COMMENTARY

Aggression in childhood and adolescence is a significant predictor of psychiatric consultation, referral to mental health services, prescription of psychotropics and hospitalisation. Yet aggression is a greatly under-researched area of childhood psychopathology. Although there are limited data on the efficacy of psychosocial and pharmacological interventions for aggression, Schur et al highlight two points. First, some psychosocial interventions seem to be more promising than others. The central component of promising interventions appears to be that they are well structured and based on the principles of learning theory.

Second, atypical antipsychotics have been assessed in a number of well designed placebo controlled trials in children with disruptive behaviour disorders. Atypical antipsychotics, especially risperidone, have been found to be effective and safe when prescribed at relatively low dosages of 0.5–2.0 mg per day. Atypical antipsychotics seem to offer clear advantages above conventional antipsychotics, especially regarding extrapyramidal adverse effects.

A number of unanswered questions remain. First, it is important to extend the knowledge base with more methodologically sound studies, including head to head comparisons of different atypical antipsychotics and of atypical antipsychotics and mood stabilisers. In this review and the accompanying guidelines,¹ the authors focus particularly on impulsive or affective types of aggression, but few data exist on the reliability and validity of distinctions between impulsive and predatory aggression. There are no accepted instruments to allow clinicians to make the distinction. Further, there is a lack of data about the relative efficacy of psychosocial and pharmacological interventions, and about the added value of combined treatment approaches, although in usual care most clinicians would tend to offer a menu of psychosocial and medical interventions when managing severe aggression in youth. Finally, we must appreciate that aggression is a symptom that may be observed in the context of various categorical diagnoses ranging from oppositional defiant disorder and conduct disorder through ADHD to posttraumatic stress disorder, mood disorders, bipolar disorder and psychosis. It is therefore of great importance that we improve our insight into the modifying and moderating role of categorical diagnoses in the efficacy and safety of treatments for aggression.