ویژگی های بالینی خشونت در کودکان و نوجوانان مراجعه کننده به یک مرکز مراقبت درجه سوم

Background and need for the study Identification and management of aggression is a major mental health priority in hospitalised patients. However, no such studies have been done in child and adolescent in-patients in India. Objectives To study the clinical and demographic features; characteristics of the aggression and methods employed to manage aggression in child and adolescent in-patients. Materials and methods Child and adolescent in-patients between the ages of 4 and 16 years who were aggressive were included. The tools used were the MINI-International Neuropsychiatric Interview (M.I.N.I) KID, Overt Aggression Scale (OAS), Children's Global Assessment Scale (CGAS), and a Semi-structured interview regarding each aggressive episode. Results 31 patients displayed aggressive behaviour out of the 131 patients who were admitted during the study period. Aggressive acts were more common in males, those with academic difficulties, who had a past history of aggression, with suicidal ideation or suicidal attempts. Aggression occurred across diagnostic categories but a significant proportion was diagnosed to have Disruptive Behaviour Disorders either as a primary diagnosis or as comorbidity. 90.6% were on psychotropic medication prior to admission. Around 2/3rd of aggressive episodes occurred in the evening and family members (85.7%) were the most common targets of aggression. Conclusion There are a few factors that can possibly help identify and predict aggression in children and adolescents in a hospital setting. More research is required to understand aggression in clinical settings.

Aggression is one of the most common reasons for referral to child and adolescent psychiatry services. Aggressive behaviour occurs frequently in child and adolescent in-patient units. Aggression in clinical settings is usually directed towards parents/caregivers, patient-peers, staff members and residents (Connor et al., 1998). In-patient aggression is associated with negative admission outcomes, longer duration of admission and use of more coercive measures such as seclusion and restraint which might be counter-therapeutic (Barton et al., 2001, Ryan et al., 2004 and Garrison et al., 1990). Identification and management of in-patient aggression is a serious clinical challenge (Garrison et al., 1990). Successful identification of high risk patients, i.e. those who are likely to display aggressive behaviour enables clinical teams to optimise the therapeutic environment and plan targeted interventions (Vivona et al., 1995). Acute and short term in-patient services are available in select psychiatric and medical institutions in India. The National Institute of Mental Health and Neurosciences (NIMHANS) Bangalore has a one of its kind psychiatric in-patient facility which was established in 1966 and caters to children and adolescents up to 16 years of age. The treating team is multi-disciplinary and employ a biopsychosocial approach in their clinical conceptualisation and management. The in-patient facility provides a structured milieu and expects a parent or caregiver to stay with the child/adolescent in the ward as part of its admission policy. This helps the treating team to observe and improve parent–child interactions. It also helps the family to be involved in the treatment process (Bharath et al., 1997). Data from the year 2002 showed that 30.4% (94) were diagnosed to have Autism Spectrum Disorders, 30.7% (95) with Disruptive Behaviour Disorders (ADHD, ODD, CD) and 34.6% (107) with Psychotic Affective Disorders (BPAD, Schizophrenia, Psychosis NOS) (Prabhuswamy et al., 2008). The above diagnostic profile illustrates the heterogeneity of the patients admitted to the in-patient facility; hence, we wanted to study aggression as a symptom, examine its frequency and characteristics in order to help plan effective management and maintain the therapeutic milieu.

Safety of patients, staff and caregivers is a major priority in mental health in-patient settings. From this study certain preadmission and clinical characteristics of the patients emerge and may be helpful in identifying those who might potentially aggress in the ward. These factors were male subjects, past history of aggression, academic difficulties, suicidal ideation and attempts. Aggression occurred across diagnostic categories but a significant number were diagnosed with disruptive behaviour disorders. More number of aggressive episodes occurred in the evening and family members were the most common targets of aggression. Risk assessment protocols and a combination of individual and milieu based interventions are required to target aggression in the in-patient setting. Larger samples with a comparison group are required to further substantiate these findings.