Learning Objectives

After the webinar, clinicians should be able to:

1. Differentiate volitional aggression from aggression related to other circumstances, eg, sensory processing problems.
2. Explain the progression of treatment for irritability and aggression in autism from nonpharmacological approaches to FDA-approved medications.
3. Prioritize treatment approaches for management of aggression as a co-occurring symptom in ADHD.
4. Describe three safety measures for prevention of aggression in office practice.

 [Transcript edited for clarity]

This is Aggression in Psychiatric Practice, a Carlat Webinar. I'm Josh Feder, the Editor-in-Chief at The Carlat Child Psychiatry Report. Learning Objectives today are to differentiate volitional aggression from aggression related to other circumstances like sensory processing problems; explain the progression of treatment for irritability and aggression in autism from non-pharmacological approaches to FDA-approved medications; prioritize treatment approaches for management of aggression as a co-occurring symptom in ADHD; and describe three safety measures for prevention of aggression in office practice.

Outline

Here's a little bit of an outline of what we're going to talk about.

• So mom comes in and…
• Madness or badness?
• Arousal and ASD
• Social-biological management of ADHD
• Bullying and conduct disorder
• Bad times: genocide, etc.
• Denoument: out in public

Mom comes in, and she tells you, “He bites, he hits, he steals, or he bullies at home or at school…” What’s wrong with these pictures? Well, talking about a child in front of a child is not so good and writing while listening is also not good form. “He has road rage. He killed.” Those things happen too. What's wrong with these pictures? You need to assess the person directly.

Madness or badness? Developmental problems include tantrums to defiance, to fighting for one's country. Arousal includes feeling overwhelmed or dysregulated in having reactive aggression. Mental illness in the DSM, we think about ADHD and affective disorders, ASD, OCD, and psychosis. What about biological reasons for aggression? For instance, temporal lobe, epilepsy, or disintegrative disorders, dementia, multiple sclerosis, and T 21. Oppositional defiant disorder, conduct disorder, antisocial and other possible etiologies. And what about the social contract: aggression in slavery, autocracy, and of course the stages of genocide.

There's a lot to consider when we're thinking about whether someone has a psychiatric condition or they're being bad, or whether they're being impacted by social determinants around them.

Developmental Stages and Aggression

• Bite
• No!
• Hit
• Take
• Cheat
• Bully
• Rape
• Kill

Kids bite. That's an oral phase if you're a psychodynamic aficionado. But they could be teething, they could be exploring, or it could be aggression. What about when kids turn about 18 months, and they're saying “No!” They're having tantrums. They have a sense of autonomy, a sense of self defiance, stamping their feet. Hitting can be instinctual or it could be modeling. Have you seen Tom and Jerry? Have you seen Daniel Tiger?

And then taking things from other kids. Do they understand? Do they know? Do they understand what sharing is? Cheating? Some kids want to win more than they want to please others. Bullying. We wonder if sex hormones are risk factors. And there's rape. We think about sex hormones, but we also think about cultural aspects that contribute to it. Killing. Well, there are a lot of reasons why people kill. Have you learned about Kohlberg’s stages of moral development?

Kohlberg’s Stages of Moral Development

Level 1: pre-conventional. Obedience and punishment orientation. How can I avoid punishment? And the second piece, self-interest orientation. What's in it for me?

Level 2: conventional. That's interpersonal accord and conformity social norms. That's the good boy or girl attitude. And then there's the conforming to authority and social order.

Level 3: post-conventional. When you go beyond the usual social ideas. Where you're oriented toward a social contract or universal ethical principles. That's when you could be a conscientious objector or stealing medicine to treat somebody who otherwise wouldn't be able to get it.

Motives for Murder: 7 classical virtues and vices 

We talked a little bit about the idea of murder, and if you ever read a murder mystery or see a show that talks about murder, we often think about the classical virtues and vices that go into it. I’m not going to go into all of them here, but you'll have them in your handout.

One day I was in a group with a number of inpatients at the Balboa Hospital (Naval Medical Center San Diego). A long time ago, there was a large Navy Seal. I'm all the way to the right. This guy's all the way to the left. He's bigger than that picture shows—he had narcissistic personality disorder, antisocial personality disorder, was a serial murderer who abused substances. He had been caught, and when he was caught, he dissociated and was hospitalized and medicated. He came after me in that group. And a patient who was a defender was very protective and kind of interrupted him before he got to me; it was out of character reaction for that guy.

ASD and arousal levels

Let's talk about autism arousal levels. Bruce Perry talks about five different arousal states, calm, alert, alarm, fear, and terror. In a calm state, you're able to meditate or think about the future of the class, what you want to do to solve a problem. In an alert state, you're able to do things like play sports or answer a question from a teacher, things you learn to do, drive a car, those kinds of things. These common alert states are functional states. However, when you're a bit overwhelmed, you might end up in an alarm state, such as drinking too much, eating too much, craving sex, having a tantrum, checking out by taking a nap, or doing something because someone told you to do it, not because it's consensual. In a fear state, Perry talks about people bolting, leaving, eloping. In a terror state, you’re paralyzed.

When people are complying, it's important to think about why they're doing it. Is it because they're learning together to solve problems or is it because they're learning to obey? If you teach someone to be compliant, you need to be careful that it's consensual. I think about the difference between a partner and a prisoner. Prisoners are at risk of abuse. When we just teach someone to comply with authority, then we're not asking them to assert themselves, they may be at risk.

You tried to kill her. I once had a case of an autistic woman who was berated by cops during an interrogation who told her over and over that she had tried to kill her grandmother, and she eventually said, “Okay, I did it.” Did she really do it? Not really. She had been taught to comply and because she had been taught to comply, she knew that someone who tells you they're your friend is your friend. The person who said she was this woman's friend actually wanted to take over the grandmother's house by having this young autistic woman kill her grandmother so that the friend could take over the house with her boyfriend who was just getting out of jail.

Once this autistic woman did give her grandmother a small thimbleful of car fluid, the woman who told her to do it bolted town and called the police on her. My client was in jail on a felony for attempted murder for a number of months, but eventually got off because we demonstrated that she had been taught through her entire educational process to comply.

Aggression in autism

Fast facts:

• Treat co-occurring conditions, eg, sleep, ADHD, depression, anxiety
• Sensorimotor, communication, and executive function support
• Naturalistic and developmental relationship-based Intervention
• Supplements and milder medications
• SGAs if you must, eg, aripiprazole, risperidone

First, treat the co-occurring conditions like sleep problems, ADHD, and depression. Look at the sensory motor problems. You know, a lot of these kids have sensory difficulties. That makes them pretty upset. What about communication difficulties? Is it that they just don't comprehend or understand? They get frustrated and aggressive and support executive function so that people can plan so that they're not surprised by changes in plans or things like that. Naturalistic and developmental relationship-based interventions are all about helping people be calm, connected in a flow of problem-solving interactions that reduce frustration, dysregulation, and aggression.

There are supplements of milder medications that you might try before you go to the second-generation antipsychotics (SGAs)—things like lavender or even daytime melatonin; milder medications like SSRIs or central alpha-agonists. If you have to use SGAs, like aripiprazole or risperidone—the only FDS-approved medications for irritability and autism—consider using metformin with them to avoid weight gain. If you can get away with it off-label, you might try something that is more weight sparing like ziprasidone or lurasidone.

Tip: The difference in autism is really clear. If you're putting somebody at table and instructing them how to behave “normally,” they may be frustrated. It may not be meaningful to them. On the other hand, if you're using a play-based approach, even when you're dealing with difficult emotions, more times than not, kids become more regulated, more able to express themselves, and more able to manage without additional medication.

In class

How about ADHD? You've got a kid in class who is running around, and the teacher puts them in the corner. Or, you can put kids at tables together rather than lined up. Have them do things together as a group. Even before that, you might run them out on the field so that they're a bit more regulated. No medications involved. Medication supports an overall plan, but it doesn't replace a good plan.

ADHD and aggression

Fast facts:

• Medication supports a good overall plan – it doesn’t replace it
• A good overall plan is one with enough staff support and uses positive approaches
• 80% can be managed if you have at least TWO good trials of stimulants (MPH, dextroamphetamine mixed salts)
• Get regular structured feedback from home and school
• Move quickly: week by week, not month by month
• If you must use another class of medication, only valproate and risperidone have decent research to support them

A good overall plan is one that has enough staff support and uses positive approaches. Eighty percent of aggression in ADHD can be managed if you use at least two good trials of stimulants, usually starting with methylphenidate because you have fewer side effects, and then going to a dexamphetamine trial (Spencer T et al, Biol Psychiatry. 2005;57:456–163).

Get regular structured feedback from home and school and move quickly—week by week, not month by month—with your medication changes to get to an adjustment that works for your patient. If you must use another class of medication only, valproate and risperidone have decent research to support their use in kids with aggression in ADHD.

On the playground

Supervision is everything. When you don't have supervision, people get bullied. When you have structured activities and supervision, kids do a lot better.

How about teaching kids to manage bullies?

One of the best pieces of advice I ever had was to teach people to say one sentence well and walk away. In this case, the kid has learned the word, “Whatever,” and says it in a very neutral fashion and walks off, tells a trusted adult. The most important way to address bullying is supervision, supervision, and more supervision by people who know what they're doing.

For firearm regulation and access, do you always ask whether kids have access to firearms? It's worth asking. And then the cardinal rule among kids and in our therapy sessions is we don't break things and we don't hurt each other and keep to it.

Parental engagement and buy-in is really important. Family therapy is often critical. You’ve got to gauge morals (eg, the Kohberg approach that we talked about earlier).

Think about family history. Think about the ghosts in the nursery for kids, people in the past who've had difficulties and whose difficulties have passed down, but also the angels of the nursery, people who had a beneficial approach, who people can model themselves after.

We talk about treating an alleged offender with a biopsychosocial approach, but in this case, it’s backwards—social psycho bio. It's the social surround that ends up being really important and even most important, but even so, symbolic approaches can help kids to manage aggressive drives (eg, play-based therapies) And whatever you do, do not put a victim and a bully together in a room to work it out. All that does is re-traumatize the victim.

Other things that help physical activity and supervised sports. There is controversy around martial arts. Are you going to teach a kid who is aggressive how to hurt people? Think about that.

Address substance use of all kinds, including alcohol and caffeine and anything else. Medications can support a good plan, but they can't make up for an inadequate one. For instance, one without adequate supervision. Stimulants, maybe. Central alpha agonist trials are pretty good for aggression in conduct disorder.

Safety in the consultation room

What about safety in your consultation room? Here's a picture of me with things getting thrown at me. That wasn't much fun. In one episode, a plastic airplane hit me in the wrong place. One kid went through a wooden dollhouse. It’s better if they're throwing a Nerf stuffed animal, blanket, something like that. I replaced my toys with soft things so that if they went flying, nobody would get hurt. Since the pandemic, it's even a little bit different.

When a child uses a fake gun in symbolic play, if they shoot you, oftentimes that creates all kinds of anxiety. I usually recommend that they shoot a puppet. Symbolic play is amazing for helping with issues of aggression and competition.

Safety in the clinic

Fast facts:

• Escape routes for your patients
• Escape routes for yourself
• Panic button systems
• Asking about weapons
• Staff awareness
• Custody cases

Make sure you have escape routes for your patients and an escape route for yourself. Panic button systems are important. Asking about weapons is important. Make sure staff is aware and alert of who's in the clinic and where they are. Remember that custody cases engender the most violence in child psychiatry and child and adolescent mental health.

Here is a map of my office. I've got a courtyard in the middle with a couple of trees. I've got two ways out of my own office—one into the courtyard, one into the waiting room. You sit in a place that is back from the patient so that the patient can egress before you, especially if they're really upset. You allow escape and then you try to slow things down. At the top of this picture in the front is the big gate that I have that stops kids from running right out into the street.

In bad times

What about addressing bad times on campus: college, high school, middle school, Congress, and globally? We know we've had subjugation of Native peoples of the Americas from the 1400s to the present. We've had the African slave trade and its aftereffects from the 1600s to the present. European colonization and aftereffects, also 1600s to the present.

We have an Anthropocene climate change acceleration from the late 1800s to the present. We had the Armenian genocide early in the 20th century, and the Jewish Holocaust and Argentinian disappearances in the mid-20th century. The refugee crises in the Middle East. Rising incarcerated acceleration rates in the US from the mid-20th century to the present. Chile and Cambodian Rwandan genocides, late 20th century. The Somalian crisis from early in the 21st century to the present.

What's the common theme? Someone thinks they're doing the world a favor by hurting a lot of other people. It's worth knowing the stages of genocide. We're not going to go through all of them, but it starts with:

Stages of genocide: classifying people > discrimination > dehumanizing > polarization of communities > preparation for mass killing > persecution > extermination > and after it all is over, denial.

Monsters that never die: Mythic Quest S1E5

There are some monsters that never die. I couldn't use the picture because we didn't have the rights, but if you ever saw Mythic Quest season 1, episode 5, there was an episode about a game you could never win, where you used a flashlight to keep the monsters away. As soon as you turned the flashlight off, they came after you.

There are other games you can never win. If you ever played Missile Defense games as a kid, a new game system will be released, this is the picture for it. I am allowed to use that because I know the company well. I'm part of them. But you never win these games. People always die in the end. And that's actually what happens in wars today, especially with AI controlling it.

Tips to fight badness

• Constant attention to the problem
• There will always be new people to cause trouble
• There will always be incitement
• Reflective practice, reflective institutions
• Training people how to respond
• Starting young…

There will always be incitement. Reflective practice helps reflective institutions help even at governmental levels, training people how to respond. Sadly, we're training people to fight, flee, and hide. And starting young.

What do I teach kids when they're going on campus to figure out how they're going to respond to people who are saying mean/bad things?

You see the mean bad things on the right. I teach them to say one sentence well, over and over. For instance, “Everyone deserves safety and peace.”

Research disclosures

I did some research about limited staff training and reflective practice change, resilience, parental behavior, and developmental trajectories in publics impacted by arm conflict in Northern Ireland.

The tagline was “Preventing the 20-year-old fighter and the two-year-old biter.” I did this with the Early Years, the Organisation for Young Children in Northern Ireland and now the Republic of Ireland, along with their media initiative for children field and graduate university. The International Network on Peace Building with Young Children and a volunteer group, Resilience With Relationships.

It was part of a Framework for Programmatic Development and conflict and post-conflict environments. You probably are aware of Bronfenbrenner’s model of looking at a child within a family, within a school setting—in this case early years—a wider community, and a culture (Bronfenbrenner U, Dev Psychol, 1986:22(6);723–742). This also includes the cycle of conflict, which includes peak conflict, de-escalation, peacebuilding, pre-conflict, and then escalation back to the peak. You can go in any direction at any time.

We developed a model where we trained parents and toddler staff and we talked about how we worried about kids growing up to be traumatized or radicalized. We talked about the reasons why kids are usually dysregulated, if it means they’re hungry, angry, lonely, tired, and all kinds of other reasons. We talked about how kids are enculturated from early on, even in utero, and then gave them a couple ways to help kids calm down when they're dysregulated. We reminded them of our goal that we want kids to be more regulated, engaging with us, and then when they grow up to be building society where we're holding a can.

And we gave them a developmental relationship-based model. Wait, join, build, where you wait and observe what the child's doing. You join what they're doing in a gentle way, and then you build on their interactions towards more problem solving. In this case, bringing in a persona all from another culture.

Finally, we talked about reflective practice first, eg, what not to do. For instance, when you're trying to help somebody, telling them to face their problems usually doesn't turn out and telling them you totally understand. Often it doesn't resonate as well because everybody's difficulties feel different to them.

But just saying things like that sounds hard, or just listening, people feel understood and can engage in problem-solving. And finally, for the person who's supporting someone who's problem solving, they're getting their own support—parallel, reflective process at all levels of the organization.

We actually found in a pilot study looking at the social emotional growth chart that parents and staff showed incredible improvements beyond expected over a three-month period in empathy and staff responsiveness and in the social emotional levels of the kids.* We've since done a controlled trial, which mirrors this finding and shows that the kids in the control group had more typical kinds of development while the kids in the test group had similar kinds of steep slopes in their improvements in social emotional capacities, as well as reductions in staff and parent stress and better sensory processing improvement as well.*

*Studies expected to be published in 2023-2024.

Anti-bullying programs

Stopbullying.gov has a number of them. Autism Is a program that's for K through 12 teacher led for the whole class. It's the only active California-approved program for active bullying and it features an autistic kid and his mom as well as a number of other examples of kids on the spectrum and other examples.

Public

What do you do when you're out in public? A child takes a candy bar and the mother's saying, “Bad thief. You need a spanking.” What do I say if I'm the cashier? “Oh my, that sounds hard.” Some sort of interrupting empathic kind of response helps to change the dynamic: “He's so cute. He looks a little tired.” “Boy, they do have a lot of energy. Yes, he seems really smart. Wow. That's a challenge.” So, you're talking about the child, empathizing with the mom. You're going to run into this plenty often. It's good to be ready and it's good to model.

Summary

Addressing the reasons for aggression can help you avoid the need to prescribe medication. When you do add medication, there are usually several non-FDA approaches to try before you get to the more potentially toxic things like second generation antipsychotics and stay sharp. Situational awareness will help you to act to prevent aggressive incidents in the clinic and in public. Use a developmentally informed approach to assess the reasons for aggression in any individual.

• Addressing the reasons for aggression can help you avoid the need to prescribe medication.
• When you do add medication, there are usually several non-FDA approaches to try before you get to the more potentially toxic second-generation antipsychotics.
• Stay sharp. Situational awareness will help you act to prevent aggressive incidents in the clinic.

Thanks so much and have a great day.

REFERENCES:

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International Association for Child and Adolescent Psychiatry and Allied Professions textbook (free online) CONDUCT DISORDERS https://iacapap.org/_Resources/Persistent/6fb0edebbe8df29086098fe1f929e36e4bf5798e/D.3-CONDUCT-DISORDER-072012.pdf

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