بسم الله الرحمن الرحيم

يا أيها الناس اتقوا ربكم الذى خلقكم من نفس واحدة و خلق

منها زوجها وبث منهما رجاال كثيرا و نساء و اتقوا الله الذى تساءلون به و االرحام ان الله كان عليكم

رقيبا

1النساء

Aggressive Behaviour In Children

Subject :

By

Mohamed Abdel-Ghani Moustafa Ali

M.B., B.CH.

Zagazig University

Supervisors

Prof. Dr. Wael Mohamed AhmedProfessor of PsychiatryFaculty of Medicine, Zagazig University

Dr. Haythem Mohamed Abou HashemAssistant Prof. of PsychiatryFaculty of Medicine, Zagazig University

Dr. Mohamed Gamal SehloLecturer of PsychiatryFaculty of Medicine, Zagazig University

Prof. Dr. Abdel-Shafy Metwaly KhashabaProfessor and Head of Psychiatry DepartmentFaculty of Medicine, Zagazig University

Prof. Dr. Abdouh Elsayed El-DoddProfessor of PsychiatryFaculty of Medicine, Tanta University

Prof. Dr. Wael Mohamed AhmedProfessor of PsychiatryFaculty of Medicine, Zagazig University

Discussion Committee

Aggression is "the maladaptive behavior which leads to the damage or destruction of some goal entity.” (Alia-Klein et al., 2008).

Many behaviors are aggressive even though they do not involve physical injury.

Verbal aggression is one example. Others include coercion, intimidation, and premeditated social ostracism of others (Lewis, 2005).

Introduction

Aggressive Behaviour In Children

PSYCHOSOCIAL ASPECT

I- FAMILY-RELATED RISK FACTORS

A. Sexual and Physical AbuseB. Parental Violence C. Broken HomeD. Parental CharacteristicsE. Mental Disorders of ParentsF. Perceived Parenting Styles (Barnow and

Freyberger, 2003).

The role of family environment in early life for later aggressive behavior (Mattson, 2003).

Pre/PerinatalComplications thatcause brain damage Maternal

rejection

Sexual, Physical Abuse

IncreasedRisk For

AggressiveBehavior

Difficult temperament

Psychological risks Low social status , young age

Of Mother ,broken home , Mental Disorder of parents

Increased risk for Postnatal

Complications

Negative Parental Style

Time

II- Community-Related Risk FactorsA- Peers: Peer groups appear to be a place for

consolidation of aggressive behaviors for youth, later on (Loeber & Hay, 1994).

B- School Factors: Disorganized school structures with lax discipline, enforcement of rules and crowded physical space (Flannery, 1997).

C- Neighborhood Factors: include poverty, gang involvement, availability of drugs and low neighborhood attachment (Maguin et al., 1995).

III- Television, Rock Music and Videos, and Computer and Video Games

1)Television and Movie Violence

Correlation between media violence and aggression (0.3) is greater than that of condom nonuse and sexually (HIV) infection (0.2), or environmental tobacco smoke and lung cancer (0.15) (Christopher, 2007).

2) Rock Music and Music Videos

Great exposure was associated with being 3.0 times more likely to hit a teacher, 2.6 times to be arrested, and 1.6 times to have an incident of STD and drug abuse (Kader, 2006).

3) Computer and Video Games

Violent video games causes increased aggression or aggressive play immediately after the video game (Benseley and Van Eenwyk, 2001).

Aggressive Behaviour In Children

GENETIC ASPECT

♦ The influence of genetic factors appears to increase over the course of development and is followed by a concomitant decrease in shared environmental factors (Blonigen & Krueger, 2007).

♦ Furthermore, genetic effects may be moderated by gender differences, as well as interactions with adverse environmental factors (Blonigen & Krueger, 2007).

I- Genetic Effects on Aggressive Behavior

Genetic factors play at least some role in the etiology of aggression (DiLalla, 2002).

Studies of children using parental reports have noted substantial genetic contributions to aggressive behaviors among twins across a wide developmental span (ages 7–16) (Eley et al., 1999).

II- Gender Differences

Several studies conclude that males exhibit higher mean levels of aggression than females (Hudziak et al., 2005).

In a longitudinal study of twins ages 3-12, gender differences were evident after age 7, with greater genetic contributions for males and larger shared environmental contributions for females (van Beijsterveldt et al., 2004).

Aggressive Behaviour In Children

NEURAL ASPECT

I- ACETYLCHOLINE:♦ ACh generally has facilitatory effects on aggressive behavior (Gay and Leaf, 1986).

♦ In most cases, the primary target is the hypothalamus (Brudzynski, 1994).

II- DOPAMINE:◊ The studies showed that dopamine facilitates aggressive behavior (Siegel, 2005).

◊ Van Erp and Miczek (2003) reported increased dopamine levels in the prefrontal cortex during aggressive encounters.

III- SEROTONIN:

Serotonin suppresses several different forms of aggressive behavior (Siegel, 2005).

A strategy using knockout mice genetically engineered to disrupt the neuronal nitric acid sythase gene, which inhibits aggression, by acting through 5-HT1A and 5- HT1B receptors leading to a dramatic increase in aggressive behavior (Chiavegatto et al., 2004).

IV- PEPTIDES

■ Include opioid peptides, substance P (SP), and cholecystokinin (CCK)

■ Opioid peptides have antiaggressive properties (Siegel, 2005).

■ SP have an excitatory action on neurons (Otsuka and Yoshioka, 1993).

■ CCK potentiates defensive rage behavior elicited from the medial hypothalamus (Siegel, 2005).

Aggressive Behaviour In Children

Neural Areas & Circuits Mediating Aggressive Behavior

Brain areas affecting aggressive behavior

The periaqueductal gray of the midbrain (PAG)

Hypothalamus

Septal nuclei

Amygdala

Prefrontal cortex

Bed nucleus of the stria terminalis (BNST)

Nucleus accumbens (Gregg and Siegel, 2001).

Summary of functional anatomical connections relevant for aggressive behavior

(Gregg, 2003).

i. Peri-aqueductal Gray Of The Midbrain

The organizing center for the expression of all the behavioral components of the aggressive response (Ogawa et al., 2005).

Sends commands to effector regions in the brainstem, which send commands to the muscles and glands, producing the components of defensive rage (e.g., pupillary dilation, increased heart rate, vocalization) (Gregg, 2003).

Efferent projections from PAG (Gregg, 2003)

ii.HypothalamusSecond in importance to the PAG in the expression of defensive aggressive behavior (Gregg, 2003).

iii.Limbic And Cortical Areas Modify the propensity of the hypothalamus and PAG to produce aggression (Halász et al., 2006). Include septal nuclei, amygdaloid complex, bed nucleus of the stria terminalis (BNST), prefrontal cortex and nucleus accumbens (Gregg and Siegel, 2001).

Aggressive Behaviour In Children

HORMONAL ASPECT

i.ADRENERGIC–NORADRENERGIC SYSTEM Aggressive behavior leads to activation of the peripheral sympathoadrenal and central noradrenergic systems (Halasz et al., 2002).

Brunner et al. (1993) have identified a large Dutch kindred showing a genetic deficiency of the MAOA enzyme. All affected males in this family showed very characteristic aggressive behavior.

Subsequent research in MAOA knockout mice confirmed human findings (Cases et al., 1995). So, enhanced noradrenergic neurotransmission increases aggressiveness in both humans and laboratory animals (Haller and Kruk, 2003).

ii.GLUCOCORTICOIDS It has been shown that plasma glucocorticoid levels are inversely correlated with aggressiveness in children with conduct disorder (McBurnett et al., 2000).

Hyporesponsiveness of plasma glucocorticoids is associated with persistent aggression in humans (including females) (Kariyawasam et al., 2004) and various animal species (e.g., dogs and fish) (Pottinger and Carrick, 2003).

Aggressive Behaviour In Children

AGGRESSIVE BEHAVIOR IN CHILD PSYCHIATRIC DISORDERS

They include:

Attention Deficit Hyperactivity Disorder

Oppositional Defiant Disorder

Conduct Disorder

Tourette's Disorder

Mood Disorders

Substance-Related Disorders

Mental Retardation

Pervasive Developmental Disorders

Intermittent Explosive Disorder

Some Epileptic Patients (Turgay, 2004).

I- Disruptive Behavior Disorders1- Conduct disorder:

The commonest aggression-related psychiatric disorder of childhood (Rutter et al., 1985).

Characterized by a repetitive, persistent pattern of behavior violating the basic rights of others (Tynan, 2006).

Aggressive acts include persistent bullying, initiating fights, using a weapon, stealing while confronting the victim, forcing someone into sexual activity, and showing physical cruelty (Christophersen and Mortweet, 2001).

2- Oppositional Defiant Disorder (ODD)

In ODD, aggression is usually verbal rather than physical.

The child loses his or her temper, argues

with adults, deliberately annoys others and is

in turn easily annoyed, blames others, and is

often angry, resentful, spiteful, or vindictive

(Lavigne et al., 2001).

II- Attention Deficit Hyperactivity Disorder A neuro-developmental disorder with core symptoms of inattention, hyperactivity and impulsive behavior present from an early age (Davies and Jennings, 2006). Children with ADHD can be rude and disinhibited leading to rule-breaking behavior. With increasing age, the symptoms of ADHD affect all areas of functioning. Later, during adolescence, some of ADHD features may be masked by delinquent behavior, drug misuse and risk-taking behavior (Davies and Jennings, 2006).

III- Mental Retardation

o Aggressive behavior is the most common reason

for psychiatric referral in children with mental

retardation (Prater and Zylstra, 2006).

o More males than females showed problems of

aggressive behavior.

o Although physical and verbal aggression were the

most frequently reported behaviors, other forms of

challenging behavior are present, particularly self-

injurious, and stereotypical behavior (Harris, 1993).

IV- Pervasive Developmental DisordersInvolve a triad of deficits in social skills,

communication, and behavior (Semple et al., 2005).

DSM-IV-TR categorizes PDDs as follows:Autism

Asperger's syndrome

Rett's syndrome

Childhood disintegrative disorder

PDD-NOS (American Psychiatric Association, 2000)

Aggressive Behavior in PDD:

They have a tendency to “lose control,”

particularly when they are in a strange

environment, or when angry and frustrated.

They may at times break things, attack

others, hurt themselves, bang their heads,

pull their hair, or bite their arms (National

Institute of Mental Health, 2007).

V- Tourette's Syndrome

Multiple motor and one or more vocal tics,

present for at least a year, causing distress and

impaired function (Semple et al., 2005).

Aggression takes the form of abrupt

uncontrollable episodes of severe verbal and/or

physical outbursts which are distressing and out of

proportion to any provocation.

Aggressive behavior tends to worsen when the

tics increase (Budman, 2007).

VI- Bipolar Disorder in Children Rare in prepubescent children but rates of

diagnosis are increasing.

Children with BPD participate in threatening

behavior toward family members, teachers, and

other children (Spencer et al., 2001).

Increased catecholaminergic and HPA axis

activities may explain the association between

BPD and aggression (Swann et al., 1994).

VII- Major Depressive Disorder Children with depression may be at risk for future aggression (Schubiner et al., 1993).

One of the factors implicated in the association between depression and aggression is 5-HT, which has been associated with depression and aggression (Coccaro, 1995).

Comorbidity with other psychiatric disorders may also be involved e.g. comorbid ODD or CD (Knox et al., 2000).

VIII- Schizophrenia in Children Twenty-five percent of children with EOS have a history of aggression or legal problems (Moran, 2007).

Yesavage (1983) and Tardiff and Sewillam (1982) attribute aggression to persecutory delusions.

Cheung et al. (1997) found aggression in patients with schizophrenia to be related to overall psychopathology, and both positive and negative symptoms.

IX- Intermittent Explosive Disorder

Discrete episodes of losing control of aggressive impulses resulting in serious assault or the destruction of property.

The symptoms appear within minutes or hours and remit spontaneously.

Other disorders of impulse control and substance use and mood, anxiety disorders have also been associated with intermittent explosive disorder (Hollander et al., 2006).

Aggressive Behaviour In Children

Cognitive-Behavioral Intervention for Childhood Aggressive behavior

Cognitions are one important link

between environmental events and

behavioral outcomes.

The goal of cognitive-behavioral

treatment is to teach children to use

cognitive mediators to guide their

behavior toward nonaggressive

responses (Hudley, 2003).

THE BRAINPOWER PROGRAMAccording to social cognitive theory, the

aggressive children attend selectively to social

cues, make biased interpretations of the

available cues, and act on beliefs that

aggressive response is the appropriate course

of action (Hudley, 2003).

The BrainPower Program seeks to modify this

dysfunctional pattern of attributional bias

(Hudley, 2001).

Aggressive Behaviour In Children

PHARMACOLOGICAL INTERVENTION

There are no studies to date that

would support the use of medication

specifically to treat child aggressive

behavior.

Moreover, the appropriate treatment

of aggression cannot be reduced to the

mere administration of medicine (Lyons

et al., 2000).

i.LITHIUM

Can reduce bullying, fighting, and temper outbursts in severely aggressive, inpatient children with CD (Campbell et al., 1984; Campbell et al., 1995; Malone et al., 2000).

Short- and long-term side effects limit the clinical use of lithium with children,

particularly those with co-morbid neurological or medical conditions (Hagino

et al., 1995).

II- ADRENERGICS

1- β-Blockers

2- α-2 Agonists: "Clonidine"

III- STIMULANTS (Methylphenidate and Dextroamphetamine)

☺Many studies have demonstrated the efficacy of stimulants in managing ADHD symptoms for up to 24 months (Greenhill; 2008).

☺ However, stimulants can be associated with insomnia, reduced appetite, stomachache, headache, and dizziness as well as long-term adverse events, including height and weight suppression (Lisska & Rivkees, 2003).

IV- ANTICONVULSANTS

a) Valproate

b)Carbamazepine

V- SEROTONERGIC AGENTS

Trazodone

Clomipramine

Buspirone

Selective Serotonin Reuptake Inhibitors

VI- BENZODIAZAPINESUse of short-acting benzodiazepines like lorazepam to treat aggression is limited to acute cases (Salzman et al., 1991).

VII- ANTIPSYCHOTICS

☺Typical Antipsychotics

☺Atypical Antipsychotics

Atypical Antipsychotics☼ Have replaced conventional antipsychotics because of their decreased propensity for serious adverse events, such as neuroleptic malignant syndrome, extrapyramidal symptoms, and tardive dyskinesia (McConville & Sorter, 2004).

☼ However, they are also associated with significant risks, including weight gain, type II diabetes, and cardiac rhythm abnormalities (Schur et al., 2003).

Among first-line atypicals: Risperidone (Risperdal)Olanzapine (Zyprexa) Quetiapine (Seroquel)Ziprasidone (Geodon)Aripiprazole (Abilify)

Risperidone is the most extensively studied medication for the treatment of aggression in children (Pappadopulos et al., 2006).

Risperidone produces significant

reductions in aggression in subjects

with a variety of diagnoses, including:

CD (Aman et al., 2002)

Autism (McDougal et al., 2005)

ODD (LeBlanc et al., 2005)

ADHD (Aman et al., 2004)

M.R. (George et al., 2008)

Finally, I would like to express my deepest appreciation and gratitude to

MY SUPERVISORS

Prof. Dr. Wael Mohamed Ahmed

Professor of Psychiatry Faculty of Medicine

Zagazig University

Dr. Haythem Mohamed Abou Hashem Assistant Professor of Psychiatry

Faculty of Medicine Zagazig University

Dr. Mohamed Gamal Sehlo Lecturer of PsychiatryFaculty of Medicine Zagazig University

DISCUSSION COMMITTEE

Prof. Dr. Abdel-Shafy Metwaly Khashaba Professor and Head of Psychiatry Department

Faculty of Medicine Zagazig University

Prof. Dr. Abdouh Elsayed El-doddProfessor of Psychiatry

Faculty of MedicineTanta University

Prof. Dr. Wael Mohamed Ahmed Professor of Psychiatry

Faculty of Medicine Zagazig University

All my professors, staff members and colleagues

for their continuous supervision, patience, generous help and fruitful remarks that are

inscribed within this work

Ramadan Karim