In this presentation, participants will… 1. Examine the two primary subtypes of aggressive behavior seen in child and adolescent outpatients 2. Review common characteristics of youth most likely to present for treatment of maladaptive aggression 3. Discuss key questions to ask during evaluation of the child who lashes out aggressively 4. Explore the research on the use of common classes of psychotropics for children and teens whose primary presenting problem is aggressive behavior Link to video: https://vimeo.com/332228331

1. Evaluation and Treatment
of Youth Presenting With
Aggressive Behavior
Stephen Grcevich, MD
President, Family Center by the Falls, Chagrin Falls OH
Clinical Associate Professor of Psychiatry, NEOMED
Transitional Medical Director
Child and Adolescent Behavioral Health
April 24, 2019

2. Learning objectives
Participants will…
• Examine the two primary subtypes of aggressive
behavior seen in child and adolescent outpatients
• Review common characteristics of youth most
likely to present for treatment of maladaptive
aggression
• Discuss key questions to ask during evaluation of
the child who lashes out aggressively
• Explore the research on the use of common
classes of psychotropics for children and teens
whose primary presenting problem is aggressive
behavior

3. Potential Conflicts of
Interest (last five years)
Source of Conflict: Company:
Consultant Ironshore, Shire
Grants/research support CAPTN/Duke Clinical Research
Institute
Speakers’ Bureaus N/A
Other financial support N/A
Publishers Harper Collins/Zondervan

4. Subtypes of aggressive
behavior:
Impulsive aggression:
• Affect: fear, anger
• Arousal level: high
• Outcome: negative
• Impulsive
• Reactive
• Defensive
• Overt
• Hostile
Predatory aggression
• Affect: self-confidence
• Arousal level: low
• Outcome: positive for self
• Controlled
• Predatory
• Offensive
• Covert
• Instrumental
Vitiello B, Stott DM. J Am Acad Child Adolesc Psychiatry 1997; 36(3) 307-315

5. Definition of maladaptive
aggression:
Aggressive behavior
occurring outside an
acceptable social context
Characterized by:
• Intensity, frequency, duration
and severity are
disproportionate to its causes
• May occur in absence of
antecedent social cues
• Behavior not terminated in
expected time frame, or in
response to feedback
Jensen P et al. J Am Acad Child Adolesc Psychiatry 2007; 46(3): 309-322

6. Characteristics of youth who
exhibit maladaptive aggression
• More school adjustment problems than anticipated
• Higher rates of peer rejection, victimization
• Difficulties in ambiguous interpersonal situations
(reading emotion in facial expressions of others)
• Prone read neutral facial expressions negatively
• Poor peer relationships
• Deficits in problem solving often emerge by age 4
• 21% of children with impulsive aggression reported to
have been a victim of physical abuse
Dodge KA (1991) In: The Development and Treatment of Childhood Aggression pp 201-218

7. Principles of
evaluation
Aggression is to a child
psychiatrist what fever is to a
pediatrician - a non-specific
sign associated with many
conditions.
We seek to identify and treat
the underlying condition(s)

8. Common conditions frequently
associated with maladaptive aggression
• ADHD
• Bipolar disorder
• Autism spectrum disorders/developmental disorders
• Post Traumatic Stress Disorder
• Anxiety disorders
• Depression
• Iatrogenic causes
Aggression often co-occurs with specific
disorders, but may not be ameliorated by
medications used to treat those disorders
Jensen et al. J Am Acad Child Adolesc Psychiatry 2007; 46(3): 309-322

9. The
importance
of a
thorough
evaluation
• Comorbidity is common
• Failure to recognize common
comorbid conditions contributes to
medication trials that worsen
aggression

10. Important questions for
parents/caregivers: aggressive behavior
• Who, what, when, where, why?
• Antecedent – Behavior – Consequence
• If you can’t identify the antecedent, it likely
originates in the child’s thought processing
• Impulsive vs. perseverative
• Immediate response to frustration vs. buildup of
frustration to major meltdown
• Rarely is aggression purely of one type
• Mix is especially common in patients with disruptive
behavior disorders and comorbid anxiety, OCD

11. Nuggets in the
medication
history?
Learning from negative
responses to previous
medication trials…
• When ADHD meds
exacerbate aggression
• When antidepressants
or anxiolytics
exacerbate aggression

12. Principles of psychopharmacology
in youth with aggressive behavior
• Treat the underlying condition(s) thought to
contribute to aggressive behavior
• Carefully screen for conditions that may be
exacerbated by treatment
• Internalizing disorders when using ADHD meds
• Conditions associated with impulsivity when using meds
linked to behavioral activation (SSRIs)
• Consider dosing more conservatively in patients
with comorbidity
• Aggression may not respond as well to
pharmacotherapy as other symptoms

13. ADHD medications in
aggression
• Stimulants have the most evidence for efficacy
in treatment of oppositional behavior, conduct
disorder and aggression (high quality)
• 40 randomized trials, 2300+ patients in trials of
2-16 weeks
• Effect sizes:
• Parent rated: 0.71
• Clinician-rated: 0.77
• Teacher-rated: 1.04
Pringscheim T et al. Can J Psychiatry 2015;60(2):42-51

14. ADHD medications in
aggression
• High-quality evidence that atomoxetine has a
small effect on oppositional behavior in youth
with ADHD, with and without ODD, Conduct
Disorder (CD)
• Effect size: 0.33
• Moderate-quality evidence that guanfacine has
a small-moderate effect on oppositionality in
youth with ADHD, with/without ODD, CD
• Very low -quality evidence that clonidine has a
small effect on oppositional behavior
Pringscheim T et al. Can J Psychiatry 2015;60(2):42-51

15. Pringscheim T et al. Can J Psychiatry 2015;60(2):42-51

16. Antipsychotics and mood
stabilizers in aggression
• Moderate evidence for moderate-large effect of
risperidone on conduct problems and
aggression in youth with sub-average IQ and
ODD, CD, with and without ADHD
• Moderate effect seen in youth with typical IQ
• One small RCT (N=19) demonstrated large
effect size for quetiapine in youth with CD +/-
ADHD
• Overall, evidence for use of antipsychotics
other than risperidone is very low
Pringscheim T et al. Can J Psychiatry 2015;60(2):52-61

17. Antipsychotics and mood
stabilizers in aggression
• Evidence for use of lithium, divalproex of low
quality
• Very low-quality evidence supporting use of
carbamazepine
• Greater than 99% of subjects in studies of
antipsychotics, all subjects in studies mood
stabilizers had ADHD plus CD and/or ODD
Pringscheim T et al. Can J Psychiatry 2015;60(2):52-61

18. Conclusions
• Thorough evaluation of the context of aggressive
behavior and identification of psychiatric
conditions that predispose or perpetuate
aggression are essential for effective treatment
• Aggression is a non-specific symptom associated
with a broad array of psychiatric conditions.
• Treatment should be focused on addressing the
psychiatric condition(s) most closely associated
with aggressive behavior