Conduct disorder, aggressive symptoms

Serotonin-Boosting Antidepressants. Antidepressants that enhance serotonin activity in the brain have also been studied in ADHD. In particular, fluoxetine (Prozac) and the serotonin-selective TCA clomipramine (Anafranil) have been the most extensively evaluated, with mixed success. They provide some benefit for aggression and impulsivity but don t significantly improve the poor attention of ADHD. As a result, the SSRls and other serotonin-boosting antidepressants do not appear to be effective first-line treatments for ADHD. Conversely, depressed patients without ADHD often show improvements in symptoms of concentration and attention when treated with a SSRI. Although SSRls are not widely used in the treatment of ADHD, they may be worthy of consideration in ADHD patients whose impulsivity is not controlled by stimulants alone. Those with comorbid conduct disorder or ODD who are prone to agitation and at times violent outbursts may be helped by the addition of a SSRI. 

Hyperactivity- For the short-term treatment of hyperactive children who show excessive motor activity with accompanying conduct disorders consisting of some or all of the following symptoms Impulsivity, difficulty sustaining attention, aggressivity, mood lability, and poor frustration tolerance. 

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). 

Because the symptoms are so disruptive to the family and to the child, conduct disorder is one of the most common reasons for referral to a pediatrician or child psychiatrist. In patients with MR, this disorder is seen less as organized, planned illicit activities and more as impulsive, unpredictable acts of violence or destruction. Such individuals may exhibit aggression toward caregivers, teachers, family members, or themselves, and they may be emotionally labile. If behavior therapy has not been effective, pharmacological treatment may be necessary. 

FIGURE 10-5. Aggressive symptoms and hostility are associated with several conditions in addition to schizophrenia, including bipolar disorder, attention deficit hyperactivity disorder (ADHD) and conduct disorder (conduct dis.), childhood psychosis, Alzheimer s and other dementias, and borderline personality disorder, among others. 

Although aggressive symptoms are common in schizophrenia, they are far from unique to this condition. Thus, these same symptoms are frequently associated with bipolar disorder, childhood psychosis, borderline personality disorder, drug abuse, Alzheimer and other dementias, attention deficit hyperactivity disorder, conduct disorders in children, and many others (Fig. 10—5). 

Anticonvulsants have sedative side effects and therefore drugs such as carbamazepine have occasionally been used to treat conduct disorders. There is no evidence that such drugs are useful in the control of aggressive symptoms. 

As monotherapy or in combination with methylphenidate for ADHD with conduct disorder or oppositional defiant disorder, may improve aggression, oppositional, and conduct disorder symptoms... 

Conventional antipsychotics improve symptoms of hyperactivity and impulsivity, but may have negative effects on learning and cognitive functioning as well as extrapyramidal side effects (e.g., dystonia and tardive dyskinesia) that limit their usefulness. The atypical antipsychotics risperidone, olanzapine, quetiapine, and ziprasidone have been used to control severe aggression in refractory cases of ADHD, particularly if conduct disorder or bipolar disorder coexists. More studies are needed to clarify their place in therapy. ... 

Pediatric PTSD is a psychiatric disorder that is prone to both under- and overdiagnosis, especially when assessments are superficially or inexpertly conducted. For example, a traumatic exposure history in combination with current externalizing behavioral symptoms does not necessarily imply a diagnosis of PTSD. Conversely, children who present with an externalizing behavioral disorder in conjunction with anxiety symptoms and aggression are often not fully evaluated for PTSD. 

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