Aggression and angry outbursts

Introduction

Aggressive behavior is one of the most common child psychiatric symptoms for which parents seek help. The difficulty with managing aggressive behavior is determining whether it is out of the ordinary from typical child development and then assessing the causes of the behavior before tackling the tough job of intervening. The following case is typical of what might present to the pediatrics office and provides a few ideas for the assessment and management of aggressive behavior.

Case summary

Dakota is a 6-year-old boy who presents for a well-child check with his father, Joe. Dakota is just finishing his kindergarten year, and the teachers have expressed concerns about his behavior in the classroom and on the playground. They note that he is often irritable and touchy, and that he will frequently have aggressive outbursts, particularly when asked to do something that he doesn’t like. He will often interrupt other children’s games, and will force children to play by his rules with a threat of, or occasional use of, hitting. In the classroom, he has been removed multiple times to the principal’s office, where he will go only with marked reluctance. He has been noted by his teachers to have difficulty attending to the classroom instructions, and frequently removes himself during circle time. They allow him to do this to avoid a power struggle. Similarly, Joe notes that the entire family is "walking on eggshells" because they never know what might set him off. They’ve tried "everything," including time out, sticker charts, and spanking, but with little effect. Joe says that he was "just like Dakota" when he was a child, and that he was "straightened out" in the Army. He wonders if some kind of boot camp or "scared straight" program would help Dakota learn his lesson.

Discussion

Diagnosis. Irritability and aggression are common manifestations of multiple child psychiatric conditions. While it’s easy to jump to the conclusion that the patient has oppositional-defiant disorder (ODD) or conduct disorder (CD) and move straight to treatment, care must be taken to evaluate common causes and co-occurring disorders that might change the treatment plan.

The differential diagnosis includes a primary mood disorder like depression, other disruptive behavior disorders such as attention-deficit/hyperactivity disorder (ADHD), a primary anxiety disorder, posttraumatic stress disorder, a learning or language disorder, and/or intellectual disability. One also must determine whether the aggression exhibited is greater than that shown by other boys his age. For this reason, the use of a scale that has normative values by age and sex makes sense. Having a standardized instrument filled out by parents and by the teachers also will help give an indication of how he is performing in multiple settings. Using a broad-based instrument that also covers mood, anxiety, and attention problems can be a quick and useful way to examine what type of co-occurring symptoms are present.

Aggression, while a heritable trait, also has a significant component from the environment. It is important to see how much of the aggression is being "caught, not taught" in the family setting. Querying as to the general level of negative, coercive parenting can be performed quickly by asking for a description of how the last outburst was managed – what the precipitant, the course, and the outcome were. Frequently, with ODD in particular, you will find a cycle of escalating threats and illogical consequences that serve to reinforce, rather than to reduce, aggressive and oppositional behavior. Practically, while the busy pediatrician may be able to manage some of this screening in a well-child check, it is likely that a separate appointment will be needed to go over the results of the screening instruments and to more fully assess the parenting environment.

At the scheduled visit designed to specifically assess the aggression:

• Make sure that both the parents and the child see this as a family-based problem. A treatment alliance with both parties is necessary to get the buy-in for any type of intervention that will occur.

• Assess the level of impairment. Are these outbursts severe only at home? In the school setting? With other people such as coaches or health care providers?

• Review the broadband screening instruments from multiple settings to make sure that this is a primary disruptive behavior disorder and not something else, particularly ADHD or a mood disorder, which will need to be managed differently.

• Determine if the aggressive behavior is impulsive/reactive or if it is planned/predatory. Is there remorse afterward (about the action, as opposed to remorse about being caught)? Lack of remorse could be an indicator of callous-unemotional traits, which have a worse prognosis.

Pearl: When asking about aggressive outbursts, make sure to concentrate not just on the outburst, but on the behavior and mood between outbursts. If the mood between outbursts is chronically irritable or sad, this might indicate a mood disorder rather than a primary disruptive behavior disorder.

Treatment. Treatment for aggressive behavior really calls for an "all hands on deck" family-based intervention. Parenting interventions will work best when the parents themselves are as healthy as they can be. Working with them to ensure that aggressive behavior, substance abuse, or anxiety is adequately treated through referral is an important step.

Next, the parenting interventions should involve those best informed by evidence-based practice, which typically include components of reducing the cycle of reinforcing aggressive behavior, noticing and rewarding prosocial behavior, and ceasing corporal punishment and replacing it with predictable, logical consequences for aggressive behavior. There are several excellent programs that therapists can use with parents, and referring to a therapist working with an evidence-based treatment program makes sense. There is a table listing parent management training packages that can be found in the American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameters for ODD (J. Am. Acad. Child. Adolesc. Psychiatry 2007;46:126-41).

Wellness interventions such as ensuring hydration and adequate caloric intake can make a difference in the management of aggression. It’s harder to maintain control when you are concentrating on the grumbling of your stomach. Further, using exercise and sports as an intervention allows children to channel some of their negative aggressive impulses into positive, prosocial activities.

Pharmacotherapy is not indicated for ODD or CD, except to target co-occurring symptoms. For example, treatment of ADHD or anxiety can quite successfully reduce impulsive or reactive aggression, and can make it easier to treat the ODD or CD through parent management techniques. In very severe cases of aggression, treatment with other agents such as mood stabilizers or antipsychotics might be indicated, but this would likely be implemented only in consultation with a child and adolescent psychiatrist.

Finally, there is little to no evidence for a mock incarceration or boot camp approach with children who exhibit oppositional behavior. In fact, it’s very possible that these kinds of programs can make the behaviors worse (J. Am. Acad. Child Adolesc. Psychiatry 1999;38:1320-1; "Aggression and Antisocial Behavior in Children and Adolescents: Research and Treatment" [New York: The Guilford Press, 2002]).

When to consult? Uncomplicated aggressive behavior can be managed by the primary care team with consultation from a therapist using evidence-based approaches. If there is poor treatment response, or if the aggression is severe enough to cause serious physical injury, or if there is concern for a cycling mood disorder (such as bipolar disorder – a topic for a later column), then consultation with a child psychiatrist is likely appropriate.

Dr. Althoff is an associate professor of psychiatry, psychology, and pediatrics at the University of Vermont, Burlington. He is director of the division of behavioral genetics and conducts research on the development of self-regulation in children. Dr. Althoff has received grants/research support from the National Institute of Mental Health, the National Institute of General Medical Sciences, and the Klingenstein Third Generation Foundation, and honoraria from the Oakstone General Publishing for CME presentations.

Introduction

Aggressive behavior is one of the most common child psychiatric symptoms for which parents seek help. The difficulty with managing aggressive behavior is determining whether it is out of the ordinary from typical child development and then assessing the causes of the behavior before tackling the tough job of intervening. The following case is typical of what might present to the pediatrics office and provides a few ideas for the assessment and management of aggressive behavior.

Case summary

Dakota is a 6-year-old boy who presents for a well-child check with his father, Joe. Dakota is just finishing his kindergarten year, and the teachers have expressed concerns about his behavior in the classroom and on the playground. They note that he is often irritable and touchy, and that he will frequently have aggressive outbursts, particularly when asked to do something that he doesn’t like. He will often interrupt other children’s games, and will force children to play by his rules with a threat of, or occasional use of, hitting. In the classroom, he has been removed multiple times to the principal’s office, where he will go only with marked reluctance. He has been noted by his teachers to have difficulty attending to the classroom instructions, and frequently removes himself during circle time. They allow him to do this to avoid a power struggle. Similarly, Joe notes that the entire family is "walking on eggshells" because they never know what might set him off. They’ve tried "everything," including time out, sticker charts, and spanking, but with little effect. Joe says that he was "just like Dakota" when he was a child, and that he was "straightened out" in the Army. He wonders if some kind of boot camp or "scared straight" program would help Dakota learn his lesson.

Discussion

Diagnosis. Irritability and aggression are common manifestations of multiple child psychiatric conditions. While it’s easy to jump to the conclusion that the patient has oppositional-defiant disorder (ODD) or conduct disorder (CD) and move straight to treatment, care must be taken to evaluate common causes and co-occurring disorders that might change the treatment plan.

The differential diagnosis includes a primary mood disorder like depression, other disruptive behavior disorders such as attention-deficit/hyperactivity disorder (ADHD), a primary anxiety disorder, posttraumatic stress disorder, a learning or language disorder, and/or intellectual disability. One also must determine whether the aggression exhibited is greater than that shown by other boys his age. For this reason, the use of a scale that has normative values by age and sex makes sense. Having a standardized instrument filled out by parents and by the teachers also will help give an indication of how he is performing in multiple settings. Using a broad-based instrument that also covers mood, anxiety, and attention problems can be a quick and useful way to examine what type of co-occurring symptoms are present.

Aggression, while a heritable trait, also has a significant component from the environment. It is important to see how much of the aggression is being "caught, not taught" in the family setting. Querying as to the general level of negative, coercive parenting can be performed quickly by asking for a description of how the last outburst was managed – what the precipitant, the course, and the outcome were. Frequently, with ODD in particular, you will find a cycle of escalating threats and illogical consequences that serve to reinforce, rather than to reduce, aggressive and oppositional behavior. Practically, while the busy pediatrician may be able to manage some of this screening in a well-child check, it is likely that a separate appointment will be needed to go over the results of the screening instruments and to more fully assess the parenting environment.

At the scheduled visit designed to specifically assess the aggression:

• Make sure that both the parents and the child see this as a family-based problem. A treatment alliance with both parties is necessary to get the buy-in for any type of intervention that will occur.

• Assess the level of impairment. Are these outbursts severe only at home? In the school setting? With other people such as coaches or health care providers?

• Review the broadband screening instruments from multiple settings to make sure that this is a primary disruptive behavior disorder and not something else, particularly ADHD or a mood disorder, which will need to be managed differently.

• Determine if the aggressive behavior is impulsive/reactive or if it is planned/predatory. Is there remorse afterward (about the action, as opposed to remorse about being caught)? Lack of remorse could be an indicator of callous-unemotional traits, which have a worse prognosis.

Pearl: When asking about aggressive outbursts, make sure to concentrate not just on the outburst, but on the behavior and mood between outbursts. If the mood between outbursts is chronically irritable or sad, this might indicate a mood disorder rather than a primary disruptive behavior disorder.

Treatment. Treatment for aggressive behavior really calls for an "all hands on deck" family-based intervention. Parenting interventions will work best when the parents themselves are as healthy as they can be. Working with them to ensure that aggressive behavior, substance abuse, or anxiety is adequately treated through referral is an important step.

Next, the parenting interventions should involve those best informed by evidence-based practice, which typically include components of reducing the cycle of reinforcing aggressive behavior, noticing and rewarding prosocial behavior, and ceasing corporal punishment and replacing it with predictable, logical consequences for aggressive behavior. There are several excellent programs that therapists can use with parents, and referring to a therapist working with an evidence-based treatment program makes sense. There is a table listing parent management training packages that can be found in the American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameters for ODD (J. Am. Acad. Child. Adolesc. Psychiatry 2007;46:126-41).

Wellness interventions such as ensuring hydration and adequate caloric intake can make a difference in the management of aggression. It’s harder to maintain control when you are concentrating on the grumbling of your stomach. Further, using exercise and sports as an intervention allows children to channel some of their negative aggressive impulses into positive, prosocial activities.

Pharmacotherapy is not indicated for ODD or CD, except to target co-occurring symptoms. For example, treatment of ADHD or anxiety can quite successfully reduce impulsive or reactive aggression, and can make it easier to treat the ODD or CD through parent management techniques. In very severe cases of aggression, treatment with other agents such as mood stabilizers or antipsychotics might be indicated, but this would likely be implemented only in consultation with a child and adolescent psychiatrist.

Finally, there is little to no evidence for a mock incarceration or boot camp approach with children who exhibit oppositional behavior. In fact, it’s very possible that these kinds of programs can make the behaviors worse (J. Am. Acad. Child Adolesc. Psychiatry 1999;38:1320-1; "Aggression and Antisocial Behavior in Children and Adolescents: Research and Treatment" [New York: The Guilford Press, 2002]).

When to consult? Uncomplicated aggressive behavior can be managed by the primary care team with consultation from a therapist using evidence-based approaches. If there is poor treatment response, or if the aggression is severe enough to cause serious physical injury, or if there is concern for a cycling mood disorder (such as bipolar disorder – a topic for a later column), then consultation with a child psychiatrist is likely appropriate.

Dr. Althoff is an associate professor of psychiatry, psychology, and pediatrics at the University of Vermont, Burlington. He is director of the division of behavioral genetics and conducts research on the development of self-regulation in children. Dr. Althoff has received grants/research support from the National Institute of Mental Health, the National Institute of General Medical Sciences, and the Klingenstein Third Generation Foundation, and honoraria from the Oakstone General Publishing for CME presentations.

Introduction

Aggressive behavior is one of the most common child psychiatric symptoms for which parents seek help. The difficulty with managing aggressive behavior is determining whether it is out of the ordinary from typical child development and then assessing the causes of the behavior before tackling the tough job of intervening. The following case is typical of what might present to the pediatrics office and provides a few ideas for the assessment and management of aggressive behavior.

Case summary

Dakota is a 6-year-old boy who presents for a well-child check with his father, Joe. Dakota is just finishing his kindergarten year, and the teachers have expressed concerns about his behavior in the classroom and on the playground. They note that he is often irritable and touchy, and that he will frequently have aggressive outbursts, particularly when asked to do something that he doesn’t like. He will often interrupt other children’s games, and will force children to play by his rules with a threat of, or occasional use of, hitting. In the classroom, he has been removed multiple times to the principal’s office, where he will go only with marked reluctance. He has been noted by his teachers to have difficulty attending to the classroom instructions, and frequently removes himself during circle time. They allow him to do this to avoid a power struggle. Similarly, Joe notes that the entire family is "walking on eggshells" because they never know what might set him off. They’ve tried "everything," including time out, sticker charts, and spanking, but with little effect. Joe says that he was "just like Dakota" when he was a child, and that he was "straightened out" in the Army. He wonders if some kind of boot camp or "scared straight" program would help Dakota learn his lesson.

Discussion

Diagnosis. Irritability and aggression are common manifestations of multiple child psychiatric conditions. While it’s easy to jump to the conclusion that the patient has oppositional-defiant disorder (ODD) or conduct disorder (CD) and move straight to treatment, care must be taken to evaluate common causes and co-occurring disorders that might change the treatment plan.

The differential diagnosis includes a primary mood disorder like depression, other disruptive behavior disorders such as attention-deficit/hyperactivity disorder (ADHD), a primary anxiety disorder, posttraumatic stress disorder, a learning or language disorder, and/or intellectual disability. One also must determine whether the aggression exhibited is greater than that shown by other boys his age. For this reason, the use of a scale that has normative values by age and sex makes sense. Having a standardized instrument filled out by parents and by the teachers also will help give an indication of how he is performing in multiple settings. Using a broad-based instrument that also covers mood, anxiety, and attention problems can be a quick and useful way to examine what type of co-occurring symptoms are present.

Aggression, while a heritable trait, also has a significant component from the environment. It is important to see how much of the aggression is being "caught, not taught" in the family setting. Querying as to the general level of negative, coercive parenting can be performed quickly by asking for a description of how the last outburst was managed – what the precipitant, the course, and the outcome were. Frequently, with ODD in particular, you will find a cycle of escalating threats and illogical consequences that serve to reinforce, rather than to reduce, aggressive and oppositional behavior. Practically, while the busy pediatrician may be able to manage some of this screening in a well-child check, it is likely that a separate appointment will be needed to go over the results of the screening instruments and to more fully assess the parenting environment.

At the scheduled visit designed to specifically assess the aggression:

• Make sure that both the parents and the child see this as a family-based problem. A treatment alliance with both parties is necessary to get the buy-in for any type of intervention that will occur.

• Assess the level of impairment. Are these outbursts severe only at home? In the school setting? With other people such as coaches or health care providers?

• Review the broadband screening instruments from multiple settings to make sure that this is a primary disruptive behavior disorder and not something else, particularly ADHD or a mood disorder, which will need to be managed differently.

• Determine if the aggressive behavior is impulsive/reactive or if it is planned/predatory. Is there remorse afterward (about the action, as opposed to remorse about being caught)? Lack of remorse could be an indicator of callous-unemotional traits, which have a worse prognosis.

Pearl: When asking about aggressive outbursts, make sure to concentrate not just on the outburst, but on the behavior and mood between outbursts. If the mood between outbursts is chronically irritable or sad, this might indicate a mood disorder rather than a primary disruptive behavior disorder.

Treatment. Treatment for aggressive behavior really calls for an "all hands on deck" family-based intervention. Parenting interventions will work best when the parents themselves are as healthy as they can be. Working with them to ensure that aggressive behavior, substance abuse, or anxiety is adequately treated through referral is an important step.

Next, the parenting interventions should involve those best informed by evidence-based practice, which typically include components of reducing the cycle of reinforcing aggressive behavior, noticing and rewarding prosocial behavior, and ceasing corporal punishment and replacing it with predictable, logical consequences for aggressive behavior. There are several excellent programs that therapists can use with parents, and referring to a therapist working with an evidence-based treatment program makes sense. There is a table listing parent management training packages that can be found in the American Academy of Child and Adolescent Psychiatry (AACAP) Practice Parameters for ODD (J. Am. Acad. Child. Adolesc. Psychiatry 2007;46:126-41).

Wellness interventions such as ensuring hydration and adequate caloric intake can make a difference in the management of aggression. It’s harder to maintain control when you are concentrating on the grumbling of your stomach. Further, using exercise and sports as an intervention allows children to channel some of their negative aggressive impulses into positive, prosocial activities.

Pharmacotherapy is not indicated for ODD or CD, except to target co-occurring symptoms. For example, treatment of ADHD or anxiety can quite successfully reduce impulsive or reactive aggression, and can make it easier to treat the ODD or CD through parent management techniques. In very severe cases of aggression, treatment with other agents such as mood stabilizers or antipsychotics might be indicated, but this would likely be implemented only in consultation with a child and adolescent psychiatrist.

Finally, there is little to no evidence for a mock incarceration or boot camp approach with children who exhibit oppositional behavior. In fact, it’s very possible that these kinds of programs can make the behaviors worse (J. Am. Acad. Child Adolesc. Psychiatry 1999;38:1320-1; "Aggression and Antisocial Behavior in Children and Adolescents: Research and Treatment" [New York: The Guilford Press, 2002]).

When to consult? Uncomplicated aggressive behavior can be managed by the primary care team with consultation from a therapist using evidence-based approaches. If there is poor treatment response, or if the aggression is severe enough to cause serious physical injury, or if there is concern for a cycling mood disorder (such as bipolar disorder – a topic for a later column), then consultation with a child psychiatrist is likely appropriate.

Dr. Althoff is an associate professor of psychiatry, psychology, and pediatrics at the University of Vermont, Burlington. He is director of the division of behavioral genetics and conducts research on the development of self-regulation in children. Dr. Althoff has received grants/research support from the National Institute of Mental Health, the National Institute of General Medical Sciences, and the Klingenstein Third Generation Foundation, and honoraria from the Oakstone General Publishing for CME presentations.