Transcript Aggressive Behavior in Children and Adolescents: Psychiatric Pathology or Pathologic Community? James Chandler MD, FRCPC Chief of Psychiatry Yarmouth Regional Hospital February 15, 2006

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 Illness
Psychosis
High Functioning Autism with
stressors
Drug induced psychosis
Trauma related disordersDissociative 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 ADHD
78% have ODD
10-25% 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 …..
Cannabis
• Increases risk of psychosis for all.
• Doubles risk of schizophrenia
developing
• Aggravates symptoms of
schizophrenia
Other 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.
Disassociation
• For the most part, dissociative
symptoms result from horrible
trauma, usually sexual abuse.
• Sexual abuse predicts violence in
kids
Aggression 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
But almost never• Movie style separation of
personalities
• Movie style changes from one
personality to another
• If these are the case, think factious
Treatment
• See a Psychiatrist soon
• Emergent use, and sometimes
chronic use of Atypical
Antipsychotics
Agitation 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
So 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 can’t cope and melt down, often even hearing
voices
– Usually improves over a few weeks
– Occasionally requires short term meds – best studied is
Risperidal
The 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
•
Common Causes of the Acute Confusional
State
•
Intoxications—alcohol; prescription, over-the-counter, and street
drugs; solvents; heavy metals; pesticides; carbon monoxide
•
Withdrawal states—alcohol, sedative-hypnotic drugs
•
Nutritional deficiencies—thiamine (Wernicke’s encephalopathy),
vitamin B12 , folate, niacin
•
Metabolic disorders—electrolyte and acid-base disturbances; hepatic,
renal, pancreatic disease
•
Infections—pneumonia, urinary tract infection, sepsis, AIDS
•
Endocrinopathies—hypo- and hyperthyroidism, hypo- and
hyperglycemia, hypo- and hyperadrenocorticism
•
Structural brain disease—traumatic brain injury, seizure disorders,
stroke, subarachnoid or parenchymal hemorrhage, epidural or subdural
hematoma, encephalitis, brain abscess
•
Postoperative states—anesthesia, electrolyte disturbances, fever,
hypoxia, analgesics
Disorders 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 (Huntington’s disease,
Wilson’s disease)
However 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 (Wilson’s, Porphyria)
• Most cases with a medical cause will
come with a medical history
When 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
In Summary• Aggression can be a symptom of a
disintegrating society
• Aggression can be a symptom of a
medical (including psychiatric)
problem
The 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….
The good news
• It won’t be hard to find causes for
aggression
• The medical treatment is relatively
non-specific and easy to remember
• Few Canadians have handguns
The 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.