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Aggression, Rage and Dyscontrol in Neurological Diseases of Children

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Aggression, Rage and Dyscontrol in Neurological Diseases of Children Journal of Pediatric Neurology 2003; 1(1): 9-14 www.jpneurology.org REVIEW ARTICLE Aggression, rage and dyscontrol in neurological diseases of children Jayaprakash A. Gosalakkal University Hospitals of Leicester, Leicestershire and Warwick Medical School, Leicester, U.K. Abstract that aggression has a neuroanatomic and chemical basis, that developmental and acquired brain Behavioral neurology has been bridging disorders contribute to recurrent interpersonal the gap between neurology and psychiatry in violence, that both biologic and sociologic factors children. There are several neuropsychiatric are involved, and that to ignore either is to invite disorders of children in which aggression is a error (2). dominant symptom. Both global disorders like There are several neuropsychiatric disorders attention deficit hyperactivity disorder as well of children in which aggression is a dominant as localized dysfunction of the brain may lead symptom e.g. Lesch-Nyhan syndrome, Prader-Willi to aggression. A number of neurometabolic syndrome etc (Tables 1 and 2). Self-mutilation has disorders as well as post-epileptic and post- been seen in 15% of institutionalized mentally surgical states may present with aggression retarded patients (3). Physical and verbal aggression in children. Drugs are sometimes effective may also be a symptom of frontal lobe epilepsy in especially in combination with a multimode children in association with other psychological approach. In this review some of the more deficits (4). Rage outbursts and increased aggression common causes for aggression in neurologically have been noted to occur in higher rates in children impaired children, the associated co-morbidities with temporal lobe epilepsy (5). and treatment are discussed. (J Pediatr Neurol Aggression can be seen both in previously 2003; 1(1): 9-14). normal children who develop pathology following an acute injury (e.g. head injury) and then become Key words: neuropsychiatric disorder, impaired child. unable to control their behavior and in adolescents in whom aggression is a manifestation of long Introduction standing antisocial personality or conduct disorder. Behavioral neurology has been bridging the gap Brain lesions and behavior between neurology and psychiatry in children. A number of behavioral problems are presented to The role of the amygdala in the neural basis for the child neurologist as a primary or secondary aggression has been well known. Animal studies symptom in the normal or developmentally delayed indicate that stimulation of the lateral and medial child. One of the more common behavioral problems hypothalamus result in different types of aggression seen in children is aggression and dyscontrol. A (6). Plotnik (7) divided aggression based on the pure biological model for aggression and dyscontrol relationship between stimulus and behavior and may have ethical and legal implications (1). argued against attributing aggressive behaviors to Neuroscientists and clinicians have demonstrated direct involvement of specific anatomical sites. In the first type stimulus produced direct aggression and in the second type stimulus produced direct aggression and in the second type stimulus to the relevant brain area produced an initial noxious Correspondence: Jayaprakash A. Gosalakkal, M.D., reaction, which lead to aggressive behavior. The Consultant Pediatric Neurologist, CDC /Windsor Building Leicester Royal Infirmary relationship between specific neuroanatomic sites Leicester LE1 5WW, United Kingdom. and aggressive behavior is complex. Most human Fax: 0 11 62 58 76 37. studies of aggression are based on ictal aggression E-mail: [email protected] and amelioration with surgery. Trieman (8) points Received: February 28, 2003. Revised: April 8, 2003. out that cerebral stimulation as part of evaluation for Accepted: April 21, 2003. epilepsy surgery rarely led to aggressive behavior. Aggression in children J A Gosalakkal 10 Table 1. Disordes which may present with aggression in Table 2. Neurometabolic diseases which may present as children aggression Attention deficit hyperactivity syndrome Huntington disease Post surgical states Wilson disease Acute confusional states Lafora disease Post ictal states Acute intermittent porphria Following an acute injury (e.g. head injury) Hartnup disease Diseases of the hypothalamus Lesch-Nyhan syndrome Episodic dyscontrol or rage attacks Neuroacanthocytosis Ictal aggression (rare) behavior. The relationship between specific with 58% of the seizure patients meeting criteria neuroanatomic sites and aggressive behavior is for the affective subtype of aggression and complex. Most human studies of aggression are 30.5% having the predatory aggression subtype. based on ictal aggression and amelioration with Unaffected siblings demonstrated low rates of surgery. Trieman (8) points out that cerebral psychiatric pathology on semi structured parental stimulation as part of evaluation for epilepsy interview and no aggression as measured by the surgery rarely led to aggressive behavior. Vitiello Aggression Scale. Aggression as a clinical manifestation of Episodic dyscontrol or rage attacks neurological disorders Children often come to neurological attention when they suddenly develop a temper tantrum, Global disorders which is out of character for the child’s’ personality. Attention deficit disorder may be taken as a The attacks may appear suddenly and explosively prototype of a global disorder with aggression as and consist of uncontrolled behaviors such as a manifestation or co morbidity. Follow up studies hitting, biting, kicking, and throwing objects around of children with this disorder have shown a high the room. Afterwards the child may be completely incidence of delinquent behavior and explosive amnesic to the event or may show remorse. There is personality disorder (9). Approximately 75 % of usually no prolonged post-ictal like phase (15). hyperactive children have some form of discipline Mark and Ervin (16) argued that the dyscontrol problem including aggressive and destructive syndrome was a product of limbic dysfunction and behavior (10). A profile characterized by behavioral that many patients improved on anticonvulsants. and cognitive impulsivity and emotional labiality Some children with complex partial seizures do may indicate a greater likelihood of the progression exhibit episodic dyscontrol interictally. There is an to adult antisocial behavior and violent impulse- increased incidence of rage attacks in children with control disorders (11). Aggression may also be a attention deficit disorder and temporal and frontal manifestation of metabolic conditions, post surgical lobe injury. states, acute confusional states and post ictal states. Ictal and interictal aggression Localized brain dysfunction Ictal acts of aggression are rare in children. It Aggressive behavior in mentally handicapped is unprovoked and usually not directed towards an children may be mediated through the frontal individual and cannot usually be modified during lobe. Children with head injury or cerebral the event. In a multicenter study involving 5400 tumors involving the frontal lobe especially may patients of varying age it was observed that only manifest aggression. Orbitofrontal injuries result 19 patients displayed aggressive behavior during in a disinhibition syndrome while rage is a more seizures (17). Resistive violence is more common common manifestation of dorsolateral prefrontal than ictal aggression. This happens when attempts damage (12). The involvement of the hypothalamus are made the patient reacts with aggression. in a range of pathological conditions may lead to It is difficult to always attribute interictal rage reactions. This is most often seen in infiltrative aggression to the epilepsy itself. Both epilepsy and diseases of the hypothalamus. Stereotactic abnormal behavior may be related to brain intervention into the posterior hypothalamus gives malfunction. Children with epilepsy may be satisfactory results for controlling both aggressive, subjected to ridicule and rejection leading to low violent behavioral disorders and intractable pain self-esteem and potential behavioral abnormalities. (13). Weissenberger et al. (14) in a study of 12 Children reared in emotionally and financially children with hypothalamic hemartoma and gelastic impoverished environments are more likely to suffer seizures noticed significant rates of aggression, from neurological disorders and the aggressiveness Aggression in children J A Gosalakkal 11 may not be related to the epilepsy per se. behaviour is not especially common in cognitively impaired children. Environmental factors, over Aggression as a manifestation of protection by caregivers etc may sometimes lead to neurometabolic disease low frustration threshold and aggressive outbursts in such children. The behaviour may also be a reflection In general, any organic condition that produces of the patient’s life experience rather than true cortical dysfunction could present with psychiatric organicity. Physical pain may arouse the aggressive symptomatology. The full range and incidence of impulse and may be non-directed aggression in neuropsychiatric manifestations are poorly studied the developmentally delayed child. Grizenko et al. for most of these diseases. In most instances, rarity (22) in a study of 176 mentally retarded individuals of these conditions precludes any one clinic from found that the severity of behaviour disturbance collecting a large enough patient base to assess the did
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