Consensus report on impulsive aggression as a symptom across diagnostic categories in child psychiatry: implications for medication studies

Confirmation of the Factor Structure and Measurement Invariance of the Children's Scale of Hostility and Aggression: Reactive/Proactive in Clinic-Referred Children With and Without Autism Spectrum Disorder

OBJECTIVE

The measurement of aggression in its different forms (e.g., physical and verbal) and functions (e.g., impulsive and instrumental) is given little attention in subjects with developmental disabilities (DD). In this study, we confirm the factor structure of the Children's Scale for Hostility and Aggression: Reactive/Proactive (C-SHARP) and demonstrate measurement invariance (consistent performance across clinical groups) between clinic-referred groups with and without autism spectrum disorder (ASD). We also provide evidence of the construct validity of the C-SHARP.

METHODS

Caregivers provided C-SHARP, Child Behavior Checklist (CBCL), and Proactive/Reactive Rating Scale (PRRS) ratings for 644 children, adolescents, and young adults 2-21 years of age. Five types of measurement invariance were evaluated within a confirmatory factor analytic framework. Associations among the C-SHARP, CBCL, and PRRS were explored.

RESULTS

The factor structure of the C-SHARP had a good fit to the data from both groups, and strict measurement invariance between ASD and non-ASD groups was demonstrated (i.e., equivalent structure, factor loadings, item intercepts and residuals, and latent variance/covariance between groups). The C-SHARP Problem Scale was more strongly associated with CBCL Externalizing than with CBCL Internalizing, supporting its construct validity. Subjects classified with the PRRS as both Reactive and Proactive had significantly higher C-SHARP Proactive Scores than those classified as Reactive only, who were rated significantly higher than those classified by the PRRS as Neither Reactive nor Proactive. A similar pattern was observed for the C-SHARP Reactive Score.

CONCLUSIONS

This study provided evidence of the validity of the C-SHARP through confirmation of its factor structure and its relationship with more established scales. The demonstration of measurement invariance demonstrates that differences in C-SHARP factor scores were the result of differences in the construct rather than to error or unmeasured/nuisance variables. These data suggest that the C-SHARP is useful for quantifying subtypes of aggressive behavior in children, adolescents, and young adults with DD.

Impact of Irritability and Impulsive Aggressive Behavior on Impairment and Social Functioning in Youth with Cyclothymic Disorder

OBJECTIVE

Research on adults with cyclothymic disorder (CycD) suggests that irritability and impulsive aggression (IA) are highly prevalent among this population. Less is known about whether these behaviors might also distinguish youth with CycD from youth without CycD. Additionally, little is known about how irritability and IA relate to one another, and whether they are associated with different outcomes. This study aimed to compare irritability and IA across diagnostic subtypes to determine whether CycD is uniquely associated with these behaviors, and to assess how irritability and IA relate to youth social and general functioning.

METHODS

Participants (n = 459), 11-18 years of age, were recruited from an urban community mental health center and an academic outpatient clinic; 25 had a diagnosis of CycD. Youth and caregivers completed measures of IA and irritability. Youth and caregivers also completed an assessment of youth friendship quality. Clinical interviewers assessed youth social, family, and school functioning.

RESULTS

Youth with CycD had higher scores on measures of irritability and IA than youth with nonbipolar disorders, but scores were not different from other youth with bipolar spectrum disorders. Measures of irritability and IA were correlated, but represented distinct constructs. Regression analyses indicated that irritability was related to friendship quality (p < 0.005). Both IA and irritability were related to social impairment (ps < 0.05-0.0005) and Child Global Assessment Scale (C-GAS) scores (ps = 0.05-0.005). CycD diagnosis was associated with poorer caregiver-rated friendship quality and social functioning (ps < 0.05).

CONCLUSIONS

We found that irritability and aggression were more severe among youth with CycD than among youth with nonbipolar diagnoses, but did not differ across bipolar disorder subtypes. Among youth seeking treatment for mental illness, irritability and IA are prevalent and nonspecific. Irritability and IA were uniquely related to our outcomes of social and general functioning, suggesting that it is worthwhile to assess each separately, in order to broaden our understanding of the characteristics and correlates of each.

Factor Validity of a Proactive and Reactive Aggression Rating Scale

Aggressive behaviors can be classified into proactive and reactive functions, though there is disagreement about whether these are distinct constructs. Data suggest that proactive and reactive aggression have different etiologies, correlates, and response to treatment. Several rating scales are available to characterize aggressive behavior as proactive or reactive; one commonly used scale was originally developed for teacher ratings, referred to here as the Antisocial Behavior Scale (ABS). However, no data are available on the psychometric properties of the ABS for parent ratings. This study examined the factor structure and convergent/divergent validity of the parent-rated ABS among 168 children aged 6-12 years with attention-deficit hyperactivity disorder, a disruptive behavior disorder, and severe aggression enrolled in a randomized clinical trial. Multidimensional item response theory was used to confirm the original factor structure. The proactive and reactive factors were distinct but moderately correlated; the algorithm items exhibited acceptable fit on the original factors. The non-algorithm items caused theoretical problems and model misfit. Convergent and divergent validity of the scale was explored between the ABS and other parent-report measures. Proactive and reactive aggression showed differential correlates consistent with expectations for externalizing symptoms. The subscales were correlated weakly or not at all with most non-externalizing symptoms, with some exceptions. Thus, the original factor structure was supported and we found preliminary evidence for the validity of the scale, though the results suggest that the constructs measured by the ABS may not be totally distinct from general behavior problems in this clinical sample.

Socioeconomic status, parenting, and externalizing problems in African American single-mother homes: A person-oriented approach

African American youth, particularly those from single-mother homes, are overrepresented in statistics on externalizing problems. The family is a central context in which to understand externalizing problems; however, reliance on variable-oriented approaches to the study of parenting, which originate from work with intact, middle-income, European American families, may obscure important information regarding variability in parenting styles among African American single mothers, and in turn, variability in youth outcomes as well. The current study demonstrated that within African American single-mother families: (a) a person-, rather than variable-, oriented approach to measuring parenting style may further elucidate variability; (b) socioeconomic status may provide 1 context within which to understanding variability in parenting style; and (c) 1 marker of socioeconomic status, income, and parenting style may each explain variability in youth externalizing problems; however, the interaction between income and parenting style was not significant. Findings have potential implications for better understanding the specific contexts in which externalizing problems may be most likely to occur within this at-risk and underserved group.

Atypical antipsychotics in the treatment of pathological aggression in children and adolescents: literature review and clinical recommendations

OBJECTIVE

To review the literature about the use of atypical antipsychotics in the treatment of pathological aggression in children and adolescents.

METHOD

The databases MEDLINE, SciELO, and LILACS were searched for publications in Portuguese or English from 1992 to August 2011 using the following keywords: mental disease, child, adolescent, treatment, atypical antipsychotic, aggressive behavior, aggression, and violent behavior.

RESULTS

Sixty-seven studies of good methodological quality and clinical interest and relevance were identified. Studies including children and adolescents were relatively limited, because few atypical antipsychotics have been approved by the Food and Drug Administration (FDA). All the medications included in this review (risperidone, olanzapine, quetiapine, ziprasidone, aripiprazole and clozapine) have some effectiveness in treating aggression in children and adolescents, and choices should be based on clinical indications and side effects.

CONCLUSIONS

There are few studies about the effectiveness and safety of atypical antipsychotics for the pediatric population, and further randomized controlled studies with larger groups of patients and more diagnostic categories, such as severe conduct disorder and oppositional defiant disorder, should be conducted to confirm the results reported up to date and to evaluate the impact of long-term use.

Risk factors for weight gain and metabolic syndrome in adolescents with psychiatric disorders: a historical prospective study

OBJECTIVE

Adolescents with mental disorders are at increased risk for being overweight or obese, and subsequently developing metabolic syndrome. However, data regarding risk factors for weight gain during psychiatric hospitalization of adolescents are limited and inconsistent. The aim of this study was to investigate the sociodemographic, clinical, and pharmacological risk factors for weight gain during psychiatric treatment, in order to improve prevention of subsequent metabolic syndrome.

METHODS

We conducted a historical prospective study of 146 adolescent patients (mean age 15.2±1.9 years, 52.7% males), consecutively admitted for day treatment in an adolescent day unit (length of stay 141±76 days). Anthropometric measurements and laboratory analyses of fasting glucose and lipid levels were conducted as part of the routine medical care at admission and discharge. Psychiatric diagnoses, medication histories, and sociodemographic data were obtained from the electronic medical records system.

RESULTS

A significant increase in age- and gender adjusted body mass index (BMI) (i.e., z score) was observed (0.5±1.2 vs. 0.7±1.1 at admission and discharge, respectively, p<0.001). Male subjects were more prone to weight gain than females (odds ratio [OR]=3.5, 95% CI=1.2-10.3) and BMI z score at admission was inversely associated with weight gain (R (2)=0.2, p<0.0001). Surprisingly, age at admission, psychiatric diagnoses, length of stay, and number of medications were not associated with weight gain. Despite weight gain, fasting blood glucose and lipid profile did not change significantly during the study period.

CONCLUSIONS

Hospitalization of adolescents in a psychiatric day unit may be associated with a significant weight gain, especially in male subjects and those with normal weight at admission. Efforts should be aimed to reduce weight gain among youth with psychiatric disorders during treatment, to avoid a subsequent metabolic syndrome.

Child and adolescent psychiatrists' attitudes and practices prescribing second generation antipsychotics

OBJECTIVE

The purpose of this study was to examine psychiatrists' attitudes and practices in prescribing second-generation antipsychotics (SGA) to children and adolescents (referred to here as "children") and identify factors associated with off-label SGA use.

METHODS

A survey was mailed to a national, randomly selected sample of 1600 child and adolescent psychiatrists identified by the American Medical Association. Multivariable logistic regression was used to identify factors, including psychiatrists' characteristics, practice characteristics, and psychiatrists' attitudes, that are associated with off-label SGA use (i.e., SGAs used in children with attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder, conduct disorder, or nonbipolar mood disorders).

RESULTS

The final sample included 340 psychiatrists. Overall, respondents reported higher use and appropriateness of SGAs for United States Food and Drug Administration (FDA)-approved disorders, symptoms of aggression, and older child age. More than one third (36%) of respondents reported some off-label SGA use. Significant predictors of off-label use were: Practicing at inpatient/residential facilities (odds ratio [OR]=4.2, p=0.001); white/non-Hispanic race/ethnicity (OR=0.3, p<0.0001), agreeing that SGAs should be used for ADHD with aggression (OR=7.1, p<0.0001); and agreeing that SGAs should be used for severe delinquent behaviors (OR=1.9, p=0.03).

CONCLUSIONS

Psychiatrists' attitudes about prescribing SGAs to children exhibiting aggressive symptoms were associated with off-label SGA use. Research is needed to understand the construct of aggression, potential interaction effects of aggression with diagnostic criteria, and their impact on SGA use.

Examination of Aggression and Self Injury in Children with Autism Spectrum Disorders and Serious Behavioral Problems

This study identified subtypes of aggression in a sample of 206 children with autism spectrum disorder (ASD) who participated in 2 risperidone trials. The narratives were derived from a parent interview about each child's 2 most pressing problems. Five subtypes of aggression emerged: hot aggression only, cold aggression only, self-injurious behavior (SIB) only, aggression and SIB, and nonaggressive. All groups showed a high rate of positive response to risperidone with no differences across subtypes. These study findings extend understanding of aggression in ASD and may be useful to guide further study on biological mechanisms and individualized treatment in ASD.

Anger induced by interferon-alpha is moderated by ratio of arachidonic acid to omega-3 fatty acids

OBJECTIVE

Anger worsens in some patients during interferon-alpha (IFN-α) therapy. Elevated anger has also been associated with lower long-chain omega-3 (LCn-3) fatty acid levels. We examined whether fatty acids could influence vulnerability to anger during IFN-α exposure.

METHODS

Plasma arachidonic acid (AA), eicosapentaenoic acid (EPA), and docosahexaenoic acid (DHA) levels were determined prior to IFN-α therapy by mass spectroscopy. Repeated-measure analyses examined the relationship between AA/EPA+DHA and the subsequent development of labile anger and irritability in 82 subjects who prospectively completed the Anger, Irritability, and Assault Questionnaire (AIAQ) during the first eight weeks of IFN-α therapy.

RESULTS

Prior to IFN-α therapy, AA/EPA+DHA did not correlate with either labile anger or irritability. Pre-treatment AA/EPA+DHA did correlate with the subsequent maximal increase in labile anger during IFN-α therapy (r=0.33; p=0.005). Over time, labile anger increased more in subjects with above median AA/EPA+DHA ratios (p<0.05). Of the 17 subjects ultimately requiring psychiatric intervention for anger, 14/17 had above-median AA/EPA+DHA ratios (p=0.009). There was also an interaction with the tumor necrosis factor-alpha (TNF-α) promoter polymorphism (A-308G), such that only those with both elevated AA/EPA+DHA and the A allele had increased labile anger (p=0.001). In an additional 18 subjects, we conversely observed that selective serotonin reuptake inhibitor treatment was associated with increased irritability during IFN-α therapy.

CONCLUSION

LCn-3 fatty acid status may influence anger development during exposure to elevated inflammatory cytokines, and may interact with genetic risk for increased brain TNF-α. LCn-3 supplements may be one strategy for minimizing this adverse side effect of IFN-α.

A novel group therapy for children with ADHD and severe mood dysregulation

OBJECTIVE

No psychosocial treatments have been developed for children with ADHD and severe mood dysregulation (SMD) despite the significant prevalence and morbidity of this combination. Therefore, the authors developed a novel treatment program for children with ADHD and SMD.

METHOD

The novel therapy program integrates components of cognitive-behavioral therapies for affect regulation with a parent-training intervention for managing recurrent defiant behaviors. It consists of nine 105-min child and parent groups run in unison. A pilot trial was conducted with seven participants with ADHD and SMD ages 7 to 12 who were on a stable stimulant regimen.

RESULTS

Six of the seven (86%) families completed the program. Participants showed large improvements in depressive symptoms, mood lability, and global functioning. Milder improvements in externalizing behaviors were observed.

CONCLUSION

Results suggest the feasibility and potential efficacy of the therapy program for children with ADHD and SMD and warrant a larger controlled trial.

An Exploratory Study of Aggression in School-Age Children: Underlying Factors and Implications for Treatment

Aggressive behaviour in school-aged children presents a significant challenge for society. If not managed, it can result in adverse academic, social, emotional, and behavioural outcomes for the child. In addition, it can create stress for families and become a significant burden for the community as these children reach adolescence and adulthood, and engage in antisocial behaviours. Using a three-step exploratory analytical strategy, this study explored parent and child reports of a diverse range of underlying developmental and clinical variables that have been identified in the literature as predictors of aggressive child behaviour, and which could be addressed within an Australian school or community context. A total of 57 children and their parents were recruited from a referral-based Western Australian child mental health service, and the wider community. A group of 31 clinically aggressive children were identified and compared to a group of 26 non-aggressive children. The aggressive group was reported as having a greater prevalence of internalising symptoms, including anxiety and depression, and their aggressive behaviour was more likely to be of the callous/unemotional type, relative to their non-aggressive counterparts. Significant predictors of belonging to the aggressive group included child social problems, thought problems, attention problems, affective problems, narcissism, symptoms of ADHD and PTS, and low maternal self-esteem. Findings are presented and discussed in the context of established theories. Recommendations for principles of treatment for aggressive children and their families are suggested.

Antipsychotic treatment patterns and aggressive behavior among adolescents in residential facilities

This study examined the association between acute aggressive behavior patterns of 145 adolescents in residential treatment facilities with use of and changes in antipsychotic medication for the chronic management of aggression. Seclusion/restraint (S/R) frequency over 12 months was used to categorize youth into none, low, moderate, and high S/R groups. Data were analyzed using longitudinal mixed effects logistic regression models that allowed for intra-subject variability over time. The high and moderate S/R groups were significantly more likely to receive antipsychotics, get higher doses, and have changes in medication compared with the none S/R group. Increases in antipsychotic dose were associated with a lower likelihood of changes in antipsychotic medication over time. Despite persistent antipsychotic use at higher doses, youth in the high and moderate S/R groups continued to be secluded/restrained frequently. The findings question the adequacy of these medications in managing aggressive behavior.

Atypical antipsychotics for disruptive behaviour disorders in children and youths

BACKGROUND

Disruptive behaviour disorders include conduct disorder, oppositional defiant disorder and disruptive behaviour not otherwise specified. Attention deficit hyperactivity disorder (ADHD) is frequently associated with disruptive behaviour disorders. The difficulties associated with disruptive behaviour disorders are demonstrated through aggression and severe behavioural problems. These often result in presentation to psychiatric services and may be treated with medications such as atypical antipsychotics. There is increasing evidence of a significant rise in the use of atypical antipsychotics for treating disruptive behaviour disorders in child and adolescent populations.

OBJECTIVES

To evaluate the effect and safety of atypical antipsychotics, compared to placebo, for treating disruptive behaviour disorders in children and youths. 

SEARCH METHODS

We searched the following databases in August 2011: CENTRAL (2011, Issue 3), MEDLINE (1948 to August Week 1), EMBASE (1980 to 2011 Week 32), PsycINFO (1806 to August Week 2 2011), CINAHL (1937 to current), ClinicalTrials.gov (searched 15 August 2011), Australian New Zealand Clinical Trials Registry (ANZCTR) (searched 15 August 2011), CenterWatch (searched 15 August 2011) and ICTRP (searched 15 August 2011).

SELECTION CRITERIA

We included randomised controlled trials with children and youths up to and including the age of 18, in any setting, with a diagnosis of a disruptive behaviour disorder. We included trials where participants had a comorbid diagnosis of attention deficit hyperactivity disorder, major depression or an anxiety disorder.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected the studies and disagreements were resolved by discussion. Two review authors extracted data independently. One review author entered data into Review Manager software and another checked it. We contacted trial authors for information about adverse effects and to provide missing data.

MAIN RESULTS

We included eight randomised controlled trials, spanning 2000 to 2008. Seven assessed risperidone and one assessed quetiapine. Three of the studies were multicentre. Seven trials assessed acute efficacy and one assessed time to symptom recurrence over a six-month maintenance period.We performed meta-analyses for the primary outcomes of aggression, conduct problems and weight changes but these were limited by the available data as different trials reported either mean change scores (average difference) or final/post-intervention raw scores and used different outcome measures. We also evaluated each individual trial's treatment effect size where possible, using Hedges' g.For aggression, we conducted two meta-analyses. The first included three trials (combined n = 238) using mean difference (MD) on the Aberrant Behaviour Checklist (ABC) Irritability subscale. Results yielded a final mean score with treatment that was 6.49 points lower than the post-intervention mean score with placebo (95% confidence interval (CI) -8.79 to -4.19). The second meta-analysis on aggression included two trials (combined n = 57) that employed two different outcome measures (Overt Aggression Scale (modified) (OAS-M) and OAS, respectively) and thus we used a standardised mean difference. Results yielded an effect estimate of -0.18 (95% CI -0.70 to 0.34), which was statistically non-significant.We also performed two meta-analyses for conduct problems. The first included two trials (combined n = 225), both of which employed the Nisonger Child Behaviour Rating Form - Conduct Problem subscale (NCBRF-CP). The results yielded a final mean score with treatment that was 8.61 points lower than that with placebo (95% CI -11.49 to -5.74). The second meta-analysis on conduct problems included two trials (combined n = 36), which used the Conners' Parent Rating Scale - Conduct Problem subscale (CPRS-CP). Results yielded a mean score with treatment of 12.67 lower than with placebo (95% CI -37.45 to 12.11), which was a statistically non-significant result.With respect to the side effect of weight gain, a meta-analysis of two studies (combined n = 138) showed that participants on risperidone gained on average 2.37 kilograms more than those in the placebo group over the treatment period (MD 2.37; 95% CI 0.26 to 4.49).For individual trials, there was a range of effect sizes (ranging from small to large) for risperidone reducing aggression and conduct problems. The precision of the estimate of the effect size varied between trials.

AUTHORS' CONCLUSIONS

There is some limited evidence of efficacy of risperidone reducing aggression and conduct problems in children aged 5 to 18 with disruptive behaviour disorders in the short term.For aggression, the difference in scores of 6.49 points on the ABC Irritability subscale (range 0 to 45) may be clinically significant. For conduct problems, the difference in scores of 8.61 points on the NCBRF-CP (range 0 to 48) is likely to be clinically significant.Caution is required due to the limitations of the evidence and the small number of relevant high-quality studies. The findings from the one study assessing impact in the longer term suggest that the effects are maintained to some extent (small effect size) for up to six months. Inadequately powered studies produced non-significant results. The evidence is restricted by heterogeneity of the population (including below average and borderline IQ), and methodological issues in some studies, such as use of enriched designs and risk of selection bias. No study addressed the issue of pre-existing/concurrent psychosocial interventions, and comorbid stimulant medication and its dosage was only partially addressed. There is currently no evidence to support the use of quetiapine for disruptive behaviour disorders in children and adolescents.It is uncertain to what degree the efficacy found in clinical trials will translate into real life clinical practice. Participants in the studies were recruited from clinical services but those who agree to take part in the clinical trials are a subset of the overall population presenting for care. There are no research data for children under five years of age. Further high-quality research is required with large samples of clinically representative youths and long-term follow-up to replicate current findings.

Treatment of maladaptive aggression in youth: CERT guidelines II. Treatments and ongoing management

OBJECTIVE

To develop guidelines for management and treatment of maladaptive aggression in youth in the areas of psychosocial interventions, medication treatments, and side-effect management.

METHODS

Evidence was assembled and evaluated in a multistep process, including systematic reviews of published literature; an expert survey of recommended practices; a consensus conference of researchers, policymakers, clinicians, and family advocates; and review by the steering committee of successive drafts of the recommendations. The Center for Education and Research on Mental Health Therapeutics Treatment of Maladaptive Aggression in Youth guidelines reflect a synthesis of the available evidence, based on this multistep process.

RESULTS

This article describes the content, rationale, and evidence for 11 recommendations. Key treatment principles include considering psychosocial interventions, such as evidence-based parent and child skills training as the first line of treatment; targeting the underlying disorder first following evidence-based guidelines; considering individual psychosocial and medical factors, including cardiovascular risk in the selection of agents if medication treatment (ideally with the best evidence base) is initiated; avoiding the use of multiple psychotropic medications simultaneously; and careful monitoring of treatment response, by using structured rating scales, as well as close medical monitoring for side effects, including metabolic changes.

CONCLUSIONS

Treatment of children with maladaptive aggression is a "moving target" requiring ongoing assimilation of new evidence as it emerges. Based on the existing evidence, the Treatment of Maladaptive Aggression in Youth guidelines provide a framework for management of maladaptive aggression in youth, appropriate for use by primary care clinicians and mental health providers.

Treatment of maladaptive aggression in youth: CERT guidelines I. Engagement, assessment, and management

OBJECTIVE

To develop guidelines for management and treatment of maladaptive aggression in the areas of family engagement, assessment and diagnosis, and initial management, appropriate for use by primary care clinicians and mental health providers. Maladaptive aggression in youth is increasingly treated with psychotropic medications, particularly second-generation antipsychotic agents. Multiple treatment modalities are available, but guidance for clinicians' assessment and treatment strategies has been inadequately developed. To address this need, the Center for Education and Research on Mental Health Therapeutics and the REACH Institute convened a steering group of national experts to develop evidence-based treatment recommendations for maladaptive aggression in youth.

METHODS

Evidence was assembled and evaluated in a multistep process that included a systematic review of published literature; a survey of experts on recommended treatment practices; a consensus conference that brought together clinical experts along with researchers, policy makers, and family advocates; and subsequent review and discussion by the steering committee of successive drafts of the recommendations. The Center for Education and Research on Mental Health Therapeutics Treatment of Maladaptive Aggression in Youth (T-MAY) guidelines reflect a synthesis of the available evidence, based on this multistep process.

RESULTS

The current article describes 9 recommendations for family engagement, assessment, and diagnosis as key prerequisites for treatment selection and initiation.

CONCLUSIONS

Recognizing the family and social context in which aggressive symptoms arise, and understanding the underlying psychiatric conditions that may be associated with aggression, are essential to treatment planning.

Heritability and longitudinal stability of impulsivity in adolescence

Impulsivity is a multifaceted personality construct that plays an important role throughout the lifespan in psychopathological disorders involving self-regulated behaviors. Its genetic and environmental etiology, however, is not clearly understood during the important developmental period of adolescence. This study investigated the relative influence of genes and environment on self-reported impulsive traits in adolescent twins measured on two separate occasions (waves) between the ages of 11 and 16. An adolescent version of the Barratt Impulsiveness Scale (BIS) developed for this study was factored into subscales reflecting inattention, motor impulsivity, and non-planning. Genetic analyses of these BIS subscales showed moderate heritability, ranging from 33-56% at the early wave (age 11-13 years) and 19-44% at the later wave (age 14-16 years). Moreover, genetic influences explained half or more of the variance of a single latent factor common to these subscales within each wave. Genetic effects specific to each subscale also emerged as significant, with the exception of motor impulsivity. Shared twin environment was not significant for either the latent or specific impulsivity factors at either wave. Phenotypic correlations between waves ranged from r = 0.25 to 0.42 for subscales. The stability correlation between the two latent impulsivity factors was r = 0.43, of which 76% was attributable to shared genetic effects, suggesting strong genetic continuity from mid to late adolescence. These results contribute to our understanding of the nature of impulsivity by demonstrating both multidimensionality and genetic specificity to different facets of this complex construct, as well as highlighting the importance of stable genetic influences across adolescence.

A phase 2a randomized, parallel group, dose-ranging study of molindone in children with attention-deficit/hyperactivity disorder and persistent, serious conduct problems

OBJECTIVE

To evaluate safety and tolerability of four doses of immediate-release molindone hydrochloride in children with attention-deficit/hyperactivity disorder (ADHD) and serious conduct problems.

METHODS

This open-label, parallel-group, dose-ranging, multicenter trial randomized children, aged 6-12 years, with ADHD and persistent, serious conduct problems to receive oral molindone thrice daily for 9-12 weeks in four treatment groups: Group 1-10 mg (5 mg if weight <30 kg), group 2-20 mg (10 mg if <30 kg), group 3-30 mg (15 mg if <30 kg), and group 4-40 mg (20 mg if <30 kg). The primary outcome measure was to evaluate safety and tolerability of molindone in children with ADHD and serious conduct problems. Secondary outcome measures included change in Nisonger Child Behavior Rating Form-Typical Intelligence Quotient (NCBRF-TIQ) Conduct Problem subscale scores, change in Clinical Global Impressions-Severity (CGI-S) and -Improvement (CGI-I) subscale scores from baseline to end point, and Swanson, Nolan, and Pelham rating scale-revised (SNAP-IV) ADHD-related subscale scores.

RESULTS

The study randomized 78 children; 55 completed the study. Treatment with molindone was generally well tolerated, with no clinically meaningful changes in laboratory or physical examination findings. The most common treatment-related adverse events (AEs) included somnolence (n=9), weight increase (n=8), akathisia (n=4), sedation (n=4), and abdominal pain (n=4). Mean weight increased by 0.54 kg, and mean body mass index by 0.24 kg/m(2). The incidence of AEs and treatment-related AEs increased with increasing dose. NCBRF-TIQ subscale scores improved in all four treatment groups, with 34%, 34%, 32%, and 55% decreases from baseline in groups 1, 2, 3, and 4, respectively. CGI-S and SNAP-IV scores improved over time in all treatment groups, and CGI-I scores improved to the greatest degree in group 4.

CONCLUSIONS

Molindone at doses of 5-20 mg/day (children weighing <30 kg) and 20-40 mg (≥ 30 kg) was well tolerated, and preliminary efficacy results suggest that molindone produces dose-related behavioral improvements over 9-12 weeks. Additional double-blind, placebo-controlled trials are needed to further investigate molindone in this pediatric population.

A preliminary investigation of corpus callosum and anterior commissure aberrations in aggressive youth with bipolar disorders

OBJECTIVE

Although behavioral deficits in bipolar disorder (BPD) are well described, the specific brain white matter (WM) disruptions have not been completely characterized, and neural mechanisms underlying dysfunction in BPD are not well established, particularly for youth with BPD and aggression. This preliminary study utilized diffusion tensor imaging (DTI) to investigate commissural tracts (corpus callosum [CC] and anterior commissure [AC]) in youth with BPD, because disruption of interhemispheric communication may contribute to the emotional deficits that are characteristic of the illness.

METHOD

DTI was used to investigate WM in 10 youth (7-17 years of age) with BPD and 10 typically developing age-matched controls. Tract-based spatial statistics voxel-wise analysis was used to compare fractional anisotropy (FA) of the two groups. We specifically focused on five subdivisions of the midsagittal CC as well as on the decussation of AC, which connects the temporal lobes. Exploratory correlations between FA values and life history of aggression scores were calculated for the BPD group.

RESULTS

Youth with BPD had significantly lower FA values in the callosal genu and AC. FA values in the AC were negatively correlated with a life history of aggression in the BPD group.

CONCLUSIONS

These results contribute to a growing literature implicating a role for the genu of the CC in BPD and are the first to report WM variations in the AC of children with BPD. Taken together with the correlational data for aggression and the role of the AC in emotional processing, our data provide preliminary evidence for a possible association between the structural integrity of the WM of the AC and aggression in pediatric BPD.

ADHD and delinquency--a developmental perspective

Attention-deficit/hyperactivity disorder (ADHD) is one of the most prevalent psychiatric disorders of childhood and adolescence. Until now, it has been unclear whether ADHD by itself constitutes a risk factor for later delinquency or does so only in combination with other disruptive symptoms. This article seeks to give a comprehensive account of the literature to shed light on the developmental pathway from childhood ADHD to adult criminality. Comorbid ADHD and conduct disorder (CD) are significantly related to a range of biological and environmental risk factors such as neurocognitive impairment, high parental psychopathology, poor social functioning, and other comorbid mental disorders, particularly substance abuse, that are described in this review. In addition, the results of treatment studies are presented, with a special focus on the results of the Multimodal Treatment Study of Children with ADHD (MTA). Although treatment programs, including medication and psychosocial treatment, can be very effective in improving the functioning of children with ADHD in the social and academic domains in the short term, there is no conclusive evidence that such treatments lower the risk for developing delinquency in adulthood.

GluA3-deficiency in mice is associated with increased social and aggressive behavior and elevated dopamine in striatum

Glutamate signaling has been implicated in the regulation of social behavior. AMPA-glutamate receptors are assembled from four subunits (GluA1-4) of mainly GluA1/2 and GluA2/3 tetramers that form ion channels of distinct functional properties. Mice lacking GluA1 showed a reduced anxiety and male aggression. To understand the role of GluA3 in modulating social behavior, we investigated GluA3-deficient mice (Gria3-/Y) on C57BL/6J background. Compared to wild type (WT) littermates (n=14), Gria3-/Y mice (n=13) showed an increase in isolation-induced male aggression (p=0.011) in home cage resident-intruder test; an increase in sociability (p=0.01), and increase in male-male social interactions in neutral arena (p=0.005); an increase in peripheral activities in open field test (p=0.037) with normal anxiety levels in elevated plus maze and light-dark box; and minor deficits in motor and balance function in accelerating rotarod test (p=0.016) with normal grip strength. Gria3-/Y mice showed no significant deficit in spatial memory function in Morris-water maze and Y-maze tests, and normal levels of testosterone. Increased dopamine concentrations in stratum (p=0.034) and reduced serotonin turnover in olfactory bulb (p=0.002) were documented in Gria3-/Y mice. These results support a role of GluA3 in the modulation of social behavior through brain dopamine and/or serotonin signaling and different AMPA receptor subunits affect social behavior through distinct mechanisms.

Weight gain and metabolic risks associated with antipsychotic medications in children and adolescents

BACKGROUND

Antipsychotic-related weight gain and metabolic adverse effects have become a major focus, especially in youth.

METHODS

Review of randomized, cohort, and pharmacoepidemiologic studies of antipsychotic-related weight gain and metabolic adverse effects and of interventions for their reduction in youth.

RESULTS

Across 34 published head-to-head and placebo-controlled studies in youth with psychotic and bipolar disorders, weight gain ranged from 3.8 to 16.2 kg with olanzapine (n=353), 0.9-9.5 kg with clozapine (n=97), 1.9-7.2 kg with risperidone (n=571), 2.3-6.1 kg with quetiapine (n=133), and 0-4.4 kg with aripiprazole (n=451). In 24 placebo-controlled trials, the numbers-needed-to-harm for weight gain ≥7% in youth with bipolar disorder and schizophrenia were 39 (confidence interval [CI]: -1 to +6, not significant) for aripiprazole, 36 (CI: -1 to +7, not significant) for ziprasidone, 9 (CI: 7-14) for quetiapine, 6 (CI: 5-8) for risperidone, and 3 (CI: 3-4) for olanzapine. Data in youth with autism and disruptive behavior disorders, available only for some antipsychotics, suggest greater weight gain, possibly due to less prior antipsychotic exposure. Three-month results from a large cohort study in antipsychotic-naïve youth indicated that metabolic effects differ among second-generation antipsychotics, despite significant weight gain with all studied agents, suggesting additional, weight-independent effects. Further, pharmacoepidemiologic work indicates that antipsychotic polypharmacy increases the risk for obesity (odds ratio [OR]: 2.28 [CI: 1.49-3.65]) or any cardiovascular, cerebrovascular, or hypertensive adverse event (OR: 1.72 [CI: 1.10-2.69]). However, despite marked weight gain and its greater impact on youth, monitoring rates are low and studies of pharmacologic and behavioral interventions are extremely limited.

CONCLUSIONS

More research is needed to develop strategies to minimize antipsychotic-related weight gain and metabolic effects in youth and to discover treatments with lower risk potential.

Experts' recommendations for treating maladaptive aggression in youth

BACKGROUND

Psychiatric treatment for children and adolescents with clinically significant aggression is common and often involves the use of antipsychotic medications. Increasingly, pediatricians are initiating or managing such treatments despite limited evidence on optimal diagnostic, psychosocial, and medication approaches for pediatric aggression.

AIMS

The objective of this study was to gather clinicians' and researchers' expertise concerning the treatment of maladaptive aggression, using expert consensus survey methods to aid the development of guidelines for pediatricians and psychiatrists on the outpatient treatment of maladaptive aggression in youth (T-MAY).

METHODS

Forty-six experts (psychiatrists, pediatricians, and researchers) with >10 years of clinical and/or research experience in the treatment of pediatric aggression completed a 27-item survey (>400 treatment alternatives) about optimal diagnostic, psychosocial, and medication treatments. Data were analyzed using descriptive statistics and confidence intervals.

RESULTS

Expert consensus methodology clearly differentiated optimal versus nonoptimal treatment strategies for maladaptive aggression. In contrast to current practice trends, results indicated that experts support the use of psychosocial interventions and parent education and training before the use of medication for maladaptive aggression at every stage of medication treatment, from diagnosis to maintenance to medication discontinuation.

CONCLUSION

Overall findings indicate that evidence-informed strategies for outpatient treatment of pediatric maladaptive aggression, guided by systematically derived expert opinions, are attainable. In light of the gap between the research literature and clinical practice, expert consensus opinion supports specific practices for optimal outpatient management in children and adolescents with severe and persistent behavioral difficulties.

Is caregiver-adolescent disagreement due to differences in thresholds for reporting manic symptoms?

INTRODUCTION

Cross-informant disagreement is common and results in different interpretations of a youth's behavior. Theoretical explanations for discrepancies typically rely on scale level analyses. This article explores whether caregivers and adolescents differ in when they notice and report symptoms of youth mania depending on the severity of overall manic disturbance.

METHOD

Participants were 459 adolescent-caregiver pairs recruited at either a community mental health center or an academic medical center. Adolescents were most likely to have a primary diagnosis of unipolar depression (37%) or attention-deficit/hyperactivity disorder/disruptive behavior disorder (36%). Nineteen percent of adolescents received a bipolar spectrum disorder diagnosis (4% bipolar I and 15% bipolar II, cyclothymia, or bipolar not otherwise specificed). Caregivers were primarily biological mothers (74%) or grandparents (8%). Adolescents and caregivers independently completed the Mood Disorder Questionnaire (MDQ) about the adolescent.

RESULTS

Item response theory analyses of the entire sample indicated that in general, both caregivers and adolescents reserved endorsement of mania symptoms for the most severely ill half of participants. Comparisons of caregiver and adolescent report of symptoms on the MDQ indicated two significant differences. Caregivers were more likely to report irritability at significantly lower severity of mania than adolescents. Adolescents endorsed only increased energy or hyperactivity at lower severities than caregivers.

CONCLUSIONS

Adolescents and caregivers will have different concerns and might report different symptoms consistent with whom the symptom impacts first. Caregivers are more likely to report behaviors such as irritability, whereas adolescents are more likely to report subjective feelings such as feeling more energetic or more hyperactive.

Psychopathology, trauma and delinquency: subtypes of aggression and their relevance for understanding young offenders

OBJECTIVE

To examine the implications of an ontology of aggressive behavior which divides aggression into reactive, affective, defensive, impulsive (RADI) or "emotionally hot"; and planned, instrumental, predatory (PIP) or "emotionally cold." Recent epidemiological, criminological, clinical and neuroscience studies converge to support a connection between emotional and trauma related psychopathology and disturbances in the emotions, self-regulation and aggressive behavior which has important implications for diagnosis and treatment, especially for delinquent populations.

METHOD

Selective review of preclinical and clinical studies in normal, clinical and delinquent populations.

RESULTS

In delinquent populations we observe an increase in psychopathology, and especially trauma related psychopathology which impacts emotions and self-regulation in a manner that hotly emotionally charged acts of aggression become more likely. The identification of these disturbances can be supported by findings in cognitive neuroscience. These hot aggressive acts can be delineated from planned or emotionally cold aggression.

CONCLUSION

Our findings support a typology of diagnostic labels for disruptive behaviors, such as conduct disorder and oppositional defiant disorder, as it appears that these acts of hot emotional aggression are a legitimate target for psychopharmacological and other trauma specific interventions. The identification of this subtype of disruptive behavior disorders leads to more specific clinical interventions which in turn promise to improve hitherto unimpressive treatment outcomes of delinquents and patients with disruptive behavior.

Genetic dissection of intermale aggressive behavior in BALB/cJ and A/J mice

Aggressive behaviors are disabling, treatment refractory, and sometimes lethal symptoms of several neuropsychiatric disorders. However, currently available treatments for patients are inadequate, and the underlying genetics and neurobiology of aggression is only beginning to be elucidated. Inbred mouse strains are useful for identifying genomic regions, and ultimately the relevant gene variants (alleles) in these regions, that affect mammalian aggressive behaviors, which, in turn, may help to identify neurobiological pathways that mediate aggression. The BALB/cJ inbred mouse strain exhibits relatively high levels of intermale aggressive behaviors and shows multiple brain and behavioral phenotypes relevant to neuropsychiatric syndromes associated with aggression. The A/J strain shows very low levels of aggression. We hypothesized that a cross between BALB/cJ and A/J inbred strains would reveal genomic loci that influence the tendency to initiate intermale aggressive behavior. To identify such loci, we conducted a genomewide scan in an F2 population of 660 male mice bred from BALB/cJ and A/J inbred mouse strains. Three significant loci on chromosomes 5, 10 and 15 that influence aggression were identified. The chromosome 5 and 15 loci are completely novel, and the chromosome 10 locus overlaps an aggression locus mapped in our previous study that used NZB/B1NJ and A/J as progenitor strains. Haplotype analysis of BALB/cJ, NZB/B1NJ and A/J strains showed three positional candidate genes in the chromosome 10 locus. Future studies involving fine genetic mapping of these loci as well as additional candidate gene analysis may lead to an improved biological understanding of mammalian aggressive behaviors.

Pharmacologic management of acutely agitated pediatric patients

Acute agitation is a state of behavioral dyscontrol that requires intervention. Medications available in rapid delivery formats are frequently administered to treat acute agitation, either as a chemical restraint or on a voluntary basis. Prior to initiating treatment, the etiology of agitation must be evaluated. In choosing a medication, general pharmacologic principles should be followed. Medication should be selected based on the underlying cause in conjunction with weighing the risks, benefits, and side effects of medications. There are three classes of medications administered to children and adolescents to treat agitation: antihistamines, benzodiazepines, and antipsychotics. The most concerning short-term side effects of antipsychotics are their adverse neurologic effects, neuroleptic malignant syndrome, and prolonged corrected QT interval. Compared with typical antipsychotics, atypical antipsychotics have a more favorable short-term side effect profile.

Labile anger during interferon alfa treatment is associated with a polymorphism in tumor necrosis factor alpha

OBJECTIVE

Inflammatory cytokines may influence both labile anger and depression. Both psychiatric conditions can occur during interferon alfa-based treatments. Evidence also indicates a central nervous system role for tumor necrosis factor alpha (TNF-alpha), whose expression may be increased by interferon alfa. A polymorphism in the promoter region of TNF-alpha has been associated with various inflammatory illnesses. We therefore hypothesized that this TNF-alpha polymorphism would influence susceptibility to psychiatric symptoms during interferon alfa therapy.

METHODS

One hundred five patients with hepatitis C, initially without active major depression (major depressive disorder), were treated with interferon alfa and then prospectively monitored using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, the Beck Depression Inventory II, the Anger Irritability and Assault Questionnaire, and circulating TNF-alpha levels. The A-308G polymorphism (rs1800629) was determined using the 5'-nuclease assay. Repeated-measure mixed-effect analyses compared changes in symptoms over time.

RESULT

Beck Depression Inventory II score increased during interferon alfa therapy (F = 6.2; P < 0.001), with 27% developing MDD. The TNF-alpha A allele was associated with worsened labile anger (F = 2.5; P < 0.05) and fatigue (F = 2.9; P < 0.05) during treatment but not with major depression incidence (chi = 0.0; P = 0.99) or increased Beck Depression Inventory II (F = 1.2; P = 0.31). Labile anger was not predicted by the serotonin transporter polymorphism (F = 0.8; P = 0.59).

DISCUSSION

During treatment with an exogenous cytokine, vulnerability to worsening labile anger-distinct from major depression-is associated with genetic variability in TNF-alpha. This has implications both for patients being treated with interferon alfa and our understanding of genetic vulnerability for different subtypes of dysphoric and mood disorders.

Neuroendocrine aspects of pediatric aggression: Can hormone measures be clinically useful?

Pediatric aggression is common in human societies, mainly presenting as impulsive aggression or predatory aggression. Numerous psychiatric disorders can contain aggression as a symptom, leading to difficulties in diagnosis and treatment. This review focuses on the biological systems that affect pediatric aggression. We review the hypothalamic-pituitary-adrenal (HPA) axis, the hypothalamic-pituitary-gonadal (HPG) axis, and the mechanisms by which these axes influence the body and mind of aggressive children and adolescents. Although this review focuses on the HPA and HPG axes, it is important to note that other biological systems have relationships with these two axes. Based on the results of the studies reviewed, elevated cortisol concentrations were associated with impulsive aggression, whereas, low levels of cortisol were associated with callous-unemotional traits similar to predatory aggression. Higher levels of dehydroepiandrosterone were correlated with higher levels of aggression as were higher levels of testosterone. However, there have been discrepancies in the results between various studies, indicating the need for more research on hormonal levels and pediatric aggression. In the future, hormonal levels may be useful in determining what treatments will work best for certain pediatric patients.

Stimulant-responsive and stimulant-refractory aggressive behavior among children with ADHD

OBJECTIVES

The objective of this study was to examine factors that are associated with aggression that is responsive versus refractory to individualized optimization of stimulant monotherapy among children with attention-deficit/hyperactivity disorder (ADHD).

METHODS

Children who were aged 6 to 13 years and had ADHD, either oppositional defiant disorder or conduct disorder, significant aggressive behavior, and a history of insufficient response to stimulants completed an open stimulant monotherapy optimization protocol. Stimulant titration with weekly assessments of behavior and tolerability identified an optimal regimen for each child. Families also received behavioral therapy. Parents completed the Retrospective-Modified Overt Aggression Scale (R-MOAS) at each visit. Children were classified as having stimulant-refractory aggression on the basis of R-MOAS ratings and clinician judgment. Differences that pertained to treatment, demographic, and psychopathology between groups with stimulant monotherapy-responsive and -refractory aggression were evaluated.

RESULTS

Aggression among 32 (49.3%) of 65 children was reduced sufficiently after stimulant dosage adjustment and behavioral therapy to preclude adjunctive medication. Those who responded to stimulant monotherapy were more likely to benefit from the protocol's methylphenidate preparation (once-daily, triphasic release), showed a trend for lower average dosages, and received fewer behavioral therapy sessions than did children with stimulant-refractory aggression. Boys, especially those with higher ratings of baseline aggression and of depressive and manic symptoms, more often exhibited stimulant-refractory aggression.

CONCLUSIONS

Among children whose aggressive behavior develops in the context of ADHD and of oppositional defiant disorder or conduct disorder, and who had insufficient response to previous stimulant treatment in routine clinical care, systematic, well-monitored titration of stimulant monotherapy often culminates in reduced aggression that averts the need for additional agents.

Impulsive aggression in attention-deficit/hyperactivity disorder: symptom severity, co-morbidity, and attention-deficit/hyperactivity disorder subtype

OBJECTIVE

The aim of this study was to characterize aggression and its relationship to psychiatric co-morbidity, attention-deficit/hyperactivity disorder (ADHD) subtype, and ADHD symptom severity in clinically referred ADHD youngsters. We also wanted to ascertain whether reactive and impulsive aggression is more prevalent than proactive aggression in an ADHD sample.

METHOD

Consecutively referred ADHD children and adolescents (n = 268) and community controls (n = 100) were assessed systematically regarding demographics, psychiatric diagnosis, overt aggression severity, proactive and reactive aggression severity, and ADHD symptom severity using correlational analysis and analysis of covariance (ANCOVA).

RESULTS

Across all aggression measures, ADHD children were more aggressive than community controls. ADHD children with nonanxiety co-morbid disorders were more aggressive than ADHD children without such co-morbidity. The number of co-morbid psychiatric diagnoses and ADHD symptom severity were significantly associated with aggression. ADHD youngsters demonstrated significantly more reactive than proactive forms of aggression across all co-morbid diagnoses.

CONCLUSIONS

Aggression is common in clinically referred ADHD youngsters and should be identified as a legitimate target for psychopharmacological treatment in children and adolescents with moderate to severe ADHD and nonanxiety co-morbid diagnostic disorders.

[Algorithms for the medical treatment of Attention-Deficit/Hyperactivity Disorder with specific co-morbidities]

BACKGROUND

In clinical practice Attention Deficit Hyperactivity Disorder (ADHD) is a challenge for diagnostic and therapeutic effort due to a number of co-morbidities, e.g., depression, anxiety disorders, Tourette Syndrome and impulsive aggression that can be a complication or a result of the core symptoms or evolve parallel to the basic disorder. The therapeutic strategies incorporate a multimodal access with a combination of psychosocial, psychotherapeutic and medical measures. The combination of various medical substances for an effective treatment of these co-morbidities, especially Serotonin-Reuptake Inhibitors (SSRIs) and atypical neuroleptics with psychostimulants has substantially reduced the occurrence of the main symptoms of the disorder in many cases and thus can also lead to a decrease in the occurrence of co-morbidities. Where this strategy fails to suffice, it is recommended to consider medical treatment strategies in combination with other substances that alternatively or in combination with psychostimulants increasingly positively influence co-morbid symptoms.

OBJECTIVE AND METHOD

Based on a Medline literature search we report the results of combined medical approaches for an effective medical treatment of the ADHD core symptoms accompanied by serious co-morbid symptoms. Hereby we focused on the above cited disorders. Combined treatment options that include psychostimulants are considered in particular. Moreover, recommendations for medical treatment strategies oriented to the clinical cardinal symptoms are presented in the form of algorithms. Evidence-based literature and practical experience are critically reviewed.

RESULTS

In most cases it will be sufficient to begin the treatment with a psychostimulant because co-morbid symptoms also will be significantly reduced. However, if the latter are in the foreground of the clinical picture, antidepressants or neuroleptics are to be considered as primary or equivalent treatment options.

CONCLUSIONS

Since in Germany most of the substances discussed are not licensed for use in paediatric treatment, proofs of efficacy in children are lacking. One also must reckon with the frequent occurrence of side effects. Finally, little data exist on treatments that include the use of psychostimulants.

Liquid risperidone in the treatment of rages in psychiatrically hospitalized children with possible bipolar disorder

OBJECTIVE

To examine the safety and efficacy of liquid risperidone to reduce duration of rages in children with severe mood dysregulation (SMD) or possible bipolar disorder (BP).

METHOD

The sample included 151 consecutive admissions of 5-12 year old children to a psychiatric inpatient unit. Diagnostic information and history of prior rage outbursts were obtained at admission. In hospital, a first rage was treated with seclusion. If a second rage occurred, the child was offered liquid risperidone to help him/her regain control. Durations of unmedicated and last medicated rage were compared. Rage frequency in children with SMD and several definitions of BP were compared.

RESULTS

Although 82 of 151 admissions were prompted by rages, rages occurred during only 49 hospitalizations and occurred more than once in only 24. In 16 multiply medicated children, duration of rages dropped from a baseline of 44.4 +/- 20.2 min to 25.6 +/- 12.5 min at the child's last dose. Neither SMD nor any definition of BP influenced rage response in this small sample. The average liquid risperidone dose was 0.02 mg/kg. All but two children also took atypical antipsychotics daily. In the evaluation of medicated rage episodes with standard rating scales, no extrapyramidal side effects, akathisia, or abnormal involuntary movements were observed, and the rate of sedation/sleepiness (7/67 = 10.4%) was similar and not significantly different from that observed during nonmedicated episodes (8/46 = 17.4%).

CONCLUSIONS

Liquid risperidone may be a safe and effective way to shorten the duration of rage episodes regardless of diagnosis. However, definitive conclusions cannot be drawn in the absence of a placebo control as children were also receiving other behavioral and psychopharmacologic treatments.

Pharmacotherapy for aggressive behaviours in persons with intellectual disabilities: treatment or mistreatment?

BACKGROUND

Antipsychotic medications have been used extensively to treat aggressive behaviours in persons with intellectual disabilities (ID) when the main psychiatric diagnoses given to them in the past were schizophrenia, childhood psychoses and ID with behaviour problems. Today, antipsychotics are still estimated to comprise 30-50% of all the psychotropics prescribed for persons with ID, although the prevalence of psychotic disorders is only 3% in this population. The overuse of antipsychotics in persons with ID could be justified if their aggressive behaviours were associated with mostly psychotic disorders and not other psychiatric disorders or factors and if the anti-aggressive properties of the antipsychotics have been supported by basic research or reviews of clinical studies. Is that so? This article explores these questions.

METHODS

The literature on aggressive behaviours, their associations with psychiatric disorders and other contributing factors and the past and current treatment options for aggressive behaviours in persons with and without ID was reviewed. Also, the literature on basic research regarding the brain receptors implicated in aggressive behaviours and the basic research and clinical studies on the anti-aggressive properties of antipsychotics was reviewed.

RESULTS

Aggressive behaviours in persons with ID serve different functions and many factors contribute to their initiation, maintenance and exacerbations or attenuation including most of the psychiatric and personality disorders. Genetic disorders, early victimisation, non-enriched and restrictive environments during childhood or later on and traumatic brain injury, which are common in persons with ID, have been associated with aggressive behaviours and with mostly non-psychotic disorders in persons with and without ID. If the factors above and the knowledge derived from studies of domestic violence and premeditated aggression in persons without ID are considered and applied during the evaluation of the most severe aggressive behaviours in persons with ID, more appropriate and effective treatment than antipsychotics can be implemented. Basic research implicates mostly the GABA and the serotonin pre-post synaptic brain receptors influence the initiation, modulation or inhibition of aggression in animals. The anti-aggressive properties of the antipsychotics have not been supported by reviews of clinical studies and basic research is absent. Antipsychotics are the indicated treatment only for psychiatric disorders and for aggressive behaviours associated with psychotic disorders and psychotic features as activation of dopamine receptor leads to defensive aggression.

CONCLUSIONS

Most of the persons with ID and aggressive behaviours do not have a diagnosis of psychotic disorder and there is lack of strong evidence supporting the anti-aggressive properties of the antipsychotics. The overuse of antipsychotics in this population may be explained by the old, faulty notion that aggressive behaviour in persons with ID is mostly associated with psychotic disorders. Given the discrediting of this notion, the use of antipsychotics in persons with ID may, in some cases, be considered mistreatment rather than proper treatment. In order to reverse the practice of over-prescribing antipsychotics for aggressive behaviours in persons with ID, basic research information on aggression must be disseminated, the search for the 'quick fix' must be abandoned and the promotion of antipsychotics as anti-aggressive drugs must be discouraged. Matching the treatment with the variables contributing to the aggressive behaviours, seeking a long-term rather than a short-term solution and avoiding the promotion of only one type of treatment for all types of aggression might change the current practice and improve the quality of life for many persons with ID.

Trends in antipsychotic drug use by very young, privately insured children

OBJECTIVE

This study describes recent trends and patterns in antipsychotic treatment of privately insured children aged 2 through 5 years.

METHOD

A trend analysis is presented of antipsychotic medication use (1999-2001 versus 2007) stratified by patient characteristics. Data are analyzed from a large administrative database of privately insured individuals. Participants were privately insured children, aged 2 through 5 years, with 12 months of continuous service enrollment in 1999-2001 (N = 400,196) or 2007 (N = 755,793). The main outcomes are annualized rates of antipsychotic use and adjusted rate ratios (ARR) of year effect on rate of antipsychotic use adjusted for age, sex, and treated mental disorder.

RESULTS

The annualized rate of any antipsychotic use per 1,000 children increased from 0.78 (95% confidence interval [CI] 0.69-0.88) (1999-2001) to 1.59 (95% CI 1.50-1.68) (2007) (ARR 1.76, 95% CI 1.56-2.00). Significant increases in antipsychotic drug use were evident for boys (ARR 1.66, 95% CI 1.44-1.90) and girls (ARR 2.26, 95% CI 1.70-3.01) and for children diagnosed with several different psychiatric disorders. Among antipsychotic-treated children in the 2007 sample, pervasive developmental disorder or mental retardation (28.2%), attention deficit/hyperactivity disorder (ADHD) (23.7%), and disruptive behavior disorder (12.9%) were the most common clinical diagnoses. Fewer than one-half of antipsychotic-treated young children received a mental health assessment (40.8%), a psychotherapy visit (41.4%), or a visit with a psychiatrist (42.6%) during the year of antipsychotic use.

CONCLUSIONS

Despite increasing rates of antipsychotic use by very young children, provision of formal mental health services remains sparse. These service patterns highlight a critical need to improve the availability of specialized and well integrated mental health care for very young children with serious mental health problems.

Childhood psychopathology and sense of coherence at age 18: findings from the Finnish from a boy to a man study

OBJECTIVE

To examine associations between childhood psychopathology and family factors at age 8, and sense of coherence (SOC) at age 18.

METHODS

The sample includes 2,314 Finnish boys born 1981 with information about psychopathology from parents and teachers using Rutter scales, and self-reports of depressive symptoms using Child Depression Inventory (CDI), and self-reports of SOC at age 18.

RESULTS

Low parental education level and living in other than two biological parent family at age 8 were associated with low SOC 10 years later. Boys with internalizing symptoms based on parent/teacher reports, and depressive symptoms based on self-reports at age 8 were at risk for lower SOC at follow-up. Comorbidity of internalizing and conduct problems had the strongest association with low SOC.

CONCLUSION

The study shows that internalizing symptoms, comorbid conduct and emotional problems, low parental education level and nonintact family at age 8 predict low SOC at age 18. Future research whether universal, selective or indicated early interventions targeted on risk factors of childhood mental health problems may result in promotion of well-being (including good SOC) in early adulthood is warranted.

Adjunctive divalproex versus placebo for children with ADHD and aggression refractory to stimulant monotherapy

OBJECTIVE

The purpose of the present study was to evaluate the efficacy of divalproex for reducing aggressive behavior among children 6 to 13 years old with attention deficit hyperactivity disorder (ADHD) and a disruptive disorder whose chronic aggression was underresponsive to a prospective psychostimulant trial.

METHOD

Children received open stimulant treatment during a lead-in phase that averaged 5 weeks. Agent and dose were assessed weekly and modified to optimize response. Children whose aggressive behavior persisted at the conclusion of the lead-in phase were randomly assigned to receive double-blind, flexibly dosed divalproex or a placebo adjunctive to stimulant for 8 weeks. Families received weekly behavioral therapy throughout the trial. The primary outcome measure was the proportion of children whose aggressive behavior remitted, defined by post-trial ratings of negligible or absent aggression.

RESULT

A significantly higher proportion of children randomly assigned to divalproex met remission criteria (eight out of 14 [57%]) than those randomly assigned to placebo (two out of 13 [15%]). Divalproex was generally well tolerated.

CONCLUSIONS

Among children with ADHD whose chronic aggressive behavior is refractory to optimized stimulant treatment, the addition of divalproex increases the likelihood that aggression will remit. A larger trial is necessary to specify with greater precision the magnitude of benefit for adjuvant divalproex.

Drug-metabolizing enzyme genotypes and aggressive behavior treatment response in hospitalized pediatric psychiatric patients

OBJECTIVE

The aim of this study was to examine the association between the CYP2D6 and CYP2C19 genotype-predicted combined phenotypes and short-term measures of psychotropic efficacy and toxicity.

METHODS

A rater-blinded, retrospective genotype association design examined a cohort of hospitalized pediatric psychiatric patients genotyped for CYP2D6 and CYP2C19 as part of clinical care. These combined genotypes were used to predict a combined phenotype. The primary efficacy outcome measure was the behavior intervention score (BIS), a function of the number of recorded timeouts/seclusions, therapeutic holds, and physical restraints. Drug tolerability was defined as the total number of recorded adverse drug reactions.

RESULTS

Primary analysis was performed on 279 pediatric patients taking CYP2D6- or CYP2C19- dependent psychotropics. Combined phenotype was associated with BIS (p = 0.01) and number of adverse drug reactions (p = 0.03). Combined poor metabolizers treated with psychotropics had the lowest BIS (highest efficacy) and the highest number of adverse drug reactions. Combined ultrarapid metabolizers had the highest BIS (lowest efficacy) and the lowest number of adverse drug reactions.

CONCLUSION

Common variants in CYP2D6 and CYP2C19 are associated with the short-term efficacy and tolerability of psychotropic medications in hospitalized pediatric patients.

Disentangling impulsiveness, aggressiveness and impulsive aggression: an empirical approach using self-report measures

There is confusion in the literature concerning the concept of impulsive aggression. Based on previous research, we hypothesize that impulsivity and aggression may be related, though not as closely as to consider them the same construct. So, our aim was to provide empirical evidence of the relationship between the impulsivity and aggressiveness constructs when considered as traits. Two widely used questionnaires [Barratt's Impulsiveness Scale (BIS) and Aggression Questionnaire-Refined (AQ-R)] were administered to 768 healthy respondents. Product-moment and canonical correlations were then calculated. In addition, a principal components analysis was conducted to explore whether impulsive aggression can be defined phenotypically as the expression of a single trait. The common variance between impulsivity and aggressiveness was never higher than 42%. The principal components analysis reveals that one component is not enough to represent all the variables. In conclusion, our results show that impulsivity and aggressiveness are two separate, although related constructs. This is particularly important in view of the misconceptions in the literature.

Rages--what are they and who has them?

OBJECTIVE

The purpose of this study was to examine rages and define their associated clinical and diagnostic conditions systematically. Children's severe anger outbursts, sometimes called "rages," have been associated with many disorders, including mania, "severe mood dysregulation," and oppositional defiant/conduct disorder. Although reactive aggression has been studied extensively, there are almost no data on this important and disabling clinical phenomenon.

METHOD

A total of 130 different 5-12 year olds were hospitalized over 151 consecutive admissions were evaluated diagnostically with information from parents, children, doctors, nursing staff, and teachers. Rages were operationally defined as agitated/angry behaviors requiring seclusion or medication because the child could not be verbally redirected to "time out." Rage behaviors were categorized as they occurred with the specially designed Children's Agitation Inventory. Hypotheses were that rages would be associated with prior treatment failure, and that children with rages would have the most co-morbidities, including learning/language disorders. We did not expect narrow-phenotype bipolar disorder to be specifically associated with rages.

RESULTS

Of 130 children, 71 (54.6%) were admitted for rages. Preadmission rages and admission taking an atypical antipsychotic significantly predicted the subsequent number of in-hospital rages. Attention-deficit/hyperactivity disorder with learning/language disorder significantly predicted the occurrence and number of rages. Bipolar disorder was the referring diagnosis in 17/49 (34.7%) admissions with rages and 15/102 (14.7%) of admissions without rages (odds ratio [OR] 3.05, confidence interval [CI] 1.36, 6.80). However, a consensus diagnosis of bipolar disorder occurred in 5 (9.1%) of the sample with rages and 5 (5.8%) in the rest of admissions.

CONCLUSIONS

Psychiatrically hospitalized children with multiple rages have complex, chronic neuropsychiatric disorders and have failed prior conventional treatment. One third of children with rages had been given a bipolar diagnosis prior to admission. However, only 9% of children with rages were given that diagnosis after careful observation.

AACAP 2006 Research Forum--Advancing research in early-onset bipolar disorder: barriers and suggestions

OBJECTIVE

The 2006 Research Forum addressed the goal of formulating a research agenda for early-onset bipolar disorder (EOBP) and improving outcome by understanding the risk and protective factors that contribute to its severity and chronicity.

METHOD

Five work groups outlined barriers and research gaps in EOBP genetics, neuroimaging, prodromes, psychosocial factors, and pharmacotherapy.

RESULTS

There was agreement that the lack of consensus on the definition and diagnosis of EOBP is the primary barrier to advancing research in BP in children and adolescents. Related issues included: the difficulties in managing co-morbidity both statistically and clinically; acquiring adequate sample sizes to study the genetics, biology, and treatment; understanding the EOBP's developmental aspects; and identifying environmental mediators and moderators of risk and protection. Similarly, both psychosocial and medication treatment strategies for children with BP are hamstrung by diagnostic issues. To advance the research in EOBP, both training and funding mechanisms need to be developed with these issues in mind.

CONCLUSIONS

EOBP constitutes a significant public health concern. Barriers are significant but identifiable and thus are not insurmountable. To advance the understanding of EOBP, the field must be committed to resolving diagnostic and assessment issues. Once achieved, with adequate personnel and funding resources, research into the field of EOBP will doubtless be advanced at a rapid pace.

Psychometric properties of the Spanish adaptation of the Barratt Impulsiveness Scale-11-A for children

Given difficulty in having children assess their own behaviour, there are few self-reports on child impulsivity. With the exception of Eysenck's 16 questionnaire, there are no self-report measures of impulsivity in children with good psychometric properties. The present study tested the possibility of using the adolescent version of the Barratt Impulsiveness Scale-11 with children. For this purpose the questionnaire was translated and backtranslated and administered to school children (182 boys and 195 girls) ages 8 to 12 years (M = 10.4, SD = 0.9). The data were analysed by exploratory factor analysis, to evaluate the factorial structure of the questionnaire, the fit of the proposed solution, and internal consistency reliabilities. Results seem to indicate that this questionnaire may be useful in assessing impulsivity in children. The three-factor structure showed slight differences with the initial questionnaire proposed by Barratt and had good or sufficient internal consistency (depending upon the scale) across the 8- to 12-yr.-old age range.

Personality subtypes in disruptive adolescent males

This study examined whether personality differences might account for meaningful heterogeneity within and across DSM-IV diagnostic categories for disruptive adolescent boys. In a broader study of personality pathology in adolescence, a national sample of 293 clinicians completed the Shedler-Westen Assessment Procedure 200-A on randomly selected outpatients aged 14 to 18 in their care. Of 138 boys in the sample, 71 had a diagnosis of Disruptive Behavior Disorders or a history of arrests. Q-factor analysis identified 3 personality subtypes within this subsample: psychopathic (n = 28), social outcast (n = 22), and impulsive delinquent (n = 17). The subtypes differed on external criterion variables indicative of a valid taxonomic distinction, notably personality ratings, clinician-report child behavior checklist subscale scores, and etiologic variables. Personality subtypes converged with subtypes of delinquent boys identified by longitudinal research, and they showed substantial incremental validity in predicting adaptive functioning beyond Disruptive Behavior Disorders diagnoses. Results suggest that dimensional personality assessment in disruptive/delinquent adolescent boys provides information beyond existing diagnoses that may prove useful in prevention, clinical conceptualization, and treatment.

Ethical issues in psychopharmacology of children and adolescents

PURPOSE OF REVIEW

This summary of the literature published over recent years focuses on the ethical aspects of interventions with psychotropic medication in child and adolescent psychiatry. Ethical issues of pharmacotherapy concern aspects of research, safety, indicated use, enhancement, information and evidence-based practice.

RECENT FINDINGS

The literature on pharmacological interventions suggests changes in prescribing patterns for some substance classes owing to regulatory authorities' warnings. For most of the commonly used medications in children and adolescents no sound database about efficacy and safety is available and knowledge about adverse events and long-term safety remains poor. This is due to a general lack of clinical trials in this population. Legislative efforts have tried to improve safety and labelling of medicines for children. Ethical issues of enhancement in minors have been increasingly discussed over recent years.

SUMMARY

The ethical aspects of psychopharmacotherapy in minors are still rarely discussed in the literature. Practical questions of research and treatment ethics such as a need for information for children and parents are pointed out; conflicts of evocation and access to care for special populations in need are identified in a field lacking adequate ethical and clinical research.

Current research in child and adolescent bipolar disorder

Although recently more research has considered children with bipolar disorder than in the past, much controversy still surrounds the validity of the diagnosis. Furthermore, questions remain as to whether or not childhood expressions of bipolarity are continuous with adult manifestations of the illness. In order to advance current knowledge of bipolar disorders in children, researchers have begun to conduct phenomenological, longitudinal, treatment, and neuroimaging studies in youths who exhibit symptoms of bipolar illness, as well as offspring of parents with bipolar disorders. Regardless of the differences between research groups regarding how bipolar disorder in children is defined, it is agreed that pediatric bipolarity is a serious and pernicious illness. With early intervention during the period of time in which youths are exhibiting subsyndromal symptoms of pediatric bipolarity, it appears that the progression of the illness to the more malignant manifestation of the disorder may be avoided. This paper will review what is currently known and what still is left to learn about clinically salient topics that pertain to bipolar disorder in children and adolescents.