Youth Aggression: Economic Impact, Causes, Prevention, and Treatment
By Leo J. Bastiaens, MD and Ida K. Bastiaens |
October 1, 2006
Recent studies in pharmacotherapy
Diagnosis-specific pharmacotherapy should be the first-line treatment to target aggressive behavior, including23: stimulantsor atomoxetinefor attention-deficit/hyperactivity disorder (ADHD), antidepressants for depressive disorders, mood stabilizers for bipolar disorders, and antipsychotic agents for psychotic disorders. However, additional pharmacologic interventions are often needed in patients who are seriously aggressive.
Dunn and colleagues24 conducted an open-label study in 24 adolescents with ADHD, oppositional defiant disorder, or conduct disorder who exhibited severe aggressive outbursts, according to the Modified Overt Aggression Scale. The initial treatment consisted of 3 weeks of 54 mg/d of extended-release methylphenidate(Drug information on methylphenidate) monotherapy, followed by 9 weeks of a combination of extended-release methylphenidate and quetiapine(Drug information on quetiapine). Quetiapine was given at dosages up to 600 mg/d. After 12 weeks, verbal aggression and physical aggression toward self, others, and property declined significantly. Both the diagnosis-specific medication and the atypical antipsychotic appeared to contribute to improvement. However, this was an open-label study without placebo or active control. It is unclear how much of a placebo effect, monotherapy with methylphenidate, or the combination treatment contributed to the results.
Connor and associates25 conducted a randomized, placebo-controlled monotherapy study with quetiapine treatment for aggressive conduct disorder. Nineteen adolescents participated in this 7-week study. Dosing was flexible; the average dosage of quetiapine at study end point was 300 mg/d 6 168 mg/d. Eight of 9 patients on medication improved, compared with 1 of 10 on placebo, according to a clinical global impression (CGI) score of 2. Quetiapine appeared to be well tolerated, although data on weight and metabolic parameters were not reported.
Atypical antipsychotics have become the mainstay of pharmacotherapy for aggression, and their use in children and adolescents has increased significantly in the last decade.26 Reasons for this increase may be their effectiveness; their fast onset of action, which makes them useful in acute settings; and their improved neurologic safety profile. Recently, however, significant concern has been raised about their metabolic side effects.
The American Psychiatric Association and the American Diabetes Association have ranked the atypical antipsychotics based on their likelihood to induce metabolic abnormalities. Aripiprazole(Drug information on aripiprazole) and ziprasidone(Drug information on ziprasidone) were characterized as being least likely to induce weight gain and metabolic side effects. Because of these potential advantages, an open nonrandomized trial of aripiprazole or ziprasidone in a community clinic population of aggressive children and adolescents was performed.27 Forty-six patients (mean age of 11.9 6 2.6) were administered the Mini International Neuropsychiatric Interview and the Child/Adolescent Symptom Inventory. Conduct, bipolar, and depressive disorders were the most common diagnoses. The primary outcome measure was the Overt Aggression Scale. Patients with significant aggressive behaviors were started on aripiprazole (n = 24) or ziprasidone (n = 22). Eighteen patients were taking concomitant anti-ADHD medication.
After 2 months, 34 patients remained in treatment, with an average dosage of aripiprazole of 4.5 mg/d 6 2.3 mg/d and of ziprasidone of 42.9 mg/d 618 mg/d. The average rating on the Overt Aggression Scale improved 63% and the average CGI score was 2.1 (much improved). There were no statistically significant differences between the aripiprazole group and the ziprasidone group in the primary outcome measure at baseline and after 2 months of treatment. However, 3 times more patients on ziprasidone than those on aripiprazole dropped out because of sedation. No other side effects were prominent, although weight change and metabolic indices require further study.Conclusion
Aggression in youth has an enormous societal impact--economically, clinically, and in terms of human suffering. While primary prevention is clearly desirable, the clinician is more involved with secondary and tertiary prevention and treatment efforts. Controlled studies are needed to sort out which medications or combinations of medications are most effective in controlling aggression in young patients. Treatment that impacts the many biological, psychological, and social factors related to aggression--and is delivered within the patient's environment--may be the most clinically effective and economically sound modality.
Dr Bastiaens is associate clinical professor of psychiatry at the University of Pittsburgh and is associated with Family Services of Western Pennsylvania. He reports that he is on the speakers' bureau and is a consultant for Bristol- Myers Squibb, Eli Lilly, Forest Laboratories, GlaxoSmithKline, Pfizer, and Takeda. He has received research honoraria from Forest Laboratories, McNeil Consumer Healthcare, and Janssen.
Ms Bastiaens is an undergraduate student at Davidson College, Davidson, NC. She reports no conflicts of interest regarding the subject matter of this article.
Drugs mentioned in this article
Methylphenidate-ER (Concerta, others)
- Connor DF, Carlson G, Chang K, et al. Juvenile maladaptive aggression: a review of prevention, treatment, service configuration and a proposed research agenda. J Clin Psychiatry. 2006;67:808-820.
- Steiner H, Petersen ML, Saxena K, et al. Divalproex sodium for the treatment of conduct disorder: a randomized controlled clinical trial. J Clin Psychiatry. 2003; 64:1183-1191.
1. Glicklich-Rosenberg L. Violence and children: a public health issue. Psychiatric Times. 1996;13(3):45-47.
2. Welsh BC. Prevention of juvenile violence: the role of public health. Presented at: Annual Conference of the Committee on Industrial Theory and Assessment; November 7-9, 2002; Lowell, Mass.
3. Haveman R, Wolfe B. The determinants of children's attainments: a review of methods and findings. J Econ Lit. 1995;33:1829-1878.
4. Donohue JJ III, Siegelman P. Allocating resources among prisons and social programs in the battle against crime. J Legal Stud. 1998;27:1-43.
5. Schweinhart LJ, Montie J, Xiang Z, et al. Lifetime Effects. The High/Scope Perry Preschool Study Through Age 40. Ypsilanti, Mich: High/Scope Press; 2005.
6. Moffitt TE. Adolescence-limited and life-course-persistent antisocial behavior: a developmental taxonomy. Psychol Rev.1993;100:674-701.
7. Vitiello B, Behar D, Hunt J, et al. Subtyping aggression in children and adolescents. J Neuropsychiatry Clin Neurosci. 1990;2:189-192.
8. Teplin LA, Abram KM, McClelland GM, et al. Psychiatric disorders in juvenile detention. Arch Gen Psychiatry. 2002;59:1133-1143.
9. McNiel DE, Eisner JP, Binder RL. The relationship between aggressive attributional style and violence by psychiatric patients. J Consult Clin Psychol. 2003; 71:399-403.
10. Conger RD, Neppl T, Kim KJ, Scaramella L. Angry and aggressive behavior across three generations: a prospective, longitudinal study of parents and children. J Abnorm Child Psychol. 2003;31:143-160.
11. McEvoy A, Welker R. Antisocial behavior, academic failure, and school climate: a critical review. J Emot Behav Dis. 2000;8:130-140.
12. Miller-Johnson S, Coie JD, Maumary-Gremaud A, et al. Peer rejection and aggression and early starter models of conduct disorder. J Abnorm Child Psychol. 2002;30:217-230.
13. Johnson JG, Cohen P, Smailes EM, et al. Television viewing and aggressive behavior during adolescence and adulthood. Science. 2002;295:2468-2471.
14. Timmons-Mitchell J, Bender MB, Kishna MA, Mitchell CC. An independent effectiveness trial of multisystemic therapy with juvenile justice youth. J Clin Child Adolesc Psychol. 2006;35:227-236.
15. Smith EP, Gorman-Smith D, Quinn WH, et al. Community-based multiple family groups to prevent and reduce violent and aggressive behavior: the GREAT Families Program. Am J Prev Med. 2004;26:39-47.
16. van Manen TG, Prins PJ, Emmelkamp PM. Reducing aggressive behavior in boys with a social cognitive group treatment: results of a randomized, controlled trial. J Am Acad Child Adolesc Psychiatry. 2004;43: 1478-1487.
17. Kazdin AE, Whitley MK. Treatment of parental stress to enhance therapeutic change among children referred for aggressive and antisocial behavior. J Consult Clin Psychol. 2003;71:504-515.
18. Orpinas P, Horne AM; Multisite Violence Prevention Project. A teacher-focused approach to prevent and reduce students' aggressive behavior: the GREAT Teacher Program. Am J Prev Med. 2004;26:29-38.
19. Connor DF, Carlson G, Chang K, et al. Juvenile maladaptive aggression: a review of prevention, treatment, service configuration and a proposed research agenda. J Clin Psychiatry. 2006;67:808-820.
20. Steiner H, Petersen ML, Saxena K, et al. Divalproex sodium for the treatment of conduct disorder: a randomized controlled clinical trial. J Clin Psychiatry. 2003;64: 1183-1191.
21. Findling RL, Steiner H, Weller EB. Use of antipsychotics in children and adolescents. J Clin Psychiatry. 2005;66(suppl 7):29-40.
22. Saxena K, Chang K, Steiner H. Treatment of aggression with risperidone in children and adolescents with bipolar disorder: a case series. Bipolar Disord. 2006;8: 405-410.
23. Steiner H, Saxena K, Chang K. Psychopharmacological strategies for the treatment of aggression in juveniles. CNS Spectr. 2003;8:298-308.
24. Dunn DW, Kronenberger WG, Giauque AL, et al. Improvement in specific aggressive outbursts in adolescents with ADHD following augmentation of methylphenidate with quetiapine. In: New Research Abstracts from the American Psychiatric Association's 2006 Annual Meeting. Arlington, Va: American Psychiatric Press; 2006:270.
25. Connor DF, McLaughlin TJ, Jeffers-Terry M. A randomized, controlled, pilot study of quetiapine in the treatment of adolescent conduct disorder. In: New Research Abstracts from the American Psychiatric Association's 2006 Annual Meeting. Arlington, Va: American Psychiatric Press; 2006:268.
26. Olfson M, Blanco C, Liu L, et al. National trends in the outpatient treatment of children and adolescents with antipsychotic drugs. Arch Gen Psychiatry. 2006; 63:679-685.
27. Bastiaens LJ. Aripiprazole or ziprasidone to treat aggression in youth. In: New Research Abstracts from the American Psychiatric Association's 2006 Annual Meeting. Arlington, Va: American Psychiatric Press; 2006:261.
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