Experts' recommendations for treating maladaptive aggression in youth

Abstract

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

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

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

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

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

FIG. 1.

Appropriateness of each method as part of a general evaluation for a child/adolescent with aggression accompanied by other emotional-behavioral problems.

FIG. 2.

Appropriateness of each method for enhancing parental and child/adolescent engagement in the treatment process.

FIG. 3.

Rating of how appropriate and essential these psychosocial treatments are for youth with maladaptive aggression.

FIG. 4.

Rating of whether specific clinical symptoms warrant use of an AAP. AAP=atypical antipsychotic.

FIG. 5.

Appropriateness of strategies as “guiding principles” on the use of polypharmacy in children and adolescents.

FIG. 6.

Assume a patient has had only a partial response to an AAP for aggressive-destructive behavior. Rate the appropriateness of adding any of the listed medications.

FIG. 7.

Rate the appropriateness of each factor as a reason for switching a child/adolescent from one antipsychotic to another. Assume an optimal therapeutic dose and the patient has been taking the agent as prescribed.