Families and schools often pressure clinicians to “do something” when children or adolescents persistently bully, threaten, or injure others. This demand poses a treatment dilemma when psychosocial and educational interventions have failed to manage pediatric aggression.
Aggression is the main reason for drug therapy in youths with conduct disorder, but very little safety and efficacy data exist to help us choose medications. This places young patients at risk for polypharmacy, unmanaged symptoms, short-term side effects, and unknown long-term consequences of exposure to psychotropics.
Table 1
4 precautions when prescribing for pediatric aggression
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| Source: American Academy of Child and Adolescent Psychiatry1 |
This article reviews the limited data on using medications to reduce aggression in children and adolescents, focusing on double-blind, placebo-controlled trials in conduct disorder. Based on this evidence and our clinical experience, we offer a sample case and treatment recommendations.
Prescribing principles
Precautions. When prescribing drugs to treat aggressive youth, remember the American Academy of Child and Adolescent Psychiatry’s precautions (Table 1)1 Recently published recommendations prepared by expert consensus are also valuable treatment guides.2
Linking treatment to diagnosis. Should we attempt to manage aggression as a manifestation of an underlying psychiatric disorder? Or should we treat it the same across all disorders? The latter approach is akin to the “fever model.”
Fever—regardless of cause—may be treated with a nonsteroidal anti-inflammatory drug. However, evidence from drug studies suggests that underlying psychiatric disorders should help determine the choice of aggression treatment. For example, a recent study in adults found that divalproex was effective for aggressive patients only within a specific diagnostic subgroup (in this case, cluster B personality disorders).3
Clinical experience also links aggression treatment with underlying diagnoses. For example, aggression secondary to agitated depression is treated with an antidepressant, whereas aggression secondary to command hallucinations in schizophrenia is treated with antipsychotics.
In treating aggression in conduct disorder (Table 2), first treat comorbid disorders—such as attention deficit/hyperactivity disorder (ADHD) or bipolar disorder—and address the child’s psychosocial and educational needs. Then if medication is appropriate, consider drugs with evidence of safety and efficacy, such as antipsychotics, lithium, and stimulants.
Antipsychotics
Three conventional antipsychotics—chlorpromazine, haloperidol, and thioridazine—are FDA-approved for controlling disruptive behaviors in children.4 No atypical antipsychotics are so indicated, but atypicals are preferred in children and adolescents because of lower risks for tardive dyskinesia, neuroleptic malignant syndrome, and extrapyramidal symptoms.2
Risperidone is the most-studied atypical antipsychotic for treating pediatric aggression, particularly in patients with low intellectual functioning or mental retardation. In a 6-week, double-blind, placebo-controlled trial, 118 children ages 5 to 12 with severely disruptive behavior and IQs of 36 to 84 were given low-dose risperidone (mean 1.16 mg/d). Risperidone reduced conduct problems significantly more than placebo, although aggression was not measured directly.5 Adverse events included somnolence, headache, vomiting, weight gain, and elevated serum prolactin. Similar results have been reported in other studies.6
Table 2
Diagnostic criteria for conduct disorder
| A. A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the persistence of three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past 6 months: | |
| Aggression to people and animals | |
| 1. often bullies, threatens, or intimidates others | 5. has been physically cruel to animals |
| 2. often initiates physical fights | 6. has stolen while confronting a victim (such as mugging, purse snatching, extortion, armed robbery) |
| 3. has used a weapon that can cause serious physical harm to others (such as a bat, brick, broken bottle, knife, gun) | 7. has forced someone into sexual activity |
| 4. has been physically cruel to people | |
| Destruction of property | |
| 8. has deliberately engaged in fire setting with the intention of causing serious damage | 9. has deliberately destroyed others’ property (other than by fire setting) |
| Deceitfulness or theft | |
| 10. has broken into someone else’s house, building, or car | 12. has stolen items of nontrivial value without confronting a victim (such as shoplifting without breaking and entering, or forgery) |
| 11. often lies to obtain goods or favors or to avoid obligations(ie, “cons” others) | |
| Serious violation of rules | |
| 13. often stays out at night despite parental prohibitions, beginning before age 13 | 15. has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period) |
| 14. is often truant from school, beginning before age 13 | |
| B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning | |
| C. If the individual is age 18 or older, criteria are not met for antisocial personality disorder. | |
| Specify severity: | |
| Mild: few if any conduct problems in excess of those required to make the diagnosis and conduct problems cause only minor harm to others (such as lying, truancy, staying out after dark without permission) | |
| Moderate: number of conduct problems and effect on others intermediate between “mild” and severe” (such as stealing without confronting a victim, vandalism) | |
| Severe: many conduct problems in excess of those required to make the diagnosis or conduct problems cause considerable harm to others (such as forced sex, physical cruelty, use of a weapon, stealing while confronting a victim, breaking and entering) | |
| Source: Reprinted with permission from the Diagnostic and statistical manual of mental disorders, 4th ed., text revision. Copyright 2000. American Psychiatric Association. | |