The Aggressive The Aggressive Child:Child:
Oppositional Defiant and Oppositional Defiant and Conduct DisordersConduct Disorders
Michael Kisicki, M.D.Seattle Children’s Hospital
Echo Glen Children’s CenterUniversity of Washington, Department of Psychiatry
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Main Points Main Points
SafetySafety
Assess and treat comorbid conditionsAssess and treat comorbid conditions
Address risk factors and bolster strengthsAddress risk factors and bolster strengths
Behavioral interventions firstBehavioral interventions first
Medications secondary and adjunctiveMedications secondary and adjunctive
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Nature of AggressionNature of Aggression
Development of contrary and aggressive Development of contrary and aggressive behaviorbehavior
Psychological factorsPsychological factors
Environmental factorsEnvironmental factors
Physiological factorsPhysiological factors
Determining pathologicDetermining pathologic
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Developmental TrajectoryDevelopmental Trajectory
From “Developmental Origins of Aggression” by Tremblay, Hartup and Archer (2005)PAL ProgramPAL Program
Developmental TrajectoryDevelopmental Trajectory
From “Developmental Origins of Aggression” by Tremblay, Hartup and Archer (2005)PAL ProgramPAL Program
Developmental TrajectoryDevelopmental Trajectory
From “Developmental Origins of Aggression” by Tremblay, Hartup and Archer (2005)PAL ProgramPAL Program
DevelopmentDevelopment
Infants promote bonding with behaviorInfants promote bonding with behavior
Anger expression by age 6 monthsAnger expression by age 6 months
Toddlers show defiance as they individuateToddlers show defiance as they individuate
Tantrums diminish in school age childrenTantrums diminish in school age children
Social conformity progresses in elementarySocial conformity progresses in elementary
Testing limits, debating, experimenting in Testing limits, debating, experimenting in early teensearly teens
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PhysiologyPhysiology
GeneticsGenetics
Autonomic nervous systemAutonomic nervous system
EndocrineEndocrine
NeuroanatomyNeuroanatomy
SerotoninSerotonin
ToxinsToxins
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Nature - NurtureNature - Nurture
Caspi, et al 2002PAL ProgramPAL Program
NeuroanatomyNeuroanatomy
Orbito/frontal: reactive Orbito/frontal: reactive aggression, negative aggression, negative affective style, affective style, impulsivityimpulsivity
Temporal: Temporal: unprovoked unprovoked aggressionaggression
Amygdala: Amygdala: interpretation of social interpretation of social cuescues
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Distinguishing PathologicDistinguishing Pathologic
SafetySafety
Variety of symptoms and settingsVariety of symptoms and settings
Proactive aggression and crueltyProactive aggression and cruelty
Use of weaponUse of weapon
Contrary to social groupContrary to social group
Behavior atypical for ageBehavior atypical for age
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AssessmentAssessment
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SAFETYSAFETYAbuse, neglectAbuse, neglect
Presence of weaponPresence of weapon
Past behaviorPast behavior
Use of drugs/alcoholUse of drugs/alcohol
Acute psychiatric illness (mania, psychosis)Acute psychiatric illness (mania, psychosis)
Suicide Suicide
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Treatment Focused HistoryTreatment Focused History
When, how, what,? Focusing on modifiable variablesWhen, how, what,? Focusing on modifiable variables
Hot or cold?Hot or cold?
Time course, association with stressor?Time course, association with stressor?
Risk factorsRisk factors
StrengthsStrengths
Information from multiple sources Information from multiple sources
Measures, scales (Vanderbilts, OAS)Measures, scales (Vanderbilts, OAS)
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Individual FactorsIndividual Factors
Family history (ADHD, DBD, PDD, mood)Family history (ADHD, DBD, PDD, mood)
Temperament, affect dysregulationTemperament, affect dysregulation
Reading, speech/languageReading, speech/language
Social skillsSocial skills
Prenatal, environmental toxic exposurePrenatal, environmental toxic exposure
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ParentingParenting
Parental mental illnessParental mental illness
Low involvementLow involvement
High conflictHigh conflict
Poor monitoringPoor monitoring
Harsh inconsistent Harsh inconsistent disciplinediscipline
Physical punishmentPhysical punishment
Lack of warmth and Lack of warmth and involvementinvolvement
Parental burn outParental burn outPAL ProgramPAL Program
Child AbuseChild Abuse
Physical abuse and neglect predict APD, Physical abuse and neglect predict APD, criminal behavior, violencecriminal behavior, violence
Abused children have social processing Abused children have social processing deficitsdeficits
Sexual abuse victims of both genders Sexual abuse victims of both genders develop DBD, girls have more internalizingdevelop DBD, girls have more internalizing
Risk reduced when removed Risk reduced when removed
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PeersPeers
Rejected and Rejected and reinforced by pro-reinforced by pro-social peerssocial peers
Uneasy affirmation Uneasy affirmation by anti-social by anti-social peerspeers
Females more Females more sensitive to sensitive to rejectionrejection
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NeighborhoodNeighborhood
More predictive of DBD More predictive of DBD than any other than any other psychopathologypsychopathology
Public housing Public housing outweighs all protective outweighs all protective factorsfactors
Disorganization, drugs, Disorganization, drugs, adult criminals, racial adult criminals, racial prejudice, poverty, prejudice, poverty, unemploymentunemployment
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Oppositional Defiant DisorderOppositional Defiant Disorder
Defiance, anger, quick temper, bullying, Defiance, anger, quick temper, bullying, spitefulness, usually before 8 years of agespitefulness, usually before 8 years of age
Usually resolves, 1/3 develop conduct disorderUsually resolves, 1/3 develop conduct disorder
High rate of comorbidityHigh rate of comorbidity
Irritability is a component (think about when Irritability is a component (think about when considering Bipolar NOS)considering Bipolar NOS)
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Conduct DisorderConduct Disorder
Repetitive + persistent, violates basic rights of Repetitive + persistent, violates basic rights of others or societal normsothers or societal norms
Aggression, property destruction, theft, deceit, Aggression, property destruction, theft, deceit, truancytruancy
Prognosis depends on age, aggression and social Prognosis depends on age, aggression and social withdrawal withdrawal
Boys: higher prevalence, more persistence and Boys: higher prevalence, more persistence and aggressionaggression
Girls: less persistent, more covert behavior and Girls: less persistent, more covert behavior and problematic relationshipsproblematic relationships
Less Aggression and more rights violations with Less Aggression and more rights violations with age.age.
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PrevalencePrevalence
5% of kids5% of kids
ODD: 2-16% of community, 50% of clinicODD: 2-16% of community, 50% of clinic
CD: 1.5-3.4% of community adolescents, CD: 1.5-3.4% of community adolescents, 30-50% in clinic30-50% in clinic
Usually resolves, 1/3 of ODD develop CDUsually resolves, 1/3 of ODD develop CD
Adult antisocial personality disorder: 2.6%Adult antisocial personality disorder: 2.6%
Boys >> girls, unless you consider Boys >> girls, unless you consider relational aggressionrelational aggression
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Comorbid DisordersComorbid Disorders
ADHD, 10x the prevalence; inattention, ADHD, 10x the prevalence; inattention, impulsivity, hyperactivity. Vanderbilts.impulsivity, hyperactivity. Vanderbilts.
MDD, 7x the prevalence; mood MDD, 7x the prevalence; mood complaints, neurovegative symptoms. complaints, neurovegative symptoms. SMFQ.SMFQ.Substance abuse, 4x the prevalence; by Substance abuse, 4x the prevalence; by history, UA. CRAFFT history, UA. CRAFFT (car, relax, alone, forget, friends, trouble)(car, relax, alone, forget, friends, trouble)
PTSD, Autism, BipolarPTSD, Autism, Bipolar
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Treatment MenuTreatment Menu
EducationEducation
Treat co-morbid medical and Treat co-morbid medical and psychiatric conditionspsychiatric conditions
Parenting supportParenting support
PsychotherapyPsychotherapy
Community/Multimodal servicesCommunity/Multimodal services
MedicationMedication
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Acute AgitationAcute Agitation
Attention to your own demeanor, Attention to your own demeanor, environmentenvironment
Provide some sense of control, choicesProvide some sense of control, choices
Distractions, foodDistractions, food
Medications (oral, risperidone liquid/Mtab)Medications (oral, risperidone liquid/Mtab)
Careful with benzos and BenadrylCareful with benzos and Benadryl
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EducationEducation
Drugs, toxinsDrugs, toxins
Parenting/abuseParenting/abuse
Parent mental healthParent mental health
Learning problemsLearning problems
Peers, communityPeers, community
Safety precautionsSafety precautions
Available resourcesAvailable resources
CommunicationCommunication
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Expert OpinionExpert Opinion
46 leading experts surveyed46 leading experts surveyed
10 years of “ballooning” off-label use of 10 years of “ballooning” off-label use of antipsychoticsantipsychotics
Decline in psychosocial interventionsDecline in psychosocial interventions
Mismatch between research and clinical Mismatch between research and clinical practicepractice
Martin & Leslie, 2003
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ComorbidityComorbidity
ADHD: medication and parenting ADHD: medication and parenting support +/- behavioral therapysupport +/- behavioral therapy
Substance abuse: targeted Substance abuse: targeted treatment, motivational interviewing, treatment, motivational interviewing, consider residentialconsider residential
Mood/Anxiety: individual therapy Mood/Anxiety: individual therapy (CBT) +/- medication(CBT) +/- medication
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PsychotherapyPsychotherapy
Part of a broader Part of a broader programprogram
Problem solving, peer Problem solving, peer mediationmediation
Social skills Social skills
Moral developmentMoral development
Anger/assertiveness Anger/assertiveness trainingtraining
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Parenting SupportParenting Support
Parent management training (PMT): Parent management training (PMT): effective across settings and overtime, but effective across settings and overtime, but does not bring out of clinical range with does not bring out of clinical range with ADHDADHD
Parent-Child Interaction Therapy (PCIT): Parent-Child Interaction Therapy (PCIT): clinically significant improvement with clinically significant improvement with ODD. 1. Child directed interaction. 2. ODD. 1. Child directed interaction. 2. Parent directedParent directed
Family Therapy has greater drop out than Family Therapy has greater drop out than PMTPMT
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BibliotherapyBibliotherapy
1-2-3 Magic 1-2-3 Magic (2004) (2004) by Thomas Phelan, by Thomas Phelan, PhD (multiple languages and video)PhD (multiple languages and video)
Winning the Whining Wars, and other Winning the Whining Wars, and other SkirmishesSkirmishes (1991) (1991) by Cynthia Whitham by Cynthia Whitham MSWMSW
The Difficult Child (2000) The Difficult Child (2000) by by Stanley Stanley Turicki, MDTuricki, MD
Parenting Your Out-of-Control Teenager Parenting Your Out-of-Control Teenager by Scott Sells, PhDby Scott Sells, PhD
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ParentingParenting
Positive Positive reinforcementreinforcement
Balanced Balanced emotional emotional valencevalence
Time outsTime outs
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Parenting (con’t)Parenting (con’t)Response cost: Response cost: withdrawing withdrawing rewardsrewards
Token economyToken economy
Consistency of Consistency of responseresponse
Priorities and Priorities and sharing sharing responsibilityresponsibility
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CommunityCommunityGet Creative! Get Creative!
Scouts, Boys and Girls Clubs, Big Scouts, Boys and Girls Clubs, Big Brother/Sister, after school activities Brother/Sister, after school activities and sports, communal parentingand sports, communal parenting
Be careful of bringing together kids with Be careful of bringing together kids with ODD/CDODD/CD
More formal programs: treatment foster More formal programs: treatment foster care, school-based programs, bullying care, school-based programs, bullying programsprograms
Promotes social skills and supervisionPromotes social skills and supervision
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Multimodal ServicesMultimodal Services
Strongest evidence for actual Strongest evidence for actual therapeutic effect in Conduct disordertherapeutic effect in Conduct disorder
Foster care, juvenile justice, public Foster care, juvenile justice, public mental healthmental health
Multisystemic therapies (MST, FFT, Multisystemic therapies (MST, FFT, FIT): family, peer, school, and FIT): family, peer, school, and neighborhood interventions plus neighborhood interventions plus behavior therapy, problem solving, behavior therapy, problem solving, +/- DBT skills+/- DBT skills
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SchoolSchool
Feeling more successful in school Feeling more successful in school alwaysalways helps behaviorhelps behavior
Testing (learning, speech, language)Testing (learning, speech, language)
AccomodationsAccomodations
Special classroomSpecial classroom
Social skills, problem solving, peer Social skills, problem solving, peer mediationmediation
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PharmacotherapyPharmacotherapy
Target medication responsive diagnosesTarget medication responsive diagnoses
Covert, premeditated generally not responsiveCovert, premeditated generally not responsive
Meds should be adjunctive and secondary to Meds should be adjunctive and secondary to behavioral interventionsbehavioral interventions
Most benign first, informed consentMost benign first, informed consent
Quantify and track results (OAS)Quantify and track results (OAS)
Stop one before starting secondStop one before starting second
Assess compliance, all meds can be divertedAssess compliance, all meds can be diverted
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ADHD + ODD/CD TreatmentADHD + ODD/CD Treatment
ADHD = ADHD+ODD in stimulant responseADHD = ADHD+ODD in stimulant response
Non-Stimulant medications not as consistentNon-Stimulant medications not as consistent
11x the non-compliance with ODD11x the non-compliance with ODD
Meds + parenting and/or behavioral therapyMeds + parenting and/or behavioral therapy
Combination therapy is better when Combination therapy is better when comparing “normalization,” and dosage of comparing “normalization,” and dosage of medication and parent preferencemedication and parent preference
Jensen et al, 2001PAL ProgramPAL Program
StimulantsStimulants
18 studies (15 RCTs). 429 kids, mostly 18 studies (15 RCTs). 429 kids, mostly elementary boys. ADHD and/or ODD/CD elementary boys. ADHD and/or ODD/CD with aggressive behavior. with aggressive behavior.
Greatest ES in ADHD + aggression, 0.9. Greatest ES in ADHD + aggression, 0.9. Lowest in MR, 0.3. Average was 0.78.Lowest in MR, 0.3. Average was 0.78.
At least 3 small studies (N=99) reduced At least 3 small studies (N=99) reduced aggression in ODD,CD without ADHDaggression in ODD,CD without ADHD
Good first choice for impulsive, reactive Good first choice for impulsive, reactive aggression. Quick trial, relatively benign.aggression. Quick trial, relatively benign.
Pappadopulos et al, 2006 PAL ProgramPAL Program
Alpha 2 AgonistsAlpha 2 AgonistsClonidine. 7 studies (4 RCTS). 114 kids. ADHD, Clonidine. 7 studies (4 RCTS). 114 kids. ADHD, CD, PTSD, Tourettes, Autism.CD, PTSD, Tourettes, Autism.
RCTs showed efficacy DBDs>Tourettes. RCTs showed efficacy DBDs>Tourettes.
Watch for sedation, dizziness, hypotensionWatch for sedation, dizziness, hypotension
Guanfacine. 4 studies, 1 controlled. 72 kids. Guanfacine. 4 studies, 1 controlled. 72 kids. ADHD +/- ticsADHD +/- tics
Mixed results. Better tolerated than clonidine.Mixed results. Better tolerated than clonidine.
ADHD kids who don’t tolerate stimulants, or kids ADHD kids who don’t tolerate stimulants, or kids with hyperarousalwith hyperarousal
Pappadopulos et al 2006 PAL ProgramPAL Program
Anti-depressantsAnti-depressants
Seretonin and aggression in ratsSeretonin and aggression in rats
SSRIs treat “impulsive aggression” in adults, SSRIs treat “impulsive aggression” in adults, primatesprimates
30-40% of depressed adults are aggressive30-40% of depressed adults are aggressive
Bupropion 3 RCTs, 2 open. 117 kids. CD and Bupropion 3 RCTs, 2 open. 117 kids. CD and ADHD. “solid support.”ADHD. “solid support.”
SSRIs mixed results, but still consideration for SSRIs mixed results, but still consideration for anxious/depressed.anxious/depressed.
Trazodone in DBD, effective for aggression. Small Trazodone in DBD, effective for aggression. Small open trial (22) open trial (22)
Pappadopulos et al 2006 PAL ProgramPAL Program
AntipsychoticsAntipsychotics
Since 2000, 9 studies in CD/ODD, ADHD, Since 2000, 9 studies in CD/ODD, ADHD, DBD, MR, Autism. 875 kidsDBD, MR, Autism. 875 kids
Risperidone, low doses, short trialsRisperidone, low doses, short trials
ES ranging from 0.7-1.96.ES ranging from 0.7-1.96.
Aripiprazole, 1 RCT, 218 children, efficacy Aripiprazole, 1 RCT, 218 children, efficacy and SE’s increased with dose.and SE’s increased with dose.
Movement and metabolic disordersMovement and metabolic disorders
Large/broad effect, short term managementLarge/broad effect, short term management
Pappadopulos et al 2006 PAL ProgramPAL Program
Mood StabilizersMood Stabilizers
Lithium. 5 RCTs. Mostly inpatient CD. Lithium. 5 RCTs. Mostly inpatient CD. Mixed. More effective in “affective, Mixed. More effective in “affective, explosive.”explosive.”
Valproic Acid. 2 studies (1 RCT). 30 kids. Valproic Acid. 2 studies (1 RCT). 30 kids. Superior to placebo in aggression in CD.Superior to placebo in aggression in CD.
Carbamazepine. 1 RCT showed no benefitCarbamazepine. 1 RCT showed no benefit
Oxcarbazepine. No dataOxcarbazepine. No data
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Mood Stabilizer, contMood Stabilizer, contLithium monitoring. Baseline Cr and Ur specific Lithium monitoring. Baseline Cr and Ur specific gravity, TSH, ?EKG. Lithium level 1 week after gravity, TSH, ?EKG. Lithium level 1 week after dose change. Monitor level, kidney, TSH every dose change. Monitor level, kidney, TSH every 2-3 months. Weight.2-3 months. Weight.
VPA monitoring. CBC+LFTs prior. Repeat, with VPA monitoring. CBC+LFTs prior. Repeat, with VPA level every few weeks in first couple VPA level every few weeks in first couple months, then 1-2 times/year. Weightmonths, then 1-2 times/year. Weight
Carbamazepine. CBC, LFTs, Renal, TSH prior. Carbamazepine. CBC, LFTs, Renal, TSH prior. Repeat q2wks for 2m, then every 3-6m.Repeat q2wks for 2m, then every 3-6m.
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Beta BlockerBeta Blocker
Propranolol (others havePropranolol (others have intolerance) intolerance)
Some evidence in adults with “impulsive, Some evidence in adults with “impulsive, explosive” rage, aggression in MR, DD explosive” rage, aggression in MR, DD dementia.dementia.
5 studies (1 RCT). 101 kids. Various dx 5 studies (1 RCT). 101 kids. Various dx (ADHD, DD, PTSD, “organic”). Largely (ADHD, DD, PTSD, “organic”). Largely positivepositive
1 RCT. 32 kids. CD. Pindolol not superior to 1 RCT. 32 kids. CD. Pindolol not superior to MPH, with significant SE’sMPH, with significant SE’s
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Thank you for coming!
Please feel free to email me with any [email protected]
For specific clinical questions, contact PAL at 1-866-501-72575
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Acknowledgement
Dr. Terry LeeDr. Robert HiltDr. William French
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