A clinical approach to the pharmacotherapy of aggression in children and adolescents

Abstract

Overt aggression in its various forms is the most prevalent symptom presenting to pediatric mental health providers, regardless of setting. It is a behavior with a heterogeneous etiology and requires a comprehensive approach to evaluation and treatment. Evaluation of the aggressive child must assess medical, neurologic, psychiatric, psychosocial, familial, and/or educational contributions to behavioral dyscontrol. Multimodal treatment is generally required. At present, there is no single medication to recommend for the treatment of aggressive behavior. Multiple medications have clinically been used in a nonspecific fashion to target excessive childhood aggression. Although successful for some, this approach increases risk for ineffective interventions accompanied by side effects. Until a scientific understanding of the developmental neurobiology of aggression leads to more specific treatment, this review suggests the use of a diagnostic-based approach to the pharmacology of aggression (FIG. 1). Descriptive diagnostic techniques should be used to define the presence of any primary or comorbid psychiatric disorder that presents with aggression as an associated symptom. Treating aggression in the context of these psychiatric syndromes appears to be the most direct approach. Aggression occurring in the context of a medication-responsive psychiatric diagnosis appears most sensitive to pharmacologic intervention. Presently, evidence for efficacy is strongest for aggression in the context of ADHD, psychotic disorder, adolescent-onset bipolar disorder, and ictal aggression It remains less clear that medication can help aggression when it occurs independently of a pharmacologically treatable comorbid psychiatric disorder. Aggression may respond to a target symptom approach where discrete behavioral symptoms that contribute to aggression, such as irritability, explosiveness, fear, or impulsivity, may be modified by medication intervention (FIG. 1). When treatment is approached in this fashion, it is standard practice to use the least toxic and safest intervention first. Behavioral treatment based on contingency management principles could be initially recommended. Medication trials should first use medications that have demonstrated empiric efficacy in reducing aggression (TABLE 1) and that have a favorable safety profile. Neuroleptics to treat aggression in nonpsychotic psychiatrically referred youth should be kept to a minimum, secondary to their significant adverse risk profile. Alternative medications, such as selective serotonin reuptake-inhibiting antidepressants, buspirone, lithium, anticonvulsants, opiate blocking agents, propranolol, nadolol, and clonidine, deserve more clinical research in pediatric aggression. These medications may offer effective and less toxic alternatives in the pharmacologic treatment of inappropriate excessive childhood aggression.