ADHD: Medication plus parent training may help kids with aggression

Combining two medications with parent training appears to improve anger, irritability and violent tendencies in children whose attention-deficit/hyperactivity disorder (ADHD) is coupled with severe aggression, a new study suggests.

"Augmented" therapy that consists of stimulant and antipsychotic drugs, along with parent training in behavioural management techniques, was rated more effective by parents than "basic" therapy pairing only the stimulant and parent training, researchers found.

"An important finding of this study was that at the end of nine weeks, approximately half of all children receiving basic therapy were still rated by their parents as being impaired... with symptoms interfering with school or social functioning," said study author Kenneth Gadow, a professor of psychiatry at Stony Brook University in New York.

"In the augmented group receiving three interventions for aggression, about one-quarter still, at the end of nine weeks, were rated by their parents as being impaired, and that suggests, even with highly effective therapies, that many of these children still have unmet treatment needs" " he added.

The drugs used in the study, published in the September issue of the Journal of the American Academy of Child and Adolescent Psychiatry, included the widely prescribed ADHD stimulant Concerta (methylphenidate) and the antipsychotic Risperdal (risperidone).

Approximately 11 percent of American children aged 4 to 17 have been diagnosed with ADHD, which includes symptoms such as impulsivity, hyperactivity, and difficulty focusing and controlling behavior, according to the U.S. Centers for Disease Control and Prevention.

As many as half of children with ADHD also display significant, disruptive aggression, according to an editorial accompanying the new research.

"This is very common among kids with ADHD, but unfortunately it complicates the picture for treatment," said Erin Schoenfelder, a clinical psychologist at Seattle Children's Hospital and assistant professor of psychiatry and behavioural health at University of Washington.

"It really is staggeringly high."

In the new research, Gadow and his colleagues divided a group of nearly 170 children aged 6 to 12 with ADHD and aggression problems into two treatment groups, basic and augmented.

The basic group received Concerta and their parents underwent behavioral management training.

The augmented group received Concerta and parental training as well, but also took the antipsychotic Risperdal. Both groups were followed for nine weeks.

While both groups of children displayed marked reduction in symptoms, improvement ratings varied depending on whether parents or teachers were making the assessment.

Parents reported that children on augmented therapy were less likely to be impaired socially or academically by their anger and irritability than children on basic therapy.

On the other hand, teachers found few differences in these measures.

Instead, teachers of those on augmented therapy reported significant drops in ADHD symptoms, especially impulsiveness, compared with teachers of children on basic therapy.

Gadow and Schoenfelder agreed that the conflicting parent-teacher ratings demonstrate a familiar concept: that children's behaviours vary in different settings, whether or not they have ADHD.

"Just like adults, they adapt their behaviours to be more appropriate for the setting they're in," Gadow said.

"People do differ, however, in their ability to modify their behaviour from one setting to the next, and some children are much more variable [in this regard]."

Schoenfelder said long-term evidence is needed indicating that combining Concerta and Risperdal is safe in children, but "it appears from this study that the combination was well-tolerated and something practitioners could [adjust the dosage of] effectively."

"Folks trying this type of treatment should have close monitoring," she added. "This is a starting point. It's a combination doctors may try when they see this blend of aggressive and hyperactive behaviours. It certainly will require adjustment . . . but it's exciting to find something helpful for a significant proportion of the kids studied."

The study authors pointed out that their findings only apply to children with ADHD who exhibit severe irritability and peer aggression.

They noted that the study's findings are not an indication of the ADHD population as a whole.

More Information: "Risperidone Added to Parent Training and Stimulant Medication: Effects on Attention-Deficit/Hyperactivity Disorder, Oppositional Defiant Disorder, Conduct Disorder, and Peer Aggression" http://www.jaacap.com/article/S0890-8567(14)00369-4/abstract

Helping families cope with autism and aggression

Madeline Rainey

Madeline Rainey holds a portrait of herself with her son when he was a child. 

Rainey hopes a UAlberta study on aggression in kids with autism will spur more research and raise awareness of how families are affected. 

Credit: Richard Siemens

Madeline Rainey admits she compares her son's existence to a life sentence.

"I watched him suffer and be blamed and judged," says Rainey, whose son Eric has autism spectrum disorder with aggression.

"I keep asking, 'When is someone going to do something and recognize the lifelong pain that my kid and I have to live with?'"

Though autism and aggression are not synonymous, many children with autism spectrum disorder (ASD) show aggressive behaviour, which has a significant and lifelong impact on families, according to a University of Alberta study.

"Little has been done to understand families coping with autism and aggression, and if these families don't receive the support they need, things can get bad very quickly," says Sandy Hodgetts, assistant professor of occupational therapy in the Faculty of Rehabilitation Medicine and lead author of the study.

Sandy Hodgetts

"The percentage of children with ASD and aggression is not known because aggression is not a core symptom of autism."

Though the study was small, it was the first to look at families dealing with autism and aggression.

The researchers followed 15 families with male children and young adults with varying levels of autism.

Nine of the 15 families brought up their child's aggression as a barrier to services.

Parents described the impact of the aggression as "constant," "never-ending" and "almost unbearable."

One mother said her son's aggression had become so bad that she was "about ready to be locked up."

Hodgetts says families dealing with aggressive behaviour struggled with social isolation, lack of respite care and limited professional supports.

"The aggressive acts are not malicious. There needs to be better understanding and mechanisms in place to train and support respite care providers and health-care professionals in this area."

Rainey agrees that specialized training could make all the difference. When Eric was in grades 11 and 12, he had a teacher who majored in special education.

She was able to be creative, understand Eric and not be deterred by his aggression.

"I'm grateful for her and we still keep in touch," says Rainey.

Though her son is now 21, Rainey hopes this study can spur more research on autism and aggression. "It raises awareness on the impact on families and can hopefully help remove the social stigma for children and parents."

She hopes that with positive change and awareness, perhaps one day other families don't have to go through what she went through.

"We went from daycare to daycare, from caregiver to caregiver. I was told the reason my son was aggressive was that I was too domineering as a mother and I was told I was too permissive.

I was told to feed my child only organic food so he wouldn't have these behavioural problems. They assumed he was some kind of monster and I was to blame," she says. "It takes a piece of your soul."

More information: Sandra Hodgetts, David Nicholas, and Lonnie Zwaigenbaum. "Home Sweet Home? Families' Experiences With Aggression in Children With Autism Spectrum Disorders." Focus on Autism and Other Developmental Disabilities. September 2013 28: 166-174, first published on January 18, 2013 DOI: 10.1177/1088357612472932

Toddlers' Aggression Strongly Associated With Genetic Factors

The development of physical aggression in toddlers is strongly associated with genetic factors and to a lesser degree with the environment, according to a new study. 

Credit: © nadezhda1906 / Fotolia

The development of physical aggression in toddlers is strongly associated with genetic factors and to a lesser degree with the environment, according to a new study led by Eric Lacourse of the University of Montreal and its affiliated CHU Sainte-Justine Hospital.

Lacourse's worked with the parents of identical and non-identical twins to evaluate and compare their behaviour, environment and genetics.

Eric Lacourse

"The gene-environment analyses revealed that early genetic factors were pervasive in accounting for developmental trends, explaining most of the stability and change in physical aggression, " Lacourse said.

"However, it should be emphasized that these genetic associations do not imply that the early trajectories of physical aggression are set and unchangeable."

"Genetic factors can always interact with other factors from the environment in the causal chain explaining any behaviour."

Over the past 25 years, research on early development of physical aggression has been highly influenced by social learning theories that suggest the onset and development of physical aggression is mainly determined by accumulated exposure to aggressive role models in the social environment and the media.

However, the results of studies on early childhood physical aggression indicate that physical aggression starts during infancy and peaks between the ages of 2 and 4.

Although for most children the use of physical aggression initiated by the University of Montreal team peaks during early childhood, these studies also show that there are substantial differences in both frequency at onset and rate of change of physical aggression due to the interplay of genetic and environmental factors over time.

Genetically informed studies of disruptive behaviour and different forms of aggression across the lifespan generally conclude that genetic factors account for approximately 50% of the variance in the population.

Lacourse and his colleagues posited and tested three general patterns regarding the developmental roles of genetic and environmental factors in physical aggression.

• First, the most consensual and general point of view is that both sources of influence are ubiquitous and involved in the stability of physical aggression.
• Second, a "genetic set point" model suggests a single set of genetic factors could account for the level of physical aggression across time. 
• A third pattern labeled 'genetic maturation' postulates new sources of genetic and environmental influences with age.

"According to the genetic maturation hypothesis, new environmental contributions to physical aggression could be of short duration in contrast to genetic factors," Lacourse explained.

About the twins cohort
This twin study was initiated by Michel Boivin of Laval University and Richard Tremblay, who is also affiliated with the University of Montreal and University College Dublin.

All parents of twins born between April 1995 and December 1998 in the Greater Montreal area (Canada) were invited to participate, which resulted in the participation of 667 monozygotic and dizygotic twin pairs.

Monozygotic means the twins originated from the same embryo -- they are genetically identical. Dizogytic means they developed in separate embryos, meaning they are not identical.

Mothers were ask to rate their twins physical aggression, by reporting behavior such as hitting, biting, kicking and fighting, at the ages of 20, 32 and 50 months.

"The results of the gene-environment analyses provided some support for the genetic set-point hypotheses, but mostly for the genetic maturation hypotheses," Lacourse said.

"Genetic factors always explained a substantial part of individual differences in physical aggression."

"More generally, the limited role of shared environmental factors in physical aggression clashes with the results of studies of singletons in which many family or parent level factors were found to predict developmental trajectories of physical aggression during preschool."

Our results suggest that the effect of those factors may not be as direct as was previously thought.

Long-term studies of physical aggression clearly show that most children, adolescent and adults eventually learn to use alternatives to physical aggression.

"Because early childhood propensities may evoke negative responses from parents and peers, and consequently create contexts where the use of physical aggression is maintained and reinforced, early physical aggression needs to be dealt with care," Lacourse said.

"These cycles of aggression between children and siblings or parents, as well as between children and their peers, could support the development of chronic physical aggression."

"We are presently exploring the impact of these gene and social environment interactions."

Journal Reference: 
Eric Lacourse, PhD, Michel Boivin, PhD, Mara Brendgen, PhD, Amélie Petitclerc, PhD, Alain Girard, MSc, Frank Vitaro, PhD, Stéphane Paquin, PhD candidate, Isabelle Ouellet-Morin, PhD, Ginette Dionne, PhD and Richard E. Tremblay, PhD. A longitudinal twin study of physical aggression during early childhood: Evidence for a developmentally dynamic genome. Psychological Medicine, January 2014

TOSCA Study: Concerta® and Risperdal®, help adolescents with ADHD, aggression

Prescribing both a stimulant and an antipsychotic drug to children with physical aggression and attention-deficit/hyperactivity disorder (ADHD), along with teaching parents to use behaviour management techniques, reduces aggressive and serious behavioural problems in the children.

This is the result of a study conducted by researchers at the Ohio State University Wexner Medical Center.

The study was conducted in conjunction with the University of Pittsburgh, Stony Brook University in New York and Case Western Reserve University in Ohio.

The findings published online this week ahead of publication in the January issue of the Journal of the American Academy of Child and Adolescent Psychiatry.

"Combination pharmacotherapy is becoming common in child and adolescent psychiatry, but there has been little research evaluating it," said first author Michael Aman, director of clinical trials at Ohio State's Nisonger Center and emeritus professor of psychology.

"Our findings may be considered somewhat controversial because they appear to support the use of two drugs over one for treating children with aggression and disruptive behaviour when things do not seem to be going well.

Many practitioners have been taught to 'Keep things simple and safe' in their medical training. In general, this is good advice."

For the "Treatment of Severe Childhood Aggression (TOSCA) Study," 168 children ages 6 to 12 who had been diagnosed with ADHD and displayed significant physical aggression were divided into two groups.

All study participants received a psychostimulant drug called OROS methylphenidate (Concerta®) and their parents received behavioural parent training for nine weeks.

The researchers called this treatment combination "basic" because both are evidence-based and have been shown to be helpful for improving both ADHD and aggression.

Researchers wanted to see if they could expand or augment this treatment by adding a second medication. If there was room for improvement at the end of the third week, a placebo was added for the "basic group," while the antipsychotic drug Risperidone (RISPERDAL®) was added for participants in the "augmented group."

Compared to the "basic group," the "augmented group" who received the stimulant drug and parent training plus risperidone showed significant improvement (on average with moderately better behaviour) on the Nisonger Child Behavior Rating Form (NCBRF) Disruptive-Total Scale, the NCBRF Social Competence subscale and the Reactive Aggression part of the Antisocial Behaviour Scale.

While there is always some risk with the addition of a second drug to the treatment package, the two drugs seemed to neutralize some of each other's potential side effects.

For instance, children in the augmented group did not seem to have as much trouble falling asleep, once the risperidone was added, Aman said.

"We conducted this study because we viewed the combination of ADHD and significant physical aggression – especially the aggression – as a serious situation," Aman said.

"It is not uncommon to use more than one medicine for other serious situations, such as when treating cancer or epilepsy for instance."

"Although doctors have often used stimulants and antipsychotics together in recent years, we did not have good evidence until now that they would work more effectively when carefully staged and given together."

More information: "Treatment of Severe Childhood Aggression (TOSCA) Study,"

Cuteness can bring out our aggression

Whether we are pinching the cheeks of an adorable toddler or enveloping a beloved pet in a bear hug, most of us have experienced the strange drive to give something cute a gigantic squeeze.

New research by two Yale University psychologists details how the sight of something cute brings out our aggressive side.

Rebecca Dyer and Oriana Aragon investigated “cute aggression” by showing study participants slide shows of either cute, funny or normal animal photographs.

As they watched, the participants held bubble wrap. The researchers, attempting to mimic the common desire to squeeze cute things, told subjects to pop as many or as few bubbles as they wished.

People watching the cute slide show popped significantly more bubbles than those viewing the funny or control pictures, according to results presented at the Society for Personality and Social Psychology annual meeting in New Orleans.

“Some things are so cute that we just can't stand it,” Dyer concludes. Cute aggression's prevalence does not mean that people actually want to harm cuddly critters, Aragon explains.

Rather the response could be protective, or it could be the brain's way of tamping down or venting extreme feelings of giddiness and happiness.

The scientists are currently conducting additional studies to determine what drives the need to squeeze.

Read the article in Scientific America

Prompt Intervention needed to reduce lifelong effects of childhood abuse

Preschool children who have been neglected or emotionally abused exhibit a range of emotional and behavioral difficulties and adverse mother-child interactions that indicate these children require prompt evaluation and interventions, according to a systematic review by Aideen Mary Naughton of NHS Public Health Wales, Pontypool in Wales, and her colleagues.

A total of 42 studies of children age 0 to 6 years with confirmed neglect or emotional abuse who had emotional, behavioural, and developmental features recorded or for whom the carer-child interaction was documented were analyzed.

Key features in the child included aggression, withdrawal or passivity, developmental delay, poor peer interaction, and transition from ambivalent to avoidant insecure attachment pattern and from passive to increasingly aggressive behaviour and negative self-representation.

Emotional knowledge, cognitive function, and language deteriorate without intervention. Poor sensitivity, hospitality, criticism, or disinterest characterize maternal-child interactions.

"Lifelong consequences include physical and mental health problems; impairments in language, social, and communication skills; and severe effects on brain development and hormonal functioning."

The study concludes, "early intervention has the potential to change children's lives."

Explore further: Traumatized mothers avoid tough talks with kids, study shows

More information: JAMA Pediatr. Published online June 10, 2013. doi:10.1001/jamapediatrics.2013.192

Saliva Testing Predicts Aggression in Boys

A new study indicates that a simple saliva test could be an effective tool in predicting violent behaviour.

The pilot study, led by Cincinnati Children's Hospital Medical Center and published this week online in the journal Psychiatric Quarterly, suggests a link between salivary concentrations of certain hormones and aggression.

Drew Barzman

Researchers, led by Drew Barzman, MD, a child and adolescent forensic psychiatrist at Cincinnati Children's, collected saliva samples from 17 boys ages 7-9 admitted to the hospital for psychiatric care to identify which children were most likely to show aggression and violence.

The samples, collected three times in one day shortly after admission, were tested for levels of three hormones: testosterone, dehydroepiandrosterone (DHEA) and cortisol.

The severity and frequency of aggression correlated with the levels of these hormones.

Barzman's team focused on rapid, real-time assessment of violence among child and adolescent inpatients, a common problem in psychiatric units, but he believes a fast and accurate saliva test could eventually have several other applications.

"We believe salivary hormone testing has the potential to help doctors monitor which treatments are working best for their patients," said Barzman. "And because mental health professionals are far more likely to be assaulted on the job than the average worker, it could offer a quick way to anticipate violent behaviour in child psychiatric units. Eventually, we hope this testing might also provide a tool to help improve safety in schools."

For this study, the saliva test was used in combination with other aggressive behavior tools, including the Brief Rating of Aggression by Children and Adolescents (BRACHA) questionnaire, an assessment tool also developed by Barzman's team to predict aggression and violence in the hospital.

"This study sample, while small, gives us the data we need to move forward," added Barzman. "We have more studies planned before we can reach a definitive conclusion, but developing a new tool to help us anticipate violent behaviour is our ultimate goal."

Reference
The Association Between Salivary Hormone Levels and Children’s Inpatient Aggression: A Pilot Study. Psychiatric Quarterly, 2013; DOI: 10.1007/s11126-013-9260-8

Violent Video Games Are a Risk Factor for Criminal Behaviour and Aggression

Iowa State researchers say there is a strong connection between violent video games and youth violence and delinquency. 

Credit: Photo by Bob Elbert

People are quick to point the finger or dismiss the effect of violent video games as a factor in criminal behaviour.

New evidence from Iowa State researchers demonstrates a link between video games and youth violence and delinquency.

Matt DeLisi

Matt DeLisi, a professor of sociology, said the research shows a strong connection even when controlling for a history of violence and psychopathic traits among juvenile offenders.

"When critics say, 'Well, it's probably not video games, it's probably how antisocial they are,' we can address that directly because we controlled for a lot of things that we know matter," DeLisi said.

"Even if you account for the child's sex, age, race, the age they were first referred to juvenile court -- which is a very powerful effect -- and a bunch of other media effects, like screen time and exposure. Even with all of that, the video game measure still mattered."

Douglas Gentile

The results were not unexpected, but somewhat surprising for Douglas Gentile, an associate professor of psychology, who has studied the effects of video game violence exposure and minor aggression, like hitting, teasing and name-calling.

"I didn't expect to see much of an effect when we got to serious delinquent and criminal level aggression because youth who commit that level of aggression have a lot of things going wrong for them. They often have a lot of risk factors and very few protective factors in their lives," Gentile said.

The study published in the April issue of Youth Violence and Juvenile Justice examined the level of video game exposure for 227 juvenile offenders in Pennsylvania.

The average offender had committed nearly nine serious acts of violence, such as gang fighting, hitting a parent or attacking another person in the prior year.

The results show that both the frequency of play and affinity for violent games were strongly associated with delinquent and violent behavior.

Craig Anderson

Craig Anderson, Distinguished Professor of psychology and director of the Center for the Study of Violence at Iowa State, said violent video game exposure is not the sole cause of violence, but this study shows it is a risk factor.

"Can we say from this study that Adam Lanza, or any of the others, went off and killed people because of media violence?

You can't take the stand of the NRA that it's strictly video games and not guns," Anderson said.

"You also can't take the stand of the entertainment industry that it has nothing to do with media violence that it's all about guns and not about media violence. They're both wrong and they're both right, both are causal risk factors."

Researchers point out that juvenile offenders have several risk factors that influence their behavior. The next step is to build on this research to determine what combination of factors is the most volatile and if there is a saturation point.

"When studying serious aggression, looking at multiple risk factors matters more than looking at any one," Gentile said.

"The cutting edge of research is trying to understand in what combination do the individual risk factors start influencing each other in ways to either enhance or mitigate the odds of aggression?"

Parents
Just because a child plays a violent video game does not mean he or she is going to act violently.

Researchers say if there is a take away for parents, it is an awareness of what their children are playing and how that may influence their behavior.

"I think parents need to be truthful and honest about who their children are in terms of their psychiatric functioning," DeLisi said.

"If you have a kid who is antisocial, who is a little bit vulnerable to influence, giving them something that allows them to escape into themselves for a long period of time isn't a healthy thing."

Reference
Violent Video Games, Delinquency, and Youth Violence: New Evidence. Youth Violence and Juvenile Justice, 2012; 11 (2): 132 DOI: 10.1177/1541204012460874

Children with callous, unemotional (CU) traits - Neurological study

A Recent study reveals that a small number of children with a 'callous' attitude towards other children and adults may be suffering from a neurological condition that pre-determines their nature.

If this is diagnosed and proven to be the case, then it will dictate the way that parents, teachers and medical practitioners deal with the child's behaviour and will determine a more focussed solution.

Background: Children with callous-unemotional (CU) traits may have a particularly malevolent view of social conflicts and a pervasive insensitivity to others’ distress.

The current study examined whether children with CU traits have unique expectations and values regarding the consequences of aggressive conflicts and a ubiquitous lack of concern for others’ feelings independent of co-occurring aggression.

Methods:  Participants were 96 (46 males, 50 females) children recruited from elementary schools within an urban city.

Associations between CU traits and child reports of outcome expectancies/values following aggressive conflicts and facets of empathy were examined after controlling for aggression, academic abilities, and demographic covariates.

Results:  Children with higher CU traits were less likely to expect that aggression would result in victim suffering and feelings of remorse.

After controlling for co-occurring aggression, children with higher CU traits were more likely to expect that aggression would result in peer dominance, while children with higher levels of aggression were more likely to expect that attacking others would reduce their aversive behaviour.

Children with higher CU traits were less concerned that aggressive behavior would result in punishment, victim suffering, and feelings of remorse.

Moreover, children with higher CU traits reported lower levels of empathetic concern and sadness in response to others’ distress outside of aggressive conflicts.

Conclusions:  Children with CU traits tend to minimize the extent to which aggression causes victim suffering and openly acknowledge caring less about distress and suffering in others.

They are less intimidated by the possibility of being punished for aggressive behavior and tend to view aggression as an effective means for dominating others.

In summary, children with CU traits have a particularly malicious social schema that may be difficult to change using conventional treatment methods.

To read the paper published in The Journal of Child Psychology and Psychiatry follow this link: Perceptions of aggressive conflicts and others’ distress in children with callous-unemotional traits: ‘I’ll show you who’s boss, even if you suffer and I get in trouble’