On the Challenge of Maladaptive and Impulsive Aggression in the Clinical Treatment Setting

Clinicians working in the mental health setting have long been challenged by children and adolescents with many different types of psychiatric disorders who are often referred for treatment because of frequent, intense, severe, and maladaptive impulsive aggression. This type of clinical presentation occurs commonly in every type of pediatric mental health treatment setting: Outpatient, inpatient, residential, and/or partial hospitalization. Impulsive aggression is often chronic, but waxes and wanes in response to multiple shifting internal and external factors, and may be extremely stressful for parents and other family members. Although normative in the young toddler and preschooler (“the terrible twos”), with development, the child begins to achieve emotional and behavioral competence and regulation such that by school entry aggression becomes increasingly verbal and not physical. With school entry, aggression is increasingly associated with understandable and recognizable antecedents, goals, and objectives.

Maladaptive aggression is defined as behavior with intent to harm another person; is elicited by minimal or routine environmental cues; is less linked to recognizable and understandable social goals; is characterized by its explosive nature, high frequency rate, and severe intensity; and is associated with significant functional impairment for the child and the child's family (Connor 2002). Impulsive aggression is behavior that occurs rapidly without a delay (“a short fuse”) that would otherwise allow the child to consider an alternative and more adaptive response to frustration or perceived threat (Jensen et al. 2007). Impulsive aggression is driven by low frustration tolerance or fear of threat (Dodge and Coie 1987).

Maladaptive and impulsive aggression in psychiatrically referred children and adolescents is common, denotes illness severity not illness specificity (Connor and McLaughlin 2006), and represents a significant public health problem with high societal costs (Foster and Jones 2005). Aggression is a major cause of referral to outpatient and inpatient child and adolescent psychiatry services (Bambauer and Connor 2005) and emergency psychiatric services (Gabel and Shindledecker 1991), predicts longer stays in psychiatric hospitals, and predicts rehospitalization in youth discharged from inpatient settings (Blader 2004). It is associated with child and adolescent psychiatry staff injury (Cunningham et al. 2003), is associated with off-label pediatric antipsychotic use (Olfson et al. 2015), and predicts combined pharmacotherapy (polypharmacy) use independently of diagnosis in referred children (Connor et al. 1997). Youth with moderate to severe impulsive aggression with and without comorbid attention-deficit/hyperactivity disorder (ADHD) are a major challenge for clinicians working in the clinical setting, as few evidence-based treatments are currently available that address these issues.

Progress in developing effective treatments for impulsive aggression has been slowed by the multiple ways of clinically identifying and characterizing the aggressive child. Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM 5) diagnoses such as oppositional defiant disorder (temper tantrums), conduct disorder (physical aggression), bipolar disorder (aggression and irritability), intermittent explosive disorder (explosive aggression), and/or disruptive mood dysregulation disorder (irritability and temper tantrums) all may have aggression as part of their symptom criteria, yet are nosologically construed as separate and non-overlapping psychiatric diagnoses (American Psychiatric Association 2013). Youth who engage in antisocial behaviors and/or delinquency may or may/not possess callous-unemotional personality traits and may or may/not demonstrate aggressive behavior as part of their repertoire, but are frequently assumed to be at heightened risk for aggression. Children who are described as irritable show negative affect such as depression associated with temper tantrums, easily being annoyed, and often being angry and resentful. However, although aggressive behavior may be expressed by children who are irritable, not all irritable persons are aggressive. Impulsive (reactive) aggression driven by fear of threat or frustration in goal-directed behavior is common in clinical samples, and is separate yet overlapping with instrumental or proactive aggression (Polman et al. 2007). In clinical samples, children with a relatively pure type of impulsive aggression can be identified, but youth ascertained as proactive aggressors in clinical settings generally have elevated reactive (impulsive) aggression scores also (Aman et al. 2014; Gadow et al. 2014). Pure proactive aggressors are difficult to find in clinical samples. Multiple methods of identifying, characterizing, and defining the aggressive child have challenged clinicians and researchers seeking to develop more specific evidenced-based and targeted therapies for impulsive aggression within these multiple contexts.

Expert consensus has concluded that impulsive aggression is identifiable and sufficiently similar in characteristics across different diagnostic categories as to constitute a key therapeutic target across multiple psychiatric disorders (Jensen et al. 2007). Progress in the field will be greatly enhanced with the development, psychometric validation, and clinical use of treatment-sensitive rating scales that precisely measure impulsive aggression within well-defined psychiatric disorders. To facilitate detection of a signal, psychopharmacological trials targeting impulsive aggression should occur within a single and well-defined DSM 5 disorder (Jensen et al. 2007). Such an approach was recently demonstrated in the Treatment of Severe Childhood Aggression (TOSCA) study of impulsive and proactive aggression in ADHD children only partially responsive to behavioral therapy and optimized stimulant treatment and then randomized to risperidone or placebo (Aman et al. 2014).

Another approach is to develop psychosocial treatments for impulsive aggression based on learning theory, emotional arousal theory, and social information-processing mechanisms (Dodge and Coie 1987; Sukhodolsky and Scahill 2012). Because cognitive mechanisms for anger and aggression appear to operate independently of specific psychiatric diagnoses, such an approach might be transdiagnostic. As such, evidence-based psychosocial therapies for impulsive aggression could be clinically applied with or without concomitant pharmacotherapy based on the individual treatment needs of the aggressive child or adolescent.

Impulsive aggression is a significant clinical and public health problem. There is a clear distinction between impulsive aggression and other forms of aggression. Greater recognition and a greater understanding of these differences and their application in clinical, research, and treatment development programs will help practitioners to meet the challenge of maladaptive impulsive aggression in the clinical treatment setting.