Aggression in children

Children In some people, especially children, barbiturates repeatedly produce excitement rather than depression. Barbiturates may produce irritability, excitability, inappropriate tearfulness, and aggression in children. Safety and efficacy of amobarbital (children younger than 6 years of age) and aprobarbital have not been established. 

Dodge, K.A. and Coie, J.D. (1987) Social information processing factors in reactive and proactive aggression in children s peer groups. / Pers Soc Psychol 53 1146-1158. 

Vitiello, B., Behar, D., Hunt, J., Stoff, D., and Ricciuti, A. (1990) Subtyping aggression in children and adolescents. J Neuropsychiatry Clin Neurosci 2 189-192. 

A review of effective pharmacological treatments for each psychiatric disorder can be found in chapters elsewhere in this volume. Medications that have been evaluated in open and double-blind studies for the behavioral management of aggression in children and adolescents are outlined below (see Table 50.3). 

TABLE 50.3 Psychotropic Medications Found Through Open and Controlled Studies to Be Helpful for Treatment of Agitation or Aggression in Children and Adolescents... 

Hinshaw, S.P. (1991). Stimulant medication in the treatment of aggression in children with attentional deficits. / Clin Child Psychol 12 301-312. 

Hiding the Risk of Prozac-Induced Mania and Aggression in Children... 

Sheth RD, Goulden KJ, Ronen GM. Aggression in children treated with clobazam for epilepsy. Clin Neuropharmacol 1994 17(4) 332-7. 

Placebo-controlled studies The effect of divalproex sodium for irritability/aggression in children and adolescents with autism spectrum disorders has been studied in 55 children in a 12-week randomized, doubleblind, placebo-controlled trial [312 ]. The only treatment-emergent adverse reaction that caused drug withdrawal was a paradoxical increase in irritability associated with... 

Reductions in aggressive behavior after treatment with amphetamine and other psyehomotor stimulants are seen in children and adolescents who have been diagnosed with hyperkinesis or attention deficit disorder. There is considerable disagreement about these diagnostic categories and about whether the violent outbursts and uncontrolled episodes of aggressive behavior are limited to the early developmental period or continue into adulthood (Mendelson et al. 1971 Minde et al. 1972). 

Arnold, L.E. Kirilcuk, V. Corson, S.A. and Corson, E.O. Levoampheta-mine and dextroamphetamine Differential effect on aggression and hyperkinesis in children and dogs. Am J Psychiatry 130 165-170, 1973. Bain, G.T., and Kometsky, C. Naloxone attenuation of the effect of cocaine on rewarding brain stimulation. Life Sci 40 1119-1125, 1987. 

CD occurs in approximately 4.56 per 100,000 pediatric patients, and UC occurs in about 2.14 cases per 100,000.43 A major issue in children with IBD is the risk of growth failure secondary to inadequate nutritional intake. Failure to thrive may be an initial presentation of IBD in this population. Aggressive nutritional interventions may be required to facilitate adequate caloric intake. Chronic corticosteroid therapy may also be associated with reductions in growth. 

In children, the intensity of the consolidation treatment is now determined not only by the child s risk classification but also by the rate of cytoreduction during induction.5 Patients who respond slowly to induction therapy (as determined by bone marrow examination early in induction) are at higher risk of relapse and are treated on more aggressive regimens. 

Smith, P.K. and Boulton, M. (1990). Rough-and-tumble play, aggression and dominance perception and behaviour in children s encounters. Human Development, 33, 271—282. 

As early as the 1940s it became clear that amphetamine could also produce a calming effect in adults prone to aggression and agitation. Later, this so-called paradoxical effect was also seen in children with hyperkinetic syndrome, the precursor to ADHD. 

Antipsychotic agents are also used for a diversity of other indications like hiccups, Tourette s syndrome, aggressive behavior in children and the elderly and alcohol withdrawal syndrome. Some of them are also used in anesthesia as they can potentiate the sedative, analgesics or anesthetic effects of other agents. Antipsychotics which are mainly active by blocking dopamine activity have also an effect on chemoreceptor trigger zone and may therefore be used as anti-emetics. 

Consensus exists that low CSF 5-HIAA is associated with poorly modulated, socially unproductive, impulsive, and/or affect-laden types of aggression (Kruesi and Jacobsen, 1997). A significant inverse correlation between CSF 5-HIAA and a lifetime history of aggression was initially established in adults (Brown et al., 1979) and later in children and adolescents (Kruesi et al., 1990, 1992). Other investigations showed that it is impulsive/affective aggression, rather than more predatory aggression, that is linked with low CSF 5-HIAA (Linnoila et ah, 1983 Virkkunen et ah, 1994, 1995 Mehlman et ah, 1994). 

Stoff, D.M., Pasatiempo, A.P., Yeung, J., Cooper, T.B., Bridger, W.H., and Rabinovich, H. (1992) Neuroendocrine responses to challenge with dl-fenfluramine and aggression in disruptive behavior disorders of children and adolescents. Psychiatry Res 43 263-276. 

A second part consists of two chapters covering other somatic interventions, including complementary, alternative, and naturopathic medicine approaches (such as St. John s wort), as well as more aggressive treatments less commonly used in children and adolescents, such as electroconvulsive therapy (ECT) and transcranial magnetic stimulation (TMS). 

The selective serotonin reuptake inhibitors (SSRI) have been used in adults for a wide variety of disorders, including major depression, social anxiety (social phobia), generalized anxiety disorder (GAD), eating disorders, premenstrual dysphoric disorder (PMDD), post-traumatic stress disorder (PTSD), panic, obsessive-compulsive disorder (OCD), trichotillomania, and migraine headaches. Some of the specific SSRI agents have an approved indication in adults for some of these disorders, as reviewed later in this chapter. The SSRIs have also been tried in children and in adults for symptomatic treatment of pain syndromes, aggressive or irritable ( short fuse ) behavior, and for self-injurious and repetitive behaviors. This chapter will review general aspects of the SSRIs and discuss their approved indications in children and adolescents. 

Although trazodone has not received an FDA indication for use in children and adolescents, it has enjoyed some success in the treatment of disruptive behavior disorders in this population. An aggressive 15-year-old male inpatient was treated with trazodone at a dosage of 200 mg/day, which resulted in decreased disruptive behavior. Following discharge from the hospital, trazodone was discontinued and the patient s violent behavior resumed. Upon return to his previous dose of 200 mg, the aggressive behavior again remitted (Fras,... 

Some (Campbell et ah, 1995 Malone, et ah, 2000) but not all (Rifkin et ah, 1997), controlled studies of lithium among children with conduct disorder (CD) appear to support lithium s efficacy in the treatment of aggression in this population. Both aggression and irritability are symptoms that cut across diverse disorders and are important confounders in studies of impulse dyscontrol. Double-blind controlled studies are needed to further validate the choice of lithium for patients with BD presenting with excessive irritability and anger outbursts (Fava, 1997). 

At the time of this publication, only one case of a manic adolescent being responsive to gabapentin for the treatment of mania has been reported (Soutullo et al., 1998). Conversely, several cases of aggressive behavior associated with gabapentin in children with seizures have been reported (Wolf et al., 1995, Khurana... 

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