By Barbara Howard, MD -
The prevalence of aggressive behavior in young children is relatively high but how we define aggression is important. When working with families it is important to ask parents or other caretakers to define what they mean by aggression - when did it start, what was going on at the time of the aggression and after, what was the incident, was it verbal or physical, was there destruction of property, was there harm to others, how did they intervene, and what was the outcome? Are the caretakers unintentionally reinforcing the behavior? What is the family’s threshold for considering something aggressive behavior? Is the behavior related to a co-morbid condition?
Incidence
Aggressive behavior in young children is common, one study of preschoolers found that:
15% - 30% of preschoolers have significant behavior problems, usually including aggression
25% - 40% of boys 2-5 years old showed moderate to high aggression
10% - 28% of girls 2-5 years old showed moderate to high aggression
The peak of aggression was seen before age 3 years
40% of severe aggression began before 8 years
60% of children with Aggressive-Oppositional Disorder also have Attention Deficit Hyperactivity Disorder
Early aggression correlates (.68) with later behavior disorders, especially conduct disorder.
Causes
There may be many causes of aggression, but overall aggression is stimulated by the thwarting of any major developmental need. For example, toddlers may have a need to eat and sleep at regular intervals and if a toddler is tired and hungry, they might become “hangry.” Older kids have a developmental need to be successful with peers and humiliating experiences can interfere with that need and increase their feelings of anger and frustration. The context of the developmental stage can be very important in understanding what may cause aggressive behavior and therefore prevent it in the future.
ADHD and Aggression
ADHD has comorbidity with other conditions.
32% also have Oppositional Defiant Disorder – predominantly hyperactive/impulsive or combined
25% also have Conduct Disorder
21% also have Anxiety Disorder
18% also have depressive disorders
12% also have learning disorders
60% also under achieve in school
4% have language disorders
ADHD and the Executive Dysfunction that Sets Kids up for Aggression
Children with ADHD are more likely to show frustration and aggression because:
They have trouble with the understanding of time. They have lack of planning, difficulties with transitioning from one activity to another, and difficulties completing tasks. They may have good intentions, but these problems can prevent their goal attainment and they may often find themselves punished for their lack of task completion.
They may misjudge how long a task may take and, to the child, the task may look overwhelming and the child may give up the task before they start.
They tend to have a smaller skillset for dealing with frustrations and are more likely to pick an aggressive first response.
They tend to answer impulsively, say the first thing that comes into their head and may have a “short fuse” demonstrating verbal aggression because they don’t modulate themselves.
They make a lot of mistakes due to impulsivity. As they don’t like making mistakes repeatedly, they try to “cover them up” which is interpreted as lying. When they are accused of lying, they get upset and aggressive.
Caregivers may not understand why the child is having difficulties and they themselves become frustrated, angry, and rejecting which can cause the child to feel hurt resulting in aggressive behavior.
What can help in these situations is for the caregiver to try to see the behavior through a different lens, although this is not an easy task. Caregivers get frustrated and angry at the defiant and naughty behavior even though the child’s behavior is a predictable outcome when s/he can’t handle the situation. It’s important to not see the child as “bad” but as struggling due to a gap in skills. Some parents find it especially difficult to see the behavior through a new lens because one or both of them have their own ADHD issues.
Treating Aggression in ADHD
Results of one study of medication in treatment resistant aggression in school aged children with ADHD:
Subjects were children 6 to 13 years old with ADHD and either Oppositional Defiant Disorder or Conduct Disorder with significant aggressive behavior and insufficient response to stimulants.
There were 50 boys and 15 girls with a mean age of 8.95 years
The open stimulant monotherapy optimization protocol used two forms of a stimulant and weekly assessments of behavior, side effects, and tolerability. All of the children and parents received behavior therapy.
The trial lasted 63 days
Treatment Trial
Weekly adjustment of doses were made starting with 18 mg of Concerta and adjusting over time up to greater than 90 mg. The mean successful dose was 52 mg. Alternatively, children started with 10 mg of Metadate and were adjusted over time up to greater than 60 mg; with mean successful dosage of 40 mg.
Provided parent education - COPE program
Results
49% of the children (responders) saw a 33% reduction in aggression with stimulant dose adjustment and behavioral therapy taking them below the cut score of the tool; no other medication was required. This was more common on Concerta compared to Metadate.
Non-responders were more likely to be boys, who had higher ratings of baseline aggression, depressive, and manic symptoms. However, they still had “significant” improvements in aggression and ADHD symptoms.
Girls had far more remission of aggressive behavior with stimulant medication, adjusting for baseline aggression, depression, and manic symptoms.
No child experienced worsening of mood-relevant symptom
Conclusion
In general, when treating school aged children with aggression co-morbid with ADHD, physicians should start with a low dose, but optimize by increasing until there are side effects. This method helps prevent under medicating and can significantly reduce aggressive behaviors.
CHADIS offers tools to help doctors, educators, and parents screen for and monitor ADHD including the Vanderbilt Assessment Scales, Conners,TM and tools for co-morbid conditions. Through CHADIS parents or staff can send secure invitations for teachers to complete tools which return automatically into CHADIS all scored, forming a graphic. Messages by SMS or email can be scheduled to collect data at intervals from parents and teachers, as well as teens. CHADIS also has clinical decision support for ADHD care including automated 504 and IEP letters. See CHADIS ADHD Patient Specific Template
CHADIS is a unique screening, decision support and patient engagement system designed to streamline and optimize healthcare by providing clinicians with evidence-based data that improves diagnosis and management of health, emotional, developmental and behavioral concerns. www.chadis.com