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=...>.▪