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 Systems What 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 …..