Abstract
Objective: Aggressive behavior is among the most common reasons for referral to psychiatric clinics and confers significant burden on individuals. Aggression remains poorly defined; there is currently no consensus on the best ways to recognize, diagnose, and treat aggression in clinical settings. In this review, we synthesize the available literature on aggression in children and adolescents and propose the concept of impulsive aggression (IA) as an important construct associated with diverse and enduring psychopathology.Methods: Articles were identified and screened from online repositories, including PubMed, PsychInfo, the Cochrane Database, EMBase, and relevant book chapters, using combinations of search terms such as “aggression,” “aggressive behavio(u)r,” “maladaptive aggression,” “juvenile,” and “developmental trajectory.” These were evaluated for quality of research before being incorporated into the article. The final report references 142 sources, published from 1987 to 2019.Results: Aggression can be either adaptive or maladaptive in nature, and the latter may require psychosocial and biomedical interventions when it occurs in the context of central nervous system psychopathology. Aggression can be categorized into various subtypes, including reactive/proactive, overt/covert, relational, and IA. IA in psychiatric or neurological disorders is reviewed along with current treatments, and an algorithm for systematic evaluation of aggression in the clinical setting is proposed.Conclusions: IA is a treatable form of maladaptive aggression that is distinct from other aggression subtypes. It occurs across diverse psychiatric and neurological diagnoses and affects a substantial subpopulation. IA can serve as an important construct in clinical practice and has considerable potential to advance research.
Highlights
Aggressive behavior is one of the most common reasons children and adolescents are referred to psychiatric clinics, and it co-occurs with several psychiatric and neurological disorders (Connor 2002; Bambauer and Connor 2005; Jensen et al 2007)
Guidelines for the clinical management of early-onset maladaptive aggression and impulsive aggression (IA) highlight the need for thorough, systematic characterization and diagnostic evaluation of the aggressive behavior before initiating treatment (Fig. 2) (Knapp et al 2012; Felthous and Stanford 2015)
We propose that IA is an important clinical concept because it (1) is an identifiable construct (Bambauer and Connor 2005; Raine et al 2006); (2) appears as a similar construct across multiple common child and adolescent psychiatric diagnoses ( Jensen et al 2007); (3) appears to be measurable in the clinical setting ( Jensen et al 2007); (4) is highly correlated with symptom severity across multiple psychiatric diagnoses (Connor and McLaughlin 2006); (5) has an identifiable neurobiology that appears distinct from other forms of serious aggression such as proactive and instrumental forms of aggression, and the CU personality traits linked to psychopathy and severe CD (Blair 2016); and (6) appears more medication responsive than predatory, instrumental forms of aggression (Blader et al 2013; Gurnani et al 2016)
Summary
Aggressive behavior is one of the most common reasons children and adolescents are referred to psychiatric clinics, and it co-occurs with several psychiatric and neurological disorders (Connor 2002; Bambauer and Connor 2005; Jensen et al 2007). A number of constructs are used to describe aggressive behavior, including symptoms (e.g., irritability or hostility) (Ramirez and Andreu 2006); diagnoses (e.g., intermittent explosive disorder [IED], disruptive mood dysregulation disorder [DMDD], oppositional defiant disorder [ODD], or conduct disorder [CD]) (American Psychiatric Association 2013); and behaviors (e.g., impulsivity) (Ramirez and Andreu 2006). This lack of well-defined nosology creates diagnostic discrepancies, which, in turn, influence the clinician’s ability to devise and tailor optimal treatment strategies for the individual patient. We focus on the concept of impulsive aggression (IA) in children and adolescents and present other characterizations and frameworks of aggression for context
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