A Narrative Review on Aggression in Children and Adolescents: Anthropology, Developmental Phenomenology, Transdiagnostic Trajectories, Contextual Nosology, and Strategic Pathways for Interventions

An evidence-based practice project was completed to develop best practice recommendations for the treatment of aggression in children and adolescents with attention deficit hyperactivity disorder (ADHD). Ovid Medline, PsychInfo, the National Guidelines Clearinghouse, and the Cochrane Database of Systematic Reviews were searched with limits set for English language, years 1996 to January 2010. A search of the pediatric literature was conducted for synthesized evidence in the form of meta-analyses, systematic reviews, or practice guidelines related to the treatment of aggression in children and adolescents with attention deficit hyperactivity disorder. Data were extracted using the LEGEND system. Three evidence-based care recommendations for the management of aggression in children and adolescents with ADHD were developed with an associated grade for the body of evidence. First-line pharmacotherapy for aggressive behavior in children and adolescents with ADHD should be ADHD medications. Additional research is needed to evaluate the efficacy of psychiatric medications on signs of aggression within the context of ADHD.

The pharmacological treatment of aggression in children and adolescents with conduct disorder. Do callous—unemotional traits modulate the efficacy of medication?

Being overweight or obese (overweight/obesity) or physically aggressive in childhood and adolescence can have lifelong consequences, hence are important public health problems. Identifying a relationship between these problems would assist in understanding their developmental origins. The present paper sought to review previous studies and use meta-analysis to evaluate whether there is evidence of a relationship between overweight/obesity and physical aggression in children and adolescents. A systematic search of studies that reported the effect of overweight/obesity (in the form of body mass index) on physical aggression was conducted. A total of 23 studies were identified, representing data from 255,377 participants. The results indicate that children and adolescents who are overweight or obese are more physically aggressive than their normal-weight or underweight peers. The average weighted standardized mean difference (the effect size) for aggression in overweight and obese children and adolescents compared to others was found to be 0.27 (95% confidence interval [CI95]: .17–.37), and was significant (p<.001). Gender sub-analysis indicated that higher physical aggression amongst overweight or obese compared to normal-weight or underweight peers is a slightly larger effect for boys (standardized mean difference of .35, CI95: .18–.52, p<.001) than girls (standardized mean difference of .24, CI95: .07–.42, p<.01). High levels of heterogeneity (94.41%) were found between study-level effect sizes. The developmental processes that may explain the association between overweight/obesity and physical aggression in children and adolescents are discussed.

Dysfunctional emotional processing has a negative impact on human behavior. In children and adolescents, deviant perception and understanding of emotional stimulation and reduced empathic functioning impair the development of important social skills. The present thesis aimed to better understand dysfunctional emotional processing in subgroups of children and adolescents with aggressive and antisocial behavior. We investigated dysfunctions in specific neurocognitive components and their influence on reactive and proactive forms of aggression. Further, characteristics defining subgroups of aggressive and antisocial children and adolescents with distinct dysfunctions in emotional processing were examined. Article 1 addresses the question if cognitive control is more susceptible to the deleterious influence of distressing emotional stimulation in patients with conduct disorder than in healthy controls. In an experimental paradigm we measured performance on a color-word Stroop test under the influence of distressing emotional stimulation. Results indicated that unlike in healthy controls, cognitive control is impaired in reactive aggressive adolescents when subjected to distressing emotional stimulation. In Article 2 we investigated the interrelation of empathy and behavior. In a sample of high-risk adolescent girls and boys we addressed the question whether cognitive and affective facets of empathy are involved in the inhibition of reactive and proactive forms of aggression and the motivation of prosocial behavior. Our data indicated that empathy is only involved in the inhibition of proactive aggression, but not in the inhibition of reactive aggression. Further, results showed that both facets of empathy contribute positively to motivate prosocial behavior. With Article 3, we aimed to identify characteristics which define subgroups of aggressive children and adolescents with specific patterns of dysfunctional emotional processing. Using model-based cluster analysis, we disaggregated variants of adolescents with conduct disorder based on anxiety symptoms and callous-unemotional traits. Variants differed in comorbid psychopathologies and personality development. We also found a gender-specific affiliation to identified variants that supports the assumption of the gender paradox in children and adolescents with conduct disorder. In conclusion, the research presented in this dissertation indicates that reactive and proactive forms of aggression are associated with distinct dysfunctions in emotional processing and supports a better understanding of factors involved in specific phenotypes of aggressive behavior. Based on the results it can be assumed that (1) impaired cognitive control in situations of emotional distress provokes reactive aggression and (2) insufficient understanding of others’ emotions enhances the risk for proactive aggression. Variants of aggressive and antisocial adolescents may by identified based on characteristics associated with these neurocognitive deficits. Findings emphasize the importance of specific treatment approaches tailored to subgroups of aggressive and antisocial children and adolescents with unique characteristics.

Do callous–unemotional traits modulate pharmacological treatment of aggression in children and adolescents with conduct disorder?

Free AccessPharmacotherapy in AutismLukas Propper and Herbert OrlikLukas Propper1. Assistant Professor of Psychiatry, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, CanadaSearch for more papers by this author and Herbert Orlik2. Associate Professor of Psychiatry, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, CanadaSearch for more papers by this authorPublished Online:October 2005https://doi.org/10.1521/capn.2005.10.3.1PDFPDF PLUS ShareShare onFacebookTwitterLinkedInRedditEmail ToolsAdd to favoritesDownload CitationsTrack Citations AboutSuggested ReadingsHollander , E., Phillips, A.T., Yeh, C.C. (2003). Targeted treatments for symptom domains in child and adolescent autism. Lancet, 362, 732–734. Crossref, Google ScholarLam , R.W. et al. (2005). Prescribing antidepressants for depression in 2005: Recent concerns and recommendations. Canadian Journal of Psychiatry, 49(12), 1–6. Google ScholarMcDougle , C.J. et al. (2005). Risperidone for the core symptom domains of autism: Results from the study by the autism network of the research units on pediatric psychopharmacology. American Journal of Psychiatry, 162(6), 1142–1148. Crossref, Google ScholarMcDougle , C.J., Stigler, K.A., Posey, D.J. (2003). Treatment of aggression in children and adolescents with autism and conduct disorder. Journal of Clinical Psychiatry, 64(Suppl 4), 16–25. Google ScholarMcDougle , C.J., Kresch, L.E., Posey, D.J. (2000). Repetitive thoughts and behavior in pervasive developmental disorders: Treatment with serotonin reuptake inhibitors. Journal of Autism and Developmental Disorders, 30(5), 427–435. Crossref, Google ScholarPosey , D.J. & McDougle, C.J. (2000). The pharmacotherapy of target symptoms associated with autistic disorder and other pervasive developmental disorders. Harvard Review of Psychiatry, 8, 45–63. Crossref, Google ScholarShea , S., Turgay, A., Carroll, A., Schulz, M., Orlik, H., Dunbar, F. (2004). Risperidone in the treatment of disruptive behavioral symptoms in children with autistic and other pervasive developmental disorders. Pediatrics, 114(5), 1329 Google Scholar Next article FiguresReferencesRelatedDetails Volume 10Issue 3Mar 2005 Information© Guilford Publications Inc.PDF download

ObjectiveThis study was conducted to compare the efficacy of clozapine vs. risperidone in the treatment of aggression in conduct disorder in children and adolescents.MethodsTwenty-four children with conduct disorder aged 6 to 16 years were randomized in a prospective, double-blind trial into two groups to receive clozapine or risperidone for 16 weeks. The Modified Overt Aggression Scale score was used as the primary outcome of the study. Secondary outcomes were Child Behavior Checklist (CBCL) externalization (CBCL-E) and internalization factors; Aggression, Hyperactivity and Delinquency subscales of CBCL-E, Child Global Assessment Scale (CGAS), Barnes Akathisia Rating Scale, and Simpson-Angus Scale.ResultsBoth antipsychotics were similarly effective in the primary outcome and in most of the secondary ones. Clozapine was more effective in CBCL-E, the delinquency subscale and the CGAS scores than risperidone (p=0.039, 0.010, and 0.021). Two subjects from the clozapine group were excluded due to a low neutrophil count at week four.ConclusionClozapine and risperidone are effective for short-term treatment of aggression in children and adolescents with conduct disorder. Clozapine was more effective than risperidone in conduct externalization factors, delinquency trait and global functioning in children and adolescents. Stronger efficacy of clozapine should be investigated in larger sample sizes using pharmacogenomic studies. White blood cell counts need to be monitored when prescribing clozapine.

A subgroup of children and adolescents with conduct disorder are characterized by severe and persistent aggression. Although there is no agreed on treatment for such aggression, lithium carbonate has shown promise in some studies involving children. Our study was designed to critically assess the efficacy of lithium in the treatment of aggression in children and adolescents using a measure specific for aggression. Subjects were inpatients with conduct disorder hospitalized because of severe and chronic aggression. A parallel-groups design was used in this double-blind, placebo-controlled trial with randomization to lithium or placebo. Only those who met the aggression criterion during the 2-week placebo-baseline period were randomized to 4 weeks of treatment. Outcome measures included Clinical Global Impressions, the Global Clinical Judgements (Consensus) Scale, and the Overt Aggression Scale. Eighty-six inpatients enrolled in the study; 40 (33 male and 7 female; median age, 12.5 years) entered and completed the treatment phase. Lithium was statistically and clinically superior to placebo. Sixteen of 20 subjects in the lithium group were responders on the Consensus ratings vs 6 of 20 in the placebo group (P=.004). Ratings on the Overt Aggression Scale decreased significantly for the lithium group vs the placebo group (P=.04). More than half of the subjects in the lithium group experienced nausea, vomiting, and urinary frequency. Lithium is a safe and effective short-term treatment for aggression in inpatients with conduct disorder, although its use is associated with adverse effects.

P.7.d.005 - Do callous–unemotional traits modulate pharmacological treatment of aggression in children and adolescents with conduct disorder?

Knowledge regarding psychopharmacology is increasingly based on clinical trials and rational algorithms. Medications are increasingly regarded as useful adjuncts in the treatment of maladaptive aggression, whether it appears as a target symptom or as a complication of a whole range of psychopathology. Properly integrated into a treatment package that uses psychotherapies and environmental manipulation, medications can provide relief from one of the most destructive forms of psychopathology. Still, more controlled clinical trials are needed, especially those comparing active interventions and those testing the synergistic and antagonistic effects of different treatment modalities.

take and those who prescribe their products. The media has a responsibility to get the story right. And the regulatory bodies have the responsibility to properly regulate. In the final analysis, the SSRI in depressed young people story may turn out to be yet another step in the process of regulating pharmacological treatments. In the USA the Pare Food and Drug Act (1906) dealt with purity of compounds. The Massengill Massacre (the manufacturing of sulphanilamide with a toxic solvent) led to toxicity safety being addressed. The thalidomide tragedy and the resulting Kefauver legislation addressed drug safety. In historical hindsight perhaps, the SSRI story will be seen as a step in the regulatory address of corporate transparency and post marketing surveillance. Matthew Kutcher is a postgraduate neuroscience student at Dalhousie University. Stan Kutcher is editor of CAPN.

ABSTRACTExecutive Functions (EFs) have been associated with aggression in children and adolescents. EFs as higher-order cognitive abilities are assumed to affect cognitive functions such as Social Information Processing (SIP). We explored SIP skills as a mediating mechanism linking EFs to aggression in adolescents with mild to borderline intellectual disability (MBID with IQ from 50–84), a high risk group for aggressive behaviors and EF impairments. A total of 153 adolescents (Mage = 15.24, SD = 1.35; 54% male) with MBID participated. Focused attention, behavioral inhibition, and working memory were tested with multiple neurocognitive tasks to define latent EF constructs. Participants responded to a video-based SIP task. A latent construct for aggression was defined by caretaker, teacher, and adolescent self-reports of aggression (Child Behavior Check List, Teacher Report Form, and Youth Self Report). Structural equation modeling was performed to test mediation. Results were consistent with mediation of the relation between focused attention and aggression by SIP, namely via hostile interpretations and self-efficacy for aggression. Behavioral inhibition was linked to aggression, but this relation was not mediated by SIP. The relation between working memory and aggression was mediated by SIP, namely via hostile interpretations, aggressive response generation and via self-efficacy for aggressive responses. Bearing the cross-sectional design in mind, support was found for SIP skills as a mechanism linking EFs, in particular focused attention and working memory, to aggression, providing a viable explanation for the high vulnerability of adolescents with MBID for aggression.

Neuroleptic drug molindone hydrochloride is a dopamine D2/D5 receptor antagonist and it is in late stage development for the treatment of impulsive aggression in children and adolescents who have attention deficient/hyperactivity disorder (ADHD). This new indication for this drug would expand the target population to include younger patients, and therefore, toxicity assessments in juvenile animals were undertaken in order to determine susceptibility differences, if any, between this age group and the adult rats. Adult rats were administered molindone by oral gavage for 13 weeks at dose levels of 0, 5, 20, or 60 mg/kg-bw/day. Juvenile rats were dosed for 8 weeks by oral gavage at dose levels of 0, 5, 25, 50, or 75 mg/kg-bw/day. Standard toxicological assessments were made using relevant study designs in consultation with FDA. Treatment-related elevation in serum cholesterol and triglycerides and decreases in glucose levels were observed in both the age groups. Organ weight changes included increases in liver, adrenal gland and seminal vesicles/prostate weights. Decreases in uterine weights were also observed in adult females exposed to the top two doses with sufficient exposure. In juveniles, sexual maturity parameters secondary to decreased body weights were observed, but, were reversed. In conclusion, the adverse effects noted in reproductive tissues of adults were attributed to hyperprolactinemia and these changes were not considered to be relevant to humans due to species differences in hormonal regulation of reproduction. On the whole, there were no remarkable differences in the toxicity profile of the drug between the two age groups.

Aggression, ADHD symptoms, and dysphoria in children and adolescents diagnosed with bipolar disorder and ADHD

Psychopharmacologic Control of Aggression and Violence in Children and Adolescents