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
Time to go down the rabbit hole, where the kid is just out of control and terrorizing everyone. The main issue with these diagnoses is how DSM suggests it has to be something chronic when in reality you’ll get parents that said for the last few days everything has been horrible. Like people don’t normally wait for months to deal with a child’s bad behavior but I get it, DSM wants to make sure it’s wayyy more than a tantrum. The behavioral diagnoses and symptoms also assume that there should be nothing organically or externally causing these issues but it has to be ruled out. Screen for:
- Abuse: always screen or report any signs of abuse and assess for increased SI or HI behaviors.
- A Recent or Changed Medication: I’ve just read an article about how Singular can cause manic symptoms but it’s not the only unconventional medication that can cause mood symptoms; antibiotics, ondansetron, prochlorperazine and even decreasing/changing medication can cause severe mood episodes.
- Diseases and Infections: again sometimes medications, antibiotics or the infection can trigger difficult behaviors. Also, PANDAS is still debatable and much research is needed in other areas as well that may cause psych problems.
- Poor Leisure Activities: I tell families to make sure they are monitoring online and social activities. If little Johnny is trying to blow up the house, avoid the zombie apocalypse movies. Avoid genres and media that may cause problems if the child is already having problems distinguishing the reality. Anything that has horror, bloody, violence, weapons, guns, explicit content, dark humor, pranks…etc. needs to be replaced with things that are practical and educational. Most of my kids that aren’t doing well are usually the ones not being monitored.
- External Factors: Also think about lead poisoning, diet/food habits, bullying, divorce or major family/housing changes, family history, accidents or physical injuries, and cultural barriers. I sometimes tell parents to be careful with football, soccer, boxing, or sports that can cause brain and personality changes.
Overall, it can be a lot to think about so things can get tricky but here’s how I start my decision-making process, and at the bottom, I’ll list a few clinical management/pearls:
- Step 1: Know what you can and cannot control. If there’s a lot of dysfunction or external factors (things out of your control), I tend to focus on what can I control or normalize. In other words, what are the expectations and standards? You’ll be surprised how many times I’ve asked a kid if they knew that kicking the neighbor’s dog is wrong or whatever bad behavior and they wouldn’t know or be completely confused. I get that it could be manipulation and the kid will play dumb but in plain English, find ways to improve parenting/environment, and be consistent. My co-worker wants the kids to feel happy and play on the floor with them, but I’m the complete opposite. I keep it formal because the kid needs to know bad behavior will NOT equal “happiness”. I sometimes treat my office like a boot camp detention center and hide all the toys.
- Step 2: Find out what did and didn’t work, so this isn’t just for the intake but for every med review, we have to hash out what isn’t working until the kid is stable and acting right (not being aggressive). Going back to being formal, I do a genetic test in the intake, not just because it helps with treatment but I hope that in a kid’s mind they’ll think, my behavior is so bad, that I have to get my DNA tested… and you know with young people, seeing is believing and hopefully, they’ll take their behaviors more serious and stop hurting people. Continue targeting the behavior.
- Step 3: Talk about meds (your plan). If you cover all your bases and are ready to start medications, I know it can be overwhelming…It’s many factors but honestly with a good intake and background information/genetic report you’re in a good position. I will discuss a test dummy patient who doesn’t have all this information to show you how you can break down a decent treatment plan:
…Tyler keeps Biting Grandma and Got Kicked out of School
Tyler is a 7y/o psych eval in your office and dad wants you to start medications. His outbursts have been getting worse, kicked out of school numerous times, and biting family members. You don’t have much time because Tyler has to be dropped off at the mother’s house and dad was late for the appointment. The parents are divorcing and the dad is trying to get primary custody, the mother is against him getting mental health treatment and think the father is just trying to keep the kid away. So let’s make it quick:
- Start with what’s approved for kids: usually aripiprazole and risperidone are best for aggression. Tyler looks rather small for his age, so what’s good about these two medications is how you can start very low .25-1mg with dosages. Try to stick with medications that you can micro-dose. Also, if the kid is small ask about eating habits (r/o extra problems and to know if they can tolerate swallowing medications).
- When is the behavior the worse?: I’ll ask parents if the irritability is usually after school or all day since Tyler got kicked out of school -you can assume it’s at school and at home since he’s biting grandma….. This matters because if the behavior is bad ALL day, I’ll dose BID but I do have kids on dosed 3-4 times a day. Overall, try to keep it 1-2 times a day to make it easy for everybody.
- Target SLEEP: the parents are going through a divorce (or insert any psychological trauma) and the poor kid is physically acting out and STRESS. Assess sleep like the 5th vital sign. Plus it’s a perfect opportunity to start r/o ADHD. If a kid is tiny, I’ll use guanfacine but if the child has poor sleep/nightmares, clonidine is more effective. If you suspect ADHD, you can discuss psychological testing, ways to improve school behavior, grades, or focus, and a plan to start a stimulant. (methylphenidate if the child is small, amphetamine if the child is average or severe ADHD)
- What about the mood?: before puberty, the mood is not too much of a problem, kids are mainly reacting to their environment and not internally like hormones, suicide, bipolar…etc. Not sure if I’m clear here but what I’m saying is “medications” should help kids control how they are responding to the environment instead of responding with anger/violence…Nevertheless, if the environment is negative, chaotic, or toxic -then the child would eventually, if not already exhibit severe mood symptoms. So I don’t usually treat the mood at first versus the aggression (hence it’s the last point here). Antipsychotics should also help with the mood but if they need something for anxiety or depression, fluoxetine and sertraline are usually my 1st line. It’s another post but I’ll make it simple, I usually prescribed fluoxetine for females because it helps with cycles, and males/before puberty usually do better with sertraline.
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 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, ask colleagues, and continue to reassess the diagnosis and treatment plan. Anything unconventional, seek professional council 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 social situation, 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. Another goal for the provider is not to get lost in the shuffle and to stay focused on what’s evidence-based, safe, and remain objective.
