Angry, Naughty Angry, Naughty ChildrenChildren

The Disruptive Behavior DisordersThe Disruptive Behavior Disorders

Michael Kisicki, M.D.Seattle Children’s Hospital

Echo Glen Children’s CenterUniversity of Washington, Department of Psychiatry.

Outline Outline

Definition and Clinical PictureDefinition and Clinical Picture

Prevalence and TrendsPrevalence and Trends

Etiology and DevelopmentEtiology and Development

Risk FactorsRisk Factors

Treatment (community, individual, Treatment (community, individual, medication)medication)

Common Clinical Situations (ADHD, Common Clinical Situations (ADHD, aggression)aggression)

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 Usually resolves, 1/3 develop conduct disorderdisorder

High rate of comorbidityHigh rate of comorbidity

ODD vs. Normal KidODD vs. Normal Kid

Chief complaint: Angry, naughty childChief complaint: Angry, naughty child

TOM ANDY

ODD vs. Normal KidODD vs. Normal Kid

Is it impairing?Is it impairing?

Are symptoms present at home Are symptoms present at home ANDAND school? school?

Is there a new temporary stressor?Is there a new temporary stressor?

Did they function well in the past?Did they function well in the past?

Conduct DisorderConduct Disorder

Repetitive + persistent, violates basic rights of others Repetitive + persistent, violates basic rights of others or societal normsor 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 age.Less Aggression and more rights violations with age.

Not Just a PhaseNot Just a Phase

Younger age of Younger age of onsetonset

Variety and number Variety and number of symptomsof symptoms

Proactive aggression Proactive aggression and crueltyand cruelty

Behavior atypical for Behavior atypical for age and genderage and gender

WeaponWeapon

Not in social contextNot in social context

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

Adult antisocial personality disorder: 2.6%Adult antisocial personality disorder: 2.6%

Slight increase by generation Slight increase by generation

Boys >> girlsBoys >> girls

Prognosis and OutcomesPrognosis and Outcomes

Cost to individual, family and societyCost to individual, family and society

Psychiatric comorbidityPsychiatric comorbidity

Substance abuseSubstance abuse

Educational problemsEducational problems

UnemploymentUnemployment

Delinquency/CriminalityDelinquency/Criminality

Violent relationshipsViolent relationships

Teen pregnancyTeen pregnancy

Generational transferGenerational transfer

Comorbidity*Comorbidity*

ADHD 10x more ADHD 10x more commoncommon

Major Depression Major Depression 7x more common7x more common

Substance Abuse Substance Abuse 4x more common4x more common

Anxiety ??????Anxiety ??????

ETIOLOGY / RISK FACTORSETIOLOGY / RISK FACTORS

DEVELOPMENTDEVELOPMENT

NormalNormalProsocial infant Prosocial infant behaviorbehavior

Toddler Toddler independenceindependence

““Terrible two’s (and Terrible two’s (and threes)”threes)”

Adolescent Adolescent experimentationexperimentation

WORRYWORRYMilestone deviationMilestone deviation

Aggression after 8 Aggression after 8 yearsyears

Drug experimentation Drug experimentation prior to adolescenceprior to adolescence

BiologyBiology

Genetics (50%)Genetics (50%)

Anatomy (frontal, Anatomy (frontal, temporal lobes)temporal lobes)

Chemistry (seretonin, Chemistry (seretonin, cortisol, testosterone)cortisol, testosterone)

Autonomic arousalAutonomic arousal

ToxinsToxins

PsychologyPsychology

TemperamentTemperament

Intelligence, reading, speech/languageIntelligence, reading, speech/language

Social skillsSocial skills

CognitionCognition

ParentingParenting

Parental mental illness*Parental mental illness*

Low involvementLow involvement

High conflictHigh conflict

Poor monitoringPoor monitoring

Harsh inconsistent Harsh inconsistent discipline*discipline*

Physical punishmentPhysical punishment

Lack of warmth and Lack of warmth and involvementinvolvement

Parental burn out*Parental burn out*

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 internalizing develop DBD, girls have more internalizing

PeersPeers

Rejected and Rejected and reinforced by pro-reinforced by pro-social peers*social peers*

Uneasy affirmation Uneasy affirmation by anti-social by anti-social peers*peers*

Females more Females more sensitive to sensitive to rejectionrejection

NeighborhoodNeighborhood

More predictive of DBD More predictive of DBD than any other than any other psychopathologypsychopathology

Public housing outweighs Public housing outweighs all protective factors*all protective factors*

Disorganization, drugs, Disorganization, drugs, adult criminals, racial adult criminals, racial prejudice, poverty, prejudice, poverty, unemploymentunemployment

EvaluationEvaluation

Co-morbid conditions (ADHD, substance Co-morbid conditions (ADHD, substance abuse, mood, anxiety/PTSD, lead toxicity, abuse, mood, anxiety/PTSD, lead toxicity, brain trauma)brain trauma)

Look for recent changes or new stressorsLook for recent changes or new stressors

Evaluate for modifiable risk factorsEvaluate for modifiable risk factors

Information from multiple sources (parent, Information from multiple sources (parent, teacher, probation)teacher, probation)

Vanderbilts, Overt Aggression ScaleVanderbilts, Overt Aggression Scale

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

What’s ineffective?What’s ineffective?

Boot campsBoot camps

Job programsJob programs

Peer Peer counselingcounseling

Home Home detentiondetention

Scared straightScared straight

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

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

PsychotherapyPsychotherapy

Part of a broader programPart of a broader program

Problem solvingProblem solving

Social skills Social skills

Moral developmentMoral development

? anger/assertiveness ? anger/assertiveness trainingtraining

? rational emotive therapy? rational emotive therapy

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 rangedoes not bring out of clinical range

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

Parenting in Primary CareParenting in Primary Care

RCT of RCT of bibliotherapy bibliotherapy versus 12 session versus 12 session parenting programparenting program

www.incredibleyeawww.incredibleyears.com (Free and rs.com (Free and Purchased Purchased material)material)

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

ParentingParenting

Positive Positive reinforcementreinforcement

Balanced Balanced emotional emotional valencevalence

Time outsTime outs

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

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

Multimodal ServicesMultimodal Services

Strongest evidence for actual therapeutic effectStrongest evidence for actual therapeutic effect

Foster care, juvenile justice, public mental healthFoster care, juvenile justice, public mental health

Multisystemic therapy: family, peer, school, and Multisystemic therapy: family, peer, school, and neighborhood interventionsneighborhood interventions

DSHS explanation of Wraparound Services. DSHS explanation of Wraparound Services. http://www.dshs.wa.gov/mentalhealth/guidetotailorhttp://www.dshs.wa.gov/mentalhealth/guidetotailoredcare.shtml.edcare.shtml.

PharmacotherapyPharmacotherapy

Rule out and treat ADHD, depression, Rule out and treat ADHD, depression, Bipolar, psychosis firstBipolar, psychosis first

After psychosocial interventions failAfter psychosocial interventions fail

Poor response without co-morbid conditionPoor response without co-morbid condition

Not just stimulants are diverted!Not just stimulants are diverted!

MarvinMarvin

11 yo healthy boy, normal development11 yo healthy boy, normal development

Irritable, rambunctiousIrritable, rambunctious

Talks back to teachers and parentTalks back to teachers and parent

Flopping in school. Kids don’t like him.Flopping in school. Kids don’t like him.

Hard to get to sleepHard to get to sleep

Family history of bipolar disorderFamily history of bipolar disorder

ADHD and ODD/CDADHD and ODD/CD

ODD is most common comorbidity in ADHD, ODD is most common comorbidity in ADHD, occurring in 60%occurring in 60%

Earlier age of onset and impairmentEarlier age of onset and impairment

More likely progression to CD and other More likely progression to CD and other psychiatric illnesspsychiatric illness

More aggression and substance abuse More aggression and substance abuse (double the risk, compared to ADHD alone)(double the risk, compared to ADHD alone)

Similar but different from BipolarSimilar but different from Bipolar

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

AlexAlex

12 yo healthy foster boy, unknown 12 yo healthy foster boy, unknown developmentdevelopment

Bullies younger kids, tortures animalsBullies younger kids, tortures animals

Foster parent scaredFoster parent scared

Truant, history of poor academicsTruant, history of poor academics

AggressionAggression

Overt, reactive aggression is most responsiveOvert, reactive aggression is most responsive

Covert, premeditated aggression is less Covert, premeditated aggression is less responsiveresponsive

Clear quantifiable goals, use of scales (OAS)Clear quantifiable goals, use of scales (OAS)

Keep it simple, one thing at a time.Keep it simple, one thing at a time.

Stop interventions that don’t help.Stop interventions that don’t help.

Modest expectations.Modest expectations.

Aggression TreatmentAggression Treatment

Treat comorbid conditionsTreat comorbid conditions

Early intervention is key, solidified by age 10-12 Early intervention is key, solidified by age 10-12 years years

2-6yo: parent management training (PCIT, PMT)2-6yo: parent management training (PCIT, PMT)

6-12yo: peer mediation, anger management, 6-12yo: peer mediation, anger management, conflict resolution training, and assertivenessconflict resolution training, and assertiveness

Teens: multimodal therapies, CBTTeens: multimodal therapies, CBT

Education: speech and language pathology Education: speech and language pathology (expressive/receptive), reading and writing (expressive/receptive), reading and writing learning disorderslearning disorders

Aggression PsychoharmacologyAggression Psychoharmacology

Atypical Antipsychotics: (Atypical Antipsychotics: (Risperidone)Risperidone). . Hostility, impulsivity, hyperactivity and Hostility, impulsivity, hyperactivity and aggression CD, BAD, psychosis, autism aggression CD, BAD, psychosis, autism spectrum disorders, intellectual disability spectrum disorders, intellectual disability

Mood Stabilizers: Lithium has large effect Mood Stabilizers: Lithium has large effect size (>1) in multiple trials. Depakote has size (>1) in multiple trials. Depakote has some efficacy, may be greater at higher some efficacy, may be greater at higher serum levels. Carbamazepine has not serum levels. Carbamazepine has not shown good benefitshown good benefit

Aggression Psychopharmacology Aggression Psychopharmacology (Con’t)(Con’t)

Alpha Agonists: Clonidine modestly Alpha Agonists: Clonidine modestly effective in reducing aggression, effective in reducing aggression, even without ADHD. Guanfacine not even without ADHD. Guanfacine not really studied.really studied.

Stimulants: Very effective when there Stimulants: Very effective when there is comorbid ADHD but questionable is comorbid ADHD but questionable without ADHDwithout ADHD

Thank you for coming!

Please feel free to email me with any questionsMichael.kisicki@seattlechildrens.org

For specific clinical questions, contact PAL at 1-866-599-PALS

Acknowledgement

Dr. Terry LeeDr. Robert Hilt