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Juvenile Maladaptive Aggression: A Review of Prevention, Treatment, and Service Configuration and a Proposed Research Agenda

Daniel F. Connor, M.D.; Gabrielle A. Carlson, M.D.; Kiki D. Chang, M.D.; Peter T. Daniolos, M.D.; Reuven Ferziger, M.D.; Robert L. Findling, M.D.; Janice G. Hutchinson, M.D., M.P.H.; Richard P. Malone, M.D.; Jeffrey M. Halperin, Ph.D.; Belinda Plattner, M.D.; Robert M. Post, M.D.; Diane L. Reynolds, M.D.; Kenneth M. Rogers, M.D.; Kirti Saxena, M.D.; and Hans Steiner, M.D., for the Stanford/Howard/AACAP Workgroup on Juvenile Impulsivity and Aggression


Objective: To review prevention programs, psychosocial and psychopharmacologic treatments, and service delivery configurations for children and adolescents with maladaptive aggression. To propose a research agenda for disorders of aggression in child and adolescent psychiatry.

Data Sources: Recent empirical studies were reviewed using searches of MEDLINE and PsycINFO (text terms: aggression, antisocial, violence, conduct, oppositional, psychosocial treatment, psychopharmacology, and prevention), relevant books, review articles, and bibliographies.

Data Extraction: Articles met the following criteria: published in an English-language, peer-reviewed journal between 1980 and 2005, included a focus on individuals < 18 years old, and included an outcome measure of relevant significance.

Study Selection: Results of 154 randomized, controlled psychosocial treatment trials, 20 controlled psychopharmacology studies, 4 open-label medication studies, and 2 psychopharmacology meta-analyses were reviewed.

Results: Prevention programs show promise for reducing future aggression in at-risk populations. Empirical support is available for the effectiveness of multifocused psychosocial treatments in reducing aggression in children and adolescents. Atypical antipsychotics, lithium, divalproex sodium, and stimulants for conduct problems associated with attention-deficit/hyperactivity disorder have empirical support for reducing aggression in selected patient populations.

Conclusions: Therapeutic nihilism in the treatment of aggressive children and adolescents with conduct problems is no longer warranted. Multifocused psychosocial interventions given early in life to at-risk children have the most support for effectiveness. However, treatments for children who routinely present to the child psychiatrist with already well-established disorders of aggression are neither robust nor well-established. Further research into maladaptive aggression in referred children and adolescents within and across psychiatric diagnoses is important for the field of child and adolescent psychiatry.

(J Clin Psychiatry 2006;67:808-820)


Received Sept. 19, 2005; accepted Dec. 21, 2005. From the University of Connecticut Health Center, Farmington (Dr. Connor); the Division of Child and Adolescent Psychiatry, School of Medicine, Stony Brook University Health Sciences Center, Stony Brook, N.Y. (Dr. Carlson); the Pediatric Mood Disorders Clinic and the Department of Psychiatry, Division of Child Psychiatry, Stanford University School of Medicine, Stanford, Calif. (Dr. Chang); the Department of Psychiatry and Behavioral Sciences, Children's National Medical Center, Washington, D.C. (Dr. Daniolos); Clinical Affairs, Ortho-McNeil Pharmaceutical, Johnson & Johnson Pharmaceuticals, Raritan, N.J. (Dr. Ferziger); the Department of Child and Adolescent Psychiatry, Case Western Reserve University School of Medicine, Cleveland, Ohio (Dr. Findling); the Department of Psychiatry, Howard University School of Medicine, Washington, D.C. (Drs. Hutchinson and Reynolds); the Department of Psychiatry, Drexel University College of Medicine, Philadelphia, Pa. (Dr. Malone); the Department of Psychology, Queens College, City University of New York, Flushing (Dr. Halperin); University Clinic for Neuropsychiatry of the Child and Adolescent, Medical University of Vienna, Vienna, Austria (Dr. Plattner); the Biological Psychiatry Branch, National Institute of Mental Health, Bethesda, Md. (Dr. Post); the Department of Psychiatry, University of Maryland School of Medicine, Baltimore (Dr. Rogers); University of Texas-Southwestern Medical Center, Dallas (Dr. Saxena); the Department of Psychiatry and Behavioral Science, Stanford University School of Medicine, Stanford, Calif. (Dr. Steiner).

No external funding was utilized in support of this review.

Financial disclosure appears at the end of this article.

We thank the following expert reviewers: Alan E. Kazdin, Ph.D., Yale University School of Medicine, New Haven, Conn., and Karen D. Wagner, M.D., Ph.D., University of Texas Medical Branch, Galveston.

Corresponding author and reprints: Daniel F. Connor, M.D., Department of Psychiatry/MC1410, University of Connecticut Health Center, 263 Farmington Ave., Farmington, CT 06030-1410 (e-mail: connor@psychiatry.uchc.edu).