ORI GIN AL PA PER

Collaborative Problem Solving (CPS) as a PrimaryMethod of Addressing Acute Pediatric PathologicalAggression Along with Other Modalities

Gaurav Kulkarni • Parikshit Deshmukh • Drew Barzman

Published online: 18 February 2010� Springer Science+Business Media, LLC 2010

Abstract The answer for treating pathologic aggression (PA) in children on inpatient

psychiatry units (based on various factors like severity of aggression and co-morbidities) is

less likely to be restrictive interventions or sedating the patient. Using seclusion and

restraints or medications to calm down the aggression is not free of adverse consequences.

A protocol is needed to safely and effectively address aggressive and violent children and

adolescents seen very commonly in psychiatry inpatient units.

Keywords Children � Adolescent � Psychiatry � Aggression � Inpatient unit �Collaborative problem solving � Pharmacology � Treatment of aggression

Introduction

Children and adolescents exhibiting aggressive behaviors many times pose a challenging

situation not only to the parents/caregivers and health care providers but this problem also

is quite taxing to the economy. Annual expenditure that the United States has to bear is

over $158 billion for adolescent violent behavior [1]. Some of the major expenses for this

growing concern in adolescents with conduct disorder and aggression are providing social

programs [2], juvenile justice costs [3] and victim costs [4].

G. Kulkarni (&)Cincinnati Children’s Hospital Medical Center, D4/37, 3333 Burnet Avenue,Cincinnati, OH 45229-3039, USAe-mail: gaurav.kulkarni@cchmc.org

P. DeshmukhW.O. Walker Center, 10524 Euclid Avenue, 8th Floor, Cleveland, OH 44106, USAe-mail: Parikshit.Deshmukh@UHhospitals.org

D. BarzmanCincinnati Children’s Hospital Medical Center, MLC 3041, 3333 Burnet Avenue,Cincinnati, OH 45229-3039, USAe-mail: drew.barzman@cchmc.org

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Psychiatr Q (2010) 81:167–175DOI 10.1007/s11126-010-9126-2

In a child psychiatry inpatient unit, the work environment may become unstable if the

child or adolescent exhibits pathological aggression. In such an unstable environment, the

staff is susceptible to assaults, which can be verbal or physical. In 2001–2002, Ryan and

colleagues conducted a prospective study of physical assaults against staff by children and

adolescents in a state psychiatric hospital [5]. Within two months, a total of 215 assaults

occurred. One-third of the total 111 hospitalized children and adolescents (ages 6–17)

assaulted the staff. 46% of these assaults resulted in physical injuries, and 3% of the

assaults needed medical assistance due to the severity of these injuries. The trigger for the

assaults was often limit setting or verbal exchange by the staff [5].

When a child is admitted to an inpatient setting for pathological aggression, it can be

difficult to select a specific treatment approach. Seclusion and restraint is one of the treatment

modalities used for controlling pediatric pathologic aggression in some inpatient settings.

However, in such settings the staff may experience several negative consequences in the

form of serious injuries and having a low morale [6]. In due course, in such facilities with

frequent seclusion and restraints, high staff turn-over may occur which can be costly [6].

A fairly new behavioral technique, the Collaborative Problem Solving (CPS) approach has

been implemented in some child psychiatry inpatient units for aggression, with some added

advantages like decreasing the oppositional behavior [7] and reducing frequency of use of

seclusion and restraint [8]. Our primary goal in this review is to develop a protocol that can be

implemented in the inpatient treatment of pathologic aggression in children and adolescents

including CPS, pharmacology, psychotherapeutic relaxation, and seclusion and restraint.

Treating Pathological Aggression on Child Psychiatric Units

When there is an aggressive child or adolescent patient on the psychiatric unit, a range of

interventions are available including the five options below. After discussing the five

options, a protocol will be presented that will take into account the severity of aggression

and the restrictiveness of each intervention. The risks and benefits of each intervention

should be taken into account including the treatment needs of the patient and safety.

Effect of Hospital/Inpatient Milieu on Aggression

dosReis et al. [9] has indicated that the use of medications and restrictive methods will

decrease when the staff is adequately trained in dealing with aggressive episodes with a

carefully planned approach for children on inpatient units. This reflects that aggression in

inpatient units may improve without initiating medications and thus further avoiding the

risk of side effects these medications. Another study [10] demonstrated the beneficial effect

of psychiatric hospitalization (without medication) on lowering aggression in children and

adolescents (ages 9–17) with conduct disorder. On the other hand, a child’s aggressive

behavior can easily be worsened if the child and adolescent inpatient setting is poorly

controlled, disorganized, and/or unstable [11].

Using Seclusion and Restraints

Seclusion and restraints on inpatient child psychiatry units should be used only when all

other less restrictive interventions has failed to work in promoting safety and controlling

the patient’s aggression [12]. Furthermore, seclusion and restraint may have a deleterious

effect on children rather than a therapeutic effect [13].

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Using Relaxation Technique

Psychotherapeutic relaxation was found to have a beneficial effect on aggressive children

and adolescents. This particular technique successfully implemented progressive muscle

relaxation in addition to creative arts therapy to lower aggression (on the Modified Overt

Aggression Scale) in child and adolescent patients ages 5–13 on an inpatient child psy-

chiatry unit. This study using psychotherapeutic relaxation (and medications) provided

evidence that this particular method may decrease aggression in children and adolescents

on child psychiatry units [14].

Collaborative Problem Solving (CPS)

Collaborative Problem Solving (CPS) is a modern approach developed by Greene [15].

CPS addresses a unique cognitive behavioral management approach for aggressive chil-

dren with an emphasis on addressing cognitive problems [15]. CPS focuses on developing

cognitive skills in parents and aggressive children and adolescents in settings like child and

adolescent inpatient psychiatric units as well as in outpatient mental health setting [7, 8, 15,

16]. A significant reduction in the use of seclusion and restraint for inpatient child psy-

chiatry aggression has occurred on a unit where CPS was implemented [8, 15].

Understanding CPS

Identifying the precipitant of the child’s violent and aggressive behavior is emphasized [6].

After identifying these triggers and defining the problem successfully, the next step is to

attempt to help the child by reaching a solution that is agreeable to both the parents and the

child. The solution is reached after considering the child’s perspective and the parents

concern. Thus, the chance of reaching a jointly acceptable solution may be optimized (see

Fig. 1) [6, 7, 15].

How Does CPS differ from Traditional Programs?

The following framework for approaching aggression and other problem behaviors among

children helps differentiate CPS from other traditional programs.

The greatest opportunity to prevent aggression/agitation is before or at the time when

the child is starting to get frustrated (Fig. 1). Therefore, focus should be on the preceding

events rather than the child’s frustrated reaction [15]. CPS teaches the parents/caregivers

and health care providers to prevent full escalation of aggressive behavior [15].

Children may need to be given directives to cope during the early phases of frustration

or stress. For children who have not fully developed the skill of problem solving, providing

possible solutions may be helpful in dealing with the anger and aggressive behavior [6].

This may help in decreasing the intensity of the aggressive events in the future.

Teaching Cognitive Skills

The possibility of CPS to be a realistic problem solving approach on inpatient units cannot

be underestimated [8]. After understanding the principles of CPS and how it differs from

other traditional behavioral methods, we simplified the model of approaching aggressive

children described by Greene et.al. The following simplified figure (based on CPS model

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[7, 15, 17]) explains the three different ways in which an adult can respond to oppositional

children and adolescents (Fig. 2).

Pharmacological Considerations for the Management of Aggression in Inpatient Child

Psychiatry Units

Studies exploring the use of medications for treating aggression in pediatric inpatients are

limited. As the main focus of this article is a review of the usefulness of CPS in managing

inpatient aggression in children and adolescents, it is beyond the scope of this review to

discuss pharmacological approaches in detail. However, we will briefly review the

important findings here.

Acute pathological aggression can be managed by various pharmacological agents on

child and adolescent inpatient units [9]. PRN (as needed) use of diphenhydramine

(benadryl) was studied by Vitiello et al. [18] for treating mild aggression in 5–13 year old

children. Both the intramuscular (IM) and oral (PO) route for the administration of

Opportunity toEvents/ Triggers prevent aggression

Child becoming frustrated Child has becomeaggressive/agitated

Traditional programs emphasize reactive approach after child becomes aggressive/ agitated

Fig. 1 Identifying and addressing triggers in children

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benadryl and placebo were used in the study. Surprisingly, the study concluded that

benadryl was equally effective as placebo in treating aggression in children [18]. However,

using ziprasidone (an atypical antipsychotic) intramuscularly has been found to be bene-

ficial for acute management of child and adolescent inpatient aggression [19–23]. IM

olanzapine has been found to be equally effective as IM ziprasidone [19]. PO risperidone

(risperdal) [24, 25], PO haloperidol (haldol) [26], PO lithium carbonate (eskalith) [26, 27]

and PO olanzapine [28] were found to be beneficial in reducing inpatient aggressive

episodes after treatment for more than 4 weeks and hence limits their usefulness on acute

inpatient treatment units. More specifically, PO lithium, PO haloperidol [26, 27] and PO

olanzapine [28] were found to be effective in patients with conduct disorder while PO

risperidone [25] was found to reduce inpatient aggressive episodes in adolescents with

disruptive behavior and sub-average intelligence. The following table explains the doses of

the medications and the ages of the patient population (see Table 1).

Side Effects

Treating with medications, even though helpful for reducing inpatient aggressive episodes,

is often associated with side-effects. The most common side-effect with ziprasidone is

feeling drowsy [21]. Other rare side-effects included seizure risk, muscle aches, and

bleeding from the nose [19, 21]. No changes in EKG or blood pressure with ziprasidone

were documented in this retrospective chart review [19]. Olanzapine was found to cause

weight gain [28]. Several side effects were reported with the use of lithium such as: nausea,

vomiting, hand tremors, and increased urinary frequency [26, 27]. Haloperidol was

Advantages of Response 3

Response type 1 Parent/caregiver demands a child to follow orders

Response type 3 Parent/caregiver involves the child in problem solving

Child not satisfied or happy about the situation, event or task at hand

Frustration start affecting child’s behavior

Response type 2 Parent/caregiver lower or remove the demand on the child

The dialogue stays steady without progressing to a loud argument

A mutually acceptable agreement is met for the parent and the child

Child acquires the skills of problem solving, frustration tolerance & impulse control

Fig. 2 Collaborative problem solving (CPS) [7, 15, 17] (Note: responses 1, 2 and 3 in the figure belowcorresponds to baskets A, C and B, respectively, in the CPS model)

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associated with acute dystonia and drooling [26] and risperidone was associated with

drowsiness, weight gain, and drooling [25].

Protocol

The heterogeneity of aggressive children and adolescents makes it difficult to design a

general approach for all patients.

Aggression secondary to a psychiatric diagnosis needs to be treated with proper diag-

nosis specific medication e.g.—in psychosis, medications such as antipsychotics can play a

vital role, while in ADHD, stimulant medications are important in reducing aggression

[30]. However, after the pharmacological management, the method and the approach of

introducing and implementing CPS essentially remains the same irrespective of the pri-

mary psychiatric diagnoses.

The protocol of implementing CPS does not differ for patients in an acute versus a

chronic setting. On child inpatient psychiatric units, the average length of stay for acute

management is brief. If the staff has received prior training, this brief time frame is

sufficient to start helping the caregivers/parents learn the technique of working collabo-

ratively with the children and adolescents. Further training sessions can be continued in an

outpatient setting.

It is important to carefully evaluate the severity when deciding on a specific intervention

for acute pathological aggression on the child psychiatry units [9]. We recommend the

following approach for aggressive child in inpatient psychiatric setting (see Fig. 3).

Conclusion

When dealing with aggression on child and adolescent psychiatry units, safety should be

the top priority. The least restrictive intervention should be considered first to address acute

pediatric pathologic aggression on the units. It is important to individualize the treatment

approach and to emphasize that if CPS is not effective in managing aggression, and the

aggression becomes too severe, then medication and/or seclusion and restraint may become

necessary to ensure safety. There is a substantial need for prospective controlled research

Table 1 Pharmacological agents for managing aggression

Medication Age groupof patient

Route and dose Frequencyand duration

Diphenhyramine (benadryl)[18]

5–13 years 25–50 mg PO/IM PRN

Olanzapine (zyprexa) [19] Less than18 years

5–10 mg IM PRN

Ziprasidone (geodon) [22] 12–13 years 10 mg IM PRN

Risperidone (risperdal) [25] Adolescents 1.5–4 mg PO Daily for 6 weeks

Haloperidol (haldol) [26] 5–13 years 1–6 mg PO Daily for 6 weeks

Lithium carbonate (eskalith)[26, 27]

5–17 years 500–2000 mg PO or more in orderto maintain blood lithium levelof 0.6–1 mmol/l

Daily for 6 weeks

Olanzapine (Zyprexa) [29] 6–11 years 0.22 mg/kg PO Daily for 4 weeks

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PresentYes No

No Yes

***

A primary psychiatric disorder has been identified as the underlying cause for

aggression

Treat the patient with appropriate medication for the primary psychiatric disorder. Eg. Aggression is caused by ADHD. Initiate stimulant medication for ADHD or optimize existing ADHD treatment. (Please refer Table # 1 for details)

Do not initiate medications immediately

Assess the severity of aggression

Potential or imminent danger to self or others

PRNmedication

and/or S & R

Initiate CPS (or other behavioral management) prior to full escalation: Talk and listen to patient to identify triggers/stressors

Start CPS training to parents/caregivers

(or behavioral management training)

Discuss with patient and generate possible solutions or give various options

Aggression gets controlled or improves

Aggression is worsening to the point of potential or imminent danger to self/others.

PRN medication and/or seclusion and restraintContinue working collaboratively with

the child or adolescent or use behavioral management.

Establish monitoringparameters

Teach parents/caregivers CPS

and staying calm in middle of disagreement

or teach behavioral management

Staff should remain calm and confident and should maintain control of the unit

Feedback from staff, patient and caregivers

Child presents with a past pattern of pathological aggression or had acute

aggression on the inpatient unit

Fig. 3 Protocol for pediatric pathological aggression on the unit

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examining the effectiveness of CPS, other behaviors techniques, and pharmacologic

modalities for inpatient treatment of aggressive children and adolescents.

Bottom Line The risk of excessively medicating children or using restrictive interven-

tions such as seclusion and restraints persists on inpatient child and adolescent psychiatry

units. Use of less invasive behavioral approaches such as CPS should be made more

universal in addressing this issue and proper training for parents and staff should be made

available.

Drug Brand Names Diphenhydramine—Benadryl, Ziprasidone—Geodon, Olanza-

pine—Zyprexa, Risperidone—Risperdal, Haloperidol—Haldol, Lithium carbonate—

Eskalith. Related Resources ‘‘The Explosive Child’’ Greene. RW. Center for Collaborative

Problem Solving (www.ccps.info).

Acknowledgement Core Library, Case Western Reserve University, Cleveland, Ohio Pratt Library,Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio. Cartoon source: Parenting press (1)Redirecting a Child Who Throws Things When Angry by Shari Steelsmith (2) Practice At Taking ‘‘No’’ foran Answer by Shari Steelsmith.

References

1. Children’s Safety Network Economics and Insurance Resource Center: State Costs of Violence Per-petrated by Youth. July, 2000. http://www.csneirc.org/pubs/tables/youth-viol.htm

2. Donohue JJ III, Siegelman P: Allocating resources among prisons and social programs in the battleagainst crime. Journal of Legal Studies 27:1–43, 1998

3. Foster EM, Jones DE; The Conduct Problems Prevention Research Group: The high costs of aggression:Public expenditures resulting from conduct disorder. American Journal of Public Health 95(10):1767–1772, October, 2005

4. Welsh BC et al.: Costs of Juvenile Crime in Urban Areas A Longitudinal Perspective Youth Violenceand Juvenile Justice, Vol. 6, No. 1, Lowell, University of Massachusetts Lowell, pp. 3–27, 2008

5. Ryan EP, Hart VS, Messick DL, et al.: A prospective study of assault against staff by youths in a statepsychiatric hospital. Psychiatric Services 55:665–670, 2004

6. American psychiatric Association: 2003 APA gold award: A more compassionate model for treatingchildren with severe mental disturbances. Psychiatric Services 54:1529–1531, November 2003

7. Greene RW, Ablon JS, Goring JC: A transactional model of oppositional behavior: Underpinnings ofthe collaborative problem solving approach. Journal of Psychosomatic Research 55(1):67–75, July,2003

8. Greene RW, Ablon JS, Hassuk B et al.: Innovations: Child & adolescent psychiatry: Use of collabo-rative problem solving to reduce seclusion and restraint in child and adolescent inpatient units. Psy-chiatric Services 57(5):610–612, May, 2006

9. dosReis S, Barnett S, Love RC et al.: A guide for managing acute aggressive behavior of youths inresidential and inpatient treatment facilities. Psychiatric Services 54(10):1357–1363, October, 2003

10. Malone RP, Luebbert JF, Delaney MA: Nonpharmacological response in hospitalized children withconduct disorder. Journal of the American Academy of Child and Adolescent Psychiatry 36(2):242–247, February, 1997

11. Delaney KR: Calming an escalated psychiatric milieu. Journal of Child and Adolescent PsychiatricNursing 7(3):5–13, July–September, 1994

12. Masters KJ, Bellonci C, Bernet W, et al.: Practice parameter for the prevention and management ofaggressive behavior in child and adolescent psychiatric institutions, with special reference to seclusionand restraint. Journal of the American Academy of Child and Adolescent Psychiatry 41(2 suppl):4S–25S, 2002

13. Finke LM: The use of seclusion is not evidence-based practice. Journal of Child and AdolescentPsychiatric Nursing 14(4):186–190, October–December, 2001

14. Bornman BA, Mitelman SA, Beer DA: Psychotherapeutic relaxation: How it relates to levels ofaggression in a school within inpatient child psychiatry: A pilot study. The Arts in Psychotherapy34(3):216–222, 2007

15. Greene RW, Ablon JS: Treating Explosive Kids: The Collaborative Problem Solving approach. NewYork, Guilford, 2005

174 Psychiatr Q (2010) 81:167–175

123

16. Greene RW, Ablon JS, Goring JC, et al.: Effectiveness of collaborative problem solving in affectivelydysregulated children with oppositional-defiant disorder: Initial findings. Journal of Consulting andClinical Psychology 72:1157–1164, 2004.

17. Greene RW, Ablon SA, Goring JC etal.: Treatment of oppositional defiant disorder in children andadolescents. In: Barrett P, Ollendick TH (Eds) Handbook of Interventions that Work with Children andAdolescents: Prevention and Treatment. West Sussex, England, Wiley, pp. 369–393, 2003

18. Vitiello B, Hill JL, Elia J et al.: P.r.n. medications in child psychiatric patients: A pilot placebo-controlled study. Journal of Clinical Psychiatry 52(12):499–501, December, 1991

19. Khan SS, Mican LM: A naturalistic evaluation of intramuscular ziprasidone versus intramuscularolanzapine for the management of acute agitation and aggression in children and adolescents. Journal ofChild and Adolescent Psychopharmacology 16(6):671–677, December, 2006

20. Staller JA: Intramuscular ziprasidone in youth: A retrospective chart review. Journal of Child andAdolescent Psychopharmacology 14(4):590–592, Winter, 2004

21. Barzman DH et al.: A retrospective chart review of intramuscular ziprasidone for agitation in childrenand adolescents on psychiatric units: Prospective studies are needed. Journal of Child and AdolescentPsychopharmacology 17(4):503–509, August, 2007

22. Hazaray E, Ehret J, Posey DJ et al.: Intramuscular ziprasidone for acute agitation in adolescents. Journalof Child and Adolescent Psychopharmacology 14(3):464–470, Fall, 2004

23. Jangro WC, Preval H, Southard R et al.: Conventional intramuscular sedatives versus ziprasidone forsevere agitation in adolescents: Case-control study. Child and Adolescent Psychiatry and Mental Health3:9, 2009.

24. Barzman DH, Findling RL: Pharmacological treatment of pathologic aggression in children. Interna-tional Review of Psychiatry 20(2):151–157, April, 2008

25. Buitelaar JK, van der Gaag RJ, Cohen-Kettenis P, Melman CT: A randomized controlled trial ofrisperidone in the treatment of aggression in hospitalized adolescents with subaverage cognitive abil-ities. Journal of Clinical Psychiatry. 62(4):239–248, April, 2001

26. Campbell M, Small AM, Green WH et al.: Behavioral efficacy of haloperidol and lithium carbonate: Acomparison in hospitalized aggressive children with conduct disorder. Archives of General Psychiatry41:650–656, 1984

27. Malone RP, Delaney MA, Luebbert JF et al.: A double-blind placebo-controlled study of lithium inhospitalized aggressive children and adolescents with conduct disorder. Archives of General Psychiatry57(7):649–654, July, 2000

28. Masi G, Milone A, Canepa G et al.: Olanzapine treatment in adolescents with severe conduct disorder.European Psychiatry 21(1):51–57, January, 2006

29. Krishnamoorthy J, King BH: Open-label olanzapine treatment in five preadolescent children. Journal ofChild and Adolescent Psychopharmacology 8(2):107–113, 1998

30. Connor DF, Glatt SJ, Lopez ID et al.: Psychopharmacology and aggression. I: A meta-analysis ofstimulant effects on overt/covert aggression-related behaviors in ADHD. Journal of the AmericanAcademy of Child and Adolescent Psychiatry 41(3):253–261, 2002

Author Biographies

Gaurav Kulkarni, MD completed his medical education in India and postdoctoral research fellowship atJohns Hopkins Hospital, Baltimore, MD, USA. Currently he is a research assistant at Cincinnati Children’sHospital Medical Center, Cincinnati, Ohio in the Child and Adolescent Forensic Psychiatry Service.

Parikshit Deshmukh, MD completed his medical education and Masters of Science in Psychotherapy andCounseling in India before entering his residency in psychiatry in University Hospital Case Medical Center,Cleveland, OH. His areas of academic interests include psychiatric disorders in patients with inflammatorybowel disease and management of pediatric aggression.

Drew Barzman, MD is an assistant professor of pediatrics and psychiatry at Cincinnati Children’s HospitalMedical Center. Dr. Barzman is the Director of the Child and Adolescent Forensic Psychiatry Service. Hisprimary research interest includes the prevention and treatment of pediatric aggression and violence.

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