Prevailing Nosology Insufficient to Identify Violent Children for Whom Psychiatric Medication Might be Considered, according to AACAP Presentation

(Enterprise Reporting from the AACAP Institute)

by John Otrompke

Current categories used to describe children who engage in dysfunctional aggression are insufficiently precise to determine when they should be treated with psychiatric medication, according to a presentation at last week’s Pediatric Psychopharmacology Update Institute in New York.

“Historically, we’d put them under the rubric of child-onset conduct disorder,” said Robert Findling, MD, MBA, vice president of psychiatric services and research at the Kennedy Krieger Institute at Johns Hopkins University in Baltimore.

Findling noted that oppositional defiance disorder is also sometimes used to characterize pediatric patients.

“But I want to make clear that while these diagnoses are suitable for many youngsters, the presence for either of these diagnoses should never be a reason for necessarily prescribing a medicine,” said Findling, who gave the presentation, entitled “Disruptive Behavior Disorders and Dysfunctional Aggression: When Might Pharmacotherapy be Considered?” at the AACAP event on Friday, January 26. “We’d like to be find a means by which to characterize these youngsters more efficiently,” he added, during an exclusive phone interview for this blog.

                                               Analyze Violent Children as Individuals, Expert Says

Aggression is either predatory (in other words, goal-directed) or affective (or impulsive), according to the presentation. “There is no pharmacological approach for the treatment of predatory aggression,” noted Findling, who pointed out that all of the research discussed in his presentation was off-label. (Findling also disclosed a number of commercial relationships between himself or his institution and ventures such as pharmaceutical companies).

The problem is that some children diagnosed with either disorder are impulsively aggressive, while others are predatory. 

“We don’t have a good label for this group of kids who often have bad outcomes,” said Findling.

Some of the characteristic acts of children who engage in dysfunctional aggression include physical cruelty to animals or people, forced sex, and possessing weapons. 

Conduct disorder, which has been validated in children four or five years old, is present in 2.5% of children, and half of children w ADHD. Twenty-five percent of those with ADHD remain impulsively aggressive even if their pharmacological therapy is optimized, according to the presentation.

“We know what happens with these kids long-term: substance abuse, jail, depression, and premature death. It’s heart-breaking to see them as they get older, start scarring over and get tougher. The take-home message is that every youngster needs to be considered as an individual,” added Findling, who recommended that researchers review the CERT guidelines for thoughts on alternative nosology.(1)

                                               Updated Results from TOSCA Study Analyzed

Findling recently co-authored an extended follow-up analysis from the TOSCA (Treatment of Severe Childhood Aggression) study.(2)

TOSCA, as originally described in a 2014 article in JAACAP(3), randomized 168 children between six and 12 years old into two arms: one group received a stimulant plus parental training along with a placebo, while the second group received the same, but with risperidone added. 

In the follow-up, Findling and colleagues analyzed data from 103 of the 168 subjects in the original 9-week trial for an additional 12 weeks, using a ‘last analysis carried forward’ technique, in which researchers took the last observations from subjects who did not complete the entire study, and “simply extended them for the rest of the study,” according to Findling.

“What got you better kept you better,” he added, noting that the participants were never re-randomized. 

Both groups in the initial TOSCA trial experienced improvements.  “Parent ratings of problem behavior showed minimal worsening of behavior from the end of the 9-week acute trial,” however, according to the abstract.

“We found in our extension study that those who did well, stayed well, regardless of what their initial treatment was,” Findling explained. 

In addition, when those who did not respond were included in the intent-to-treat analysis, subjects who received risperidone showed more improvement than those who did not, according to certain measures, such as the Antisocial Behavior Scale Reactive Aggression subscale (p = 0.03).

¹ Rosato N, Correll C, Pappadopulos E, et al. Treatment of Maladaptive Aggression in Youth: CERT Guidelines II. Treatments and Ongoing Management. Pediatrics, May 2012. 

http://pediatrics.aappublications.org/content/early/2012/05/23/peds.2010-1361

² Findling R, Townsend L, Brown N, et al. “The Treatment of Severe Childhood Aggression Study: 12 Weeks of Extended, Blinded Treatment in Clinical Responders.” Journal of Child and Adolescent Psychopharmacology. February 2017, 27(1): 52-65. https://doi.org/10.1089/cap.2016.0081

³ Aman MG, Bukstein OG, Gadow KD, et al. What does risperidone add to parent training and stimulant for severe aggression in child attention-deficit/hyperactivity disorder? J Am Acad Child Adolesc Psychiatry. 2014;53:47-60.