The Aggressive Child:

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.

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

3. Gerald • 6 year old • Angry when video games limited • Poked mom’s face out of family portraits • Talks back to teachers • Provokes peers, bossy • Hits younger sister

4. Esmerelda • 9 year old cranky girl • Aggressive and destructive tantrums • Cries unpredictably • Treated for ADHD, without benefit • Low energy, appetite

5. Reginald • 15 year old boy in Wyoming Boy’s School • Assault, burglary, arson, shoplifting • Drug commerce and use • Parents have criminal history

6. Lilliana • 14 year old girl, psychiatric inpatient • Aggression towards family • History of sexual abuse by babysitter • Difficulty sleeping, nightmares • Hyperarousal, irritability

7. Winifred • 9 year old, language delay • Toe walking, spins when toilet flushes • No interest in social play • Pulls hair of dog and sister

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

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

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

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

12. 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

13. Physiology • Genetics • Autonomic nervous system • Endocrine • Neuroanatomy • Serotonin • Toxins

14. Nature - Nurture Caspi, et al 2002

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

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

17. Assessment

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

19. 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)

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

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

22. 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

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

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

25. 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)

26. 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.

27. 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

28. 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

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

30. 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

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

32. 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

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

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

35. 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

36. 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

37. Parenting Positive reinforcement Balanced emotional valence Time outs

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

39. 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

40. 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

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

42. 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

43. 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 Jensen et al, 2001

44. 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. Pappadopulos et al, 2006

45. 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 Pappadopulos et al 2006

46. 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) Pappadopulos et al 2006

47. 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 Pappadopulos et al 2006

48. 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

49. 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.

50. 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