Novel guidelines manage youth maladaptive aggression

By Liam Davenport

Recommendations for the engagement, assessment, treatment, and management of maladaptive aggression in youth have been developed by US experts to improve treatment planning and selection.

The Treatment of Maladaptive Aggressive in Youth Steering Committee, chaired by Peter Jensen (The Resource for Advancing Children's Health Institute, New York), conducted a literature review identifying studies to help the development of evidence-based guidelines that take into account the patient's severity and source of symptoms, development, primary diagnosis, coexisting conditions, and family situations.

The findings were presented at a 2-day conference of 90 experts in child, adolescent, and family mental health matters to develop consensus recommendations on assessment and diagnosis, psychopharmacology, side-effect assessment and management, and parent education, engagement, and psychosocial interventions.

The resulting guidelines are published in two papers in Pediatrics.

For the engagement, assessment, and management of maladaptive aggression, recommendations include engaging parents and patients during the initial evaluation, conducting a thorough diagnostic work-up before initiating pharmacologic treatment, and using standardized measures to assess treatment effects and outcomes. They also suggest considering referral to a psychiatrist or emergency department in cases of acute aggression, and the development of an appropriate treatment plan with the patient/family, with the aim of achieving "buy-in."

Psychosocial treatment recommendations include assisting the family in obtaining parent and child skills training, and encouraging the child and family to take an active role in implementing psychosocial strategies.

It is recommended that initial medication should be targeted to the underlying disorder, that antipsychotic medications be considered for severe persistent aggression, and that a mood stabilizer be added in cases of a partial response to a first-line antipsychotic.

Titration scheduling should also be considered, and adequate medication trials should be carried out before switching medication.

The experts say: "Treatment of children with maladaptive aggression is a 'moving target' requiring ongoing assimilation of new evidence as it emerges.

"Based on the existing evidence, the Treatment of Maladaptive Aggression in Youth guidelines provide a framework for management of maladaptive aggression in youth, appropriate for use by primary care clinicians and mental health providers."

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