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  1. The Aggressive Child: Oppositional Defiant and Conduct Disorders Michael Kisicki, M.D. Seattle Children’s Hospital Echo Glen Children’s Center University of Washington, Department of Psychiatry PAL Program

  2. Main Points Safety Assess and treat comorbid conditions Address risk factors and bolster strengths Behavioral interventions first Medications secondary and adjunctive PAL Program

  3. Nature of Aggression • Development of contrary and aggressive behavior • Psychological factors • Environmental factors • Physiological factors • Determining pathologic PAL Program

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

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

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

  7. Development • Infants promote bonding with behavior • Anger expression by age 6 months • Toddlers show defiance as they individuate • Tantrums diminish in school age children • Social conformity progresses in elementary • Testing limits, debating, experimenting in early teens PAL Program

  8. Physiology • Genetics • Autonomic nervous system • Endocrine • Neuroanatomy • Serotonin • Toxins PAL Program

  9. Nature - Nurture PAL Program Caspi, et al 2002

  10. Neuroanatomy • Orbito/frontal: reactive aggression, negative affective style, impulsivity • Temporal: unprovoked aggression • Amygdala: interpretation of social cues PAL Program

  11. Distinguishing Pathologic • Safety • Variety of symptoms and settings • Proactive aggression and cruelty • Use of weapon • Contrary to social group • Behavior atypical for age PAL Program

  12. Assessment PAL Program

  13. SAFETY • Abuse, neglect • Presence of weapon • Past behavior • Use of drugs/alcohol • Acute psychiatric illness (mania, psychosis) • Suicide PAL Program

  14. Treatment Focused History • When, how, what,? Focusing on modifiable variables • Hot or cold? • Time course, association with stressor? • Risk factors • Strengths • Information from multiple sources • Measures, scales (Vanderbilts, OAS) PAL Program

  15. Individual Factors Family history (ADHD, DBD, PDD, mood) Temperament, affect dysregulation Reading, speech/language Social skills Prenatal, environmental toxic exposure PAL Program

  16. Parenting Parental mental illness Low involvement High conflict Poor monitoring Harsh inconsistent discipline Physical punishment Lack of warmth and involvement Parental burn out PAL Program

  17. Child Abuse Physical abuse and neglect predict APD, criminal behavior, violence Abused children have social processing deficits Sexual abuse victims of both genders develop DBD, girls have more internalizing Risk reduced when removed PAL Program

  18. Peers Rejected and reinforced by pro-social peers Uneasy affirmation by anti-social peers Females more sensitive to rejection PAL Program

  19. Neighborhood More predictive of DBD than any other psychopathology Public housing outweighs all protective factors Disorganization, drugs, adult criminals, racial prejudice, poverty, unemployment PAL Program

  20. Oppositional Defiant Disorder Defiance, anger, quick temper, bullying, spitefulness, usually before 8 years of age Usually resolves, 1/3 develop conduct disorder High rate of comorbidity Irritability is a component (think about when considering Bipolar NOS) PAL Program

  21. Conduct Disorder Repetitive + persistent, violates basic rights of others or societal norms Aggression, property destruction, theft, deceit, truancy Prognosis depends on age, aggression and social withdrawal Boys: higher prevalence, more persistence and aggression Girls: less persistent, more covert behavior and problematic relationships Less Aggression and more rights violations with age. PAL Program

  22. Prevalence 5% of kids ODD: 2-16% of community, 50% of clinic CD: 1.5-3.4% of community adolescents, 30-50% in clinic Usually resolves, 1/3 of ODD develop CD Adult antisocial personality disorder: 2.6% Boys >> girls, unless you consider relational aggression PAL Program

  23. Comorbid Disorders • ADHD, 10x the prevalence; inattention, impulsivity, hyperactivity. Vanderbilts. • MDD, 7x the prevalence; mood complaints, neurovegative symptoms. SMFQ. • Substance abuse, 4x the prevalence; by history, UA. CRAFFT (car, relax, alone, forget, friends, trouble) • PTSD, Autism, Bipolar PAL Program

  24. Treatment Menu Education Treat co-morbid medical and psychiatric conditions Parenting support Psychotherapy Community/Multimodal services Medication PAL Program

  25. Acute Agitation • Attention to your own demeanor, environment • Provide some sense of control, choices • Distractions, food • Medications (oral, risperidone liquid/Mtab) • Careful with benzos and Benadryl PAL Program

  26. Education Drugs, toxins Parenting/abuse Parent mental health Learning problems Peers, community Safety precautions Available resources Communication PAL Program

  27. Expert Opinion • 46 leading experts surveyed • 10 years of “ballooning” off-label use of antipsychotics • Decline in psychosocial interventions • Mismatch between research and clinical practice Martin & Leslie, 2003 PAL Program

  28. Comorbidity ADHD: medication and parenting support +/- behavioral therapy Substance abuse: targeted treatment, motivational interviewing, consider residential Mood/Anxiety: individual therapy (CBT) +/- medication PAL Program

  29. Psychotherapy Part of a broader program Problem solving, peer mediation Social skills Moral development Anger/assertiveness training PAL Program

  30. Parenting Support Parent management training (PMT): effective across settings and overtime, but does not bring out of clinical range with ADHD Parent-Child Interaction Therapy (PCIT): clinically significant improvement with ODD. 1. Child directed interaction. 2. Parent directed Family Therapy has greater drop out than PMT PAL Program

  31. Bibliotherapy 1-2-3 Magic (2004) by Thomas Phelan, PhD (multiple languages and video) Winning the Whining Wars, and other Skirmishes (1991) by Cynthia Whitham MSW The Difficult Child (2000) by Stanley Turicki, MD Parenting Your Out-of-Control Teenager by Scott Sells, PhD PAL Program

  32. Parenting Positive reinforcement Balanced emotional valence Time outs PAL Program

  33. Parenting (con’t) Response cost: withdrawing rewards Token economy Consistency of response Priorities and sharing responsibility PAL Program

  34. Community Get Creative! Scouts, Boys and Girls Clubs, Big Brother/Sister, after school activities and sports, communal parenting Be careful of bringing together kids with ODD/CD More formal programs: treatment foster care, school-based programs, bullying programs Promotes social skills and supervision PAL Program

  35. Multimodal Services Strongest evidence for actual therapeutic effect in Conduct disorder Foster care, juvenile justice, public mental health Multisystemic therapies (MST, FFT, FIT): family, peer, school, and neighborhood interventions plus behavior therapy, problem solving, +/- DBT skills PAL Program

  36. School • Feeling more successful in school always helps behavior • Testing (learning, speech, language) • Accomodations • Special classroom • Social skills, problem solving, peer mediation PAL Program

  37. Pharmacotherapy Target medication responsive diagnoses Covert, premeditated generally not responsive Meds should be adjunctive and secondary to behavioral interventions Most benign first, informed consent Quantify and track results (OAS) Stop one before starting second Assess compliance, all meds can be diverted PAL Program

  38. ADHD + ODD/CD Treatment ADHD = ADHD+ODD in stimulant response Non-Stimulant medications not as consistent 11x the non-compliance with ODD Meds + parenting and/or behavioral therapy Combination therapy is better when comparing “normalization,” and dosage of medication and parent preference PAL Program Jensen et al, 2001

  39. Stimulants 18 studies (15 RCTs). 429 kids, mostly elementary boys. ADHD and/or ODD/CD with aggressive behavior. Greatest ES in ADHD + aggression, 0.9. Lowest in MR, 0.3. Average was 0.78. At least 3 small studies (N=99) reduced aggression in ODD,CD without ADHD Good first choice for impulsive, reactive aggression. Quick trial, relatively benign. PAL Program Pappadopulos et al, 2006

  40. Alpha 2 Agonists • Clonidine. 7 studies (4 RCTS). 114 kids. ADHD, CD, PTSD, Tourettes, Autism. • RCTs showed efficacy DBDs>Tourettes. • Watch for sedation, dizziness, hypotension • Guanfacine. 4 studies, 1 controlled. 72 kids. ADHD +/- tics • Mixed results. Better tolerated than clonidine. • ADHD kids who don’t tolerate stimulants, or kids with hyperarousal PAL Program Pappadopulos et al 2006

  41. Anti-depressants • Seretonin and aggression in rats • SSRIs treat “impulsive aggression” in adults, primates • 30-40% of depressed adults are aggressive • Bupropion 3 RCTs, 2 open. 117 kids. CD and ADHD. “solid support.” • SSRIs mixed results, but still consideration for anxious/depressed. • Trazodone in DBD, effective for aggression. Small open trial (22) PAL Program Pappadopulos et al 2006

  42. Antipsychotics • Since 2000, 9 studies in CD/ODD, ADHD, DBD, MR, Autism. 875 kids • Risperidone, low doses, short trials • ES ranging from 0.7-1.96. • Aripiprazole, 1 RCT, 218 children, efficacy and SE’s increased with dose. • Movement and metabolic disorders • Large/broad effect, short term management PAL Program Pappadopulos et al 2006

  43. Mood Stabilizers • Lithium. 5 RCTs. Mostly inpatient CD. Mixed. More effective in “affective, explosive.” • Valproic Acid. 2 studies (1 RCT). 30 kids. Superior to placebo in aggression in CD. • Carbamazepine. 1 RCT showed no benefit • Oxcarbazepine. No data PAL Program

  44. Mood Stabilizer, cont • Lithium monitoring. Baseline Cr and Ur specific gravity, TSH, ?EKG. Lithium level 1 week after dose change. Monitor level, kidney, TSH every 2-3 months. Weight. • VPA monitoring. CBC+LFTs prior. Repeat, with VPA level every few weeks in first couple months, then 1-2 times/year. Weight • Carbamazepine. CBC, LFTs, Renal, TSH prior. Repeat q2wks for 2m, then every 3-6m. PAL Program

  45. Beta Blocker • Propranolol (others have intolerance) • Some evidence in adults with “impulsive, explosive” rage, aggression in MR, DD dementia. • 5 studies (1 RCT). 101 kids. Various dx (ADHD, DD, PTSD, “organic”). Largely positive • 1 RCT. 32 kids. CD. Pindolol not superior to MPH, with significant SE’s PAL Program

  46. PAL Program

  47. Thank you for coming! Please feel free to email me with any questions For specific clinical questions, contact PAL at 1-866-501-72575 PAL Program

  48. Acknowledgement Dr. Terry Lee Dr. Robert Hilt Dr. William French PAL Program