Acute aggression in child and adolescent psychiatric patients should be addressed with psychosocial crisis management before resorting to medication, according to an expert consensus panel convened by the Center for the Advancement of Children's Mental Health at Columbia University and the New York State Office of Mental Health. Their two-part report in the February Journal of the American Academy of Child and Adolescent Psychiatry reviewed the safety and efficacy of treatments for aggression in young patients (Schur et al., 2003) and offered treatment recommendations and rationale (Pappadopulos et al., 2003).
The Treatment Recommendations for the Use of Antipsychotics for Aggressive Youth (TRAAY) were formulated from expert consensus and assessment of available evidence. The recommendations address severe impulsive aggression, including verbal threats of violence toward oneself or others. The recommendations do not extend to predatory aggression or what has been described as planned and self-controlled aggressive behavior (Vitiello et al., 1990).
Although TRAAY were developed independently of the American Academy of Child and Adolescent Psychiatry (AACAP), they complement the Academy's practice parameters for preventing and managing aggressive behavior (Masters et al., 2002). Unlike other treatment guideline projects, such as those of the AACAP, the American Psychiatric Association and the Texas Medication Algorithm Project (TMAP) (Miller et al., 1999), which consider specific diagnostic entities, TRAAY address the behavioral manifestations of patients with a variety of disorders.
Also unlike these other projects, TRAAY were developed with relatively little controlled data to draw upon. The panel explained, "Our target population is composed of patients who are excluded from most research." With the absence of controlled research, interventions with aggressive youth appear to have evolved from heuristic clinical practices, adult treatment literature and case reports.
In order to provide more substantive treatment rationales and coherent strategies, the TRAAY panel reviewed intervention methods and any evidence for efficacy, utilizing both literature and patient chart review (Schur et al., 2003). To develop wellfounded recommendations despite scarce controlled data, the panel also elicited expert opinion through focus groups and surveys and finalized recommendations in a Medication Consensus Workshop (Pappadopulos et al., 2003).
The panel explained, "We have tailored our actions to utilize the evidence base along with a rigorous expert consensus process to address areas for which research is lacking."
Intervention Safety and Efficacy