Transcript Agitation Care in the Emergency Department

The Aggressive Child:
Oppositional Defiant Disorder
Robert Hilt, MD, FAAP
May 5th, 2012
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May 5, 2012
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Disclosure Statement
• I have no relevant financial relationships with
the manufacturer(s) of any commercial
product(s) and/or provider of commercial
services discussed in this CME activity.
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Case “A”
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6 year old boy
Angry if video games limited
Talks back to mom and teachers
Bossy with friends
Hits younger sister
During tantrum, poked mom’s face out of a
family portrait
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Case “B”
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10 year old girl
Hyperactive & inattentive since preschool
Gets frequent timeouts for being “bad”
Is disliked by peers at school
Seems bright, but has poor grades
Now hitting parents/peers when doesn’t get her
way
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Case “C”
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15 year old boy now in Wyoming Boy’s School
Assault, burglary, arson, shoplifting
Using and selling drugs
Parents have criminal history
History of school failure
Aggression problems since elementary school
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What is Aggression?
• Forceful action or procedure, often with intent to
dominate or master
• Usually results from an inability to resolve a selfperceived vital conflict or need through a nonforceful means
• Is not always pathological: aggression can be
socially appropriate or developmentally normal
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Developmental Aggression
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Infants promote bonding with early behavior
Anger appears by age 6 months
Toddlers show defiance as they individuate
Tantrums diminish, social conformity increase
in school age children
• Testing new limits, impulses in early teens
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Development of Aggression
From “Developmental Origins of Aggression” by Tremblay, Hartup and Archer (2005)
Hitting, Biting, Kicking age 2-11 years
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From “Developmental Origins of Aggression” by Tremblay, Hartup and Archer (2005)
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Violent Crime in Young Adults
From “Developmental Origins of Aggression” by Tremblay, Hartup and Archer (2005)
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Oppositional Defiant Disorder:
What Is It?
• Recurrent pattern of negativistic, hostile, defiant
behavior
▫ More frequent than typical for age
▫ Causes impaired functioning
▫ Usually present by age 8 years
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DSM-IV ODD checklist:
4 + symptoms within past 6 months
1. Often loses temper
2. Often argues with adults
3. Often actively defies or refuses to comply with adult
requests or rules
4. Often deliberately annoys people
5. Often blames others for his or her mistakes or
misbehavior
6. Often touchy or easily annoyed by others
7. Often angry or resentful
8. Often spiteful or vindictive
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Gender Differences in Aggression
• Males: relatively more physical attacks
• Females: relatively more verbal or relational
attacks
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Prevalence of ODD
• About a 5% current prevalence rate
▫ Pre-pubertal boys > girls
• Fairly persistent symptoms
▫ About 3/4 still meet criteria ~2 years after
diagnosis
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Causes of ODD
• Research consistently points toward a
multifactorial origin
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Psychology
Biology
Social/School
Family
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Psychological Contributing Factors
• Disordered processing of social information:
▫ Underutilize social cues
 i.e. don’t respond to a frown
▫ Misattribute hostile intent
 i.e. think accidental contact was an attack
▫ Generate fewer solutions to problems
▫ Expect a reward from aggression
 Intermittent reinforcement
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Psychological Contributing Factors
• Insecure attachment
▫ Reactive Attachment Disorder a clear example
 Found in chronic neglect/maltreatment
 Honeymoon phase, then mistrust of new caregivers
 Extreme oppositional limit testing
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Social Contributing factors
• Community violence
▫ Especially antisocial behavior within the family
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Lack of parental supervision
Lack of positive parental involvement
Inconsistent discipline
Marital discord
Child abuse
Bullying
School failure
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Biological Contributing Factors
• Exogenous biological factors
▫ drugs in utero, toxins, malnutrition
• Endogenous biological factors
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Low sympathetic responsiveness
Low cortisol
High testosterone
Cognitive processing deficits
 Communication deficits especially
• Temperament
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What is Temperament?
• Stable personality traits traceable from infancy
through adulthood
• Some of these traits are noted as more difficult
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High intensity
More negative moods
Irregular patterns
Negative first impressions
Less readily adaptable to change
Chess & Thomas, NY Longitudinal Study
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Temperament and ODD
• Helpful to think that most ODD is related to
mismatch in fit between:
▫ Child’s temperament
▫ Parent’s (& society’s) expectations
Chess & Thomas, NY Longitudinal Study
The Vicious Cycle
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Negative
Attention
Negative
Behavior
(Parent yells at child,
loses control )
(child reacts negatively,
has outburst)
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ODD and the Vicious Cycle
• Break the cycle by
▫ Parenting education
 Including behavior management training
▫ Show parent that other responses to child can
yield better results
▫ Special time/positive time for parent and child
▫ Parent support, therapy
 an un-nurtured parent can’t help their difficult child
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Example of less skilled response
• “Put the toy away”
• Child yells or tantrums
• Parent yells back, aversively demands
compliance
• Child may learn:
▫ they only mean it when they explode
▫ this is the only attention I get, which is better than
nothing
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Another Example of less skilled
response
• “Put the toy away”
• Child yells or tantrums
• Parent removes the demand
▫ Child learns that tantrums work
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A more skillful response
• “Put the toy away”
• Child yells or tantrums
• One calm repetition of the request
• Follow with firm limit regarding any continued
or worsening behavior
▫ i.e. withdraw attention/praise until task is
completed
▫ No parent “explosion”
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Therapy for ODD
• Behavior management training (often called
parent training)
▫ Evidence based treatment for age <5
• Child training
▫ EBT for middle/high school age
▫ Requires active child participation
• Multicomponent treatment
▫ Delinquent adolescents
▫ Use both of the above
▫ Examples are MST, MTFC
SM Eyberg et al 2008
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Behavior Management Training
• Generally done by a psychologist or other skilled
mental health therapist
• Teaches behavioral techniques to reduce family
stress and child oppositionality
▫ Including proper use of “time out”
• Often uses “token economy” system
• Parents learn better communication with school
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Specific Examples of Behavior
Management Training Programs
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Helping the Noncompliant Child (HNC)
Incredible Years
Parent-Child Interaction Therapy (PCIT)
Parent Management Training Oregon Model
(PMTO)
• Positive Parenting Program (Triple P)
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Common Elements in ODD Therapy
that works
From 2007 Hawaii CAMHD review, n=88 studies
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Encourage Regular “Special Time”
• Pick a multiple times a week occasion
▫ 15-30 minutes long
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Child selects the activity
Label it “special time”
Happens regardless of good vs. bad day
1:1 without interruption
End on time
Parent needs their own time too
From www.palforkids.org
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Problem with good behavior
training
• Parents often resist treatments centered on them
▫ Child-only treatment is unlikely to succeed
• Manual based, evidence based treatments are
hard to find
▫ If therapist works directly with parents, greater
chance of success
▫ Parenting skills groups can help
▫ Supplement with self-help learning/readings
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Value of Self-Directed Treatment
• “Bibliotherapy” worked just as well as therapist
lead therapy in a RCT of “Incredible Years”
program
▫ Unless family attended 9 or more therapist
sessions, then the therapist group did better
JV Lavigne et al 2008
Self-Help Behavior Management
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Excerpt from Hilt
2010 Primary Care
Principles for Child
Mental Health,
www.wyomingpal.org
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Give Time Out Tips for success
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Set limits that are consistent
Focus on changing only one misbehavior at a time
After announce the time out, do not continue to engage
Time outs occur immediately after the misbehavior
If use warnings, make them count
Keep your cool
You (not child) determine when time out is done
Need to have other positive times with your child
• Key is an immediate, temporary withdrawal of positive
parent attention
From www.wyomingpal.org
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After making a therapy referral:
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Encourage good parent/teacher communication
Suggest self help supplements
Monitor if the intervention helps
Consider co-morbidities
▫ Especially if not improving
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ODD Comorbities
• ADHD
▫ about 10x the frequency as general population
• Major Depression
▫ about 7x the frequency as general population
• Substance Abuse
 about 4x the frequency as general population
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ADHD and ODD
• About 50% of ADHD cases have co-morbid ODD
• Still, need to be cautious about over-calling
presence of ADHD
▫ Particularly if very young
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Young Children and ADHD
• Some degree of inattention, hyperactivity and defiance
is developmentally normal for preschool children
▫ So is it normal for the age?
• At least 1/3rd of all preschoolers in one survey noted by
their parents to have significant inattention or
hyperactivity
▫ compare to the ~7% lifetime prevalence of ADHD
Smidts DP and Oosterlaan J 2007;
JAACAP practice parameter 2007
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Sorting “Normal” from ADHD
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Peer context
Persistence across settings
Functional impairment
Increase skepticism with lower age
▫ Age 6 and up, rating scale impairment assessments of
home/school are thought to be reliable
▫ 4-5 years I have more skepticism
▫ 3-4 years I’m very skeptical
▫ <3 years very few in psychiatry would say is possible to make
an ADHD diagnosis
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Classroom Interventions for ADHD
• You can recommend the following:
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Smaller Class size
Sit in front
Clear rules and consequences
Slower assignment pace
Untimed tests
Daily parent to teacher communication
Homework tutoring
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First Line Medications for ADHD
 Two general groups of medicines
 Stimulants
 Non-stimulants
 When one fails, stop it and try another
 If med. treatment unsatisfactory:
 Think comorbidity
 Re-evaluate diagnosis
 Consider behavior therapy and/or alternative
medications
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If determine has ADHD and ODD
• Treating ADHD is shown to significantly
improve the ODD
▫ Stimulants, in particular
▫ Less evidence for other medications
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Review of Comorbid ODD/ADHD trials
• Methylphenidate
▫ 7 RCTs all show decreased aggression
 Effect size ~0.75
• Atomoxetine
▫ 4 RCTs show mildly decreased aggression
 Effect size ~0.15
E Pappadopulos et al, 2006
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What About Conduct Disorder?
• Often follows ODD
• Aggression to people and animals
• Destruction of property
▫ Fire setting
• Deceitfulness or theft
▫ Lies to obtain goods
• Serious violations of rules
▫ Running away, frequently truant
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Conduct Disorder
• About ½ of conduct disorder children continue
these problems into adulthood
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Substance abuse
Mood disorders
Anxiety disorders
Learning/cognitive disorders
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Conduct Disorder
• Inherent failure of parental authority
▫ Are there other parenting arrangements that
would work better?
▫ Occasionally substitute authority (even a judge)
can make a positive difference
• Inherent rejection of available motivations to do
“good”
▫ Other ways to motivate in a positive direction?
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Multi-Systemic Therapy
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Steer teens into positive peer group associations
Support parents
Support school
Behavior management training
Problem solving skills training
• Research supported for chronic, violent juvenile
offenders
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Medications for ODD and Conduct
Disorder?
• Yes, if a treatable comorbidity
▫ ADHD
▫ Depression
▫ Anxiety
• Discourage their use if no treatable comorbidity
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Hot versus Cold Aggression
• “Cold” aggression is calculating, planned,
instrumental to obtain a goal
▫ Not reduced by medications
• “Hot” aggression is impulsive, poorly planned,
has high CNS fight/flight arousal
▫ Might be reduced by medications
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Medication role with “hot” aggression
• Not to be a primary treatment
▫ Primary treatment is psychosocial
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Alpha agonists
Beta blockers
Antipsychotics
“mood stabilizers” (like lithium/valproic acid)
None FDA approved for this indication
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Bipolar Disorder NOS: “everyone” has it now
• Label often given to impulsive, aggressive
kids
▫ “rapid cycling”
▫ No true mania has occurred
• Often the justification for medication
treatment
• Future prognosis rarely is to have true
bipolar
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Bipolar NOS
• Why so commonly diagnosed?
▫ Sounds better to us than “I don’t know”
• Bipolar medicines have many non-specific
effects
▫ All can decrease impulsivity and aggression
▫ We see a response & think the bipolar label must
have been correct
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Key Points: Why Do Kids Get
Agitated?
• Environmental trigger
▫ i.e. self-defense, stress
• Facilitated by an acute disorder
▫ i.e. depression, panic disorder
• Inherent to a chronic disorder
▫ i.e. ODD, Conduct Disorder
• Child feels is the best way to obtain a goal
▫ i.e. has poor language ability
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Key Points with Aggression
• Is multifactorial
• Best intervention is with child’s environment
rather than child self-reflection to change
• Self-help parent readings/videos are almost as
good as therapist treatments
• Look for treatable comorbidities (i.e. ADHD)
• Resolve any recurring conflicts (i.e. bullying)
• Medications are infrequently the answer for
ODD/conduct disorder
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Questions?
www.wyomingpal.org
877-501-7257
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