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Clinical and Research News
Look Beyond Conduct Disorder in Impulsive Aggression
Psychiatric News
Volume 42 Number 7 page 22-22

Impulsive aggression, as opposed to planned aggression, can take many forms in children and adolescents—irritability, temper tantrums, punching a sibling, striking another youngster or teacher. And for some time now, it has been of growing concern to Peter Jensen, M.D., a professor of child psychiatry at Columbia University.

It started when he was associate director of child and adolescent research at the National Institute of Mental Health from 1989 to 2000, he told Psychiatric News recently. He became convinced, after often hearing from clinicians, families, and researchers, that severe impulsive aggression was a problem for youngsters with a number of DSM illnesses, not just with conduct disorder. He also observed that impulsive aggression often landed young people in inpatient, juvenile-justice, or residential-treatment settings. And he knew that there were no approved medical treatments for impulsive aggression in youth and that drug companies expressed little interest in developing medications for it.

Jensen's concern about impulsive aggression in youth spurred him to action in 2004. He organized a conference of scientists, parents, representatives from groups advocating for children, and leaders from the National Institute of Mental Health and the Food and Drug Administration (FDA) to review what was known about clinically severe impulsive aggression and to jump-start research to find effective treatments for it.

The conference confirmed Jensen's impression that impulsive aggression is not just a problem for "bad kids," but for many youth with attention-deficit/hyperactivity disorder (ADHD), autism, bipolar disorder, childhood psychosis, depression, disruptive behavior disorders, posttraumatic stress disorder, and other psychiatric illnesses. In other words, impulsive aggression is not a symptom of a specific diagnosis. Like fever and pain, it is a symptom of numerous illnesses, and also like fever and pain, its intensity may serve as a bellwether for the extent of illness per se.

Jensen was also pleasantly surprised that conference participants agreed that even though a gold standard for measuring impulsive aggression in youngsters does not exist, yardsticks that are currently available are good enough to use in the design of impulsive-aggression treatment trials. For example, a small subset of questions included on the Aberrant Behavior Checklist, Child Behavior Checklist, General Behavior Inventory, and other rating instruments have been found to measure impulsive aggression in youth in a consistent manner.

Indeed, Jensen said, conference participants weighed in on how treatment trials for impulsive aggression might be organized. For instance, standard treatments for ADHD have already been approved by the FDA. but these treatments do not necessarily counter impulsive aggression. So if one wanted to see whether a medication might subdue ADHD-related impulsive aggression, it could be added to standard treatments for ADHD. In contrast, since no medications for treating autism have been approved by the FDA to date, a potential medication for autism-related impulsive aggression might be tested by pitting it against a placebo.

This year, Jensen's crusade against impulsive aggression in youth unfurled still more. Results from the 2004 consensus conference were published in the March Journal of the American Academy of Child and Adolescent Psychiatry. And on February 12 and 13 Jensen and his colleagues, in conjunction with the federally funded Rutgers Center for Education, Research, and Training on Mental Health Therapeutics, held another consensus conference on impulsive aggression in youth. This time scientists, clinicians, parent representatives, and mental health policy leaders from three large states—California, New York, and Texas—attended. Their task was to decide how clinicians might better manage children and adolescents with severe impulsive aggression in outpatient settings.

"The guidelines are in draft," said Jensen, "and once vetted further by the group, will be submitted for publication, along with a toolkit to help clinicians implement better practices in this area."

An abstract of the report from the 2004 conference "Consensus Report on Impulsive Aggression as a Symptom Across Diagnosis Categories in Child Psychiatry: Implications for Medical Studies" is posted at<www.jaacap.com/pt/re/jaacap/abstract.00004583-200703000-00006.htm;jsessionid=...>.

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