Aggression in children and adolescents is commonly displayed in the community and is even more commonly seen in clinical settings. As symptoms of an underlying disorder, aggressive behaviors should be comprehensively evaluated, and developmental, medical, and substance-use disorders should be identified and treated. This article reviews the most common psychiatric conditions associated with aggression and suggests appropriate psychopharmacologic interventions. Tables with recommended agents for each psychiatric disorder, as well as dosing ranges for each agent, are included.
It is an unfortunate fact that aggressive, violent, dangerous, and potentially lethal behaviors are rather common in the lives of American youth. The Centers for Disease Control and Prevention, of the US Department of Health and Human Services, conducts the national Youth Risk Behavior Surveillance every 2 years; the most recent complete data have been published for 2009. In that survey, representative samples of public high school students (grades 9–12) were carefully questioned about various risk behaviors. Regarding those behaviors that have relevance to aggression, the following statistics were reported for the year preceding the survey: of all students, 31.5% had been in at least 1 fight, 3.8% had been in at least 1 fight that led to an injury that required medical intervention, 11.1% had been in at least 1 fight on school property, and 9.8% had experienced dating violence. In the preceding 30 days, of all students, on at least 1 occasion 17.5% had carried a weapon (eg, gun, knife, or club), 5.9% had carried a gun, 5.6% had carried a weapon on school property, and 7.7% of students had been threatened or injured with a weapon on school property.
Aggressive behaviors are the final step in a sequence that begins with some type of provoking stimulus ( Fig. 1 ). The initiating event can be objective and obvious, such as a person being pushed or hit, or it can be subjective and subtle (and not necessarily obvious to an observer), such as a person being disrespected or ignored. In individuals who display reactive aggression, disruptive behaviors are fueled by an immediate, intense emotional reaction to a real or perceived threat. Rational thinking is briefly and strongly influenced by their feelings, or is bypassed altogether. Another type of aggression, proactive aggression, may initially be triggered by negative emotions (eg, anger, envy, or greed), but that is overridden by a relatively dispassionate thought process that allows for a delayed and calculated response (ie, the person can wait to get their revenge). This article focuses on the reactive type of aggression, the more common type that is seen in clinical settings.

Anger is the most common emotion that leads to aggression. Aggressive behaviors can be diverse and are highly variable between individuals ( Fig. 2 ). Patterns of aggression tend to be more predictable in any given individual. For example, some people only display verbal forms of aggression, such as yelling, using profanities, or making threats to harm others. Aggression that is outwardly directed is more frightening for those who witness it, and is associated with more serious consequences. By the time that aggression causes damage to property, and especially to people (also called violent behavior), there is a high likelihood that the aggressive person will come into contact with either the medical or legal systems.

To eliminate current, or prevent future, aggression, it is important to keep in mind that there are many developmental, substance-related, and psychiatric disorders that can increase the risk for the emergence of aggressive behaviors. What follows is a review of the most common mental disorders associated with aggression and their treatments, focusing on psychopharmacologic agents. (The treatment of anger and aggression associated with developmental disorders is addressed in the article by Joseph L. Calles Jr elsewhere in this issue.)
Psychiatric disorders associated with aggression
Attention-deficit and Disruptive Behavior Disorders
In the Diagnostic and statistical manual of mental disorders (4th edition, text revision) (DSM-IV-TR) this category is made up of attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD). As the term implies, disruptive behaviors, including aggression and violence, are a core feature of all 3 disorders. In a Canadian study of 129 consecutive children and adolescents who were referred for aggressive behavior, 93.02% were diagnosed with ODD, 88.37% with ADHD, and 38.75% with CD.
ADHD
ADHD is fairly common in the general population. A national survey of 3042 youths (8–15 years of age) found the 12-month prevalence rate for ADHD to be 8.6%. The previously cited Canadian study found that, in those diagnosed with ADHD, 80% had displayed aggressive behavior, 27% had used weapons in an aggressive fashion, and 28% had been cruel to animals.
Treatment
The recommended first choice for medication treatment of ADHD-related aggressive behaviors is usually a psychostimulant or atomoxetine. A meta-analysis of the effects of stimulants on aggression-related behaviors in ADHD found the overall, average, weighted effect size to be a strong 0.84 for overt aggression. For the 7 studies (of the 28 total studies) that identified ADHD as the primary diagnosis, without comorbid ODD and/or CD, the average effect size of stimulants on overt aggressive behaviors is 0.745, which is still fairly strong.
The evidence for the efficacy of atomoxetine (a selective norepinephrine reuptake inhibitor) in the treatment of aggressive behaviors associated with ADHD is indirect, in that studies have looked at reductions in ODD behaviors, but not specifically at reductions in aggressive behaviors. However, given that ODD is a further risk factor for aggression (see later discussion) and that 40% to 60% of children with ADHD also have ODD, the use of atomoxetine should be considered, especially if patients are refractory to, intolerant of, or worsened by stimulant medications. To achieve a good clinical response, atomoxetine dosing may have to be higher (1.8 mg/kg/d) than is usually used (1.2 mg/kg/d).
Stimulants and atomoxetine are used to treat ADHD and associated aggressive behaviors, but those very medications may also precipitate hostility and aggression. Patients should be carefully monitored, and medications should be lowered or discontinued if aggressive behaviors worsen.
ODD
The lifetime prevalence of ODD, based on a national retrospective survey of adults, was estimated to be 10.2%. Survey results from Canada found that, in those diagnosed with ODD, 77% had displayed aggressive behavior, 27% had used weapons in an aggressive fashion, and 28% had been cruel to animals; these values are not much different than those associated with ADHD.
Treatment
Even in the absence of ADHD, the approach to treatment of aggression in ODD starts out the same, that is, good trials of stimulants (methylphenidate and/or amphetamines) followed by atomoxetine. If only a partial response is achieved with maximum doses of those medications, augmentation can be tried with divalproex, risperidone, or clonidine.
CD
CD is fortunately not very common in the general population; only 2.1% of those aged 8–15 years meet the diagnostic criteria. The Canadian study on disruptive behavior disorders found that, in those diagnosed with CD, 90% had displayed aggressive behavior, 52% had used weapons in an aggressive fashion, and 54% had been cruel to animals. Although the rate of aggressive behavior in CD is somewhat higher than the rates seen in ADHD and ODD, the rates for weapon use and animal cruelty are almost twice those seen in the other 2 disorders.
Treatment
It is readily apparent that CD is the most disturbing disorder in this category, the successful treatment of which should be a high clinical and societal priority. Many different psychotropic medications have been used to treat CD, especially to try and reduce aggression. The most common therapeutic agent has been lithium carbonate, used alone or in combination with other agents. A 4-week study of very aggressive, hospitalized youth (median age 12.5 years) found lithium to be clinically and statistically superior to placebo in reducing the ratings of aggressive behaviors. A more recent study of children and adolescents (8–17 years; mean 14.2 years) with CD who were treated with lithium carbonate, with or without an atypical antipsychotic (AA; either risperidone or olanzapine), were retrospectively followed up 6 to 12 months after initiating treatment. Almost one-half showed a significant reduction in overt aggression scores; however, the lithium-plus AA/lithium-alone ratio was about 2:1.
Various trials of AA monotherapy have been conducted in the treatment of CD-related aggression, including with aripiprazole (open-label study), quetiapine (randomized, double-blind, placebo-controlled pilot study), olanzapine (retrospective chart review), and risperidone (randomized, double-blind, placebo-controlled pilot study). With the exception of quetiapine, the AAs significantly reduced aggressive behaviors compared with placebo.
As had been previously mentioned, divalproex can be used as an augmentation agent in ODD; it can also be used as monotherapy to treat CD. A study of youth with CD, most (66%) incarcerated for violent offenses, compared 2 different levels of divalproex dosing: high-dose (500–1,500 mg daily) and low-dose (≤250 mg daily). There were no significant reductions in suppression of anger scores between the 2 groups; however, the high-dose group did have a significant improvement in impulse control. Given that overt affective aggression is impulsive by nature, the use of divalproex in patients with CD may help to reduce impulsivity and, by extension, associated aggressive behaviors.
Mood Disorders
Major depressive disorder
Depression is another psychiatric disorder that is relatively common in youth. In a meta-analysis of studies over 30 years, overall prevalence estimates were 2.8% for those less than 13 years of age and 5.6% for those aged 13 to 18 years. Depression is also associated with aggression, beginning at a very young age. A survey of caregivers of 3- to 6-year-old children, who were placed into 1 of 4 diagnostic groups, found that the group rates of physical aggression were in the following descending order: comorbid depressed/disruptive; pure disruptive; pure depressed; and, healthy. Although not as common as in the presence of disruptive behaviors, the risk for aggression in depressed children is increased compared with nondepressed children. In a study of adolescents (aged 13–17 years) with diagnosed major depressive disorder (MDD), rates of aggression were high, with 70% reporting frequent verbal aggression, 24% with frequent physical aggression, and 14% being arrested for aggressive behaviors.
Treatment
The agents of choice for pediatric depression, with or without aggression, have been the selective serotonin reuptake inhibitors (SSRIs). Their ameliorative effects on aggression derive from decreases in negative affect and impulsivity, and an increase in social assertiveness. Given that the US Food and Drug Administration (FDA) has approved fluoxetine and escitalopram for the treatment of pediatric MDD, those should be the initial agents of choice for the treatment of depression comorbid with aggression, although theoretically any antidepressant with serotonergic activity may work. Any antidepressant may also cause or exacerbate aggression, but, in the case of fluoxetine, a meta-analysis did not support an association between its use and aggression and/or hostility-related events compared with placebo.
Bipolar disorder
The prevalence of bipolar disorder is much less common than depression in the general pediatric population, estimated at 1.0% to 1.5%, but is much higher (17%–30%) in pediatric psychiatric clinics. It is generally agreed that aggressive behaviors are very common in pediatric bipolar disorder. This seems to be a combination of the mood disturbance (mostly irritability) and the high rates of comorbid ADHD (60%–90%) and CD (40%–70%).
Treatment
It is fortunate that many of the medications that have demonstrated efficacy in the treatment of aggression (lithium carbonate, divalproex, AAs) are also the medications used to treat bipolar disorder. Treatment guidelines should be followed regarding the initial and sequenced selections of psychopharmacologic agents.
Severe mood dysregulation
The term severe mood dysregulation (SMD), or a variant thereof, is being considered for inclusion as a diagnosis in the next (fifth) edition of the DSM. The concept of SMD evolved from clinical observations of children who were being diagnosed with bipolar disorder, but who had continuous (not cyclic) irritability and the absence of mania, hyperarousal (eg, insomnia vs decreased need for sleep in bipolar disorder), and increased reactivity to negative stimuli. Lifetime prevalence is estimated at 3.3% in mostly white, mostly male 9- to 19-year-olds. The most common disorders comorbid with SMD are ADHD, CD, and ODD. What is relevant to the topic of this article is that the reactivity of SMD presents as frequent (≥3 times weekly) temper tantrums, verbal rages, and/or aggression toward people or property.
Treatment
A 6-week randomized, double-blind, placebo-controlled trial of lithium was conducted with 7- to 17-year-olds diagnosed with SMD. There were 2 surprising results: a 45% improvement during the 2-week placebo run-in; and, no significant differences between the lithium and placebo groups on outcome measures. This is consistent with the findings from a retrospective, community-based study of patients with ADHD (6–18 years), with comorbid bipolar disorder or mood disorder not otherwise specified (NOS; under which SMD was subsumed). Despite similar treatments, including pharmacotherapy (mostly aripiprazole), the patients with mood disorder NOS/SMD improved significantly less than the patients with bipolar disorder.
A different approach to treatment can be tried in patients with comorbid ADHD and SMD. A study of 5- to 12-year-old children with both diagnoses used a combination of methylphenidate and behavior modification. Results showed a 45% improvement in irritability and aggression in the active treatment group, double that seen in the placebo group. Based on their findings, the investigators make the statement that “the use of mood-stabilizing medications as a first-line treatment may not be necessary to achieve improvement in children with ADHD and SMD.”
Anxiety Disorders
Anxiety disorders are some of the most common psychiatric disorders in children and adolescents, with prevalence rates in the 6% to 20% range. Based on a review of the literature, there seems to be an association between anxiety disorders and disruptive behavior disorders, and between anxiety symptoms and reactive aggression. However, the explanation for the observed comorbidity is unclear, and could include coincidence, mutual predispositions, or shared risk factors.
Posttraumatic stress disorder
In 1 urban sample, the lifetime prevalence of posttraumatic stress disorder (PTSD) in the general youth population was found to be 9.2%, whereas in a national sample of 12- to 17-year-olds 3.7% of boys and 6.3% of girls met the diagnostic criteria for PTSD. Of the 3 symptom clusters in PTSD (reexperiencing, avoidance, and hyperarousal) it is the hyperarousal that is most likely to contribute to aggressive behaviors. In young children new-onset aggressive and oppositional behaviors could be manifestations of an experienced traumatic event.
Treatment
There are very few studies of pharmacologic agents in child and adolescent PTSD, and there are no FDA-approved medications for PTSD in the pediatric population. As such, medication interventions are usually extrapolated from adult studies. A reasonable first choice of medication would be an SSRI, especially sertraline or paroxetine (as they are approved for PTSD in adults). Dosing should start low to prevent an exacerbation of irritability and aggressiveness, a known side effect of serotonergic agents. If the SSRIs are partially effective, or noneffective, they may be augmented with or replaced by an AA, a mood stabilizer, or an alpha2-agonist (especially clonidine).
Panic disorder
It is currently appreciated that children and adolescents can experience panic attacks, and suffer with actual panic disorder at the rate of 0.5% to 5.0% in the general population and 0.2% to 10.0% in psychiatric settings. That knowledge was not always available, however, as research on panic disorder in younger people lagged for many years, because of ongoing debates about whether or not it existed in that age group. An adult study evaluated anger in patients with panic disorder, obsessive-compulsive disorder, social phobia (also known as social anxiety disorder), and specific phobia, and compared it to nonclinical controls. With the exception of the specific phobia group, the other anxiety groups experienced higher levels of anger than did controls. However, when comorbid depression was accounted for, the anger differential disappeared, except in those with panic disorder, who were prone to “lose their temper and express their anger aggressively.”
Treatment
There are currently no FDA-approved medications for the treatment of panic disorder in children and adolescents. The antidepressants that are approved for panic disorder in adults (fluoxetine, sertraline, paroxetine, and venlafaxine) are often used off label in younger patients. The same caution about worsening aggression that was mentioned regarding the SSRIs in PTSD also applies to panic disorder. The benzodiazepines are also used to treat panic disorder in adults, but their use in younger patients with aggressive tendencies runs the great risk of behavioral disinhibition and worsening of symptoms.
Schizophrenia and Other Psychotic Disorders
The development of schizophrenia before adulthood is so uncommon, and before age 13 years so rare, that the designations early-onset schizophrenia (EOS), with onset before age 18 years, and very-early-onset schizophrenia (VEOS), with onset before age 13 years, have been adopted for research and clinical use. An Australian study examined 85 patients (aged 13–25 years; two-thirds male) with new-onset psychosis and varied diagnoses, including 44.7% with schizophrenia and 10.6% with schizophreniform disorder. Results found physically aggressive behaviors in 43.5% of patients, and 27.1% of the sample had assaulted another person or used a weapon. The most serious offenses were associated with regular cannabis use and behavioral disinhibition, both common in younger ages, which was also a risk factor.
Treatment
Compared with the adult schizophrenia literature, there is a paucity of information on the treatment of aggression associated with EOS or VEOS. Some information can, therefore, be derived from adult studies to try and inform the treatment of younger, aggressive patients with schizophrenia. A 2-year follow-up study of community-living adults with schizophrenia demonstrated a significant reduction in the risk of violent behavior with the use of AAs (clozapine, risperidone, or olanzapine) compared with typical antipsychotics, such as haloperidol. In another study involving adults with treatment-resistant schizophrenia, clozapine demonstrated superiority (over olanzapine and risperidone) in the reduction of aggressive behaviors. In one of the few studies involving children and adolescents with schizophrenia, a small number of aggressive patients with childhood-onset schizophrenia, who were previously nonresponsive to either olanzapine or risperidone, showed reductions in violent episodes and thoughts when treated with clozapine. Given the potentially serious side effects associated with clozapine, olanzapine and risperidone are safer agents to use initially.
Tourette and Other Tic Disorders
Tourette disorder (also called Tourette syndrome) is a chronic motor and vocal tic disorder, with strong familial aggregation and high comorbidity, especially with obsessive-compulsive disorder and, to a lesser degree, ADHD. Prevalence figures vary widely from 1:100 to 1:10,000, depending on the diagnostic criteria used. In addition to comorbid psychiatric disorders, approximately 25% to 70% of children with Tourette disorder display recurrent episodes of explosive anger or aggression (rage attacks), which are often described as the most impairing symptoms.
Treatment
Considering the high degree of comorbidity with other psychiatric disorders, the initial treatment of Tourette disorder with medications will depend on identifying and prioritizing the other diagnoses. However, a reasonable first choice to address both tics and aggression would be one of the AAs, with many clinicians electing to start with risperidone.
Intermittent Explosive Disorder
As the name implies, intermittent explosive disorder (IED) is defined as episodic aggressive outbursts that are excessive in response to environmental stressors, and are not caused by medical, substance-use, or other psychiatric disorders. IED is actually more common than was once believed, with a current diagnostic lifetime rate of 2.37% and 6.32% in a community sample. The histories of adults with IED are notable for the onset of the disorder, on average, sometime in early adolescence.
Treatment
Given the likely under-recognition, underdiagnosis, or misdiagnosis of IED (as, eg, bipolar disorder) in clinical settings, it is not surprising that there are no good quality psychopharmacologic studies to help guide treatment. What is available suggests trials of essentially all of the medications that have been mentioned for the other disorders in this article. My preference is to start with one of the mood stabilizers, either lithium carbonate or an anticonvulsant, which are usually well tolerated by younger patients.

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