abuse: targeted Substance abuse: targeted treatment, motivational interviewing, treatment, motivational interviewing, consider residentialconsider residential

Mood/Anxiety: individual therapy Mood/Anxiety: individual therapy (CBT) +/- medication(CBT) +/- medication


PsychotherapyPsychotherapy

Part of a broader Part of a broader programprogram

Problem solving, peer Problem solving, peer mediationmediation

Social skills Social skills

Moral developmentMoral development

Anger/assertiveness Anger/assertiveness trainingtraining


Parenting SupportParenting Support

Parent management training (PMT): Parent management training (PMT): effective across settings and overtime, but effective across settings and overtime, but does not bring out of clinical range with does not bring out of clinical range with ADHDADHD

Parent-Child Interaction Therapy (PCIT): Parent-Child Interaction Therapy (PCIT): clinically significant improvement with clinically significant improvement with ODD. 1. Child directed interaction. 2. ODD. 1. Child directed interaction. 2. Parent directedParent directed

Family Therapy has greater drop out than Family Therapy has greater drop out than PMTPMT


BibliotherapyBibliotherapy

1-2-3 Magic 1-2-3 Magic (2004) (2004) by Thomas Phelan, by Thomas Phelan, PhD (multiple languages and video)PhD (multiple languages and video)

Winning the Whining Wars, and other Winning the Whining Wars, and other SkirmishesSkirmishes (1991) (1991) by Cynthia Whitham by Cynthia Whitham MSWMSW

The Difficult Child (2000) The Difficult Child (2000) by by Stanley Stanley Turicki, MDTuricki, MD

Parenting Your Out-of-Control Teenager Parenting Your Out-of-Control Teenager by Scott Sells, PhDby Scott Sells, PhD


ParentingParenting

Positive Positive reinforcementreinforcement

Balanced Balanced emotional emotional valencevalence

Time outsTime outs


Parenting (con’t)Parenting (con’t)Response cost: Response cost: withdrawing withdrawing rewardsrewards

Token economyToken economy

Consistency of Consistency of responseresponse

Priorities and Priorities and sharing sharing responsibilityresponsibility


CommunityCommunityGet Creative! Get Creative!

Scouts, Boys and Girls Clubs, Big Scouts, Boys and Girls Clubs, Big Brother/Sister, after school activities Brother/Sister, after school activities and sports, communal parentingand sports, communal parenting

Be careful of bringing together kids with Be careful of bringing together kids with ODD/CDODD/CD

More formal programs: treatment foster More formal programs: treatment foster care, school-based programs, bullying care, school-based programs, bullying programsprograms

Promotes social skills and supervisionPromotes social skills and supervision


Multimodal ServicesMultimodal Services

Strongest evidence for actual Strongest evidence for actual therapeutic effect in Conduct disordertherapeutic effect in Conduct disorder

Foster care, juvenile justice, public Foster care, juvenile justice, public mental healthmental health

Multisystemic therapies (MST, FFT, Multisystemic therapies (MST, FFT, FIT): family, peer, school, and FIT): family, peer, school, and neighborhood interventions plus neighborhood interventions plus behavior therapy, problem solving, behavior therapy, problem solving, +/- DBT skills+/- DBT skills


SchoolSchool

Feeling more successful in school Feeling more successful in school alwaysalways helps behaviorhelps behavior

Testing (learning, speech, language)Testing (learning, speech, language)

AccomodationsAccomodations

Special classroomSpecial classroom

Social skills, problem solving, peer Social skills, problem solving, peer mediationmediation


PharmacotherapyPharmacotherapy

Target medication responsive diagnosesTarget medication responsive diagnoses

Covert, premeditated generally not responsiveCovert, premeditated generally not responsive

Meds should be adjunctive and secondary to Meds should be adjunctive and secondary to behavioral interventionsbehavioral interventions

Most benign first, informed consentMost benign first, informed consent

Quantify and track results (OAS)Quantify and track results (OAS)

Stop one before starting secondStop one before starting second

Assess compliance, all meds can be divertedAssess compliance, all meds can be diverted


ADHD + ODD/CD TreatmentADHD + ODD/CD Treatment

ADHD = ADHD+ODD in stimulant responseADHD = ADHD+ODD in stimulant response

Non-Stimulant medications not as consistentNon-Stimulant medications not as consistent

11x the non-compliance with ODD11x the non-compliance with ODD

Meds + parenting and/or behavioral therapyMeds + parenting and/or behavioral therapy

Combination therapy is better when Combination therapy is better when comparing “normalization,” and dosage of comparing “normalization,” and dosage of medication and parent preferencemedication and parent preference

Jensen et al, 2001PAL ProgramPAL Program

StimulantsStimulants

18 studies (15 RCTs). 429 kids, mostly 18 studies (15 RCTs). 429 kids, mostly elementary boys. ADHD and/or ODD/CD elementary boys. ADHD and/or ODD/CD with aggressive behavior. with aggressive behavior.

Greatest ES in ADHD + aggression, 0.9. Greatest ES in ADHD + aggression, 0.9. Lowest in MR, 0.3. Average was 0.78.Lowest in MR, 0.3. Average was 0.78.

At least 3 small studies (N=99) reduced At least 3 small studies (N=99) reduced aggression in ODD,CD without ADHDaggression in ODD,CD without ADHD

Good first choice for impulsive, reactive Good first choice for impulsive, reactive aggression. Quick trial, relatively benign.aggression. Quick trial, relatively benign.

Pappadopulos et al, 2006 PAL ProgramPAL Program

Alpha 2 AgonistsAlpha 2 AgonistsClonidine. 7 studies (4 RCTS). 114 kids. ADHD, Clonidine. 7 studies (4 RCTS). 114 kids. ADHD, CD, PTSD, Tourettes, Autism.CD, PTSD, Tourettes, Autism.

RCTs showed efficacy DBDs>Tourettes. RCTs showed efficacy DBDs>Tourettes.

Watch for sedation, dizziness, hypotensionWatch for sedation, dizziness, hypotension

Guanfacine. 4 studies, 1 controlled. 72 kids. Guanfacine. 4 studies, 1 controlled. 72 kids. ADHD +/- ticsADHD +/- tics

Mixed results. Better tolerated than clonidine.Mixed results. Better tolerated than clonidine.

ADHD kids who don’t tolerate stimulants, or kids ADHD kids who don’t tolerate stimulants, or kids with hyperarousalwith hyperarousal

Pappadopulos et al 2006 PAL ProgramPAL Program

Anti-depressantsAnti-depressants

Seretonin and aggression in ratsSeretonin and aggression in rats

SSRIs treat “impulsive aggression” in adults, SSRIs treat “impulsive aggression” in adults, primatesprimates

30-40% of depressed adults are aggressive30-40% of depressed adults are aggressive

Bupropion 3 RCTs, 2 open. 117 kids. CD and Bupropion 3 RCTs, 2 open. 117 kids. CD and ADHD. “solid support.”ADHD. “solid support.”

SSRIs mixed results, but still consideration for SSRIs mixed results, but still consideration for anxious/depressed.anxious/depressed.

Trazodone in DBD, effective for aggression. Small Trazodone in DBD, effective for aggression. Small open trial (22) open trial (22)


AntipsychoticsAntipsychotics

Since 2000, 9 studies in CD/ODD, ADHD, Since 2000, 9 studies in CD/ODD, ADHD, DBD, MR, Autism. 875 kidsDBD, MR, Autism. 875 kids

Risperidone, low doses, short trialsRisperidone, low doses, short trials

ES ranging from 0.7-1.96.ES ranging from 0.7-1.96.

Aripiprazole, 1 RCT, 218 children, efficacy Aripiprazole, 1 RCT, 218 children, efficacy and SE’s increased with dose.and SE’s increased with dose.

Movement and metabolic disordersMovement and metabolic disorders

Large/broad effect, short term managementLarge/broad effect, short term management


Mood StabilizersMood Stabilizers

Lithium. 5 RCTs. Mostly inpatient CD. Lithium. 5 RCTs. Mostly inpatient CD. Mixed. More effective in “affective, Mixed. More effective in “affective, explosive.”explosive.”

Valproic Acid. 2 studies (1 RCT). 30 kids. Valproic Acid. 2 studies (1 RCT). 30 kids. Superior to placebo in aggression in CD.Superior to placebo in aggression in CD.

Carbamazepine. 1 RCT showed no benefitCarbamazepine. 1 RCT showed no benefit

Oxcarbazepine. No dataOxcarbazepine. No data


Mood Stabilizer, contMood Stabilizer, contLithium monitoring. Baseline Cr and Ur specific Lithium monitoring. Baseline Cr and Ur specific gravity, TSH, ?EKG. Lithium level 1 week after gravity, TSH, ?EKG. Lithium level 1 week after dose change. Monitor level, kidney, TSH every dose change. Monitor level, kidney, TSH every 2-3 months. Weight.2-3 months. Weight.

VPA monitoring. CBC+LFTs prior. Repeat, with VPA monitoring. CBC+LFTs prior. Repeat, with VPA level every few weeks in first couple VPA level every few weeks in first couple months, then 1-2 times/year. Weightmonths, then 1-2 times/year. Weight

Carbamazepine. CBC, LFTs, Renal, TSH prior. Carbamazepine. CBC, LFTs, Renal, TSH prior. Repeat q2wks for 2m, then every 3-6m.Repeat q2wks for 2m, then every 3-6m.


Beta BlockerBeta Blocker

Propranolol (others havePropranolol (others have intolerance) intolerance)

Some evidence in adults with “impulsive, Some evidence in adults with “impulsive, explosive” rage, aggression in MR, DD explosive” rage, aggression in MR, DD dementia.dementia.

5 studies (1 RCT). 101 kids. Various dx 5 studies (1 RCT). 101 kids. Various dx (ADHD, DD, PTSD, “organic”). Largely (ADHD, DD, PTSD, “organic”). Largely positivepositive

1 RCT. 32 kids. CD. Pindolol not superior to 1 RCT. 32 kids. CD. Pindolol not superior to MPH, with significant SE’sMPH, with significant SE’s


Thank you for coming!

Please feel free to email me with any [email protected]

For specific clinical questions, contact PAL at 1-866-501-72575


Acknowledgement

Dr. Terry LeeDr. Robert HiltDr. William French


the aggressive child:

Documents

settingsproactive aggression

reactive aggression

antisocial peersfemales

social groupbehavior

aggressive child

scales vanderbilts

violenceabused children

unprovoked aggressionamygdala