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Evaluation and Treatment of Youth Presenting With Aggressive Behavior

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In this presentation, participants will…

1. Examine the two primary subtypes of aggressive behavior seen in child and adolescent outpatients
2. Review common characteristics of youth most likely to present for treatment of maladaptive aggression
3. Discuss key questions to ask during evaluation of the child who lashes out aggressively
4. Explore the research on the use of common classes of psychotropics for children and teens whose primary presenting problem is aggressive behavior

Link to video: https://vimeo.com/332228331

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Evaluation and Treatment of Youth Presenting With Aggressive Behavior

  1. 1. Evaluation and Treatment of Youth Presenting With Aggressive Behavior Stephen Grcevich, MD President, Family Center by the Falls, Chagrin Falls OH Clinical Associate Professor of Psychiatry, NEOMED Transitional Medical Director Child and Adolescent Behavioral Health April 24, 2019
  2. 2. Learning objectives Participants will… • Examine the two primary subtypes of aggressive behavior seen in child and adolescent outpatients • Review common characteristics of youth most likely to present for treatment of maladaptive aggression • Discuss key questions to ask during evaluation of the child who lashes out aggressively • Explore the research on the use of common classes of psychotropics for children and teens whose primary presenting problem is aggressive behavior
  3. 3. Potential Conflicts of Interest (last five years) Source of Conflict: Company: Consultant Ironshore, Shire Grants/research support CAPTN/Duke Clinical Research Institute Speakers’ Bureaus N/A Other financial support N/A Publishers Harper Collins/Zondervan
  4. 4. Subtypes of aggressive behavior: Impulsive aggression: • Affect: fear, anger • Arousal level: high • Outcome: negative • Impulsive • Reactive • Defensive • Overt • Hostile Predatory aggression • Affect: self-confidence • Arousal level: low • Outcome: positive for self • Controlled • Predatory • Offensive • Covert • Instrumental Vitiello B, Stott DM. J Am Acad Child Adolesc Psychiatry 1997; 36(3) 307-315
  5. 5. Definition of maladaptive aggression: Aggressive behavior occurring outside an acceptable social context Characterized by: • Intensity, frequency, duration and severity are disproportionate to its causes • May occur in absence of antecedent social cues • Behavior not terminated in expected time frame, or in response to feedback Jensen P et al. J Am Acad Child Adolesc Psychiatry 2007; 46(3): 309-322
  6. 6. Characteristics of youth who exhibit maladaptive aggression • More school adjustment problems than anticipated • Higher rates of peer rejection, victimization • Difficulties in ambiguous interpersonal situations (reading emotion in facial expressions of others) • Prone read neutral facial expressions negatively • Poor peer relationships • Deficits in problem solving often emerge by age 4 • 21% of children with impulsive aggression reported to have been a victim of physical abuse Dodge KA (1991) In: The Development and Treatment of Childhood Aggression pp 201-218
  7. 7. Principles of evaluation Aggression is to a child psychiatrist what fever is to a pediatrician - a non-specific sign associated with many conditions. We seek to identify and treat the underlying condition(s)
  8. 8. Common conditions frequently associated with maladaptive aggression • ADHD • Bipolar disorder • Autism spectrum disorders/developmental disorders • Post Traumatic Stress Disorder • Anxiety disorders • Depression • Iatrogenic causes Aggression often co-occurs with specific disorders, but may not be ameliorated by medications used to treat those disorders Jensen et al. J Am Acad Child Adolesc Psychiatry 2007; 46(3): 309-322
  9. 9. The importance of a thorough evaluation • Comorbidity is common • Failure to recognize common comorbid conditions contributes to medication trials that worsen aggression
  10. 10. Important questions for parents/caregivers: aggressive behavior • Who, what, when, where, why? • Antecedent – Behavior – Consequence • If you can’t identify the antecedent, it likely originates in the child’s thought processing • Impulsive vs. perseverative • Immediate response to frustration vs. buildup of frustration to major meltdown • Rarely is aggression purely of one type • Mix is especially common in patients with disruptive behavior disorders and comorbid anxiety, OCD
  11. 11. Nuggets in the medication history? Learning from negative responses to previous medication trials… • When ADHD meds exacerbate aggression • When antidepressants or anxiolytics exacerbate aggression
  12. 12. Principles of psychopharmacology in youth with aggressive behavior • Treat the underlying condition(s) thought to contribute to aggressive behavior • Carefully screen for conditions that may be exacerbated by treatment • Internalizing disorders when using ADHD meds • Conditions associated with impulsivity when using meds linked to behavioral activation (SSRIs) • Consider dosing more conservatively in patients with comorbidity • Aggression may not respond as well to pharmacotherapy as other symptoms
  13. 13. ADHD medications in aggression • Stimulants have the most evidence for efficacy in treatment of oppositional behavior, conduct disorder and aggression (high quality) • 40 randomized trials, 2300+ patients in trials of 2-16 weeks • Effect sizes: • Parent rated: 0.71 • Clinician-rated: 0.77 • Teacher-rated: 1.04 Pringscheim T et al. Can J Psychiatry 2015;60(2):42-51
  14. 14. ADHD medications in aggression • High-quality evidence that atomoxetine has a small effect on oppositional behavior in youth with ADHD, with and without ODD, Conduct Disorder (CD) • Effect size: 0.33 • Moderate-quality evidence that guanfacine has a small-moderate effect on oppositionality in youth with ADHD, with/without ODD, CD • Very low -quality evidence that clonidine has a small effect on oppositional behavior Pringscheim T et al. Can J Psychiatry 2015;60(2):42-51
  15. 15. Pringscheim T et al. Can J Psychiatry 2015;60(2):42-51
  16. 16. Antipsychotics and mood stabilizers in aggression • Moderate evidence for moderate-large effect of risperidone on conduct problems and aggression in youth with sub-average IQ and ODD, CD, with and without ADHD • Moderate effect seen in youth with typical IQ • One small RCT (N=19) demonstrated large effect size for quetiapine in youth with CD +/- ADHD • Overall, evidence for use of antipsychotics other than risperidone is very low Pringscheim T et al. Can J Psychiatry 2015;60(2):52-61
  17. 17. Antipsychotics and mood stabilizers in aggression • Evidence for use of lithium, divalproex of low quality • Very low-quality evidence supporting use of carbamazepine • Greater than 99% of subjects in studies of antipsychotics, all subjects in studies mood stabilizers had ADHD plus CD and/or ODD Pringscheim T et al. Can J Psychiatry 2015;60(2):52-61
  18. 18. Conclusions • Thorough evaluation of the context of aggressive behavior and identification of psychiatric conditions that predispose or perpetuate aggression are essential for effective treatment • Aggression is a non-specific symptom associated with a broad array of psychiatric conditions. • Treatment should be focused on addressing the psychiatric condition(s) most closely associated with aggressive behavior

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