Disorders Associated with Aggression in Kids
- Conduct Disorder (CD): repetitive significant violations of social rules and the rights of others over the course of a year.
- Intermittent Explosive Disorder (IED): requires recurrent behavioral outbursts in which the child does not control aggressive impulses.
- Oppositional Defiant Disorder (ODD): developmentally inappropriate opposition to and defiance of adult rules and requests for more than 6 months.
Introduction
It is difficult to manage aggressive behaviors and the DSM is helpful to understand how these issues requires treatment. However, it’s important to rule out organic or external causes before concluding it’s mainly psychiatric related. Key areas to screen for include:
- Abuse: always mandatory to assess for signs of abuse and increased suicidal or homicidal ideation.
- Medication Changes: Some medications (e.g., montelukast, antibiotics, etc.) can cause mood symptoms, so recent medication changes should be considered.
- Medical Conditions, Diseases, and Infections: Infections or its medications and treatment can trigger behavioral issues. Medical conditions that may induce aggressiveness includes seizures, CA, COPD/asthma/low oxygen incidents, CVA/TBI, dementia, etc.
- Leisure activities: Monitor the child’s media consumption. Violent or explicit content can worsen behavioral issues.
- Additional and External Factors: Consider factors like low sleep, lead poisoning, dietary deficiencies, bullying, family changes (e.g., divorce), or physical injuries (e.g., concussions from sports) that can all affect normal behaviors.
Carefully assess all possible influences on a child’s behavior before considering a major behavioral diagnosis. This is also important for the scope of practice, legalities, courts, etc. truly be careful with diagnosing someone with personality disorder or autism, for example in the initial assessments… Overall, it can be a lot to think about and things can get tricky but here’s how I generally start a decision-making process, and at the bottom, I’ll list a few clinical management/pearls:
- Know What You Can and Cannot Control: Focus on setting expectations and standards for the behaviors. Kids may not always understand that their behavior is wrong, thus therapy is usually the standard for treatment because teaching and learning is so imperative. Consider maintaining frequent (<1x/month) wellness checks or formal structures to help reinforce not rewarding bad behaviors and to evaluate if treatment is helpful or needs to change.
- Keep Checking (not just at the scheduled sessions): Communicating (but documenting) outside of schedule sessions can also hopefully avoid a crises. Continue to use formal approaches like discussing genetic testing, additional medication management, and collaborating with others care members. Also discussing intensive options, e.g. being rehomed, inpatient/residential options can also emphasize how the behavior is serious and requires attention.
- About Treatment: sometimes medications are started immediately depending on the severity of the behaviors. Despite most medications aren’t FDA-approved for kids, consider using the medications that are normally used to treat aggressive psych symptoms and used appropriate dosages (start at the lowest and titrate slowly). Continue to consider adding non-pharmacological options like magnesium, melatonin supplements.
An Example of Trouble
BK is a 7y/o psych eval in your office and dad wants to start medications. His outbursts is getting worse, he’s been doing poorly in school, biting his classmates, and now he’s biting the grandmother. You don’t have much time because BK has to be dropped off at the mother’s house and the father was late to the appointment. The parents are divorcing and the father is trying to get primary custody, the mother is against the kid getting mental health treatment and think the father is just trying to keep father away, but the mother hasn’t been sober and has been unreliable. So let’s make it quick:
- Step 1- Consider the severity of the situation and appropriate medication for aggression: Harming self or others, is a clear justification to start treatment. Consider common medications that treat impulsivities, e.g. aripiprazole or risperidone or FDA-approved medications for kids and can be micro-dosed (0.25–1 mg). Medications also depends on the child’s size when determining dosages and be aware of eating habits to ensure they can tolerate PO medications and be mindful of metabolic risks. If family declined medications, etc. document the refusal and how you addressed the concerns and risks of being non-adherent.
- Step 2- Assess the Timing of the Aggression: Ask when the irritability is worse (e.g., after school, all day, at the other parent’s house). Since BK’s behavior is problematic both at school and at home (e.g., biting grandma), dosing might be required 1-2 times a day. For example, you can dose the medication twice a day if the aggression is all day or before school, if the aggression is primarily at school. Also be aware of changes of the mood and medications related to the menstrual cycle that may require a higher dosage of treatment.
- Step 3- Assess Sleep & Rule Out ADHD: Sleep is a crucial factor, especially for school, learning, controlling the mood, etc. Sleep is usually affected during a divorce/life changes or in vulnerable circumstances. Sometimes it can resolve on it’s own, but with children, monitor and document sleep like the 5th vital sign. Poor sleep can contribute to an increase of stress and aggression, in which the kid is already not coping well. If ADHD is suspected, consider guanfacine for smaller children or clonidine for those with major sleep issues. Discuss psychological testing and the possible use of stimulants (e.g. methylphenidate for smaller children, or amphetamines for more severe ADHD).
- Step 4- Consider the Stress, Mood, and Social Factors: Before puberty, kids’ moods are more reactive to their environment rather than the internal changes like hormones. Therefore, the child is more affected by socioeconomic factors, the family dynamics, etc. and targeting the home life may also be more helpful. However, medications can assist the child to not become overstimulated and respond more appropriately to the environment and with changes. Antipsychotics can also help with mood regulation or impulsivities, but for anxiety or depression, consider fluoxetine, sertraline (often recommended for females related to menstrual cycles) and escitalopram or sertraline (often recommended for males).
- Step 5- Discussed the Plan of Care: include risks vs. benefits of treatment, alternatives, what to do in emergencies, how to to manage side-effects or any med issues, etc.
The appointment is over and you didn’t cover everything but at least you covered the main areas; aggression (mood) and sleep. For the next follow-up appointments, keep targeting the aggression/mood until stability. If it didn’t work, increase the dosages or switch to the next medication in line. If the behavior is still difficult, consider a mood stabilizer, genetic testing, ask colleagues, and continue to reassess the diagnosis and treatment plan. Anything unconventional, seek additional professional resources or your peers, don’t be afraid to ask for help and document WELL.
Lastly, try to make sure everyone is on the same page in a complex family or social situation or in general, no matter how difficult it gets. Don’t let a parent pin you against another parent or take sides. Stay neutral unless it’s something concerning, be aware of court-orders, and try to keep the topics mainly about the treatment and focus on what’s helpful, safe, and remain objective.
