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.
Main Points
Safety
Assess and treat comorbid conditions
Address risk factors and bolster strengths
Behavioral interventions first
Medications secondary and adjunctive
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
Esmerelda
9 year old cranky girl
Aggressive and destructive tantrums
Cries unpredictably
Treated for ADHD, without benefit
Low energy, appetite
Reginald
15 year old boy in Wyoming Boy’s School
Assault, burglary, arson, shoplifting
Drug commerce and use
Parents have criminal history
Lilliana
14 year old girl, psychiatric inpatient
Aggression towards family
History of sexual abuse by babysitter
Difficulty sleeping, nightmares
Hyperarousal, irritability
Winifred
9 year old, language delay
Toe walking, spins when toilet flushes
No interest in social play
Pulls hair of dog and sister
Nature of Aggression
Development of contrary and aggressive
behavior
Psychological factors
Environmental factors
Physiological factors
Determining pathologic
Developmental Trajectory
From “Developmental Origins of Aggression” by Tremblay, Hartup and Archer (2005)
Developmental Trajectory
From “Developmental Origins of Aggression” by Tremblay, Hartup and Archer (2005)
Developmental Trajectory
From “Developmental Origins of Aggression” by Tremblay, Hartup and Archer (2005)
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
Physiology
Genetics
Autonomic nervous system
Endocrine
Neuroanatomy
Serotonin
Toxins
Nature - Nurture
Caspi, et al 2002
Neuroanatomy
Orbito/frontal: reactive
aggression, negative
affective style,
impulsivity
Temporal:
unprovoked
aggression
Amygdala:
interpretation of social
cues
Distinguishing Pathologic
Safety
Variety of symptoms and settings
Proactive aggression and cruelty
Use of weapon
Contrary to social group
Behavior atypical for age
Assessment
SAFETY
Abuse, neglect
Presence of weapon
Past behavior
Use of drugs/alcohol
Acute psychiatric illness (mania,
psychosis)
Suicide
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)
Individual Factors
Family history (ADHD, DBD, PDD, mood)
Temperament, affect dysregulation
Reading, speech/language
Social skills
Prenatal, environmental toxic exposure
Parenting
Parental mental illness
Low involvement
High conflict
Poor monitoring
Harsh inconsistent
discipline
Physical punishment
Lack of warmth and
involvement
Parental burn out
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
Peers
Rejected and
reinforced by prosocial peers
Uneasy affirmation
by anti-social
peers
Females more
sensitive to
rejection
Neighborhood
More predictive of DBD
than any other
psychopathology
Public housing
outweighs all protective
factors
Disorganization, drugs,
adult criminals, racial
prejudice, poverty,
unemployment
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)
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.
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
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
PTSD, Autism, Bipolar
(car, relax, alone, forget, friends, trouble)
Treatment Menu
Education
Treat co-morbid medical and
psychiatric conditions
Parenting support
Psychotherapy
Community/Multimodal services
Medication
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
Education
Drugs, toxins
Parenting/abuse
Parent mental health
Learning problems
Peers, community
Safety precautions
Available resources
Communication
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
Comorbidity
ADHD: medication and parenting
support +/- behavioral therapy
Substance abuse: targeted treatment,
motivational interviewing, consider
residential
Mood/Anxiety: individual therapy
(CBT) +/- medication
Psychotherapy
Part of a broader
program
Problem solving, peer
mediation
Social skills
Moral development
Anger/assertiveness
training
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
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
Parenting
Positive
reinforcement
Balanced
emotional
valence
Time outs
Parenting (con’t)
Response cost:
withdrawing
rewards
Token economy
Consistency of
response
Priorities and
sharing
responsibility
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
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
School
Feeling more successful in school always
helps behavior
Testing (learning, speech, language)
Accomodations
Special classroom
Social skills, problem solving, peer
mediation
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
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
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
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
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
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
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
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.
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
Thank you for coming!
Please feel free to email me with any questions
[email protected]
For specific clinical questions, contact PAL at 1866-501-72575
Acknowledgement
Dr. Terry Lee
Dr. Robert Hilt
Dr. William French
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