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Marques S, Correia-de-Sá T, Guardiano M, Sampaio-Maia B, Ferreira-Gomes J. Emotion dysregulation and depressive symptoms mediate the association between inhibitory control difficulties and aggressive behaviour in children with ADHD. Front Psychiatry 2024; 15:1329401. [PMID: 38690203 PMCID: PMC11059059 DOI: 10.3389/fpsyt.2024.1329401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 04/02/2024] [Indexed: 05/02/2024] Open
Abstract
Background/objectives Impulsive aggressive behaviour, although not a core symptom, is often part of the clinical presentation of attention-deficit/hyperactivity disorder (ADHD). Recently, impulsive aggression has been attributed to emotion dysregulation, which is currently conceptualised as a transdiagnostic factor and seems to contribute to the co-occurrence of other problems in ADHD. Thus, this study investigated the presence of impulsive aggressive behaviour and explored whether emotion dysregulation mediates the relationship between inhibitory control difficulties and aggressive behaviour in children with ADHD. Because ADHD may act as a risk factor for the development of other conditions, such as internalising problems, we aimed to understand whether depressive symptoms contribute to this relationship. Methods Seventy-two children were recruited from a hospital and the community, 38 of whom had ADHD and 34 were typically developing (TD). Parents completed the Child Behaviour Checklist, the Behaviour Rating Inventory of Executive Function, and the Emotion Regulation Checklist. Simple mediation and serial mediation models were performed to test our hypotheses. Results Aggressive behaviour was significantly higher in ADHD children compared to TD children. Emotion dysregulation fully mediated the relationship between inhibitory control difficulties and aggressive behaviour in ADHD children. Adding depressive symptoms to the model increased the explained variance in aggressive behaviour. Conclusion The main result of our study supports the role of emotion dysregulation and depressive symptoms in mediating the relationship between inhibitory control difficulties and impulsive aggressive behaviour in children with ADHD. This highlights that aggressive behaviour is, in part, a result of the inability of the child to appropriately regulate their emotions. Future interventions may be tailored to improve emotion regulation skills to address aggressive behaviour.
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Affiliation(s)
- Sofia Marques
- Institute of Psychology and Educational Sciences, Lusíada University, Porto, Portugal
- CIPD—Psychology for Development Research Centre, Lusíada University, Porto, Portugal
| | - Teresa Correia-de-Sá
- Department of Biomedicine, Faculty of Medicine, University of Porto, Porto, Portugal
- INEB—Institute of Biomedical Engineering, University of Porto, Porto, Portugal
- i3S—Institute for Research & Innovation in Health, University of Porto, Porto, Portugal
| | - Micaela Guardiano
- Department of Paediatrics, Unit of Neurodevelopmental Paediatrics, University Hospital Centre of São João, Porto, Portugal
| | - Benedita Sampaio-Maia
- INEB—Institute of Biomedical Engineering, University of Porto, Porto, Portugal
- i3S—Institute for Research & Innovation in Health, University of Porto, Porto, Portugal
- Faculty of Dental Medicine, University of Porto, Porto, Portugal
| | - Joana Ferreira-Gomes
- Department of Biomedicine, Faculty of Medicine, University of Porto, Porto, Portugal
- i3S—Institute for Research & Innovation in Health, University of Porto, Porto, Portugal
- IBMC—Institute for Molecular and Cell Biology, University of Porto, Porto, Portugal
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Carlson GA, Althoff RR, Singh MK. Future Directions: The Phenomenology of Irritable Mood and Outbursts: Hang Together or Hang Separately 1. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY : THE OFFICIAL JOURNAL FOR THE SOCIETY OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY, AMERICAN PSYCHOLOGICAL ASSOCIATION, DIVISION 53 2024; 53:309-327. [PMID: 38588602 DOI: 10.1080/15374416.2024.2332999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/10/2024]
Abstract
Recognition of the importance of irritable mood and outbursts has been increasing over the past several decades. This "Future Directions" aims to develop a set of recommendations for future research emphasizing that irritable mood and outbursts "hang together," but have important distinctions and thus also need to "hang separately." Outbursts that are the outcome of irritable mood may be quite different from outbursts that are the trigger or driving force that make youth and his/her environment miserable. What, then, is the relation between irritable mood and outbursts? As the field currently stands, we not only cannot answer this question, but we may also lack the tools to effectively do so. Here, we will propose recommendations for understanding the phenomenology of irritable mood and outbursts so that more directed and clinically useful assessment tools can be designed. We discuss the transdiagnostic and treatment implications that relate to improvements in measurement. We describe the need to do more than repurpose our current assessment tools, specifically interviews and rating scales, which were designed for different purposes. The future directions of the study and treatment of irritable mood and outbursts will require, among others, using universally accepted nomenclature, supporting the development of tools to measure the characteristics of each irritable mood and outbursts, understanding the effects of question order, informant, development and longitudinal course, and studying the ways in which outbursts and irritable mood respond to treatment.
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Affiliation(s)
- Gabrielle A Carlson
- Psychiatry and Pediatrics, Renaissance School of Medicine at Stony Brook University
| | - Robert R Althoff
- Psychiatry, Pediatrics, & Psychological Science, University of Vermont
| | - Manpreet Kaur Singh
- Professor of Psychiatry and Behavioral Sciences, University of California Davis School of Medicine
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3
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Hawker P, Bellamy J, McHugh C, Wong TY, Williams K, Wood A, Anderson V, Tonge BJ, Ward P, Sciberras E, Bellgrove MA, Silk T, Lin PI, Eapen V. Effectiveness of lifestyle interventions for improving the physical health of children and adolescents taking antipsychotic medications: protocol for a systematic review and meta-analysis. BMJ Open 2023; 13:e073893. [PMID: 37890972 PMCID: PMC10619077 DOI: 10.1136/bmjopen-2023-073893] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 10/04/2023] [Indexed: 10/29/2023] Open
Abstract
INTRODUCTION Children and adolescents are increasingly prescribed antipsychotic medications off-label in the treatment of behavioural disorders. While antipsychotic medications are effective in managing behavioural issues, they carry a significant risk of adverse events that compromise ongoing physical health. Of particular concern is the negative impact antipsychotic medications have on cardiometabolic health. Interventions that aim to modify lifestyle habits have the potential to alleviate the adverse effects of antipsychotic medication by enhancing weight management, increasing physical activity, promoting better nutritional practices, improving dietary habits and promoting healthier sleep patterns and sleep hygiene. However, a comprehensive review has not been performed to ascertain the effectiveness of lifestyle interventions for children and adolescents who are at increased risk of antipsychotic-induced compromises to their physical health. METHODS AND ANALYSIS This systematic review will follow the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. Four databases will be searched without any year constraints to identify randomised controlled trials that are published in the English language and report a lifestyle intervention compared with usual care with any physical health outcome measure. Trial registers and results repositories will be scoured to identify additional studies. Two reviewers will independently conduct screening, data extraction and quality assessment and compare the results. Quantitative data will be synthesised, where appropriate, through a random-effects meta-analysis model. Otherwise, data will be reported in a qualitative (narrative) synthesis. Heterogeneity will be quantified using the I2 statistic. The Cochrane Risk of Bias 2 tool will be used for risk of bias assessment. The Grading of Recommendations, Assessment, Development and Evaluation system will be used to evaluate the cumulative body of evidence. ETHICS AND DISSEMINATION Ethics approval is not required. The publication plan will target high-impact, peer-reviewed journals that fall under the scope of Psychiatry and Mental Health. PROSPERO REGISTRATION NUMBER CRD42022380277.
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Affiliation(s)
- Patrick Hawker
- Discipline of Psychiatry & Mental Health, UNSW, Sydney, New South Wales, Australia
| | - Jessica Bellamy
- University of Wollongong, Wollongong, New South Wales, Australia
| | - Catherine McHugh
- Discipline of Psychiatry & Mental Health, UNSW, Sydney, New South Wales, Australia
| | - Tsz Ying Wong
- Discipline of Psychiatry & Mental Health, UNSW, Sydney, New South Wales, Australia
| | | | - Amanda Wood
- Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - Vicki Anderson
- The Royal Children's Hospital Melbourne, Melbourne, Victoria, Australia
| | | | - Philip Ward
- Discipline of Psychiatry & Mental Health, UNSW, Sydney, New South Wales, Australia
| | | | | | - Tim Silk
- Deakin University, Burwood, Victoria, Australia
| | - Ping-I Lin
- UNSW, Sydney, New South Wales, Australia
- Neuroscience Research Australia, Randwick, New South Wales, Australia
| | - Valsamma Eapen
- Discipline of Psychiatry & Mental Health, UNSW, Sydney, New South Wales, Australia
- ICAMHS, South Western Sydney Local Health District, Liverpool, New South Wales, Australia
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4
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Evans SC, Shaughnessy S, Karlovich AR. Future Directions in Youth Irritability Research. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY : THE OFFICIAL JOURNAL FOR THE SOCIETY OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY, AMERICAN PSYCHOLOGICAL ASSOCIATION, DIVISION 53 2023; 52:716-734. [PMID: 37487108 DOI: 10.1080/15374416.2023.2209180] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
Research on irritability in children and adolescents has proliferated over the last 20 years. The evidence shows the clinical and developmental significance of irritable mood and behavior in youth, and it has led to significant changes in mental health classification, diagnosis, and services. At the same time, this research (including our own) has led to relatively little new in terms of practical, empirically based guidance to improve interventions and outcomes. In this article, we briefly summarize some of these developments and current evidence-based practices. We then put forth two key substantive challenges (the "whats") for future research to address: (a) the need for more effective treatments, especially evaluating and adapting evidence-based treatments that are already well-established for problems related to irritability (e.g., cognitive-behavioral therapies for internalizing and externalizing problems); and (b) the need for a better mechanistic understanding of irritability's phenomenology (e.g., phasic vs. tonic irritability, how frustration unfolds) and putative underlying mechanisms (e.g., cognitive control, threat and reward dysfunction). Lastly, we suggest three methodological approaches (the "hows") that may expedite progress in such areas: (a) ecological momentary assessment, (b) digital health applications, and (c) leveraging existing datasets. We hope this article will be useful for students and early-career researchers interested in tackling some of these important questions to better meet the needs of severely irritable youth.
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Wojciechowski T. ADHD as a Predictor of Quicker Time to Violent Recidivism and a Moderator of the Exposure to Violence-Violent Recidivism Relationship. VIOLENCE AND VICTIMS 2023; 38:593-610. [PMID: 37380339 DOI: 10.1891/vv-2021-0183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
Research on the role that attention-deficit hyperactivity disorder (ADHD) plays as a moderator of the relationship between exposure to violence and violent recidivism is limited. The Pathways to Desistance data were analyzed to examine these relationships. Survival analysis was used to examine ADHD as a risk factor predicting time to violent recidivism. Cox-proportional hazard modeling was used to assess the impact of ADHD on violent recidivism risk and examine ADHD as a moderator of the relationship between exposure to violence and violent recidivism. Results indicated that ADHD predicted quicker time to recidivism. The effect of witnessed violence was significantly weaker for participants with ADHD at baseline than those without ADHD at baseline. The direct effect of ADHD diagnosis at baseline on violent recidivism risk was only significant when the hypothesized interaction terms were included in the model. These findings suggest that individuals with ADHD may be less vulnerable to the impact of witnessing violence on their own risk for perpetrating violence. Effective targeting of treatment should be understood within this context.
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Stepanova E, Langfus JA, Youngstrom EA, Evans SC, Stoddard J, Young AS, Van Eck K, Findling RL. Finding a Needed Diagnostic Home for Children with Impulsive Aggression. Clin Child Fam Psychol Rev 2023; 26:259-271. [PMID: 36609931 DOI: 10.1007/s10567-022-00422-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/19/2022] [Indexed: 01/09/2023]
Abstract
Aggressive behavior is one of the most common reasons for referrals of youth to mental health treatment. While there are multiple publications describing different types of aggression in children, it remains challenging for clinicians to diagnose and treat aggressive youth, especially those with impulsively aggressive behaviors. The reason for this dilemma is that currently several psychiatric diagnoses include only some of the common symptoms of aggression in their criteria. However, no single diagnosis or diagnostic specifier adequately captures youth with impulsive aggression (IA). Here we review select current diagnostic categories, including behavior and mood disorders, and suggest that they do not provide an adequate description of youth with IA. We also specifically focus on the construct of IA as a distinct entity from other diagnoses and propose a set of initial, provisional diagnostic criteria based on the available evidence that describes youth with IA to use for future evaluation.
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Affiliation(s)
- Ekaterina Stepanova
- Virginia Commonwealth University, 1308 Sherwood Ave, Richmond, VA, 23220, USA.
| | - Joshua A Langfus
- University of North Carolina at Chapel Hill, 235 E Cameron Ave, CB# 3270, Chapel Hill, NC, 27514, USA
| | - Eric A Youngstrom
- University of North Carolina at Chapel Hill, 103 Westchester Pl, Chapel Hill, NC, 27514-5237, USA
| | - Spencer C Evans
- University of Miami, 5665 Ponce de Leon Blvd, Coral Gables, FL, 33146, USA
| | - Joel Stoddard
- University of Colorado Anschutz Medical Campus, Aurora, 13123 East 16Th Ave, Aurora, CO, 80045, USA
| | - Andrea S Young
- Johns Hopkins University, 1800 Orleans Street, Bloomberg 12N, Baltimore, MD, 21287, USA
| | - Kathryn Van Eck
- Johns Hopkins University, 1800 Orleans Street, Bloomberg 12N, Baltimore, MD, 21287, USA
| | - Robert L Findling
- Virginia Commonwealth University, 501 N 2Nd St 4Th Floor, PO Box 980308, Richmond, VA, 23298-0308, USA
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7
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Youngstrom EA, Young AS, Van Eck K, Stepanova E, Langfus JA, Carlson G, Findling RL. Developing Empirical Latent Profiles of Impulsive Aggression and Mood in Youths across Three Outpatient Samples. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY : THE OFFICIAL JOURNAL FOR THE SOCIETY OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY, AMERICAN PSYCHOLOGICAL ASSOCIATION, DIVISION 53 2023; 52:196-211. [PMID: 34125637 PMCID: PMC9173587 DOI: 10.1080/15374416.2021.1929251] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE Aggression with impulsivity and reactivity (AIR) may distinguish a subset of youth from those with attention problems, rule-breaking behavior, or mood disorders, potentially with differential treatment response. Yet, DSM-5 and ICD-10 do not include an AIR diagnosis. Thus, we empirically grouped youths into profiles based on AIR, manic, depressive, rule-breaking, and self-harm behaviors; examined which profiles replicated across three samples; and characterized profile sets on demographic and clinical features. METHOD After harmonizing data from three samples (n = 679, n = 392, n = 634), Latent Profile Analysis (LPA) assigned youth to profiles based on caregiver-reported measures of AIR, manic, depressive, rule-breaking, and self-harm behaviors. Profiles from each sample were grouped into sets based on profile similarity. Analyses tested differences in diagnoses, sex, and race, age, functioning, and mood severity. RESULTS Eight-profile solutions fit best. Seven profiles replicated across samples: high AIR and self-harm, lower depressive and manic scores; high AIR, manic symptoms, and self-harm; high depression symptoms; three smaller sets with high manic and depressive symptoms and moderate AIR; and two high rates of bipolar diagnoses and family bipolar history. Two sets were high on both AIR and mood symptoms, were the most impaired, and had the highest comorbidity. CONCLUSIONS Analyses support an empirical definition of AIR, separate from mood disorders. Profile sets distinguished by level of AIR and mood symptoms differed in demographic and diagnostic characteristics as well as functioning. Importantly, a set emerged with high AIR but low mood indicators and with high rates of ADHD and ODD, but not mood disorder.
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Affiliation(s)
- Eric A Youngstrom
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill
| | | | | | | | - Joshua A Langfus
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill
| | - Gabrielle Carlson
- Department of Psychiatry, State University of New York at Stony Brook
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8
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Baweja R, Waxmonsky JG. Updates in Pharmacologic Strategies for Emotional Dysregulation in Attention Deficit Hyperactivity Disorder. Child Adolesc Psychiatr Clin N Am 2022; 31:479-498. [PMID: 35697397 DOI: 10.1016/j.chc.2022.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Emotional dysregulation (ED) manifesting as irritability or aggression produces appreciable impairment in children with attention deficit hyperactivity disorder and a main reason why they present for treatment. Central nervous system (CNS) stimulants seem to be a safe and tolerable treatment of most youth with these presentations. Optimization of CNS stimulants dose in combination with psychosocial interventions led to reductions in ED. Randomized controlled trials support that addition of risperidone further reduces aggression when these treatments are not sufficient. There is evidence for the efficacy of divalproex, molindone and selective serotonin reuptake inhibitor improve these outcomes when used as adjunct to CNS stimulants.
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Affiliation(s)
- Raman Baweja
- Department of Psychiatry and Behavioral Health, Penn State College of Medicine, 500 University Drive, Hershey, PA 17033, USA.
| | - James G Waxmonsky
- Department of Psychiatry and Behavioral Health, Penn State College of Medicine, 500 University Drive, Hershey, PA 17033, USA
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9
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Long H, Fan M, Li Q, Yang X, Huang Y, Xu X, Ma J, Xiao J, Jiang T. Structural and functional biomarkers of the insula subregions predict sex differences in aggression subscales. Hum Brain Mapp 2022; 43:2923-2935. [PMID: 35289969 PMCID: PMC9120556 DOI: 10.1002/hbm.25826] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Revised: 01/22/2022] [Accepted: 02/23/2022] [Indexed: 01/01/2023] Open
Abstract
Aggression is a common and complex social behavior that is associated with violence and mental diseases. Although sex differences were observed in aggression, the neural mechanism for the effect of sex on aggression behaviors remains unclear, especially in specific subscales of aggression. In this study, we investigated the effects of sex on aggression subscales, gray matter volume (GMV), and functional connectivity (FC) of each insula subregion as well as the correlation of aggression subscales with GMV and FC. This study found that sex significantly influenced (a) physical aggression, anger, and hostility; (b) the GMV of all insula subregions; and (c) the FC of the dorsal agranular insula (dIa), dorsal dysgranular insula (dId), and ventral dysgranular and granular insula (vId_vIg). Additionally, mediation analysis revealed that the GMV of bilateral dIa mediates the association between sex and physical aggression, and left dId–left medial orbital superior frontal gyrus FC mediates the relationship between sex and anger. These findings revealed the neural mechanism underlying the sex differences in aggression subscales and the important role of the insula in aggression differences between males and females. This finding could potentially explain sexual dimorphism in neuropsychiatric disorders and improve dysregulated aggressive behavior.
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Affiliation(s)
- Haixia Long
- College of Computer Science and Technology, Zhejiang University of Technology, Hangzhou, China
| | - Ming Fan
- Institute of Biomedical Engineering and Instrumentation, Hangzhou Dianzi University, Hangzhou, China
| | - Qiaojun Li
- School of Information Engineering, Tianjin University of Commerce, Tianjin, China
| | - Xuhua Yang
- College of Computer Science and Technology, Zhejiang University of Technology, Hangzhou, China
| | - Yujiao Huang
- Zhijiang College, Zhejiang University of Technology, Hangzhou, China
| | - Xinli Xu
- College of Computer Science and Technology, Zhejiang University of Technology, Hangzhou, China
| | - Ji Ma
- College of Computer Science and Technology, Zhejiang University of Technology, Hangzhou, China
| | - Jie Xiao
- College of Computer Science and Technology, Zhejiang University of Technology, Hangzhou, China
| | - Tianzi Jiang
- Brainnetome Center and National Laboratory of Pattern Recognition, Institute of Automation, Chinese Academy of Sciences, Beijing, China.,School of Artificial Intelligence, University of Chinese Academy of Sciences, Beijing, China.,CAS Center for Excellence in Brain Science and Intelligence Technology, Institute of Automation, Chinese Academy of Sciences, Beijing, China.,The Clinical Hospital of Chengdu Brain Science Institute, MOE Key Lab for Neuroinformation, University of Electronic Science and Technology of China, Chengdu, China.,The Queensland Brain Institute, University of Queensland, Brisbane, Queensland, Australia
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10
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Joseph JJ, Mela M, Pei J. Aggressive behaviour and violence in children and adolescents with FASD: A synthesizing review. Clin Psychol Rev 2022; 94:102155. [DOI: 10.1016/j.cpr.2022.102155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 02/09/2022] [Accepted: 03/23/2022] [Indexed: 11/03/2022]
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11
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Sherwood SN, Carlson GA, Freeman AJ. Decreasing rate of inpatient pediatric bipolar disorder diagnosis in the US between 2004 and 2010. Bipolar Disord 2022; 24:149-160. [PMID: 34664344 DOI: 10.1111/bdi.13145] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 10/05/2021] [Accepted: 10/09/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Diagnosis of bipolar disorder (BD) increased substantially among youth between the mid-1990s and mid-2000s in the United States. This dramatic increase in diagnosis resulted in concern regarding the potential for misdiagnosis of BD among youth. However, the rate of BD diagnosis in the United States had not been evaluated nationally since the mid-2000s. It was unclear whether changes in diagnostic rates continued to occur. Therefore, the present study aimed to assess the pattern of longitudinal trends in the rate of national inpatient BD diagnosis subsequent to 2004. METHODS Data included a nationally representative dataset of inpatient hospitalizations between 1996 and 2010. De-identified data were obtained from the National Hospital Discharge Survey (NHDS) conducted annually by the National Center for Health Statistics. RESULTS The proportion of BD diagnoses relative to all psychiatric diagnoses increased between 1996 and 2004 among children and adolescents. The proportion of BD diagnoses then decreased between 2004 and 2010 among children but continued to increase for adolescents. However, population-adjusted rates of BD diagnosis per 10,000 individuals in the general population initially increased until the mid-2000s and then decreased until 2010 for both children and adolescents. CONCLUSIONS Rates of BD diagnosis substantially decreased for youth between the mid-2000s and 2010. This decline coincided with recommendations for more conservative diagnostic practices due to concerns about overdiagnosis and increasing awareness of the side effects of front-line medications used to treat BD in youth. Findings provide insight into changing trends in inpatient service utilization for BD in the United States.
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Affiliation(s)
| | - Gabrielle A Carlson
- Psychiatry and Pediatrics, State University of New York at Stony Brook, East Setauket, New York, USA
| | - Andrew J Freeman
- Department of Psychology, University of Nevada, Las Vegas, Nevada, USA.,Division of Child and Family Services, Nevada Department of Health and Human Services, Las Vegas, Nevada, USA
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12
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Ibrahim K, Noble S, He G, Lacadie C, Crowley MJ, McCarthy G, Scheinost D, Sukhodolsky DG. Large-scale functional brain networks of maladaptive childhood aggression identified by connectome-based predictive modeling. Mol Psychiatry 2022; 27:985-999. [PMID: 34690348 PMCID: PMC9035467 DOI: 10.1038/s41380-021-01317-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Revised: 09/07/2021] [Accepted: 09/22/2021] [Indexed: 01/05/2023]
Abstract
Disruptions in frontoparietal networks supporting emotion regulation have been long implicated in maladaptive childhood aggression. However, the association of connectivity between large-scale functional networks with aggressive behavior has not been tested. The present study examined whether the functional organization of the connectome predicts severity of aggression in children. This cross-sectional study included a transdiagnostic sample of 100 children with aggressive behavior (27 females) and 29 healthy controls without aggression or psychiatric disorders (13 females). Severity of aggression was indexed by the total score on the parent-rated Reactive-Proactive Aggression Questionnaire. During fMRI, participants completed a face emotion perception task of fearful and calm faces. Connectome-based predictive modeling with internal cross-validation was conducted to identify brain networks that predicted aggression severity. The replication and generalizability of the aggression predictive model was then tested in an independent sample of children from the Adolescent Brain Cognitive Development (ABCD) study. Connectivity predictive of aggression was identified within and between networks implicated in cognitive control (medial-frontal, frontoparietal), social functioning (default mode, salience), and emotion processing (subcortical, sensorimotor) (r = 0.31, RMSE = 9.05, p = 0.005). Out-of-sample replication (p < 0.002) and generalization (p = 0.007) of findings predicting aggression from the functional connectome was demonstrated in an independent sample of children from the ABCD study (n = 1791; n = 1701). Individual differences in large-scale functional networks contribute to variability in maladaptive aggression in children with psychiatric disorders. Linking these individual differences in the connectome to variation in behavioral phenotypes will advance identification of neural biomarkers of maladaptive childhood aggression to inform targeted treatments.
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Affiliation(s)
- Karim Ibrahim
- Child Study Center, Yale University School of Medicine, New Haven, CT, USA.
| | - Stephanie Noble
- Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - George He
- Department of Psychology, Yale University, New Haven, CT, USA
| | - Cheryl Lacadie
- Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, CT, USA
| | - Michael J Crowley
- Child Study Center, Yale University School of Medicine, New Haven, CT, USA
| | | | - Dustin Scheinost
- Child Study Center, Yale University School of Medicine, New Haven, CT, USA
- Department of Diagnostic Radiology, Yale University School of Medicine, New Haven, CT, USA
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13
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Harima Y, Miyawaki D, Goto A, Hirai K, Sakamoto S, Hama H, Kadono S, Nishiura S, Inoue K. Associations Between Chronic Irritability and Sensory Processing Difficulties in Children and Adolescents. Front Psychiatry 2022; 13:860278. [PMID: 35573381 PMCID: PMC9095987 DOI: 10.3389/fpsyt.2022.860278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2022] [Accepted: 04/05/2022] [Indexed: 11/13/2022] Open
Abstract
Irritability is one of the most common reasons for which children and adolescents are referred for psychiatric evaluation and care. However, clinical irritability is difficult to define; thus, its prevalence varies widely. Chronic irritability may be associated with sensory processing difficulties (SPD), but little is known about the relationship between these two factors in clinical populations. In this study, we examined the prevalence of chronic irritability and its association with SPD in 166 children aged 5-16 years who were referred to the psychiatric outpatient clinic of the Osaka City University Hospital. Chronic irritability and parent-reported scores for the Short Sensory Profile, Infant Behavior Checklist-Revised, Child Behavior Checklist, and Kiddie Schedule for Affective Disorders and Schizophrenia for School-Age Children (Present and Lifetime version) questionnaires were used for assessment. A total of 22 children (13.2%) presented with chronic irritability (i.e., the irritability group) and were more likely to have oppositional defiant disorder, externalizing problems, and attention issues than those without chronic irritability (i.e., the control group). SPD were reported in eight (36%) patients in the irritability group and in 21 (15%) in the control group (p = 0.029). Moreover, compared to the control group, the irritability group showed a significant difference in almost all items of the Short Sensory Profile. Chronic irritability was associated with more severe overall SPD, even after adjusting for possible confounding factors (internalizing and externalizing problems, age, sex, and low income). We provide evidence to support our hypothesis that chronic irritability is associated with SPD in children and adolescents. Therefore, SPD should be assessed to provide appropriate interventions in children and adolescents with chronic irritability.
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Affiliation(s)
- Yuji Harima
- Department of Neuropsychiatry, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Dai Miyawaki
- Department of Neuropsychiatry, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Ayako Goto
- Department of Neuropsychiatry, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Kaoru Hirai
- Department of Neuropsychiatry, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan.,Department of Pediatrics, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Shoko Sakamoto
- Department of Neuropsychiatry, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Hiroki Hama
- Department of Neuropsychiatry, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Shin Kadono
- Department of Neuropsychiatry, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Sayaka Nishiura
- Department of Neuropsychiatry, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
| | - Koki Inoue
- Department of Neuropsychiatry, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
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14
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Sukhodolsky DG, Ibrahim K, Kalvin CB, Jordan RP, Eilbott J, Hampson M. Increased amygdala and decreased frontolimbic r esting- s tate functional connectivity in children with aggressive behavior. Soc Cogn Affect Neurosci 2021; 17:634-644. [PMID: 34850939 PMCID: PMC9250305 DOI: 10.1093/scan/nsab128] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 10/08/2021] [Accepted: 11/30/2021] [Indexed: 11/13/2022] Open
Abstract
Childhood maladaptive aggression is associated with disrupted functional connectivity within amygdala-prefrontal circuitry. In this study, neural correlates of childhood aggression were probed using the intrinsic connectivity distribution, a voxel-wise metric of global resting-state brain connectivity. This sample included 38 children with aggressive behavior (26 boys, 12 girls) ages 8-16 years and 21 healthy controls (14 boys, 6 girls) matched for age and IQ. Functional MRI data were acquired during resting state, and differential patterns of intrinsic functional connectivity were tested in a priori regions of interest implicated in the pathophysiology of aggressive behavior. Next, correlational analyses tested for associations between functional connectivity and severity of aggression measured by the Reactive-Proactive Aggression Questionnaire in children with aggression. Children with aggressive behavior showed increased global connectivity in the bilateral amygdala relative to controls. Greater severity of aggressive behavior was associated with decreasing global connectivity in the dorsal anterior cingulate and ventromedial prefrontal cortex. Follow-up seed analysis revealed that aggression was also positively correlated with left amygdala connectivity with the dorsal anterior cingulate, ventromedial and dorsolateral prefrontal cortical regions. These results highlight the potential role of connectivity of the amygdala and medial prefrontal and anterior cingulate cortices in modulating the severity of aggressive behavior in treatment-seeking children.
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Affiliation(s)
- Denis G Sukhodolsky
- Correspondence should be addressed to Denis G. Sukhodolsky, Child Study Center, Yale School of Medicine, 230 South Frontage Road, New Haven, CT 06520, USA. E-mail:
| | - Karim Ibrahim
- Child Study Center, Yale School of Medicine, New Haven, CT 06520, USA
| | - Carla B Kalvin
- Child Study Center, Yale School of Medicine, New Haven, CT 06520, USA
| | - Rebecca P Jordan
- Child Study Center, Yale School of Medicine, New Haven, CT 06520, USA
| | - Jeffrey Eilbott
- Child Study Center, Yale School of Medicine, New Haven, CT 06520, USA,SurveyBott Consulting, Guilford, CT 06437, USA
| | - Michelle Hampson
- Child Study Center, Yale School of Medicine, New Haven, CT 06520, USA,Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT 06520, USA,Department of Psychiatry, Yale School of Medicine, New Haven, CT 06520, USA,Department of Biomedical Engineering, Yale University, New Haven, CT 06520, USA
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15
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Closing the gap: unmet needs of individuals with impulsive aggressive behavior observed in children and adolescents. CNS Spectr 2021; 26:448-456. [PMID: 32228725 DOI: 10.1017/s1092852920001224] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Impulsive aggressive (IA, or impulsive aggression) behavior describes an aggregate set of maladaptive, aggressive behaviors occurring across multiple neuropsychiatric disorders. IA is reactive, eruptive, sudden, and unplanned; it provides information about the severity, but not the nature, of its associated primary disorder. IA in children and adolescents is of serious clinical concern for patients, families, and physicians, given the detrimental impact pediatric IA can have on development. Currently, the ability to properly identify, monitor, and treat IA behavior across clinical populations is hindered by two major roadblocks: (1) the lack of an assessment tool designed for and sensitive to the set of behaviors comprising IA, and (2) the absence of a treatment indicated for IA symptomatology. In this review, we discuss the clinical gaps in the approach to monitoring and treating IA behavior, and highlight emerging solutions that may improve clinical outcomes in patients with IA.
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16
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Ceresoli-Borroni G, Nasser A, Adewole T, Liranso T, Xu J, Schwabe S, Findling RL. A Double-Blind, Randomized Study of Extended-Release Molindone for Impulsive Aggression in ADHD. J Atten Disord 2021; 25:1564-1577. [PMID: 32338106 DOI: 10.1177/1087054720909084] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: To evaluate efficacy and safety of SPN-810 (extended-release molindone) in a Phase-2b, randomized, double-blind, placebo-controlled, dose-ranging study of children (6-12 years) with ADHD and persistent impulsive aggression (IA). Method: After lead-in, children were randomized to (a) placebo (N = 31); (b) low-dose (N = 29, 12/18 mg/day); (c) medium-dose (N = 30, 24/36 mg/day); and (4) high-dose (N = 31, 36/54 mg/day) groups. Treatment included ~2.5-week titration, 3-week maintenance, and 1-week tapering/conversion, alongside existing monotherapy (stimulants/nonstimulants) and behavioral therapy. The primary endpoint was change in Retrospective-Modified Overt Aggression Scale (R-MOAS) score at end of study, with safety monitored. Results: A total of 95 (78.5%) children completed the study. Aggression (R-MOAS) improved with low and medium doses (low dose: p = .031; medium dose: p = .024; high dose: p = .740). The most common adverse events were headache (10.0%), sedation (8.9%), and increased appetite (7.8%). Conclusion: These results suggest SPN-810 may be effective in reducing residual IA behaviors in children with ADHD. Research is still needed to support the benefit-risk profile of SPN-810 in pediatric populations.
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Affiliation(s)
| | - Azmi Nasser
- Supernus Pharmaceuticals, Inc., Rockville, MD, USA
| | | | | | - Jiahong Xu
- Supernus Pharmaceuticals, Inc., Rockville, MD, USA
| | | | - Robert L Findling
- Johns Hopkins University, Baltimore, MD, USA.,Virginia Commonwealth University, Richmond, VA, USA
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17
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Benton TD, Muhrer E, Jones JD, Lewis J. Dysregulation and Suicide in Children and Adolescents. Child Adolesc Psychiatr Clin N Am 2021; 30:389-399. [PMID: 33743946 DOI: 10.1016/j.chc.2020.10.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Suicide rates continue to rise among children and adolescents; suicide is the second leading cause of death in the United States. Although research studies have identified factors associated with suicide risks for youths, none distinguishes those who have suicidal ideation from those who most likely will make an attempt or die by suicide. Most studies focus on psychiatric diagnoses associated with suicide risks. Recent studies suggest that cross-cutting symptom profiles may be a stronger predictor of risks for suicide than diagnosis. This article provides an overview of emotional dysregulation as it relates to suicidal ideation, intent, and behaviors for youth.
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Affiliation(s)
- Tami D Benton
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia, 3440 Market Street, Suite 410, Philadelphia, PA 19104, USA; Department of Psychiatry, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA.
| | - Eli Muhrer
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia, 3440 Market Street, Suite 410, Philadelphia, PA 19104, USA
| | - Jason D Jones
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia, 3440 Market Street, Suite 410, Philadelphia, PA 19104, USA; Department of Psychiatry, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
| | - Jason Lewis
- Department of Child and Adolescent Psychiatry and Behavioral Sciences, Children's Hospital of Philadelphia, 3440 Market Street, Suite 410, Philadelphia, PA 19104, USA; Department of Psychiatry, University of Pennsylvania, Perelman School of Medicine, Philadelphia, PA, USA
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18
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Li J, Hojlo MA, Chennuri S, Gujral N, Paterson HL, Shefchek KA, Genetti CA, Cohn EL, Sewalk KC, Garvey EA, Buttermore ED, Anderson NC, Beggs AH, Agrawal PB, Brownstein JS, Haendel MA, Holm IA, Gonzalez-Heydrich J, Brownstein CA. Underrepresentation of Phenotypic Variability of 16p13.11 Microduplication Syndrome Assessed With an Online Self-Phenotyping Tool (Phenotypr): Cohort Study. J Med Internet Res 2021; 23:e21023. [PMID: 33724192 PMCID: PMC8074853 DOI: 10.2196/21023] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 12/26/2020] [Accepted: 01/16/2021] [Indexed: 12/24/2022] Open
Abstract
Background 16p13.11 microduplication syndrome has a variable presentation and is characterized primarily by neurodevelopmental and physical phenotypes resulting from copy number variation at chromosome 16p13.11. Given its variability, there may be features that have not yet been reported. The goal of this study was to use a patient “self-phenotyping” survey to collect data directly from patients to further characterize the phenotypes of 16p13.11 microduplication syndrome. Objective This study aimed to (1) discover self-identified phenotypes in 16p13.11 microduplication syndrome that have been underrepresented in the scientific literature and (2) demonstrate that self-phenotyping tools are valuable sources of data for the medical and scientific communities. Methods As part of a large study to compare and evaluate patient self-phenotyping surveys, an online survey tool, Phenotypr, was developed for patients with rare disorders to self-report phenotypes. Participants with 16p13.11 microduplication syndrome were recruited through the Boston Children's Hospital 16p13.11 Registry. Either the caregiver, parent, or legal guardian of an affected child or the affected person (if aged 18 years or above) completed the survey. Results were securely transferred to a Research Electronic Data Capture database and aggregated for analysis. Results A total of 19 participants enrolled in the study. Notably, among the 19 participants, aggression and anxiety were mentioned by 3 (16%) and 4 (21%) participants, respectively, which is an increase over the numbers in previously published literature. Additionally, among the 19 participants, 3 (16%) had asthma and 2 (11%) had other immunological disorders, both of which have not been previously described in the syndrome. Conclusions Several phenotypes might be underrepresented in the previous 16p13.11 microduplication literature, and new possible phenotypes have been identified. Whenever possible, patients should continue to be referenced as a source of complete phenotyping data on their condition. Self-phenotyping may lead to a better understanding of the prevalence of phenotypes in genetic disorders and may identify previously unreported phenotypes.
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Affiliation(s)
- Jianqiao Li
- Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA, United States.,The Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, MA, United States
| | - Margaret A Hojlo
- Department of Psychiatry and Behavioral Sciences, Boston Children's Hospital, Boston, MA, United States.,Tommy Fuss Center for Neuropsychiatric Disease Research, Boston Children's Hospital, Boston, MA, United States
| | - Sampath Chennuri
- Innovation and Digital Health Accelerator, Boston Children's Hospital, Boston, MA, United States
| | - Nitin Gujral
- Innovation and Digital Health Accelerator, Boston Children's Hospital, Boston, MA, United States
| | - Heather L Paterson
- Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA, United States.,The Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, MA, United States
| | - Kent A Shefchek
- Department of Environmental and Molecular Toxicology, Oregon State University, Corvallis, OR, United States
| | - Casie A Genetti
- Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA, United States.,The Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, MA, United States
| | - Emily L Cohn
- Innovation and Digital Health Accelerator, Boston Children's Hospital, Boston, MA, United States
| | - Kara C Sewalk
- Computational Epidemiology Group, Boston Children's Hospital, Boston, MA, United States
| | - Emily A Garvey
- Department of Psychiatry and Behavioral Sciences, Boston Children's Hospital, Boston, MA, United States.,Tommy Fuss Center for Neuropsychiatric Disease Research, Boston Children's Hospital, Boston, MA, United States
| | - Elizabeth D Buttermore
- Human Neuron Core, Translational Neuroscience Center, Boston Children's Hospital, Boston, MA, United States
| | - Nickesha C Anderson
- Department of Neurology, Boston Children's Hospital, Boston, MA, United States
| | - Alan H Beggs
- Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA, United States.,The Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, MA, United States.,Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Pankaj B Agrawal
- Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA, United States.,The Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, MA, United States.,Department of Pediatrics, Harvard Medical School, Boston, MA, United States.,Division of Newborn Medicine, Boston Children's Hospital and Harvard Medical School, Boston, MA, United States
| | - John S Brownstein
- Innovation and Digital Health Accelerator, Boston Children's Hospital, Boston, MA, United States.,Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Melissa A Haendel
- Center for Health Artificial Intelligence, University of Colorado Anschutz, Aurora, CO, United States
| | - Ingrid A Holm
- Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA, United States.,The Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, MA, United States.,Department of Pediatrics, Harvard Medical School, Boston, MA, United States
| | - Joseph Gonzalez-Heydrich
- The Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, MA, United States.,Department of Psychiatry and Behavioral Sciences, Boston Children's Hospital, Boston, MA, United States.,Tommy Fuss Center for Neuropsychiatric Disease Research, Boston Children's Hospital, Boston, MA, United States.,Department of Psychiatry, Harvard Medical School, Boston, MA, United States
| | - Catherine A Brownstein
- Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA, United States.,The Manton Center for Orphan Disease Research, Boston Children's Hospital, Boston, MA, United States.,Tommy Fuss Center for Neuropsychiatric Disease Research, Boston Children's Hospital, Boston, MA, United States.,Department of Pediatrics, Harvard Medical School, Boston, MA, United States
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19
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Yoo HJ, Han JM, Kim K, Song G, Yee J, Chung JE, Lee KE, Gwak HS. Association between attention deficit hyperactivity disorder and aggression subscales in adolescents. Brain Behav 2021; 11:e02030. [PMID: 33439553 PMCID: PMC7994686 DOI: 10.1002/brb3.2030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 12/22/2020] [Accepted: 12/28/2020] [Indexed: 12/18/2022] Open
Abstract
INTRODUCTION The aim of this study is to identify the association between Attention Deficit Hyperactivity Disorder (ADHD) proneness and aggressive propensity in adolescents. METHODS A quantitative, large-scale, cross-sectional study was performed from April to May 2016 in Korea. The survey questionnaire included overall health behaviors, as well as scales for assessing ADHD proneness (revised short form of the Conners-Wells Adolescent Self-Report Scale; CASS[S]) and aggressive behavior (Buss-Perry Aggression Questionnaire; BPAQ) in adolescents. Area under the receiver operator characteristic (AUROC) curves was constructed to determine the cut-off value of total aggression score for discriminating ADHD proneness. RESULTS A total of 2,432 students participated in the survey, and 1,872 of them completed the questionnaire, indicating a response rate of 77.0%. Based on CASS(S), 33 (1.8%) subjects were classified as the ADHD group. AUROC curve analysis showed that a score of 68.5 points had higher sensitivity (83.3%) and specificity (69.4%) to discriminate ADHD proneness. ADHD proneness was significantly associated with higher aggression subdomain scores (physical, verbal, anger, and hostility). Especially, anger and hostility had a stronger relationship with ADHD proneness than did physical and verbal aggression. A multivariable analysis demonstrated that ADHD proneness was significantly related to body mass index in the top 10% of the study population, alcohol consumption, gastrointestinal trouble, daytime sleepiness, and total aggression score of 68.5 points or higher. Adolescents who had total aggression scores of 68.5 points or higher showed a 9.8-fold (95% confidence interval [CI] 3.3-28.8) higher risk of ADHD compared with those who had scores less than 68.5 points. CONCLUSIONS Our results demonstrated that ADHD proneness was significantly associated with aggression propensity. In particular, anger and hostility were more closely associated with ADHD proneness than were other aggression subdomains.
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Affiliation(s)
- Hee Jeong Yoo
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Republic of Korea.,Department of Pharmacy, National Medical Center, Seoul, Republic of Korea
| | - Ji Min Han
- College of Pharmacy, Chungbuk National University, Cheongju, Republic of Korea
| | - Kitai Kim
- Department of Communication, Honam University, Gwangju, Republic of Korea
| | - Gonjin Song
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Republic of Korea
| | - Jeong Yee
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Republic of Korea
| | - Jee Eun Chung
- College of Pharmacy, Institute of Pharmaceutical Science and Technology, Hanyang University, Ansan, Republic of Korea
| | - Kyung Eun Lee
- College of Pharmacy, Chungbuk National University, Cheongju, Republic of Korea
| | - Hye Sun Gwak
- College of Pharmacy and Graduate School of Pharmaceutical Sciences, Ewha Womans University, Seoul, Republic of Korea
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20
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Sultan RS, Liu SM, Hacker KA, Olfson M. Adolescents With Attention-Deficit/Hyperactivity Disorder: Adverse Behaviors and Comorbidity. J Adolesc Health 2021; 68:284-291. [PMID: 33541601 DOI: 10.1016/j.jadohealth.2020.09.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 09/14/2020] [Accepted: 09/27/2020] [Indexed: 12/31/2022]
Abstract
PURPOSE AND OBJECTIVE There is growing evidence that adolescents with ADHD develop long-term impairments and adverse outcomes, yet less is known about their adverse behaviors. To quantify rates of mental health comorbidities in adolescents with ADHD and compare the risks of adverse behaviors among adolescents with and without ADHD. METHODS We performed a cohort analysis of 6,483 youth from the National Comorbidity Survey Adolescent Supplement (NCS-A), a nationally representative in-person structured diagnostic interview of adolescents aged 14-18 years focusing on mental, emotional, and behavioral disorders. MAIN OUTCOMES (1) Percentages with comorbid anxiety, mood, disruptive behavior, and substance use disorders. (2) Strength of associations of ADHD with several adverse behaviors, including suicidal symptoms, aggression, behavior regulation, life events, education, and substance use. Odds ratios were adjusted for age, sex, and race. RESULTS Among the sample of 6,483 adolescents, overall, 9.5% met the criteria for ADHD. Most (69.5%) of adolescents with ADHD had at least one comorbid mental health condition. As compared to adolescents without ADHD, those with ADHD were significantly more likely to have had a suicide attempt (aOR 2.9, 95% CI = 1.3-6.6) and to have had perpetrated physical aggression (aOR 2.3, 95% CI = 1.7-3.2). Adolescents with ADHD were also more likely to have been expelled from school or fired from a job (aOR 3.3, 95% CI = 1.7-6.5) and to have had problems related to drinking alcohol (95% CI = 1.2-2.9). CONCLUSIONS ADHD in adolescents is a complicated disorder with elevated risks for a wide range of adverse behaviors.
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Affiliation(s)
- Ryan S Sultan
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York State Psychiatric Institute, New York, New York.
| | - Shang-Min Liu
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York State Psychiatric Institute, New York, New York
| | - Karen A Hacker
- Allegheny County Health Department, University of Pittsburgh School of Medicine and Graduate School of Public Health, Pittsburgh, Pennsylvania
| | - Mark Olfson
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York State Psychiatric Institute, New York, New York
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21
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Knackfuss ACU, Leibenluft E, Brotman MA, de Moura Silveira Júnior É, Simioni A, Teixeira LS, Gerchmann L, Fijtman A, Trasel AR, Sperotto D, Manfro AG, Kapczinski F, Sant'Anna MK, Salum GA. Differentiating irritable mood and disruptive behavior in adults. TRENDS IN PSYCHIATRY AND PSYCHOTHERAPY 2020; 42:375-386. [PMID: 33295573 PMCID: PMC7879084 DOI: 10.1590/2237-6089-2019-0078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Accepted: 04/06/2020] [Indexed: 11/23/2022]
Abstract
Introduction Irritability has both mood and behavioral manifestations. These frequently co-occur, and it is unclear to what extent they are dissociable domains. We used confirmatory factor analysis and external validators to investigate the independence of mood and behavioral components of irritability. Methods The sample comprised 246 patients (mean age 45 years; 63% female) from four outpatient programs (depression, anxiety, bipolar, and schizophrenia) at a tertiary hospital. A clinical instrument rated by trained clinicians was specifically designed to capture irritable mood and disruptive behavior dimensionally, as well as current categorical diagnoses i.e., intermittent explosive disorder (IED); oppositional defiant disorder (ODD); and an adaptation to diagnose disruptive mood dysregulation disorder (DMDD) in adults. Confirmatory factor analysis (CFA) was used to test the best fitting irritability models and regression analyses were used to investigate associations with external validators. Results Irritable mood and disruptive behavior were both frequent, but diagnoses of disruptive syndromes were rare (IED, 8%; ODD, 2%; DMDD, 2%). A correlated model with two dimensions, and a bifactor model with one general dimension and two specific dimensions (mood and behavior) both had good fit indices. The correlated model had root mean square error of approximation (RMSEA) = 0.077, with 90% confidence interval (90%CI) = 0.071-0.083; comparative fit index (CFI) = 0.99; and Tucker-Lewis index (TLI) = 0.99, while the bifactor model had RMSEA = 0.041; CFI = 0.99; and TLI = 0.99 respectively). In the bifactor model, external validity for differentiation of the mood and behavioral components of irritability was also supported by associations between irritable mood and impairment and clinical measures of depression and mania, which were not associated with disruptive behavior. Conclusions Psychometric and external validity data suggest both overlapping and specific features of the mood vs. disruptive behavior dimensions of irritability.
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Affiliation(s)
- Ana Cláudia U Knackfuss
- Seção de Afeto Negativo e Processos Socias, Hospital de Clínicas de Porto Alegre, Departamento de Psiquiatria, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Ellen Leibenluft
- Section on Mood Dysregulation and Neuroscience, Intramural Research Program, National Institute of Mental Health, Bethesda, MD, USA
| | - Melissa A Brotman
- Section on Mood Dysregulation and Neuroscience, Intramural Research Program, National Institute of Mental Health, Bethesda, MD, USA
| | - Érico de Moura Silveira Júnior
- Programa de Transtorno Bipolar, Laboratório de Psiquiatria Molecular, Hospital de Clíncias de Porto Alegre, Departamento de Psiquiatria, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - André Simioni
- Seção de Afeto Negativo e Processos Socias, Hospital de Clínicas de Porto Alegre, Departamento de Psiquiatria, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Lorenna S Teixeira
- Seção de Afeto Negativo e Processos Socias, Hospital de Clínicas de Porto Alegre, Departamento de Psiquiatria, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Luciana Gerchmann
- Seção de Afeto Negativo e Processos Socias, Hospital de Clínicas de Porto Alegre, Departamento de Psiquiatria, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Adam Fijtman
- Programa de Transtorno Bipolar, Laboratório de Psiquiatria Molecular, Hospital de Clíncias de Porto Alegre, Departamento de Psiquiatria, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Andrea R Trasel
- Programa de Transtorno Bipolar, Laboratório de Psiquiatria Molecular, Hospital de Clíncias de Porto Alegre, Departamento de Psiquiatria, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Daniela Sperotto
- Seção de Afeto Negativo e Processos Socias, Hospital de Clínicas de Porto Alegre, Departamento de Psiquiatria, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Arthur G Manfro
- Seção de Afeto Negativo e Processos Socias, Hospital de Clínicas de Porto Alegre, Departamento de Psiquiatria, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Flávio Kapczinski
- Programa de Transtorno Bipolar, Laboratório de Psiquiatria Molecular, Hospital de Clíncias de Porto Alegre, Departamento de Psiquiatria, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Márcia K Sant'Anna
- Programa de Transtorno Bipolar, Laboratório de Psiquiatria Molecular, Hospital de Clíncias de Porto Alegre, Departamento de Psiquiatria, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
| | - Giovanni A Salum
- Seção de Afeto Negativo e Processos Socias, Hospital de Clínicas de Porto Alegre, Departamento de Psiquiatria, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS, Brazil
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22
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Murray AL, Obsuth I, Zirk-Sadowski J, Ribeaud D, Eisner M. Developmental Relations Between ADHD Symptoms and Reactive Versus Proactive Aggression Across Childhood and Adolescence. J Atten Disord 2020; 24:1701-1710. [PMID: 27585832 DOI: 10.1177/1087054716666323] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: Past research has provided some preliminary evidence that ADHD and reactive aggression have overlapping neurocognitive bases. Based on this, we tested the hypothesis that ADHD symptoms are closely coupled in developmental terms with reactive aggression, more so than with proactive aggression with which it has been postulated to be only indirectly linked. Method: We used latent growth curve analysis to estimate the developmental relations between ADHD symptoms and subtypes of aggressive behavior in a normative sample of 1,571 youth (761 female, 810 male) measured from ages 7 to 15. Results: Individual ADHD trajectories were significantly and substantially correlated with individual trajectories in both aggressive subtypes; however, consistent with our hypothesis, the relation with reactive aggression was significantly stronger. Conclusion: Our study provides some of the first evidence for a differential relation between ADHD symptoms and aggression subtypes not only cross-sectionally but also in terms of their longitudinal developmental trajectories.
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Affiliation(s)
| | | | | | - Denis Ribeaud
- Swiss Federal Institute of Technology in Zurich (ETH), Switzerland
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23
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Hamed SA, Elhadad AF, Farghaly HS. Evaluation of the effectiveness of valproic acid for treating cyanotic breath holding spells: A Pilot prospective study. Expert Rev Clin Pharmacol 2020; 13:1263-1270. [PMID: 32969724 DOI: 10.1080/17512433.2020.1828059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Cyanotic breath-holding spells (CBHS) are self-limited conditions among younger children. Frequent spells cause parents' fear and anxiety. Seizures, brain damage and sudden death have been rarely reported with BHS. Some reported spells' frequency reduction with iron or piracetam. We evaluated the effectiveness of valproic acid (VPA) to treat CBHS and predictors of improvement. METHODS Participants were 90 children with CBHS (≥4/week) (age: 1.6±0.4yrs). They were treated with VPA (5 mg/kg/d). Follow-ups occurred after 3-≥6 months. Autonomic nervous system functions were evaluated. RESULTS The majority (74.4%) had daily spells and 19% had ≥2 spells/d. Crying or anger provoked spells. Postural hypotension was found in 46.7%. They had normal electroencephalography and QT, QTc interval or QTd or QTcd and heart rate. Compared to controls, postural fall in systolic (>20mmHg) and diastolic (>10mmHg) blood pressures and mean arterial pressure (>10mmHg) were observed in 46.7%, 74.4% and 72.2% and miosis observed with 0.125% pilocarpine in 28.9% (P=0.001). Spells' frequency reduction (P=0.001) occurred within 3 months with VPA. The independent prdictors for spell' frequency reduction were reduction of anger and crying [OR=4.52(95%CI=2.35-6.04), P =0.01]. CONCLUSION VPA therapy reduces CBHS' frequency. Mood improvement is a suggestive effective mechanism. CLINICAL TRIAL REGISTRATION www.clinicaltrials.gov identifier is NCT04482764.
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Affiliation(s)
- Sherifa A Hamed
- Department of Neurology and Psychiatry, Assiut University Hospital , Assiut, Egypt
| | - Ali F Elhadad
- Department of Neuropsychiatry, Al Azher University , Assiut, Egypt
| | - Hekma S Farghaly
- Department of Pediatrics, Children's Hospital, Assiut University Hospital , Assiut, Egypt
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Intermittent explosive disorder subtypes in the general population: association with comorbidity, impairment and suicidality. Epidemiol Psychiatr Sci 2020; 29:e138. [PMID: 32638683 PMCID: PMC7327434 DOI: 10.1017/s2045796020000517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
AIMS Intermittent explosive disorder (IED) is characterised by impulsive anger attacks that vary greatly across individuals in severity and consequence. Understanding IED subtypes has been limited by lack of large, general population datasets including assessment of IED. Using the 17-country World Mental Health surveys dataset, this study examined whether behavioural subtypes of IED are associated with differing patterns of comorbidity, suicidality and functional impairment. METHODS IED was assessed using the Composite International Diagnostic Interview in the World Mental Health surveys (n = 45 266). Five behavioural subtypes were created based on type of anger attack. Logistic regression assessed association of these subtypes with lifetime comorbidity, lifetime suicidality and 12-month functional impairment. RESULTS The lifetime prevalence of IED in all countries was 0.8% (s.e.: 0.0). The two subtypes involving anger attacks that harmed people ('hurt people only' and 'destroy property and hurt people'), collectively comprising 73% of those with IED, were characterised by high rates of externalising comorbid disorders. The remaining three subtypes involving anger attacks that destroyed property only, destroyed property and threatened people, and threatened people only, were characterised by higher rates of internalising than externalising comorbid disorders. Suicidal behaviour did not vary across the five behavioural subtypes but was higher among those with (v. those without) comorbid disorders, and among those who perpetrated more violent assaults. CONCLUSIONS The most common IED behavioural subtypes in these general population samples are associated with high rates of externalising disorders. This contrasts with the findings from clinical studies of IED, which observe a preponderance of internalising disorder comorbidity. This disparity in findings across population and clinical studies, together with the marked heterogeneity that characterises the diagnostic entity of IED, suggests that it is a disorder that requires much greater research.
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Carlson GA, Chua J, Pan K, Hasan T, Bied A, Martin A, Klein DN. Behavior Modification Is Associated With Reduced Psychotropic Medication Use in Children With Aggression in Inpatient Treatment: A Retrospective Cohort Study. J Am Acad Child Adolesc Psychiatry 2020; 59:632-641.e4. [PMID: 31381991 DOI: 10.1016/j.jaac.2019.07.940] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 07/29/2019] [Accepted: 07/29/2019] [Indexed: 01/27/2023]
Abstract
OBJECTIVE There are few data to guide management of agitated and aggressive psychiatrically hospitalized children. Available studies do not account for setting, age, sex, diagnosis, admission reason, or clinical intervention. Seclusion, restraint, and physical holds (S/R/H) are usually the only outcome measure. In this study, we examine changes in PRN (pro re nata, or "as needed") psychotropic medication use to manage severe aggression on a children's psychiatric inpatient unit, comparing rates before and after a behavior modification program (BMP) was discontinued. METHOD We compare 661 children (aged 5-12 years) in 5 cohorts over 10 years, 510 (77%) of whom were admitted for aggressive behavior. PRN use per 1,000 patient-days was the primary outcome measure, but S/R/H was also examined. We use the following as predictors: BMP status, full- or half-time child and adolescent psychiatrist (CAP) oversight, diagnosis, age, length of stay, and neuroleptic use. RESULTS Children admitted for aggression had high rates of externalizing disorders (79%), low rates of mood (27%) and anxiety (21%) disorders, and significantly higher rates of PRN and S/R/H (p < .001) use. Rate of PRN use was significantly lower (p < .001) when the BMP was present (mean [SD], 163 [319] per 1,000 patient-days) than when it was absent (483 [569]; p < .001). Higher PRN use was predicted by BMP absence, neuroleptic treatment, and young patient age (p < .001), and by half-time CAP oversight (p = .002). CONCLUSION In this sample of young children with primarily externalizing disorders, data support the effectiveness of a BMP in lowering rates of PRN and S/R/H use.
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Affiliation(s)
| | - Jaclyn Chua
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY
| | - Katherine Pan
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY
| | - Tahsin Hasan
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY
| | - Adam Bied
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY
| | - Andrés Martin
- Child Study Center, Yale School of Medicine, New Haven, CT
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Meyer E, Michel G. Étude des comportements parentaux dans les liens entre symptomatologie du TDAH et comportements agressifs chez les enfants entre 3 et 6 ans. ANNALES MEDICO-PSYCHOLOGIQUES 2020. [DOI: 10.1016/j.amp.2020.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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27
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Ceresoli-Borroni G, Liranso T, Brittain ST, Connor DF, Evans CJ, Findling RL, Hwang S, Fry N, Candler SA, Robb AS, Saylor KE, Nasser A, Schwabe S. Application of the Impulsive Aggression Diary in Adolescents with Attention-Deficit/Hyperactivity Disorder. J Child Adolesc Psychopharmacol 2019; 29:599-607. [PMID: 31343272 DOI: 10.1089/cap.2018.0089] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Objective: Impulsive aggression (IA) is a maladaptive form of aggressive behavior that is an associated feature of neuropsychiatric disorders, including attention-deficit/hyperactivity disorder (ADHD). As one of the most common forms of aggressive behavior, IA is a serious clinical concern. Recognition, monitoring, and management of IA symptoms are complicated by the lack of IA-specific psychometric instruments and evidence-based treatments. A recently developed electronic observer-reported outcome instrument has been validated in children for monitoring the frequency of 15 IA-related behaviors in the context of ADHD. This study seeks to first determine if the behaviors included in the pediatric IA diary are applicable to adolescents with ADHD, and second, compare the reliability of adolescent versus parent reporters. Methods: We evaluated the utility of the pediatric IA diary through concept elicitation and cognitive interviews with 17 pairs of parents and adolescents (aged 13-17 years) with IA and ADHD, supplemented with 15 new behaviors potentially applicable to adolescents. Results: The behaviors most frequently reported by adolescents included arguing (93.8%), raising their voice/shouting/yelling (93.8%), hitting others (87.5%), slamming (87.5%), pushing/shoving (81.3%), breaking (75.0%), fighting (75.0%), throwing (75.0%), and cursing (68.8%). The behaviors most commonly reported by parents included raising their voice/shouting/yelling (94.1%), arguing (88.2%), being disrespectful/mean/rude (88.2%), slamming (88.2%), throwing (88.2%), cursing (82.4%), hitting others (82.4%), pushing/shoving (82.4%), breaking (76.5%), name-calling (76.5%), and threatening (70.6%). Of all commonly reported behaviors, only being "disrespectful/mean/rude" and "breaking" are not part of the pediatric IA diary, likely due to the imprecision of these terms. No significant usability issues were found for the IA diary device. Conclusions: These findings suggest that the 15-item pediatric IA diary should be applicable to adolescent populations to appropriately characterize IA behaviors in individuals with ADHD. Furthermore, this study indicated that parents may be more reliable reporters of IA behavior than adolescents.
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Affiliation(s)
| | - Tesfaye Liranso
- Department of Clinical Research, Supernus Pharmaceuticals, Inc., Rockville, Maryland
| | - Scott T Brittain
- Department of Clinical Research, Supernus Pharmaceuticals, Inc., Rockville, Maryland
| | - Daniel F Connor
- Department of Psychiatry, Division of Child & Adolescent Psychiatry, University of Connecticut School of Medicine, Farmington, Connecticut
| | | | - Robert L Findling
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, Maryland.,Department of Psychiatry and Behavioral Sciences, Kennedy Krieger Institute, Baltimore, Maryland
| | - Steve Hwang
- Department of Research Science, Endpoint Outcomes, Boston, Massachusetts
| | - Nicholas Fry
- Department of Clinical Research, Supernus Pharmaceuticals, Inc., Rockville, Maryland
| | - Shawn A Candler
- Department of Clinical Research, Supernus Pharmaceuticals, Inc., Rockville, Maryland
| | - Adelaide S Robb
- Department of Psychiatry and Behavioral Sciences, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia.,Department of Psychiatry and Behavioral Sciences, Children's National Medical Center, Washington, District of Columbia
| | | | - Azmi Nasser
- Department of Clinical Research, Supernus Pharmaceuticals, Inc., Rockville, Maryland
| | - Stefan Schwabe
- Department of Clinical Research, Supernus Pharmaceuticals, Inc., Rockville, Maryland
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Ceresoli-Borroni G, Liranso T, Brittain ST, Connor DF, Evans CJ, Findling RL, Hwang S, Candler SA, Robb AS, Nasser A, Schwabe S. A Novel Assessment Tool for Impulsive Aggression in Children with Attention-Deficit/Hyperactivity Disorder. J Child Adolesc Psychopharmacol 2019; 29:592-598. [PMID: 31369291 PMCID: PMC6786341 DOI: 10.1089/cap.2019.0035] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Objective: To establish the validity and reliability of a provisional 30-item impulsive aggression (IA) diary in children (ages 6-12 years, inclusive) with attention-deficit/hyperactivity disorder (ADHD). Methods: The provisional 30-item IA diary was administered for 14 days to parents of children with ADHD and IA symptoms (n = 103). Key inclusion criteria: confirmed ADHD diagnosis; signs of IA as measured by a Retrospective-Modified Overt Aggression Scale (R-MOAS) score ≥20 and an Aggression Questionnaire score of -2 to -5. Analyses included inter-item correlations, exploratory factor analysis (EFA), item response theory (IRT) modeling, internal consistency, test-retest reliability (TRT), concurrent validity (estimated by correlation between the IA diary and the R-MOAS/Nisonger Child Behavior Rating Form), and known-groups methods. Results: The prevalence rates of 15 (50.0%) items were found to be too low (<1%) for analysis; three items with prevalence rates ≤1% were retained, as content validity was deemed high by clinical experts. The remaining 12 behavior items had prevalence rates of 2.7%-73.6%. EFA and IRT models confirmed two subdomains in the IA diary included within a general domain of IA behavior frequency, yielding a single total behavioral frequency score (TBFS). Internal consistency was high for this TBFS (marginal reliability = 0.86 and α = 0.73). TRT for the TBFS, based on the intraclass correlation coefficient, was 0.8. Concurrent validity of TBFS with R-MOAS ranged from r = 0.49 to r = 0.62. Conclusion: The final 15-item IA diary is a reliable, psychometrically validated IA measurement tool that will allow clinicians and researchers to assess the frequency of IA behavior.
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Affiliation(s)
| | - Tesfaye Liranso
- Department of Clinical Research, Supernus Pharmaceuticals, Inc., Rockville, Maryland
| | - Scott T. Brittain
- Department of Clinical Research, Supernus Pharmaceuticals, Inc., Rockville, Maryland
| | - Daniel F. Connor
- Department of Psychiatry, Division of Child and Adolescent Psychiatry, University of Connecticut School of Medicine, Farmington, Connecticut
| | | | - Robert L. Findling
- Department of Psychiatry and Behavioral Sciences, The Johns Hopkins University, Baltimore, Maryland
- Department of Psychiatry and Behavioral Sciences, Kennedy Krieger Institute, Baltimore, Maryland
| | - Steve Hwang
- Department of Research Science, Endpoint Outcomes, Boston, Massachusetts
| | - Shawn A. Candler
- Department of Medical Affairs, Supernus Pharmaceuticals, Inc., Rockville, Maryland
| | - Adelaide S. Robb
- Department of Psychiatry and Behavioral Sciences, Children's National Medical Center, Washington, District of Columbia
- Department of Psychiatry and Behavioral Sciences, George Washington University, Washington, District of Columbia
| | - Azmi Nasser
- Department of Clinical Research, Supernus Pharmaceuticals, Inc., Rockville, Maryland
| | - Stefan Schwabe
- Department of Research and Development, Supernus Pharmaceuticals, Inc., Rockville, Maryland
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Connor DF, Newcorn JH, Saylor KE, Amann BH, Scahill L, Robb AS, Jensen PS, Vitiello B, Findling RL, Buitelaar JK. Maladaptive Aggression: With a Focus on Impulsive Aggression in Children and Adolescents. J Child Adolesc Psychopharmacol 2019; 29:576-591. [PMID: 31453715 PMCID: PMC6786344 DOI: 10.1089/cap.2019.0039] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Objective: Aggressive behavior is among the most common reasons for referral to psychiatric clinics and confers significant burden on individuals. Aggression remains poorly defined; there is currently no consensus on the best ways to recognize, diagnose, and treat aggression in clinical settings. In this review, we synthesize the available literature on aggression in children and adolescents and propose the concept of impulsive aggression (IA) as an important construct associated with diverse and enduring psychopathology. Methods: Articles were identified and screened from online repositories, including PubMed, PsychInfo, the Cochrane Database, EMBase, and relevant book chapters, using combinations of search terms such as "aggression," "aggressive behavio(u)r," "maladaptive aggression," "juvenile," and "developmental trajectory." These were evaluated for quality of research before being incorporated into the article. The final report references 142 sources, published from 1987 to 2019. Results: Aggression can be either adaptive or maladaptive in nature, and the latter may require psychosocial and biomedical interventions when it occurs in the context of central nervous system psychopathology. Aggression can be categorized into various subtypes, including reactive/proactive, overt/covert, relational, and IA. IA in psychiatric or neurological disorders is reviewed along with current treatments, and an algorithm for systematic evaluation of aggression in the clinical setting is proposed. Conclusions: IA is a treatable form of maladaptive aggression that is distinct from other aggression subtypes. It occurs across diverse psychiatric and neurological diagnoses and affects a substantial subpopulation. IA can serve as an important construct in clinical practice and has considerable potential to advance research.
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Affiliation(s)
- Daniel F. Connor
- Department of Psychiatry, Division of Child & Adolescent Psychiatry, University of Connecticut Medical School, Farmington, Connecticut.,Address correspondence to: Daniel F. Connor, MD, Department of Psychiatry, Division of Child & Adolescent Psychiatry, University of Connecticut Medical School, 263 Farmington Avenue, MC 1410, Farmington, CT 06030-1410
| | - Jeffrey H. Newcorn
- Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York
| | | | | | - Lawrence Scahill
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Adelaide S. Robb
- Department of Psychiatry and Behavioral Sciences, Children's National Medical Center, Washington, District of Columbia.,Department of Psychiatry and Behavioral Sciences, George Washington University, Washington, District of Columbia
| | - Peter S. Jensen
- Department of Psychiatry, University of Arkansas for Medical Science, Little Rock, Arkansas
| | - Benedetto Vitiello
- Section of Child and Adolescent Neuropsychiatry, University of Turin, Turin, Italy
| | - Robert L. Findling
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, Maryland.,Department of Psychiatry and Behavioral Sciences, Kennedy Krieger Institute, Baltimore, Maryland
| | - Jan K. Buitelaar
- Department of Cognitive Neuroscience, Donders Institute for Brain, Cognition and Behaviour, Radboud University Medical Center, Nijmegen, The Netherlands
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30
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Young AS, Youngstrom EA, Findling RL, Van Eck K, Kaplin D, Youngstrom JK, Calabrese J, Stepanova E, The Lams Consortium. Developing and Validating a Definition of Impulsive/Reactive Aggression in Youth. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY 2019; 49:787-803. [PMID: 31343896 DOI: 10.1080/15374416.2019.1622121] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The goal of this study is to develop a rational data-driven definition of impulsive/reactive aggression and establish distinctions between impulsive/reactive aggression and other common childhood problems. This is a secondary analysis of data from Assessing Bipolar: A Community Academic Blend (ABACAB; N = 636, ages 5-18), Stanley Medical Research Institute N = 392, ages 5-17), and the Longitudinal Assessment of Manic Symptoms (LAMS; N = 679, ages 6-12) studies, which recruited youths seeking outpatient mental health services in academic medical centers and community clinics. Following Jensen et al.'s (2007) procedure, 3 judges independently rated items from several widely used scales in terms of assessing impulsive/reactive aggression. Principal components analyses (PCA) modeled structure of the selected items supplemented by items related to mood symptoms, rule-breaking behavior, and hyperactivity/impulsivity to better define the boundaries between impulsive/reactive aggression and other common childhood symptoms. In the rational item selection process, there was good agreement among the 3 experts who rated items as characterizing impulsive/reactive aggression or not. PCA favored 5 dimension solutions in all 3 samples. Across all samples, PCA resulted in rule-breaking behavior, aggression-impulsive/reactive (AIR), mania, and depression dimensions; there was an additional hyperactive/impulsive dimension in the LAMS sample and a self-harm dimension in ABACAB and Stanley samples. The dimensions demonstrated good internal consistency; criterion validity coefficients also showed consistency across samples. This study is a step toward developing an empirically derived nosology of impulsive aggression/AIR. Findings support the validity of the AIR construct, which can be distinguished from manic and depressive symptoms as well as rule-breaking behavior.
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Affiliation(s)
- Andrea S Young
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University
| | - Eric A Youngstrom
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill
| | - Robert L Findling
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University
| | - Kathryn Van Eck
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University
| | - Dana Kaplin
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University
| | - Jennifer K Youngstrom
- Department of Psychology and Neuroscience, University of North Carolina at Chapel Hill
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Sultan RS, Wang S, Crystal S, Olfson M. Antipsychotic Treatment Among Youths With Attention-Deficit/Hyperactivity Disorder. JAMA Netw Open 2019; 2:e197850. [PMID: 31348506 PMCID: PMC6661708 DOI: 10.1001/jamanetworkopen.2019.7850] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
IMPORTANCE Significant concern exists over treating youths with attention-deficit/hyperactivity disorder (ADHD) with antipsychotic medications, yet little is known about the factors associated with antipsychotic treatment. OBJECTIVES To describe the percentage of youths who fill antipsychotic prescriptions in the year following a new diagnosis of ADHD and characterize the clinical and demographic factors associated with antipsychotic initiation. DESIGN, SETTING, AND PARTICIPANTS A retrospective longitudinal cohort analysis of antipsychotic treatment was performed in 187 563 youths, aged 3 to 24 years, with a new diagnosis of ADHD (without recent diagnosis of any US Food and Drug Administration [FDA]-indicated conditions for antipsychotic treatment). The sample was derived from the 2010 to 2015 MarketScan Commercial Database, with the analysis completed between November 1, 2018, and May 30, 2019. MAIN OUTCOMES AND MEASURES The percentage of youths prescribed an antipsychotic in the first year following a new diagnosis of ADHD. Among those prescribed antipsychotic medications, the percentage who received a diagnosis of conduct disorder, oppositional defiant disorder, or a disorder for which 1 or more antipsychotic medication has received an indication for use in youths from the FDA (schizophrenia, bipolar disorder, and Tourette disorder) and the percentage that filled an antipsychotic prescription before filling a stimulant prescription (methylphenidate or amphetamine derivative). RESULTS Of the 187 563 youths included in the study, 114 305 (60.9%) were male with a mean (SD) age of 13.74 (5.61) years. In the year following a new ADHD diagnosis, 4869 youths (2.6%; 95% CI, 2.5%-2.7%) with ADHD were prescribed an antipsychotic. Youths treated with antipsychotics with ADHD were more likely than their peers who were not receiving an antipsychotic to have recently received diagnoses of self-harm and/or suicidal ideation (adjusted odds ratio [aOR], 7.5; 95% CI, 5.9-9.6), oppositional defiant disorder (aOR, 4.4; 95% CI, 3.9-4.9), and substance use disorder (aOR, 4.0; 95% CI, 3.6-4.5). The youths who received antipsychotics were also more likely to have received inpatient treatment (aOR, 7.9; 95% CI, 6.7-9.3). During the year following the new ADHD diagnosis, 52.7% (95% CI, 51.3%-54.1%) of youths treated with antipsychotics received a diagnosis for which antipsychotics have either an FDA or evidence-supported indication for their use. Among youths who initiated antipsychotic medications, 47.9% (95% CI, 46.5%-49.3%) did not receive a stimulant prescription between their ADHD diagnosis and antipsychotic initiation. Antipsychotic prescribing was proportionally highest for preschool-aged children (4.3%) and associated with neurodevelopmental disorders (aOR, 3.9; 95% CI, 1.3-11.2) and recent inpatient mental health treatment (aOR, 8.9; 95% CI, 1.7-45.8). CONCLUSIONS AND RELEVANCE Approximately half of youths with a new ADHD diagnosis may have an evidence-supported indication for an antipsychotic medication. Less than half of these youths received a stimulant; the evidence-supported first line treatment for ADHD, before the antipsychotic was initiated. Use of antipsychotic prescribing appears to be associated with high levels of psychiatric comorbidity.
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Affiliation(s)
- Ryan S. Sultan
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, New York
- New York State Psychiatric Institute, New York
| | - Shuai Wang
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, New York
- New York State Psychiatric Institute, New York
| | - Stephen Crystal
- Institute for Health, Health Care Policy, and Aging Research, Rutgers University, New Brunswick, New Jersey
| | - Mark Olfson
- Department of Psychiatry, College of Physicians and Surgeons, Columbia University, New York, New York
- New York State Psychiatric Institute, New York
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Robb AS, Schwabe S, Ceresoli-Borroni G, Nasser A, Yu C, Marcus R, Candler SA, Findling RL. A proposed anti-maladaptive aggression agent classification: improving our approach to treating impulsive aggression. Postgrad Med 2019; 131:129-137. [PMID: 30678534 DOI: 10.1080/00325481.2019.1574401] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Proper drug categorization enables clinicians to readily identify the agents most appropriate for patients in need. Currently, patients with maladaptive aggression do not all always fall into a single existing diagnostic or treatment category. Such is the case for those with impulsive aggression (IA). IA is an associated feature of numerous neuropsychiatric disorders, and can be described as eruptive, aggressive behavior or a 'short fuse'. Although agents from a broad spectrum of drug classes have been used to treat maladaptive aggression, few have been tested distinctly in patients with IA, and there is no drug specifically indicated by the US Food and Drug Administration (US FDA) for IA. Further, current treatments often fail to sufficiently treat IA symptomatology. These issues create an unclear and inadequate treatment path for patients. Here we will propose the establishment of a class of anti-maladaptive aggression agents to begin addressing this clinical issue. The development of such a class would unify the various drugs currently used to treat maladaptive aggression and streamline the treatment approach towards IA. As an important case example of the range of candidate drugs that could fit into a new anti-maladaptive aggression agent category, we will review an investigational IA pharmacotherapy. SPN-810 (extended-release molindone) is currently being investigated as a novel treatment for children with IA and ADHD. Based on these studies we will review how SPN-810 may be well suited for a new, anti-maladaptive aggression drug class and more precisely, a proposed subgroup of IA modulators. The goal of this review is to begin improving the identification of and therapeutic approach for maladaptive aggression as well as IA through more precise anti-maladaptive aggression agent categorization.
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Affiliation(s)
- Adelaide S Robb
- a Psychology and Behavioral Health , Children's National Medical Center , Washington , DC , USA
| | - Stefan Schwabe
- b Research & Development , Supernus Pharmaceuticals, Inc. , Rockville , MD , USA
| | | | - Azmi Nasser
- c Clinical Research , Supernus Pharmaceuticals, Inc. , Rockville , MD , USA
| | - Chungping Yu
- d Preclinical DMPK and Pharmacology , Supernus Pharmaceuticals, Inc. , Rockville , MD , USA
| | - Ronald Marcus
- c Clinical Research , Supernus Pharmaceuticals, Inc. , Rockville , MD , USA
| | - Shawn A Candler
- e Medical Affairs , Supernus Pharmaceuticals, Inc. , Rockville , MD , USA
| | - Robert L Findling
- f Psychiatry and Behavioral Sciences , Johns Hopkins University , Baltimore , MD , USA.,g Psychiatric Services and Research , Kennedy Krieger Institute , Baltimore , MD , USA
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Abstract
Background Impulsive aggression (IA) is considered a maladaptive form of aggression that is reactive and overt and occurs outside of the acceptable social context. Many children and adolescents with attention-deficit/hyperactivity disorder (ADHD) display clinically significant aggression, with the predominant subtype being IA. However, there is currently no Food and Drug Administration-approved medication specifically to treat IA. The pathophysiology of IA is not fully understood, although it has been suggested to include the dopamine, norepinephrine, and serotonin systems. Methods SPN-810 (extended-release molindone) is being developed for the novel indication of IA and is currently being studied in patients treated for ADHD. Molindone is an indole derivative and a dopamine D2 receptor antagonist. Results The in vitro pharmacological studies described in the current manuscript demonstrate that the active substance molindone (SPN-810M) is a potent antagonist for the dopamine receptors, D2S and D2L, and the serotonin receptor, 5-HT2B, at therapeutic concentrations. The in vitro studies further demonstrate that the antagonist effect of SPN-810M is due to the parent drug and not the metabolites, and that the antagonism is not affected by the presence of norepinephrine or dopamine neurotransmitters. In addition, studies investigating the potential differential effects of the enantiomers of SPN-810M have demonstrated that the R(−) enantiomer is more potent than S(+), showing greater regulatory effect on D2S and D2L receptors. Conclusion Overall, the results of the in vitro SPN-810M pharmacological studies provide some insight into how SPN-810M modulates the serotonin and dopamine pathways that play a role in IA.
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Affiliation(s)
- Chungping Yu
- Preclinical DMPK and Pharmacology, Supernus Pharmaceuticals, Inc., Rockville, MD, USA,
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Baker M, Carlson GA. What do we really know about PRN use in agitated children with mental health conditions: a clinical review. EVIDENCE-BASED MENTAL HEALTH 2018; 21:166-170. [PMID: 30361330 PMCID: PMC10270407 DOI: 10.1136/ebmental-2018-300039] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 09/16/2018] [Accepted: 09/20/2018] [Indexed: 11/03/2022]
Abstract
What is the evidence that 'pro re nata' (PRN) medication is effective for ending agitated outbursts in children and adolescents in psychiatric emergency rooms or inpatient units? Literature search was performed for studies of PRN medication use in children and adolescents that included an outcome measure. One randomised controlled trial, three prospective studies and six retrospective studies that included some outcome measure were identified. Outcome measures were heterogeneous, and frequently did not use standardised metrics assessing agitation level to measure effectiveness. The single small Randomized Controlled Trial (RTC) does not find a difference between placebo and medication, and outcomes of other studies do not control for potential placebo effect of the intervention itself as opposed to the medication. There is insufficient evidence to support the common practice of PRN medications for the management of acute agitation, and no data with which to inform clinical practice, such as which medicines and doses are helpful for specific populations or situations. Psychiatrists have no evidence-based medication interventions for acutely managing agitated outbursts in children and adolescents.
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Affiliation(s)
- Megan Baker
- Department of Child and Adolescent Psychiatry, NYU School of Medicine, New York City, New York, USA
| | - Gabriellle A Carlson
- Department of Psychiatry and Pediatrics, Stony Brook University School of Medicine, Stonybrook, New York, USA
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Gillentine MA, White JJ, Grochowski CM, Lupski JR, Schaaf CP, Calarge CA, Calarge CA. CHRNA7 copy number gains are enriched in adolescents with major depressive and anxiety disorders. J Affect Disord 2018; 239:247-252. [PMID: 30029151 PMCID: PMC6273479 DOI: 10.1016/j.jad.2018.07.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 05/15/2018] [Accepted: 07/07/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Neuronal nicotinic acetylcholine receptors (nAChRs), specifically the α7 nAChR encoded by the gene CHRNA7, have been implicated in behavior regulation in animal models. In humans, copy number variants (CNVs) of CHRNA7 are found in a range of neuropsychiatric disorders, including mood and anxiety disorders. Here, we aimed to determine the prevalence of CHRNA7 CNVs among adolescents and young adults with major depressive disorder (MDD) and anxiety disorders. METHODS Twelve to 21 year-old participants with MDD and/or anxiety disorders (34% males, mean ± std age: 18.9 ± 1.8 years) were assessed for CHRNA7 copy number state using droplet digital PCR (ddPCR) and genomic quantitative PCR (qPCR). Demographic, anthropometric, and clinical data, including the Beck Anxiety Index (BAI), Beck Depression Inventory (BDI), and the Inventory of Depressive Symptoms (IDS) were collected and compared across individuals with and without a CHRNA7 CNV. RESULTS Of 205 individuals, five (2.4%) were found to carry a CHRNA7 gain, significantly higher than the general population. No CHRNA7 deletions were identified. Clinically, the individuals carrying CHRNA7 duplications did not differ significantly from copy neutral individuals with MDD and/or anxiety disorders. CONCLUSIONS CHRNA7 gains are relatively prevalent among young individuals with MDD and anxiety disorders (odds ratio = 4.032) without apparent distinguishing clinical features. Future studies should examine the therapeutic potential of α7 nAChR targeting drugs to ameliorate depressive and anxiety disorders.
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Affiliation(s)
- Madelyn A. Gillentine
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas.,Jan and Dan Neurological Research Institute, Texas Children’s Hospital, Houston, Texas
| | - Janson J. White
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
| | | | - James R. Lupski
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas.,Human Genome Sequencing Center, Baylor College of Medicine, Houston, Texas.,Texas Children’s Hospital, Houston, Texas
| | - Christian P. Schaaf
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas.,Jan and Dan Neurological Research Institute, Texas Children’s Hospital, Houston, Texas
| | - Chadi A. Calarge
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas
| | - Chadi A Calarge
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, TX 77030, United States.
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Carlson GA, Klein DN. Commentary: Frying pan to fire? Commentary on Stringaris et al. (2018). J Child Psychol Psychiatry 2018; 59:740-743. [PMID: 29924397 PMCID: PMC6093282 DOI: 10.1111/jcpp.12873] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2018] [Indexed: 01/28/2023]
Abstract
The bipolar disorder diagnosis in prepubertal children became popular because it answered a clinical need to treat the explosive behavior component of irritability and the hope that antimanic strategies would be helpful. Poor definition of episodes resulted in mixing chronic and episodic irritability in samples of children with bipolar disorder. The subsequent dramatic increase in neuroleptic use is a testimony to the importance of the problem of irritability and our need to better understand it. Insofar as our use of the term irritability conflates proneness to anger with the subsequent aggressive response, it will again not be clear who is being studied. We need to uncouple the mood and behavior aspects of irritability for further study or we will have traded the imprecision of "bipolar" for the imprecision of irritability.
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Affiliation(s)
- Gabrielle A. Carlson
- Professor of Psychiatry and Pediatrics, Stony Brook University School of Medicine
| | - Daniel N. Klein
- Distinguished Professor of Psychology, Stony Brook University
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Gillentine MA, White JJ, Grochowski CM, Lupski JR, Schaaf CP, Calarge CA. CHRNA7 Deletions are Enriched in Risperidone-Treated Children and Adolescents. J Child Adolesc Psychopharmacol 2017; 27:908-915. [PMID: 28817303 PMCID: PMC5725633 DOI: 10.1089/cap.2017.0068] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Aggression is among the most common indications for referral to child and adolescent mental health services and is often challenging to treat. Understanding the biological underpinnings of aggression could help optimize treatment efficacy. Neuronal nicotinic acetylcholine receptors (nAChRs), specifically the α7 nAChR, encoded by the gene CHRNA7, have been implicated in aggressive behaviors in animal models as well as humans. Copy number variants (CNVs) of CHRNA7 are found in individuals with neuropsychiatric disorders, often with comorbid aggression. In this study, we aimed to determine the prevalence of CHRNA7 CNVs among individuals treated with risperidone, predominantly for irritability and aggression. METHODS Risperidone-treated children and adolescents were assessed for CHRNA7 copy number state using droplet digital PCR and genomic quantitative PCR. Demographic, anthropometric, and clinical data, including the Child Behavior Checklist (CBCL), were collected and compared across individuals with and without the CHRNA7 deletion. RESULTS Of 218 individuals (90% males, mean age: 12.3 ± 2.3 years), 7 (3.2%) were found to carry a CHRNA7 deletion and one proband carried a CHRNA7 duplication (0.46%). T-scores for rule breaking, aggression, and externalizing behavior factors of the CBCL were higher in the deletion group, despite taking 58% higher dose of risperidone. CONCLUSIONS CHRNA7 loss may contribute to a phenotype of severe aggression. Given the high prevalence of the deletion among risperidone-treated youth, future studies should examine the therapeutic potential of α7 nAChR-targeting drugs to target aggression associated with CHRNA7 deletions.
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Affiliation(s)
- Madelyn A. Gillentine
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas.,Jan and Dan Neurological Research Institute, Texas Children's Hospital, Houston, Texas
| | - Janson J. White
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas
| | | | - James R. Lupski
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas.,Human Genome Sequencing Center, Baylor College of Medicine, Houston, Texas.,Texas Children's Hospital, Houston, Texas
| | - Christian P. Schaaf
- Department of Molecular and Human Genetics, Baylor College of Medicine, Houston, Texas.,Jan and Dan Neurological Research Institute, Texas Children's Hospital, Houston, Texas
| | - Chadi A. Calarge
- Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Houston, Texas
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van Schalkwyk GI, Lewis AS, Beyer C, Johnson J, van Rensburg S, Bloch MH. Efficacy of antipsychotics for irritability and aggression in children: a meta-analysis. Expert Rev Neurother 2017; 17:1045-1053. [PMID: 28847182 DOI: 10.1080/14737175.2017.1371012] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Aggression and irritability in children occur across a range of diagnoses, and are associated with both economic cost and negative psychosocial outcomes. Antipsychotics are frequently prescribed in these cases. METHODS A random effects meta-analysis of 14 random controlled trials was conducted. Overall effect sizes for antipsychotics for irritability and aggression were extracted. Subgroup analyses were conducted according to diagnostic indication, specific medication and degree of sedation. Meta-regression examined effects of antipsychotic dose. RESULTS Overall, antipsychotics were effective in reducing aggression and irritability (SMD = 0.74, 95% confidence interval [CI] 0.57-0.92, z = 8.4, p < 0.0001). In stratified subgroup analysis, individual antipsychotic agents did not differ in efficacy (χ2 = 1.1, df = 3, p = 0.78). However, aripiprazole and risperidone demonstrated significant benefit over placebo. Antipsychotic efficacy did not differ significantly based on diagnostic indication (χ2 = 4.2, df = 4, p = 0.39). Meta-regression showed no overall dose effect. CONCLUSIONS Clinical data supports the efficacy of risperidone and aripiprazole for aggression and irritability across diagnoses, with insufficient data available for other agents. Available data does not support a difference in efficacy based on underlying diagnosis, choice of agent, or its degree of sedation.
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Affiliation(s)
| | - Alan S Lewis
- b Department of Psychiatry , Yale University , New Haven , CT , USA
| | - Chad Beyer
- a Child Study Center , Yale University , New Haven , CT , USA
| | - Jessica Johnson
- a Child Study Center , Yale University , New Haven , CT , USA
| | - Samuel van Rensburg
- c School of Nursing , Fairfield University School of Nursing , Fairfield , CT , USA
| | - Michael H Bloch
- a Child Study Center , Yale University , New Haven , CT , USA.,b Department of Psychiatry , Yale University , New Haven , CT , USA
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Loy JH, Merry SN, Hetrick SE, Stasiak K. Atypical antipsychotics for disruptive behaviour disorders in children and youths. Cochrane Database Syst Rev 2017; 8:CD008559. [PMID: 28791693 PMCID: PMC6483473 DOI: 10.1002/14651858.cd008559.pub3] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND This is an update of the original Cochrane Review, last published in 2012 (Loy 2012). Children and youths with disruptive behaviour disorders may present to health services, where they may be treated with atypical antipsychotics. There is increasing usage of atypical antipsychotics in the treatment of disruptive behaviour disorders. OBJECTIVES To evaluate the effect and safety of atypical antipsychotics, compared to placebo, for treating disruptive behaviour disorders in children and youths. The aim was to evaluate each drug separately rather than the class effect, on the grounds that each atypical antipsychotic has different pharmacologic binding profile (Stahl 2013) and that this is clinically more useful. SEARCH METHODS In January 2017, we searched CENTRAL, MEDLINE, Embase, five other databases and two trials registers. SELECTION CRITERIA Randomised controlled trials of atypical antipsychotics versus placebo in children and youths aged up to and including 18 years, with a diagnosis of disruptive behaviour disorders, including comorbid ADHD. The primary outcomes were aggression, conduct problems and adverse events (i.e. weight gain/changes and metabolic parameters). The secondary outcomes were general functioning, noncompliance, other adverse events, social functioning, family functioning, parent satisfaction and school functioning. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. Two review authors (JL and KS) independently collected, evaluated and extracted data. We used the GRADE approach to assess the quality of the evidence. We performed meta-analyses for each of our primary outcomes, except for metabolic parameters, due to inadequate outcome data. MAIN RESULTS We included 10 trials (spanning 2000 to 2014), involving a total of 896 children and youths aged five to 18 years. Bar two trials, all came from an outpatient setting. Eight trials assessed risperidone, one assessed quetiapine and one assessed ziprasidone. Nine trials assessed acute efficacy (over four to 10 weeks); one of which combined treatment with stimulant medication and parent training. One trial was a six-month maintenance trial assessing symptom recurrence.The quality of the evidence ranged from low to moderate. Nine studies had some degree of pharmaceutical support/funding. Primary outcomesUsing the mean difference (MD), we combined data from three studies (238 participants) in a meta-analysis of aggression, as assessed using the Aberrant Behaviour Checklist (ABC) ‒ Irritability subscale. We found that youths treated with risperidone show reduced aggression compared to youths treated with placebo (MD -6.49, 95% confidence interval (CI) -8.79 to -4.19; low-quality evidence). Using the standardised mean difference (SMD), we pooled data from two risperidone trials (190 participants), which used different scales: the Overt Aggression Scale ‒ Modified (OAS-M) Scale and the Antisocial Behaviour Scale (ABS); as the ABS had two subscales that could not be combined (reactive and proactive aggression), we performed two separate analyses. When we combined the ABS Reactive subscale and the OAS-M, the SMD was -1.30 in favour of risperidone (95% CI -2.21 to -0.40, moderate-quality evidence). When we combined the ABS Proactive subscale and OAS-M, the SMD was -1.12 (95% CI -2.30 to 0.06, moderate-quality evidence), suggesting uncertainty about the estimate of effect, as the confidence intervals overlapped the null value. In summary, there was some evidence that aggression could be reduced by risperidone. Data were lacking on other atypical antipsychotics, like quetiapine and ziprasidone, with regard to their effects on aggression.We pooled data from two risperidone trials (225 participants) in a meta-analysis of conduct problems, as assessed using the Nisonger Child Behaviour Rating Form ‒ Conduct Problem subscale (NCBRF-CP). This yielded a final mean score that was 8.61 points lower in the risperidone group compared to the placebo group (95% CI -11.49 to -5.74; moderate-quality evidence).We investigated the effect on weight by performing two meta-analyses. We wanted to distinguish between the effects of antipsychotic medication only and the combined effect with stimulants, since the latter can have a counteracting effect on weight gain due to appetite suppression. Pooling two trials with risperidone only (138 participants), we found that participants on risperidone gained 2.37 kilograms (kg) more (95% CI 0.26 to 4.49; moderate-quality evidence) than those on placebo. When we added a trial where all participants received a combination of risperidone and stimulants, we found that those on the combined treatment gained 2.14 kg more (95% CI 1.04 to 3.23; 3 studies; 305 participants; low-quality evidence) than those on placebo. Secondary outcomesOut of the 10 included trials, three examined general functioning, social functioning and parent satisfaction. No trials examined family or school functioning. Data on non-compliance/attrition rate and other adverse events were available from all 10 trials. AUTHORS' CONCLUSIONS There is some evidence that in the short term risperidone may reduce aggression and conduct problems in children and youths with disruptive behaviour disorders There is also evidence that this intervention is associated with significant weight gain.For aggression, the difference in scores of 6.49 points on the ABC ‒ Irritability subscale (range 0 to 45) may be clinically significant. It is challenging to interpret the clinical significance of the differential findings on two different ABS subscales as it may be difficult to distinguish between reactive and proactive aggression in clinical practice. 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. Weight gain remains a concern.Caution is required in interpreting the results due to the limitations of current evidence and the small number of high-quality trials. There is a lack of evidence to support the use of quetiapine, ziprasidone or any other atypical antipsychotic for disruptive behaviour disorders in children and youths and no evidence for children under five years of age. It is uncertain to what degree the efficacy found in clinical trials will translate into real-life clinical practice. Given the effectiveness of parent-training interventions in the management of these disorders, and the somewhat equivocal evidence on the efficacy of medication, it is important not to use medication alone. This is consistent with current clinical guidelines.
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Affiliation(s)
- Jik H Loy
- Waikato DHBChild and Adolescent Mental Health206 Colllingwood StreetHamiltonNew Zealand
| | - Sally N Merry
- University of AucklandDepartment of Psychological MedicinePrivate Bag 92019AucklandNew Zealand1142
| | - Sarah E Hetrick
- Orygen, The National Centre of Excellence in Youth Mental Health and The Centre of Youth Mental Health, University of Melbourne35 Poplar RoadParkvilleMelbourneVictoriaAustralia3054
| | - Karolina Stasiak
- University of AucklandDepartment of Psychological MedicinePrivate Bag 92019AucklandNew Zealand1142
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Yamamuro K, Tsujii N, Ota T, Kishimoto T, Iida J. Pharmacotherapy for the treatment of aggression in pediatric and adolescent patients with autism spectrum disorder comorbid with attention-deficit hyperactivity disorder: A questionnaire survey of 571 psychiatrists. Psychiatry Clin Neurosci 2017; 71:554-561. [PMID: 28317224 DOI: 10.1111/pcn.12523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Revised: 03/07/2017] [Accepted: 03/14/2017] [Indexed: 01/03/2023]
Abstract
AIM Both attention-deficit hyperactivity disorder (ADHD) and autism spectrum disorder (ASD) are frequently accompanied by serious aggression that requires psychiatric treatment. However, little is known about the experiences psychiatrists have had using pharmacotherapy to treat aggression in patients who have both ASD and ADHD (ASD/ADHD). The purpose of this study was to examine the experiences of Japanese child and adolescent psychiatrists in prescribing medication for aggression in patients with ASD/ADHD. METHODS A prospective questionnaire was mailed to 2001 psychiatrists affiliated with the Japanese Society for Child and Adolescent Psychiatry. Multivariate logistic regression analysis was used to identify factors predicting the outcome of pharmacotherapeutic treatment of aggression in pediatric and adolescent patients with ASD/ADHD. RESULTS Of 2001 psychiatrists, 571 (28.5%) completed the full questionnaire (final sample). Of these, 488 (85.4%) prescribed psychotropic medication in treating pediatric and adolescent patients with ASD/ADHD, 299 (61.3%) of them doing so to treat aggression. Prescribers' duration of practice (odds ratio, 1.055; P = 0.038) and patient symptoms of residual impulsivity (odds ratio, 2.479; P = 0.039) increased the odds of prescribing psychotropic medications to treat aggression in these patients. The respondents reported a similar effect for patients with ADHD/ASD compared with those with ADHD only in treating aggression. CONCLUSION Japanese psychiatrists tended to prescribe psychotropic medication for aggression in pediatric and adolescent patients with ASD/ADHD. Future studies examining aggression in pediatric and adolescent patients with ASD/ADHD should aim to accumulate evidence for the use of psychotropic medications, which could help clinicians make better decisions.
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Affiliation(s)
- Kazuhiko Yamamuro
- Department of Psychiatry, Nara Medical University School of Medicine, Kashihara, Japan
| | - Noa Tsujii
- Department of Neuropsychiatry, Kindai University Faculty of Medicine, Osaka, Japan
| | - Toyosaku Ota
- Department of Psychiatry, Nara Medical University School of Medicine, Kashihara, Japan
| | - Toshifumi Kishimoto
- Department of Psychiatry, Nara Medical University School of Medicine, Kashihara, Japan
| | - Junzo Iida
- Faculty of Nursing, Nara Medical University School of Medicine, Kashihara, Japan
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Affiliation(s)
- Melissa A. Brotman
- Emotion and Development Branch, National Institute of Mental Health, Bethesda, Maryland 20892;, ,
| | - Katharina Kircanski
- Emotion and Development Branch, National Institute of Mental Health, Bethesda, Maryland 20892;, ,
| | - Ellen Leibenluft
- Emotion and Development Branch, National Institute of Mental Health, Bethesda, Maryland 20892;, ,
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Cackowski S, Krause-Utz A, Van Eijk J, Klohr K, Daffner S, Sobanski E, Ende G. Anger and aggression in borderline personality disorder and attention deficit hyperactivity disorder - does stress matter? Borderline Personal Disord Emot Dysregul 2017; 4:6. [PMID: 28331620 PMCID: PMC5356413 DOI: 10.1186/s40479-017-0057-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 03/10/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The impact of stress on anger and aggression in Borderline Personality Disorder (BPD) and Attention Deficit Hyperactivity Disorder (ADHD) has not been thoroughly investigated. The goal of this study was to investigate different aspects of anger and aggression in patients with these disorders. METHODS Twenty-nine unmedicated female BPD patients, 28 ADHD patients and 30 healthy controls (HC) completed self-reports measuring trait anger, aggression and emotion regulation capacities. A modified version of the Point Subtraction Aggression Paradigm and a state anger measurement were applied under resting and stress conditions. Stress was induced by the Mannheim Multicomponent Stress Test (MMST). RESULTS Both patient groups scored significantly higher on all self-report measures compared to HCs. Compared to ADHD patients, BPD patients reported higher trait aggression and hostility, a stronger tendency to express anger when provoked and to direct anger inwardly. Furthermore, BPD patients exhibited higher state anger than HCs and ADHD patients under both conditions and showed a stress-dependent anger increase. At the behavioral level, no significant effects were found. In BPD patients, aggression and anger were positively correlated with emotion regulation deficits. CONCLUSIONS Our findings suggest a significant impact of stress on self-perceived state anger in BPD patients but not on aggressive behavior towards others in females with BPD or ADHD. However, it appears to be pronounced inwardly directed anger which is of clinical importance in BPD patients.
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Affiliation(s)
- Sylvia Cackowski
- Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim/Heidelberg University, J5, D-68159 Mannheim, Germany
| | - Annegret Krause-Utz
- Department of Clinical Psychology, Faculty of Social and Behavioural Science, Leiden University, Leiden, The Netherlands
| | - Julia Van Eijk
- Department of Neuroimaging, Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
| | - Katrin Klohr
- Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim/Heidelberg University, J5, D-68159 Mannheim, Germany
| | - Stephanie Daffner
- Department of Psychosomatic Medicine and Psychotherapy, Central Institute of Mental Health Mannheim, Medical Faculty Mannheim/Heidelberg University, J5, D-68159 Mannheim, Germany
| | - Esther Sobanski
- Department of Psychiatry and Psychotherapy, Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
| | - Gabriele Ende
- Department of Neuroimaging, Central Institute of Mental Health, Medical Faculty Mannheim/Heidelberg University, Mannheim, Germany
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Tudor ME, Ibrahim K, Bertschinger E, Piasecka J, Sukhodolsky DG. Cognitive-Behavioral Therapy for a 9-Year-Old Girl With Disruptive Mood Dysregulation Disorder. Clin Case Stud 2016; 15:459-475. [PMID: 29081722 DOI: 10.1177/1534650116669431] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Disruptive mood dysregulation disorder (DMDD) is a relatively new diagnosis in the field of childhood onset disorders. Characterized by both behavior and mood disruption, DMDD is a purportedly unique clinical presentation with few relevant treatment studies to date. The current case study presents the application of cognitive-behavioral therapy (CBT) for anger and aggression in a 9-year-old girl with DMDD, co-occurring attention deficit hyperactivity disorder (ADHD), and a history of unspecified anxiety disorder. At the time of intake evaluation, she demonstrated three to four temper outbursts and two to three episodes of aggressive behavior per week, in addition to prolonged displays of non-episodic irritability lasting hours or days at a time. A total of 12 CBT sessions were conducted over 12 weeks and 5 follow-up booster sessions were completed over a subsequent 3-month period. Irritability-related material was specially designed to target the DMDD clinical presentation. Post-treatment and 3-month follow-up assessments, including independent evaluation, demonstrated significant decreases in the target symptoms of anger, aggression, and irritability. Although the complexities of diagnosing and treating DMDD warrant extensive research inquiry, the current case study suggests CBT for anger and aggression as a viable treatment for affected youth.
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[Intermittent Explosive Disorder: A Controversial Diagnosis]. REVISTA COLOMBIANA DE PSIQUIATRIA 2016; 45:214-23. [PMID: 27569016 DOI: 10.1016/j.rcp.2015.11.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 08/25/2015] [Accepted: 11/05/2015] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Intermittent explosive disorder (IED) is aan externalizing externalising disorder characterized characterised by recurrent aggression episodes. Even though this disorder was described several decades ago, and it carries personal and social consequences, there is little in the medical scientific literature on this. bibliographic production about it is scanty. OBJECTIVE To perform a conceptualization conceptualisation of this disorder, through the review and bibliometric analysis of the available scientific articles. MATERIAL AND METHODS A search was performed in databases with the english English terms intermittent explosive disorder, impulse disorders control [MeSH], in combination with other terms. A bibliometric analysis in the GoPubMed® search engineer was also performed using all data obtained in the search. was also perfomed. DISCUSSION IED prevalence ranges from 1.4% to 7%, it presents more frequently during middle adolescence, and with more noticeable repercussions in men males than in womenfemales. The psychopathological core of IED is the impulsive aggressive behaviour that presents in the form of «attacks» that occurs in response to a lower precipitating stimulus. Scientific publications about IED are few and relatively recent, and the vast majority is provided bycomes from the United States (56.56%), and headed by a single author. This fact highlights the need to replicate the findings described about the IED in order to demonstrate the validity and reliability of its diagnostic criteria. It is possible that doubts about the existence of a diagnosis lead have led to such a scant literature about the IED. CONCLUSIONS Available studies about IED allow have allowed characterizing a group of subjects with episodes of impulsive aggression to be characterised, but this description requires replication in different latitudesneeds to be repeated in different areas.
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Fibert P, Relton C, Heirs M, Bowden D. A comparative consecutive case series of 20 children with a diagnosis of ADHD receiving homeopathic treatment, compared with 10 children receiving usual care. HOMEOPATHY 2016; 105:194-201. [PMID: 27211327 DOI: 10.1016/j.homp.2015.09.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 08/13/2015] [Accepted: 09/25/2015] [Indexed: 10/22/2022]
Abstract
UNLABELLED 20 consecutively enrolled children age 5-16 with Attention Deficit Hyperactivity Disorder (ADHD) received treatment by a homeopath (8 consultations and individualized remedies) for one year. Ten subsequently enrolled children received similar time and attention for 4 months. The study explored optimum treatment protocols; the effectiveness, deliverability and acceptability of treatment; and the feasibility of outcome measurement and recruitment. Parents completed Conners' Parent Rating Scale, Revised Long Version ( CPRS-R L) every 4 months, from which DSMIV total scores were extracted; and Measure Your Own Medical Outcome Profile (MYMOP) every consultation. An interaction between time (baseline/4 months) and group (treatment/non-treatment) was found .756 F (1,28)=9.06, p=0.005. The intervention was associated with statistically significant improvements in treated children over the year: CPRS-R L (t (18)=4.529, p≤0.000); MYMOP (t (18)=6.938, p≤0.000). Mean DSMIV total t scores decreased at each time point: baseline: 85 (SD 5.1); 4 months 76.2 (SD 10.9); and 12 months 71.5 (SD 12.77). Recruitment of control participants was problematic. Recruitment to treatment was feasible via ADHD support groups, charities, police support agencies and social services, not schools or NHS services. Attending appointments was problematic for some participants, but home visits did not improve uptake. The best venue was a familiar clinic. Some participants took medicines inappropriately, but generally taking homeopathic remedies was acceptable and well implemented. CPRS-R L (80 items) was problematic for some parents. MYMOP was preferred by parents but not acceptable to stakeholders. In this small consecutive sample the intervention was associated with improvements in criminality, anger and children with a concomitant diagnosis of Autism Spectrum Disorder ASD. Treatment by a homeopath was associated with sustained, increasing improvements and the intervention was acceptable to participants. More methodically rigorous research is warranted. "We recommend that future research in this area uses comparative effectiveness randomised controlled trial designs. We also recommend that these trials measure outcomes of relevance to stakeholder needs - the people and services who care for those with ADHD - parents, teachers and social workers and the criminal justice system".
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Affiliation(s)
- Philippa Fibert
- Goldsmiths, University of London, New Cross, London SE14 6NW, UK; School of Health and Related Research, University of Sheffield, 30 Regent Court, Sheffield S1 4DA, UK.
| | - Clare Relton
- School of Health and Related Research, University of Sheffield, 30 Regent Court, Sheffield S1 4DA, UK
| | - Morag Heirs
- Northern College of Acupuncture, 61 Micklegate, York YO1 6LJ, UK
| | - Deborah Bowden
- Goldsmiths, University of London, New Cross, London SE14 6NW, UK
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Fristad MA, Wolfson H, Algorta GP, Youngstrom EA, Arnold LE, Birmaher B, Horwitz S, Axelson D, Kowatch RA, Findling RL. Disruptive Mood Dysregulation Disorder and Bipolar Disorder Not Otherwise Specified: Fraternal or Identical Twins? J Child Adolesc Psychopharmacol 2016; 26:138-46. [PMID: 26859630 PMCID: PMC4800383 DOI: 10.1089/cap.2015.0062] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVE The purpose of this study was to examine similarities and differences between disruptive mood dysregulation disorder (DMDD) and bipolar disorder not otherwise specified (BP-NOS) in baseline sociodemographic and clinical characteristics and 36 month course of irritability in children 6-12.9 years of age. METHODS A total of 140 children with DMDD and 77 children with BP-NOS from the Longitudinal Assessment of Manic Symptoms cohort were assessed at baseline, then reassessed every 6 months for 36 months. RESULTS Groups were similar on most sociodemographic and baseline clinical variables other than most unfiltered (i.e., interviewer-rated regardless of occurrence during a mood episode) Young Mania Rating Scale (YMRS) and parent-reported General Behavior Inventory-10 Item Mania (PGBI-10M) items. Children with DMDD received lower scores on every item (including irritability) except impaired insight; differences were significant except for sexual interest and disruptive-aggressive behavior. Children with DMDD received lower scores on eight of 10 PGBI-10M items, the other two items rated irritability. Youth with DMDD were significantly less likely to have a biological parent with a bipolar diagnosis than were youth with BP-NOS. Children with DMDD were more likely to be male and older than children with BP-NOS, both small effect sizes, but had nearly double the rate of disruptive behavior disorders (large effect). Caregiver ratings of irritability based on the Child and Adolescent Symptom Inventory-4R (CASI-4R) were comparable at baseline; the DMDD group had a small but significantly steeper decline in scores over 36 months relative to the BP-NOS group (b = -0.24, SE = 0.12, 95% CI -0.48 to -0.0004). Trajectories for both groups were fairly stable, in the midrange of possible scores. CONCLUSIONS In a sample selected for elevated symptoms of mania, twice as many children were diagnosed with DMDD than with BP-NOS. Children with DMDD and BP-NOS are similar on most characteristics other than manic symptoms, per se, and parental history of bipolar disorder. Chronic irritability is common in both groups. Comprehensive evaluations are needed to diagnose appropriately. Clinicians should not assume that chronic irritability leads exclusively to a DMDD diagnosis.
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Affiliation(s)
- Mary A. Fristad
- Department of Psychiatry and Behavioral Health, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Hannah Wolfson
- Department of Psychiatry and Behavioral Health, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | | | - Eric A. Youngstrom
- Department of Psychology, University of North Carolina, Chapel Hill, North Carolina
| | - L. Eugene Arnold
- Department of Psychiatry and Behavioral Health, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Boris Birmaher
- Department of Psychiatry, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Sarah Horwitz
- Department of Child and Adolescent Psychiatry, New York University School of Medicine, New York, New York
| | - David Axelson
- Department of Psychiatry and Behavioral Health, The Ohio State University Wexner Medical Center, Columbus, Ohio.,Section of Child and Adolescent Psychiatry, Nationwide Children's Hospital, Columbus, Ohio
| | - Robert A. Kowatch
- Department of Psychiatry and Behavioral Health, The Ohio State University Wexner Medical Center, Columbus, Ohio.,Section of Child and Adolescent Psychiatry, Nationwide Children's Hospital, Columbus, Ohio
| | - Robert L. Findling
- Department of Psychiatry, Johns Hopkins Children's Center/ Kennedy Krieger Institute, Baltimore, Maryland
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Saylor KE, Amann BH. Impulsive Aggression as a Comorbidity of Attention-Deficit/Hyperactivity Disorder in Children and Adolescents. J Child Adolesc Psychopharmacol 2016; 26:19-25. [PMID: 26744906 PMCID: PMC4779282 DOI: 10.1089/cap.2015.0126] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE This article examines the characteristics of impulsive aggression (IA) as a comorbidity in children and adolescents with attention-deficit/hyperactivity disorder (ADHD), focusing on its incidence, impact on ADHD outcomes, need for timely intervention, and limitations of current treatment practices. METHODS Relevant literature was retrieved with electronic searches in PubMed and PsycINFO using the search strategy of "ADHD OR attention deficit hyperactivity disorder" AND "impulsive aggression OR reactive aggression OR hostile aggression OR overt aggression" AND "pediatric OR childhood OR children OR pre-adolescent OR adolescent" with separate searches using review OR clinical trial as search limits. Key articles published before the 2007 Expert Consensus Report on IA were identified using citation analysis. RESULTS More than 50% of preadolescents with ADHD combined subtype reportedly display clinically significant aggression, with impulsive aggression being the predominant subtype. Impulsive aggression is strongly predictive of a highly unfavorable developmental trajectory characterized by the potential for persistent ADHD, increasing psychosocial burden, accumulating comorbidities, serious lifelong functional deficits across a broad range of domains, delinquency/criminality, and adult antisocial behavior. Impulsive aggression, which triggers peer rejection and a vicious cycle of escalating dysfunction, may be a key factor in unfavorable psychosocial outcomes attributed to ADHD. Because severe aggressive behavior does not remit in many children when treated with primary ADHD therapy (i.e., stimulants and behavioral therapy), a common practice is to add medication of a different class to specifically target aggressive behavior. CONCLUSIONS Impulsive aggression in children and adolescents with ADHD is a serious clinical and public health problem. Although adjunctive therapy with an aggression-targeted agent is widely recommended when aggressive behaviors do not remit with primary ADHD therapy, empirical evidence does not currently support the use of any specific agent. Randomized controlled trials are needed to identify aggression-targeted agents with favorable benefit-risk profiles.
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Connor DF. On the Challenge of Maladaptive and Impulsive Aggression in the Clinical Treatment Setting. J Child Adolesc Psychopharmacol 2016; 26:2-3. [PMID: 26835875 DOI: 10.1089/cap.2015.0204] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Daniel F Connor
- Department of Psychiatry, University of Connecticut School of Medicine , Farmington, Connecticut
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Sukhodolsky DG, Wyk BCV, Eilbott JA, McCauley SA, Ibrahim K, Crowley MJ, Pelphrey KA. Neural Mechanisms of Cognitive-Behavioral Therapy for Aggression in Children and Adolescents: Design of a Randomized Controlled Trial Within the National Institute for Mental Health Research Domain Criteria Construct of Frustrative Non-Reward. J Child Adolesc Psychopharmacol 2016; 26:38-48. [PMID: 26784537 PMCID: PMC4779273 DOI: 10.1089/cap.2015.0164] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE We present the rationale and design of a randomized controlled trial of cognitive-behavioral therapy (CBT) for aggression in children and adolescents, which is conducted in response to the National Institute of Mental Health (NIMH) Research Domain Criteria (RDoC) approach initiative. Specifically, the study is focused on the brain-behavior associations within the RDoC construct of frustrative non-reward. On the behavioral level, this construct is defined by reactions elicited in response to withdrawal or prevention of reward, most notably reactive aggression. This study is designed to test the functional magnetic resonance (fMRI) and electrophysiological (EEG) correlates of aggression and its reduction after CBT. METHODS Eighty children and adolescents with high levels of aggression across multiple traditional diagnostic categories, ages 8-16, will be randomly assigned to receive 12 sessions of CBT or 12 sessions of supportive psychotherapy. Clinical outcomes will be measured by the ratings of aggressive behavior collected at baseline, midpoint, and endpoint evaluations, and by the Improvement Score of the Clinical Global Impressions Scale assigned by an independent evaluator (blinded rater). Subjects will also perform a frustration-induction Go-NoGo task and a task of emotional face perception during fMRI scanning and EEG recording at baseline and endpoint. RESULTS Consistent with the NIMH strategic research priorities, if functional neuroimaging and EEG variables can identify subjects who respond to CBT for aggression, this can provide a neuroscience-based classification scheme that will improve treatment outcomes for children and adolescents with aggressive behavior. CONCLUSIONS Demonstrating that a change in the key nodes of the emotion regulation circuitry is associated with a reduction of reactive aggression will provide evidence to support the validity of the frustrative non-reward construct.
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Affiliation(s)
| | - Brent C. Vander Wyk
- Child Study Center, Yale University School of Medicine, New Haven, Connecticut
| | - Jeffrey A. Eilbott
- Child Study Center, Yale University School of Medicine, New Haven, Connecticut
| | - Spencer A. McCauley
- Child Study Center, Yale University School of Medicine, New Haven, Connecticut
| | - Karim Ibrahim
- Child Study Center, Yale University School of Medicine, New Haven, Connecticut
| | - Michael J. Crowley
- Child Study Center, Yale University School of Medicine, New Haven, Connecticut
| | - Kevin A. Pelphrey
- Child Study Center, Yale University School of Medicine, New Haven, Connecticut
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50
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Gurnani T, Ivanov I, Newcorn JH. Pharmacotherapy of Aggression in Child and Adolescent Psychiatric Disorders. J Child Adolesc Psychopharmacol 2016; 26:65-73. [PMID: 26881859 DOI: 10.1089/cap.2015.0167] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Aggression is a common, yet complex, behavioral complaint, and a frequent indication for referral to child and adolescent psychiatrist treatment. This article reviews the evidence supporting pharmacotherapy of aggression in youth, with a primary focus on impulsive aggression (the primary indication for this intervention). Relevant diagnostic considerations and consensus guidelines are discussed. METHODS Articles examining the role of medications in the treatment of aggression in youth with pathological aggression were identified using PubMed and MEDLINE® databases over the past 15 years (2000-2015); selected articles published prior to 2000 and deemed to be of high relevance were searched and also included. Search terms included: Aggression, aggressive, disruptive behavior, conduct, youth, children, and adolescents. Cited references were also searched for relevant articles. RESULTS There are a number of evidence-based medication treatments for aggression, which are generally best considered in the context of differential diagnosis and ongoing evidence-based psychosocial interventions. Impulsive aggression is generally considered the type of aggression most amenable to medication, but other aggression subtypes may also possibly respond to treatment. Medication classes with positive evidence include the psychostimulants and α-2 agonists (in the presence of attention-deficit/hyperactivity disorder [ADHD] and/or disruptive behavior disorders), mood stabilizing agents, and atypical antipsychotics. Published guidelines recommend systematic and adequate trials of medications in sequential order, to optimize response and minimize polypharmacy. Guidelines for safety monitoring are available for many of the medications used for aggression in youth, and are also discussed. CONCLUSIONS Aggression in children carries a high risk of poor outcomes, and, therefore, a better understanding of treatment options is a high priority. The available literature points to the importance of identifying the underlying disorder, when possible, and using this information to guide treatment selection. Future studies are needed to better inform the treatment of aggression across disorders, and the treatment of different aggression subtypes.
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Affiliation(s)
- Tina Gurnani
- 1 Department of Psychiatry, Mount Sinai-St. Luke's Hospital Center , New York, New York
| | - Iliyan Ivanov
- 1 Department of Psychiatry, Mount Sinai-St. Luke's Hospital Center , New York, New York.,2 Department of Psychiatry, Icahn School of Medicine at Mount Sinai , New York, New York
| | - Jeffrey H Newcorn
- 2 Department of Psychiatry, Icahn School of Medicine at Mount Sinai , New York, New York
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