TREATMENT OF MALADAPTIVE AGGRESSION IN YOUTH

7/31/2019 TREATMENT OF MALADAPTIVE AGGRESSION IN YOUTH

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2

TABLEOFCONTENTS

INTRODUCTION

T-MAYSteeringCommitteeStatement 3

T-MAYRecommendations 4

ASSESSMENT+DIAGNOSIS 5

BOLDER 6

TREATMENTPLANNING+MANAGEMENTPLANNING 7

PRESTO 8

PSYCHOSOCIALINTERVENTIONS 9

TheFamilyCollaborationTreatmentPlan:6BasicQuestions 11

ActionPlans:ATemplateforCreatingShort-,Intermediate-andLong-termActionPlans 12

MEDICATIONTREATMENTS 14

UsualMedicationDosingandTitrationIntervalsofAntipsychotics(APs) 15

UsualMedicationDosingandTitrationIntervalsofMoodStabilizers(MSs) 17

Footnotes:LiverEnzymeInducersandInhibitors 18

SIDEEFFECTMANAGEMENT 19

RelativeSide-effects:SafetyandTolerabilityofAntipsychoticsandMoodStabilizers 20

RelativeSideEffects:Footnotes 21

StrategiesfortheManagementofSideeffectstoAntipsychoticsandMoodStabilizers 22

MEDICATIONMAINTENANCE+DISCONTINUATION 23

ClinicalPearlsofSideEffectsManagement 23

MinimizingSideEffectsWhenSwitchingPsychotropicMedications 23

APPENDIX 24

AlgorithmFortheTreatmentofADHDWithComorbidAggression 25

AlgorithmFortheTreatmentofDepression/AnxietyWithComorbidAggression 26

ActionPlans:ATemplateforCreatingShort-,Intermediate-andLong-termActionPlans 27

ActionPlans:TipsForFamilies 29

DietaryandPhysicalActivityRecommendations

30

APSide-effectsChecklist 31

ClinicalGlobalImpressions(CGI) 32

BriefPsychiatricRatingScaleForChildren(BPRS-C-9) 33

ModifiedOvertAggressionScale(MOAS) 35

YoungManiaRatingScale 36

BIBLIOGRAPHY 38



3

INTRODUCTION

Psychotropic agents, particularly second-generation antipsychotics and mood stabilizers, are increasingly

prescribed toyouthonanoutpatient basis for the treatment of overtaggression, a symptom thatmayhave

multiplecauses.Theselarge-scaleshiftsin treatmentpracticeshaveoccurreddespitepotentiallytroublingside-

effectsandalackofsupportiveempiricalevidence.Withtheincreaseintheprescriptionofpsychotropicagents

outsideofFDA-approvedindications,concernshavebeenraisedovertreatmentdecision-making,appropriateuse

of alternative therapies, long-term management, safety of multiple drug regimens, and successful parental

engagementandeducation.Givenitsindistinctetiologyandvariabilityinfrequencyandseverityofsymptoms,as

well as the presenceof overlappingcomorbidities, treatingandmanagingaggression is generally difficult and

complex. Toaddress this clinical need and improve outcomes for childrenand adolescentswithmaladaptive

aggression, a steering committee was established to spearhead a consensus development and quality

improvementinitiativeforclinicianstreatingsuchchildrenandadolescents.

Through the collaboration of The REsource for Advancing Children’s Health Institute (REACH), the Center for

EducationandResearchonMentalHealthTherapeutics(CERTs)atRutgersUniversity,ColumbiaUniversity/New

YorkStatePsychiatricInstituteandparticipatingnationalexpertsinthefieldsofpolicy,research,advocacyand

child and adolescent psychiatry, the Treatment ofMaladaptive Aggression in Youth (T-MAY) guidelines were

developed.UnderthedirectionoftheT-MAYSteeringCommittee,theguidelinedevelopmentprocessinvolved:(1)

extensiveliteraturereviews;(2)anexpertconsensussurveytobridgeexistinggapsintheliterature;(3)atwo-day

consensusconferenceinvolvingcontentexperts;and(4)successiverefinementof theguidelinesthroughfurther

inputfromtheT-MAYSteeringCommittee(citedbelow).TheresultingT-MAYrecommendationsfordiagnosisand

assessment,treatmentplanningandside-effectmanagementarethedirectresultofthesepartneredclinicaland

policyresearchefforts.*

The guidelines are intended for both primary care and specialty mental health prescribers. As such, T-MAY

ultimatelyreliesonphysicianexpertiseanddiscretion,andisnotintendedtoundermineclinicaljudgment.Here,

wepresentthecompanion“T-MAYClinician’sToolKit,”aconcisereferenceguidedesignedtoaidcliniciansintheir

implementation of T-MAY. This handbook provides a systematic, evidence-based treatment approach, but it

representsonlythefirststepinanongoingprocess.Pleasecontactusattheemailaddressesbelowwithquestions

orsuggestions.Wearegreatlyinterestedinyourfeedbackontheutility,format,andcontentofthisguide.

PeterJensen,MDPeterJensen,M.D.

Chair,T-MAYSteeringCommittee

PresidentandCEO,TheREACHInstitute

*[email protected]

*contactforT-MAYmanuscriptpreprints

StephenCrystal,Ph.D.

PrincipalInvestigator,CERTS

RutgersUniversity

[email protected]

SherriBendele,Ph.D.

AlannaChait,B.S.

ChristophCorrell,M.D.

LynnCrismon,PharmD

RobertFindling,M.D

TobiasGerhard,Ph.D.

KarenHart

CindyHopkins

PenelopeKnapp,M.D.DanielleLaraque,M.D.

LaurelLeslie,M.D.

JudyLucas,APN,Ed.D

MarkOlfson,M.D.

ScottoRosato,Ph.D

NancyParker

MarkWolraich,M.D.

DavidWoodlock,M.S.

SherrieBendele,B.S.

AlannaChait,B.S.

ChristophCorrell,M.D.

M.LynnCrismon,Pharm.D.

RobertFindling,M.D.

TobiasGerhard,Ph.D.

CindyGibson

KarenHart,B.S.

PenelopeKnapp,M.D.

DanielleLaraque,M.D.

LaurelK.Leslie,M.D.,M.P.H.

JohnLochman,Ph.D.

JudithA.Lucas,APN,Ed.D.

MattPerkins,M.D.

MarkOlfson,M.D.

ElizabethPappadopuls,Ph.D.

NancyScottoRosato,Ph.D.

NancyParker

MarkWolraich,M.D.



4

T-MAYRECOMMENDATIONS

Note:Theorderoftheserecommendationsmaybetailoredtoeachpatient’sspecificconditionandneeds.

ASSESSMENT+DIAGNOSIS

Engagepatientsandparents(emphasizeneedfortheiron-goingparticipation) Conductathoroughinitialevaluationanddiagnosticwork-upbeforeinitiatingtreatment Definetargetsymptomsandbehaviorsinpartnershipwithparentsandchild Assesstargetsymptoms,treatmenteffectsandoutcomeswithstandardizedmeasures

INITIALTREATMENT+MANAGEMENTPLANNING

Conductariskassessmentandifneeded,considerreferraltomentalhealthspecialistorER Partnerwithfamilyindevelopinganacceptabletreatmentplan Providepsychoeducationandhelpfamiliesformrealisticexpectationsabouttreatment Helpthefamilytoestablishcommunityandsocialsupports

PSYCHOSOCIALINTERVENTIONS

Provideorassistthefamilyinobtainingevidence-basedparentandchildskillstraining Identify,assessandaddressthechild’ssocial,educationalandfamilyneeds,andsetobjectivesand

outcomeswiththefamily Engagechildandfamilyinmaintainingconsistentpsychological/behavioralstrategies

SIDE-EFFECTMANAGEMENT

Assessside-effects,anddoclinically-relevantmetabolicstudiesandlaboratorytestsbasedonestablished

guidelinesandschedule Provideaccessibleinformationtochildrenandparentsaboutidentifyingandmanagingside-effects Useevidence-basedstrategiestopreventorreduceside-effects

Collaboratewithmedical,educationaland/ormentalhealthspecialistsifneeded

MEDICATIONTREATMENTS

Select initial medication treatment to target theunderlying disorder(s); follow guidelines for primary

disorder(whenavailable)

If severe aggression persists following adequate trials of appropriate psychosocial and medicationtreatmentsforunderlyingdisorder,addanAP,tryadifferentAP,oraugmentwithamoodstabilizer(MS) Avoidusingmorethantwopsychotropicmedicationssimultaneously Use the recommended titration schedule and deliver an adequate medication trial before adjusting

medication

MEDICATIONMAINTENANCE+DISCONTINUATION

Ifresponseisfavorable,continuetreatmentforsixmonths. Taperordiscontinuemedicationsinpatientswhoshowaremissioninaggressivesymptoms≥6months



5

Thecheck-listprovidesanessentialoverviewof theT-MAYtreatmentguidelinesdevelopedthroughtheprocess

outlinedintheintroduction.Thefollowingpagesof thissectionoutlineexperts’opinionsasdepictedintheflow

diagram,entitledT-MAYRecommendations.Althoughunderstandingaggressionasamulti-facetedsymptomisthe

mainfocusofourguidelines,wealsoemphasizetheimportanceofathoroughdiagnosticwork-up;assessmentof

relevant disorders and presenting behaviors of the child; engagement and collaboration of families in the

treatmentplan;andappropriatemonitoringandevaluationofsymptomsthroughoutthetreatmentprocess.

ForeachstepoftheT-MAYapproach,mnemonics,tools,strategiesandchartsareappendedthroughout.Information

notembeddedinthebodyofthetextcanbefoundintheappendices.

ASSESSMENTANDDIAGNOSIS

Given the multiple etiologies of aggression, as well as the variety of risk factors associated with outbursts,

interpersonal aggression and oppositionality, a comprehensive assessment is necessary for understanding the

developmentandcontextofmaladaptivebehaviors.Impulsiveaggressionisasymptomandtreatmenttargetin

multiplechildhooddisorders,includingAttentionDeficit-HyperactivityDisorder(ADHD),ConductDisorder,Bipolar

Disorder and Autistic Spectrum Disorders (including Pervasive Developmental Disorders). Assessments should

carefullyevaluate thechild’s physical andcognitivefunctioning and include their performance andbehavior in

home,schoolandinothersocial,peer-dominatedspheres.(PleaseseeBOLDERfollowingtheT-MAYguidelinesfor

assessmentanddiagnosis).

ENGAGEPATIENTSANDPARENTS

Relationship-building can determine family and patient knowledge-base, identify perceived barriers to

adherencetotreatment,andaffecttheoverallviabilityoftheestablishedtreatmentandmanagementplan.

Considerationsofthefamily’scurrentlevelofstress,functioningstatusandbeliefsabouttreatmentshouldbe

clearlyunderstood

Getaclearpictureofhowtheyhaveattemptedtodealwiththisovertaggressionuptothepointofyourvisitwith them. Ask if they have reached out to other family members, community organizations, or other

clinicians.Iftheanswerisno,askwhytheyfinallychosetoseekmedicaltreatment

CONDUCTANINITITIALEVALUATIONANDPERFORMADIAGNOSTICWORK-UPBEFOREINITIATINGTREATMENT

Identify the family’s concerns, and the reasons they are seeking treatment by contextualizing the target

symptomsintermsoftime/space/location.Includeboththefamilyandthechilddisplayingovertaggressionin

yourquestion-and-answer

Determinetheirperceptionsof theovertaggression:Whatis causing theaggressive symptomstoappear?

Wheredo theyoccurmostly?Whataretherisks for injuryofthechild toselfandothers?Whataretheir

expectationsfortreatment?Howdotheywanttobeinvolved?

Toruleoutpotentialcontributoryco-occurringsymptomsordisorderswhichcouldhaveasignificanteffectonprognosis,allpossibledocumentationofthechild’streatmenthistoryshouldbecollectedtograspthe

character,intensityandfrequencyoftargetsymptoms

UsingtheDSMorICDdiagnosticcriteriatoassessotherpsychiatricormedicalcomorbiditiesisanessential

firststepininitiatingtreatmentandmanagementplanning

Assesstargetsymptomsusingavailablescalesandratingtools(seeappendix,please)

Performnecessarydiagnosticlaboratorytests





7

TREATMENTPLANNING

Multiplefactorsarelikelyrelatedtotheonsetandmaintenanceofaggressioninchildrenandadolescentswith

mentalhealthdisorders.Thesefactorsspanawidevarietyofdomains,includinginbornbiologicalandgenetic

anomalies,themedia,andlargersocio-culturalforces,interactivefamilyprocesses,schoolandcommunity

influences,limitationsinthechild’scognitive,physical,socialandcommunicationskills,aswellasothercontributorsfromrelationshipswithparents,caretakersandpeers.Determiningthemostlikelysetoffactors

underpinningandelicitingthechild’saggressioncanbequiteintricate,andoftenlieoutsidethescopeofasingle

professionals’areaofexpertise.(PleaseseePRESTOfollowingT-MAYguidelinesfortreatmentplanning).

CONDUCTARISKASSESSMENT,GETREINFORCEMENTSANDREFERIFNEEDED

When acute aggression is the cause of concern, the child and family must be carefully interviewed to

determinethelevelandlikelihoodofphysicalriskthechildpresentsothersandtohim/herself.Assessingthe

child’sintentiontoharmselforothers,his/herdegreeof impulsivity,childand familyhistoryof aggression,

family parenting style, and the parents’ methods of reward and punishment can help to ascertain the

appropriateinformationaboutthefrequency,duration,triggers,andriskofthechild’saggressivebehaviors

Inadditiontothefamilydynamic,specialattentionshouldbepaidtodeterminingtheimpactofthechild’ssocialnetwork,andthepotentialroleofdrugand/oralcoholuse/abuseinincitingaggression

Given the varied environmental and psychiatric contexts in which aggression can occur, clinicians are

encouraged to identify potential obstacles from their on-going collection of data, to optimize treatment

conditions

PROVIDEPSYCHOEDUCATIONANDSETREALISTICEXPECTATIONSABOUTTREATMENT

Engagingpatientsandtheirfamiliesfromthestartoftheassessmentphasebetterensurestheiropennessto

participatingindialoguesaboutimpulsiveaggression,DSMdisordersthatmaybepresentandstrategiesto

managethechild’sbehavior.

Cliniciansshouldseektomaximizecommunicationandeffectivelearningbyfirstinquiringaboutparents’and

children’spre-existingconcerns,beliefsandunderstandingsaboutthecauses,consequencesand

interventionsforaggression.Ifassumptionsareinvalidormyth-based,providersshouldmakecomplete,easy-

to-readinformationmaterialsavailableinthefamily’spreferredlanguageandformat.

Inorderforfamiliestofullyunderstandtherisks,benefitsandtrade-offsinvolvedinaddressingaggression,

informationshouldinclude(1):whatisknownaboutthecausesofaggression;(2)consequencesifnot

addressed;(3)thevariousenvironmental,psychosocialandmedicationinterventionsavailable;(4)typesof

medicalandeducationalassistancethefamilycanreceive;(5)sourcesofculturally-appropriatefamilysupport,

andadditionalservicesandoutletsforinformationinthelocalcommunity.

Outliningthefamily’sandcommunity’sroleinthiswaycansignificantlyimpactthepatient-clinician

relationship,treatmentadherenceandoutcomesinanoptimisticandconstructiveway.

HELPTHEFAMILYTOESTABLISHCOMMUNITYANDSOCIALSUPPORTS

Developinganappropriatetreatmentplanwiththepatientandfamilyshouldtakeintoaccounttheirconcerns,fears,andexpectations.Similarly,specifictreatmentgoalsinkeyareasoffunctioningshouldbe

agreeduponbyfamilymembers.

Plansfortheshort-term,long-term,andemergencysituations,areallequallyimportantanddeserve

coordination.Itisessentialthatacrisisplanbeco-developedwiththefamilythatoutlineshowemergency

situationsshouldbehandled.Identifyingpotentialin-patientandout-patientclinicalservicesanddiscussing

therolesofparentsandclinicalprovidersarekeyelementstoplanforwhenpreparingthefamilyforimminent

distress.





9

PSYCHOSOCIALINTERVENTIONS

Althoughavarietyofmedicationsshowsubstantialefficacyinreducingaggressionassociatedwithdifferent

primaryconditions(Schuretal.,2003;Turgayetal.,2002;Croonenberghsetal.,2005;Findlingetal.,2004;

Greenhilletal.,1985),evidenceforthesuccessfulmanagementofaggressioninyouthincludestheprovisionof

psychoeducation,andsettingrealisticexpectationsabouttreatmentwiththepatientandfamily.TechniquessuchasParent-ManagementTraining,School-BasedSocialSkillsTrainingandgeneralpreventionprogramshaveshown

efficacyinreducingaggression(Tremblayetal.,1995;Kellametal.,1994),promotingpositive,pro-socialand

compliantbehaviorinchildrenandencouragingparentstoadoptmoreconsistentandpredictablechild-

managementstrategies(Patterson,1982;Pattersonetal.,1992;Webster-StrattonandSpitzer,1996).Proper

managementofangercanleadtoreducednumberofincidentsofphysicalaggressionandimprovedparentand

teacherratingsofbehavior.

Identifying andorganizingyourselfthroughperforminga thoughtfuland thoroughevaluationanddiagnosis has

allowed you toidentifyandorganizeyour thoughtsandpotential concerns. Having gotten toknow the family

better,youandthefamilycanmoveontothenextphase:usinginnovativeproblem-solvingandcollectivewisdom

totackleaggressionwithpracticalapplicationandpredication.Foryoungerchildren,multimodaltreatmentplanapproaches that involve parent and child training and/or therapy have demonstrated the greatest efficacy in

managingpersistentaggressivebehaviors.Duringourliteraturereview,itbecameapparentthatcertainevidence-

basedtreatmentsweremorelikelytobeusedwitholderchildrenandfamilieswithyoungerchildren.Thisisnot

unusual, given that age and developmental level of the child contribute significantly to the decisionofwhich

treatmentmodalitytoemploy.

PROVIDEORASSISTTHEFAMILYINOBTAININGEVIDENCE-BASEDINFORMATION

Itis important for families tofeel asif theireffortsup tothepoint ofrequestingyourhelp (thehelpof a

physician) have not been in vain. Most parents have read available books, sought out the advice of a

professional counselor or therapist, have had repeated discussions with their child’s teachers, and havespokentofamilyandfriendsabouttheimpactaggressionhasontheirandthechild’slife.

Creatingagoodlifeandcraftingapromisingfutureforachildwithaggressionisincrediblycomplicated,and

willrequiretrialanderror.Cliniciansshouldseektomaximizecommunicationandeffective learningbyfirst

inquiringaboutparents’and children’spre-existingconcerns, beliefsandunderstandings about thecauses,

consequencesandinterventionsforaggression.

Ifassumptionsareinvalidormyth-based,providersshouldmakecomplete,easy-to-understandinformation

materialsavailableinthefamily’spreferredlanguageandcommunicationformat.Inorderforfamiliestofully

understand therisks,benefits,and trade-offsinvolvedinaddressingaggression, information should include

(1): what is known about the causes of aggression; (2) consequences if not addressed; (3) the various

environmental, psychosocial, andmedication interventions available; (4) types ofmedical andeducational

assistancethefamilycanreceive;(5)sourcesofculturally-appropriatefamilysupportandadditionalservices

andoutletsforinformationinthelocalcommunity.Someindividualsmayprefervisuallearningmaterials(i.e.,

DVDs,videotapes,andvideostreams)overwrittenmaterials.

ASSESSANDADDRESSTHECHILD’SSOCIAL,MEDICATION,EDUCATIONALANDFAMILYNEEDS

Though relying onwhat you know ishelpful, it isnecessaryto work alongside the family todebug those

standardizedtechniquesandapplythetoolsinawaythatisappropriateforthecircumstance,in“reallife.”

PleaseseetheFamilyCollaborativePlan:sixbasicquestionstobeansweredbytheclinician,childandfamily.



10

Please see the Psychosocial Treatment Planning and Management of Overt Aggression for Families and

Clinicians,atemplatetodevelopshort-term,intermediate,andlong-termactionplanstomanageandmonitor

thetreatmentofovertaggression

ENGAGECHILDANDFAMILYINMAINTAININGCONSISTENTPSYCHOLOGICAL/BEHAVIORALSTRATEGIES

Eachfamilyhastomaketreatmentdecisionsbasedontheavailableresourcesandwhatmakesthebestsense

fortheirchild.

Emphasizethefamily’sneedforon-goingfamilyandcommunitysupport.

Treatingaggressionrequiresflexibilityinplanning;preparethefamilyformultiplechangeslikelytobeneeded

throughouttreatment.



11

FAMILYCOLLABORATIVETREATMENTPLAN

Dispensing what seems like simple, typical medical advice isn’t always enough to send a family home fully-

equippedwithtakingonsomethingasperplexingandinroadasaggression.Thedifferencebetweenwhatcanbe

readin anyinformation booklet (nomatterhowadept thereader isorhowcomprehensivethe narrative)andwhatworkstocounteraggressioninthe“realworld,”liesintheparticularsofadaptingtheadvicetothegiven

circumstances of that child and family. A “one-size-fits-all” treatment, whether or not it’s coupled with

sophisticatedpharmaceuticals,willnotgetattheunderlyingsourcesoftheaggression.

The6BasicQuestionsoutlineaseriesofquestionsthatcanhelpparents,childrenintreatment,anddoctorsto

standardizetheireffortstowardspreventingthesymptomsofaggressiontoarise.Byestablishinganswerstothe

abovequestionsasacollaborative,compliancetotreatmentismorelikelytobesuccessful.ThoughtheFamily

CollaborativePlanmayappearatfirst-glanceasa“cookbook”outline,itisnecessarythatyoukeepinmindthat

theanswerstothese6BasicQuestionsmaychangeoverthecourseoftreatment.Itwouldbewisetogetintothepracticeofansweringthesequestionseachandeverytimeyoumeetwiththefamilytoavoidconfusion.

ActionPlans,alongwiththeFamilyCollaborativePlan,helptopromotelong-termvisionandshort-term

motivationfortreatmentplanningandmanagementofside-effects.Treatingaggressionisoftenchallenging,but

short-,intermediate-andlong-termplanningcankeepeveryonefocusedonorganizingresources,meetingthe

family’sneedsandensuringthatallpartieshaveaclearawarenessofwhattheymustdoinordertohelpthechild

intreatmentachieveaparticularobjectiveoroutcome.

6BASICQUESTIONS:

1 – WHOis/aretheactiveagent(s)(physician,therapist,caregiver,teacher,patient,etc.)?

2–WHATisthetreatmentgoal?Whattherapeuticmodalityisgoingtobeused?

3– WHEREisthetreatmentbeinggiven?Isitlocation-specific?

4– WHYisthepatientbeingtreated?Whichsymptom(s)aretargeted?

5– WHENistherapygiven?

WHENshouldmedicationbeadministered?

6– HOWMANYsessionsoftherapyaresuggestedoveradeterminedperiodoftime?

HOWMUCHmedication(dose)isprescribed?



ACTIONPLANS:PSYCHO-SOCIALTREATMENTPLANNING+MANAGEMENTOFOVERTAGGRESSIONFORFAMILIESANDCLINICIANS

ATemplatetoDevelopShort-,Intermediate-andLong-termAc9onPlanstoManageandMonitorTreatmentofOvertAggression

CHILD'SNEEDS WHAT? WHO? WHERE? WHEN? HOWMUCH? WHY?

Whyistheac9onimportant?

ADDRESSING Ho wwill t hen eed( s) b e W ho isth eac9v eagent ? Istrea tm en t lo ca 9o n- Wh at isth e9m e- fram e? H owm an ysess io ns o f Ta rge9 ngwhich

NEEDS+IDENTIFYING addressed?Whatresources Whoisaccountable? and9mespecific? Howfrequentaresessions? therapyaresuggested? symptom(s)?

RESOURCES areavailable? Whowillassistyou? Typeofenvironment? HowoenisRxdistributed? WhatistheRxdose? Short-termgoals?

Objec9ves?

SOCIAL+EMOTIONAL: WHAT? WHO? WHERE? WHEN? HOWMUCH? WHY?

Learnorigami;buy DiningRoomTable Developingaskillorhobby

funpaperandfinda Parents/GuardiansandChild oracommunity- WeekendAernoons 1-29mesaweek canincreaseinterest,

IMPROVING "how-to"book offeredclass dedica9on,anda

SELF-ESTEEM feelingofaccomplishment.

Canfacilitatelearningfrom

Discusswithteacher; Parents/Guardians&Teacher Discussonceaweek;ask peers+sharedexperiences.

exp ress y ou rco ncerns M ay wan tto d is cu ss At t heS ch oo l Befo reo rAerS ch oo l chi ld every day a bo ut t he can a ls ofa ci lita te

MAKING andexpecta9ons withotherparents childrenatSchool Moreposi9vesocial

FRIENDS interac9ons;increased

plannedac9vi9es

withotherstudents.

MEDICALNEEDS: WHAT? WHO? WHERE? WHEN? HOWMUCH? WHY?

Determineifprescribed Child AtHome IntheAM Chartsleepandbehavioral Findingthebesttypeand

me d re gi me n is be st + Pare nt s/ Guar di an s At Sc hool I n the a e rno on p a er ns dai ly; di sc uss w it h dos e of me di ca9 on wi ll

MAKINGTHEMOST doc ume nt what you no9 ce Te ac he r and Doc to r At the doc to rs offic e At ni ght doc tor mo nt hl y. r es ul t in fe we r or no

OFMEDICINE side-effects,andimprove

overallphysical,social

andmentalwell-being.

Rea dup t o learnab ou t C hild G oto h ighqu alit ywebs it es Recordch an ges in m oo d+ C ha rt s leep a nd b eh av io ra l

side-effects+document Parents/Guardians forinforma9on+findlocal behavior.Reportdras9c paernsdaily;discusswith Monitoringside-

MONITORING changesinbehavior/mood TeacherandDoctor sourcesinthecommunity changestodoctorASAP. doctormonthly. effectswillhelpyou

SIDE-EFFECTS todiscernwhetheror

notmedica9onisworkingforyourchild.

EDUCATIONALNEEDS: WHAT? WHO? WHERE? WHEN? HOWMUCH? WHY?

Beerunderstand Startimmediately;it'sbest RequestaweeklyProgress Understandingyour

yourchild'sacademic Parents/Guardians AtSchoolwiththeTeacher tostartatthebeginning Reporttotrackbehavior+ child'sapprehension,

PERFORMANCE strengths+weaknesses oftheschoolweek. learning(e.g.,testscores) perceivedhardshipand

INSCHOOL atudestoward

learningcanhelpyouto

iden9fynewwaysto

Discussanddevelop Aerschool makelearningfunand

aHWplantoaddress Parents/GuardiansandChild Atthekitchentable and, Everyday/week exci9ng.Allevia9ngthe

DOING assignmentload onweekends stressorsofschoolcan

HOMEWORK improveoverall

9meatthekitchentable.

12



FAMILYNEEDS: WHAT? WHO? WHERE? WHEN? HOWMUCH? WHY?

Makethechildfeelgood Parents/Guardians AtHome Posi9vefeedbackand

abouttheextra9meyou Siblings DuringAc9vi9es Allthe9me praiseshouldbe Raisingachild

CHILDIN spendwithhim/her Teacher AtSchool givenasmuchaspossible thatrequiresspecial

TREATMENT aen9onandaddi9onal

9me,especiallywhenthere

areotherchildrenin

Eachshouldhave9mealone; Discussyourneedswiththe thefamily,canbe

p aren ts m us tbo th a greeo n Paren ts /G ua rd ia ns G oou t, o rst ay in chi ld ren, a nd fa mily At lea st o nceaweek d ifficu lt o nev eryo ne.

PARENTS ac9onplans+rewardsystem orsier

Strongintra-family

communica9oniskey

tomaintenance+progress.

Spendquality9mewith Letthesiblingsdecide; Asmuchaspossible.You

othersiblings.Express Parents/Guardians&Siblings showinterestintheir canformalizeplanson Atleastonceaweek IncludingeveryoneintheSIBLINGS concernfortheirhealth,too hobbies+socialevents aweeklybasis. ac9onplans,spending

individual9mewith

familymembers,andtaking

9meforyourself,

Includeyourchildrenin Parents/Guardians Meetasagrouptodevelop Onceaweek, iskeytodecreasing

planningac9vi9eswhere Si blings Decideasagroup the fami lycalendar.It should or twice confli ctsinthehome,

FAMILYAS everyoneisincluded ChildinTreatment beinview+revisable. amonth andpreven9ngfeelingsof

AWHOLE negligence,burnout

orburden.

Modifiedfrom:PeterS.Jensen,MD(2004).MakingtheSystemWorkforYouandYourChildWithADHD.GuilfordPress.PP.51and254.

Note:Thischartishelpfulinthatitprovidesexamplesofhowtoestablishshort-term,intermediate,andlong-termoutcomesandgoalswiththechildandfamily.Ablankcopycanbe

foundintheappendixforrepeateduse.

13





USUALMEDICATIONDOSINGANDTITRATIONINTERVALSOFANTIPSYCHOTICS(APs)*

DOSE DOSE MEDICATION STARTING HALF TIMETO TITRATION PRINCIPAL LIVER LIVER

ANTIPSYCHOTIC RANGE STRENGTH FORMULATIONS DOSE LIFE PEAK INTERVALS LIVER ENZYME ENZYME

(mg) (mg) (availableforuse) (mg) (hrs) (hrs) (days) ENZYME INDUCER INHIBITOR

SECONDGENERATIONANTIPSYCHOTICS(SGA)

ARIPIPRAZOLE Child: 2,5,10,15, po,imshort, 2to5 50to72 3to5 whenstarngat 2D6>3A4 3A4 2D6

(ARI) 2.5-15 20,30tbl; diss.,liquid 2mg,mayincrease 3A4

10,15diss, doseevery3rdday;

Adol: liquid1 a_ersteadystate,

5to15 (30mg=25mL) Chlorpromazine increasedose

Dose≈7.5mg every7-14days

CLOZAPINE Child: 25;100 po 12.5 12 1to4 25mgdaily 1A2>2C19 1A2 1A2

(CLO) 150-300 or, 2C19>3A4 2C19 2C19

Adol: Chlorpromazine everyotherday 3A4>2C9 3A4 3A4

200-600 Dose≈50mg 2C9>2D6 2C9

OLANZAPINE N/A .5,5,7.5,10,15,20tb po,imshort, 5to10 30 6 increaseat 1A2 1A2 1A2

(OLA) 5,10,15,20diss; diss. Chlorpromazine intervals>5days 2D6 2D6 2D6

10im Dose≈5mg 3A4 3A4 3A4

PALIPERIDONE 3to12 3,6,9 po,ER 3 21to30 24 increaseat <10% N/A N/A

(PAL) Chlorpromazine intervals>5days Hepac

Dose≈3mg Clearance

QUETIAPINE 150to750 25,100,200 po,XR 50-100IR 6to7 2 100mgperday 3A4 3A4 3A4

(QUE) 200-300XRChlorpromazine

Dose≈75mg

RISPERIDONE Child: 0.5,1,2,3,4tablets; po,imlong, 0.5to1 3 1to2 increaseat 2D6>3A4 2D6 2D6

(RIS) 1.5-2 0.5,1,2diss; diss.,liquid intervalsof0.5-1 3A4 3A4

Adol: liquid1mg/mL Chlorpromazine perdayor>5days

2to4 30mlbol Dose≈2mg

ZIPRASIDONE 80to160 20,40,60,80 poimshort 20to40 increaseat20-40 Aldehyde 3A4 3A4

(ZIP) tablets Chlorpromazine 7 5 perday Oxidase

Dose≈60mg >3A4

Modifiedfrom:Correll2008(CorrellCU).AnpsychocsandAdjuncveMedicaons.In:TextbookofaChildandAdolescentPsychiatry.MDulcan(ed.),AmericanPsychiatricPublishing,Inc.NewYork.

Modifiedfrom:2004.TRAAY-APocketReferenceGuide.NewYorkStateOfficeofMentalHealth,ResearchFoundaonforMentalHygiene,Inc.andtheTrusteesofColumbiaUniversity.

15



TYPICALMEDICATIONDOSINGANDTITRATIONINTERVALSOFANTIPSYCHOTICS*


ANTIPSYCHOTIC RANGE STRENGTH FORMULATIONS DOSE LIFE PEAK INTERVALS LIVER ENZYME ENZYME


FIRSTGENERATIONANTIPSYCHOTICS(FGA)

HALOPERIDOL 1to6

0.5,1,2,5,10,20

ta blets, po,imshort

0.25-1

3 - 6 po 2 -6 po

increasedoseby

0.5kg 3A4 3A4 3A4

(HAL)

2;10mg/mLliquid,5

im i m lo ng Ch lo rp ro maz in e 1 0- 20 im .05 im

intervalsof5-7

days

Dose»2mg

MOLINDONE 20to140 5,10,25,50 po 0.5-1mg/kg/d 1.5 1.5 N/A 2D6 2D6 2D6

(MOL) dividedin3-4doses

Chlorpromazine

Dose≈10mg

PERPHENAZINE 8to32 2,4,8,16 p o T BD ; no d ata ava il ab le 8 to 1 2 1 t o 3 T BD ; no d ata 2D6 2D6 2D6

(PER) Chlorpromazine available

Dose≈10mg

Modifiedfrom:Correll2008(CorrellCU).Anpsychocs+AdjuncveMedicaons.TextbookofaChild+AdolescentPsychiatry.MDulcan(ed.),AmericanPsychiatricPublishing,Inc.NewYork.

16



USUALMEDICATIONDOSINGANDTITRATIONINTERVALSOFMOODSTABILIZERS*


MOODSTABILIZER RANGE STRENGTH FORMULATIONS DOSE LIFE PEAK INTERVALS LIVER ENZYME ENZYME


CARBAMAZEPINE 100-800

100,200,100

mg/5mL po 100mgB.I.D.(tbl), Inial 4to5 Add<100mg/day 3A4>2D6 3A4 3A4

1/2tspQID(susp) 25-65 atweeklyintervals, 2D6.1A2 2D6 2D6

for6-12years Later t.i.dorq.i.d.(tbl) Auto- 1A2 1A2

12to17 lopmalreponse Inducer

CARBAMAZEPINE 100-800 100,200,400 po 100mg Inial 3to12 Add100mg/day 3A4>2D6 3A4 3A4

ER for6-12years 25-65 atweeklyintervals 2D6.1A2 2D6 2D6

B.I.D.orT.I.D. Later b.i.dunl Auto- 1A2 1A2

12to17 opmalresponse Inducer

DIVALPROEX 500-2000 125,250,500 po 10-15mg/kg /d 9to16 3to4 Add5-10mg /kgday CYP450 Rifampin #please

B.I.D.orT.I.D. q7days;givewith C29 Seco- see

fo od . In cre as e ( we ak b arb it al fo ot no te

rapidlytolowest inhibitor)

effecvedose

Increasedoseby5-

DIVALPROEX 500-2000 250,500 po 10-15mg /kg/daypo 9to16 7to14 10mg/kg /wkunl CYP450 Rifampin # please

ER opmalresponse; C29 Seco- see

clinicalresponseis ( weak bar bital f ootnote

atplasmalevels inhibitor)

of85-125µg/mL

Keepstarng

LAMOTRIGINE 50-200 25,100,150,200 po 24-34 1.4-4.8 dosestablefor2wks, Glucu- N/A N/Aonly25mg increaseby ronidaon

<16yo,oronDVP 12.5-25mg;butif

<16yo,oronDVP,

increaseby12.5mg

15-20mg/kg/dB.I.D Renal Renal Renal

L IT HI UM 6 00 - 1 80 0

8mEq/5mL po or 20-24 1to3 Dosewklybasedon Eliminaon Eliminaon Eliminaon

T.I.D. plasmaLi+levels Only Only Only

1800mg/d,

LITHIUM serumlevel 300,450 po 150-300mgB.I.D. 24 4 Doseaccording Renal Renal Renal

CR 1-1.5mEq/L toneed Eliminaon Eliminaon Eliminaon

adults Only Only Only

Modifiedfrom:CorrellandSchenck.CorrellCUandSchenckEM.AssessingandTreangPediatricBipolarDisorder.OxfordAmericanPsychiatryLibrary.Inpreparaon.

17



FOOTNOTES:TYPICALMEDICATIONDOSINGANDTITRATIONINTERVALSOFANTIPSYCHOTICS+MOODSTABILIZERS

*LIVERENZYMEINDUCERS

1A2:Smoking;Carbamazepine(weak)

2C9:Rifampin;Secobarbital

2C19:Carbamazepine;Norethindrone;Prednisone;Rifampin

2D6:Carbamazepine(highdoses)

3A4:Carbamazepine;Phenytoin;Phenobarbital;Rifampin;St.John’sWart

*LIVERENZYMEINHIBITORS

1A2:Fluvoxamine;Omeprazole;GrapefruitJuice

2C9:Fluconazole;Amiodarone;Fenofibrate;FluvastaKn;Fluvoxamine;Isoniazid;LovastaKn;Phenylbutazone;Probenicid;Sertraline;Sulfamethoxazole;Sulphaphenazole;Teniposide;Voriconazole;Zafirlukast

2C19:Lansoprazole;Omeprazole;Pantoprazole;Rabeprazole;Chloramphenicol;CimeKdine;Felbamate;FluoxeKne;Fluvoxamine;Indomethacin;etoconazole;Modafinil;Oxacarbazepine;Probenicid;Ticlopidine;Topiramate2D6:Bupropion;FluoxeKne;ParoxeKne;Terbinafine;Quinidine

3A4:Clarithromycin;Erythromycin;Fluconazole;Fluvoxamine;Indinavir;Itraconazole;etoconazole;Nelfinavir;Nefazodone;Ritonavir;GrapefruitJuice

NOTES

*AlargepartofthedataisextrapolatedfromadultpopulaKons.Therefore,informaKoncontainedinthetablemaychangeasmoredatafromlargepediatricpopulaKonsbecomeavailable.

a-Dosesneedtobeindividualizedbasedonefficacyandtolerability.

b-Averagedoserangeprovidedforadolescentswithschizophreniaorbipolardisorder;forprepubertalpaKentsorthosewithotherdiagnoses,averagedosemaybeapproximately33%to50%lower.

#:DivalproexlevelsmaybeincreasedwhencombinedwiththefollowingmedicaKons:Fluconazole;Amiodarone;Fenofibrate;FluvasKn;Fluvoxamine;Isoniazid;LovastaKn;Phenylbutazone;Probenicid;Setraline;

ChildrenonpsychotropicmedicaKonsshouldbeseenbytheirprescribingcliniciannolessthanonceeverythreemonths.Thisisabareminimum.Childreninacutesengs,whodisplayunsafebehavior,

experiencesignificantside-effects,ordonotrespondtomedicaKontrials,orareinanacKvephaseofamedicaltrialshouldbeseenmorefrequently.

IflaboratorytestsareindicatedtomonitortherapeuKclevelsofamedicaKonortomonitorpotenKalorgansystemdamagefromamedicaKon,theselabstudiesshouldbeperformedeverythreemonthsataminimum

(maintenancephase).IfthemedicaKonisbeinginiKated,theselabtestsshouldbeperformedmorefrequentlyunKlabaselineisachieved.

N/A=Notapplicable;NoDataAvailable.

B.I.D.-bisindie,adirecKontotakemedicaKontwicedaily

diss.-dissolvable

ER-extendedrelease

imshort/long-medicaKonisdeliveredbyintramuscularinjecKon

IR-immediatereleaseliquid-medicaKoncomesinliquidform,andtakenbymouth

mEq-milliequivalent

po- perorem,adirecKontotakeamedicaKonbymouth

T.I.D.-terindie,adirecKontotakemedicaKonthreeKmesdaily

TBD-tobedetermined;datanotyetavailable

XR-extendedrelease

18



19

SIDEEFFECTMANAGEMENT

Having establisheda strongworking relationshipwiththe familymemberswillhelptomonitor theeffecteach

medicationhasonthechild’saggression,andoverallwell-being.Methodsformanagingsideeffectsaredoneona

case-by-casebasis,giventhe need to consider family concerns, tolerability, efficacy, and because each child’s

responseprofilewillbeunique.Evenasmoredatabecomeavailablefromlargepediatricpopulations,itisunlikely

that the implementation of successful treatment plans will ever be standardized. Assessing and managing

clinically-relevantside-effectsrequirethatthetendingphysician,familyandchildareawareofthebenefitsand

risksofeachmedicationtoeffectivelyutilizepharmacologicalapproachesforclinicalaggression.

ASSESSCLINICALLY-RELEVANTSIDEEFFECTS

Ingeneral,thereisadirect,positiverelationshipbetweendoseandadverseeffect(s),anduseofmorethan

oneantipsychotic(AP)increasestheriskforAP-relatedside-effects.

Studiesandtestsbasedonestablishedguidelinesshouldbeusedwheneveravailable.

Iflaboratorytestsare indicatedtomonitortherapeuticlevelsofamedicationor tomonitorpotentialorgan

systemdamagefromamedication,theselabstudiesshouldbeperformedeverythreemonthsataminimum

(maintenancephase).Ifthemedicationisbeinginitiated,theselabtestsshouldbeperformedmorefrequently

untilabaselineisachieved.

PROVIDEACCESSIBLEINFORMATIONABOUTIDENTIFYINGANDMANAGINGSIDEEFFECTS

Educating the parent and childaboutthe knownsideeffects ofantipsychoticsandmood stabilizershelps

providethemwiththeknowledgetomonitorimprovementsandidentifymedicationsideeffects.

PleaseseeRelativeSideEffects:SafetyandTolerabilityofAntipsychoticsandMoodStabilizers(p.20).

USEEVIDENCE-BASEDSTRATEGIESTOPREVENTORREDUCESIDEEFFECTS

Reducingandpreventingsideeffectsisimportanttoavoidunintendedconsequencesofmedication. PleaseseeStrategiesfor theManagementofRelativeSide Effects toAntipsychotics (AP)+MoodStabilizers

(MS)(p.22).

COLLABORATEWITHMEDICAL,EDUCATIONALAND/ORMENTALHEALTHSPECIALISTS

Identifyintegralplayersinthetreatmentandassignthemroles.

Response to treatment cannot be adequately monitored by using clinical interview and clinical judgment

alone.

Finding the best treatment plan requiresthemobilization ofexisting resources aswell asmobilizing your

existingresources.Familymembersandotherprofessionalcaregiverscanhelpyoufindthemostappropriate,

effectivetreatmentforeachuniquechild.



RELATIVESIDE-EFFECTS:SAFETY+TOLERABILITYOFANTIPSYCHOTICSANDMOODSTABILIZERS

Compara'veOverviewofSide-effectProfilesofSecond-andFirst-Genera'onAn'psycho'cMedica'onsandMoodStabilizers*

ADVERSEEFFECT(S) T IME D OSE SECOND-GENERATIONANTIPSYCHOTICS(SGA) FIRST-GENERATION MOODSTABILIZERS(MS)1,2,3* COURSE DEPENDENCY ARI CLO OLA PAL QUE RIS ZIP HAL MOL PER CBZ* LI* LTG VP*

ACUTE Early +++ + 0 + ++ 0 ++ + +++ ++ ++ 0 + 0 0

PARKINSONISM

AKATHISIA Early/Inter- +++ ++ + + + + + +/++ +++ ++ ++ 0 + 0 0

mediate

DIABETES Late +? +a +++ +++ +a ++ + +a +a +a + +a +a +a +/++

↑LIPIDS Early/Inter- 0? +a +++ +++ +a +/++ + +a +a +a + +a +a +a +

mediate

NEUTROPENIA First6mo. +? + +++ + + + + + + + + ++ 0 + +

ORTHOSTASIS Early/ +++ + +++ ++ + ++c + 0 0 + + 0 0 0 0

Titra'on

↑PROLACTIN Early +++ 0 0 +/++ +++ 0 +++ + ++ ++ ++ 0 0 0 0

↑QTcINTERVAL Early/ +? +d +d +d +d +d +d ++d +d +d +d 0 0 0 0

Titra'on

SEDATION Early/May +++ + +++ ++ + ++c + + + + + + +/+ + ++

Improve

SEIZURES During +++ + ++a + + + + + + + + 0 0 0 0

Titra'on

STEVENSJOHNSON HighStart ++ + + + + + + + + + + + + ++ +

SYNDROME Dose;Fast

(SERIOUS);RASH Titra'on

TARDIVE Late ++ +a 0 +e +a +e + +e ++ +/++ +/++ 0 0 0 0

DYSKINESIA

WITHDRAWAL EarlyTaper +++ ++ 0 + + + + + ++ +/++ +/++ 0 0 0 0

DYSKINESIA FastSwitch

WEIGHTGAIN First3-6 0? + +++ +++ +/++ ++ ++ + + + ++ + +/++ + ++

Months

ModifiedfromCorrell2008(CorrellCU:An'psycho'cUseinChildren+Adolescents:MinimizingAdverseEffectstoMaximizeOutcomes.JAmAcadChildAdolescPsychiatry2008;47:9-20)

and,from:CorrellandSchenk(CorrellCUandSchenkEM:AssessingandTrea'ngPediatricBipolarDisorder.OxfordAmPsychiatryLibrary.InPrepara'on.

Modifiedfrom:2004.TRAAY-APocketReferenceGuide.NewYorkStateOfficeofMentalHealth,ResearchFounda'onforMentalHygiene,Inc.andtheTrusteesofColumbiaUniversity.

20



FOOTNOTES:RELATIVESIDE-EFFECTSFORSGAs,FGAsandMOODSTABILIZERS

Compara'veOverviewofSideEffectProfiles

+ -+++ Thereisa (low to high)direct,posi'verela'onshipbetweendoseandadverseeffect(s)

a-Thereisinsufficientlong-termdatatofullydeterminetherisk

b-Unlikelyduetolowriskfactorsinchildhoodandadolescents,andlonglag'meforcerebrovasculardiseasetodevelop

c-Lessathigherdoses(?Above250mg/day)

d-Relevanceforthedevelopmentoftorsadedepointsnotestablished

e-Lessthan1%peryearinadultswhowereoenpre-treatedwithFGAs

f-Ofunclearclinicalrelevance

g-(1)Hyponatremia/SIADHisevidentwithCarbamazepine(CBZ);thedosedependencyis+

h-(2)HypothyroidismisevidentwithLithium(LI);thedosedependencyis+++

i-(3)Hyperparathyroidismisevidentwithmoodstabilizers:Carbamazepine(CBZ);Lithium(Li);andValproicAcid(VP);thedosedependencyis+foreach

j-(4)Polycys'covariesoccurredin1090ofyoungadultswomentreatedwithValproicAcid(VP)forayear

*Alargepartofthedataisextrapolatedfromadultpopula'ons.Therefore,informa'oncontainedinthetablemaychangeasmoredatafromlargepediatricpopula'onsbecomeavailable

*UseofmorethanoneAPincreasestheriskforAP-relatedside-effects

21



STRATEGIESFORTHEMANAGEMENTOFRELATIVESIDE-EFFECTSTOANTIPSYCHOTICS(AP)+MOODSTABILIZERS

SuggestedTreatmentCourses/Interven3onstoRestoreRelevantAbnormalityinPediatricPa3entsCATEGORY POTENTIALSIDE-EFFECTS FIRST-LINEOPTIONS ALTERNATIVECONSIDERATIONS

( No t ne ce ssa ri ly i n ord er o f pr io ri ty ) ( No t ne ce ssa ri ly i n ord er o f pr io ri ty )

An3- Co ns 3p a3o n H ig h fib er d ie t; G iv e flu id s; Bu lk l ax a3v es or sto ol so e ne r; De cr ea se d os e Sw itc h AP/ MS

Cholinergic DryMouth Givesugarlessgumorhardcandy;Decreasedose SwitchAP/MS

Orthosta3cHypotension TeachPt.howtochangepostureslowly;Increasehydra3on;Decreasedose Cardiologyconsult;SwitchAP/MS

Cardiac S li gh tl y Pr ol on ge d QTc I nt er val (> 450≤ 500Ms ec s) R ep eat EKG; De cr ease d os e C ar di ol og y co ns ul t; D is co n3 nu e AP/ MS ; Sw it ch AP wi th n or mal EKG

Tachycardia Cardiologyconsult;Decreasedose Cardiologyconsult;SwitchAP/MS

VeryProlongedQTcInterval(>500Msecs) Discon3nueAP;RepeatEKG;Cardiologyconsult SwitchAPwithlessQTcprolonga3on

Confusion Assessformedicalillness+illicit druguse;Decreasedose;Neurologyconsult Obtainserumlevels;Discon3nueAP;SwitchAP

Cogni3ve+ H eadach e Add analg es ic ; Wait for i mp ro ve me nt ; Ru le -o ut t en si on h eadach e D ec re as e do se ; If t he re are p ro bl em s wi th v is io n, n eu ro lo gy c on su lt

Central MemoryProblems Decreasedose Neuro+neuropsychologyconsult;Medsatbed3me;SwitchAP

NervousSys Seda3on/Hypersomnia GiveAP/MSatbed3me;Discon3nueotherseda3ngmedica3ons;Decreasedose SwitchAP/MS

Se iz ur es G et EEG ; Ne ur ol og y co ns ul t; De cr ea se A P do se ; Sw itc h AP ; In cr ea se MS do se D is co n3 nu e AP/M S

Di ab ete s Ob ta in fa s3n g gl uco se + l ip id s at ba se li ne , , a nd 6 m ont hs ; En do cr in e co nsu lt; Sw itc h AP/ MS

Diabetes+ Symptom-managementeduca3on;Implementdiet/exerciseprogram

Weight WeightGain Nutri3onconsult;Implementdiet/exerciseprogram;Monitorfas3ng SwitchAP/MS

(developmentallyinappropriate) glucose,cholesterolandtriglyceridesatbaseline,,and6months

Amenorrhea Ruleoutpregnancy,hyperthyroidism+renalproblems;Obtainprolac3nlevels Gynconsult;Waittoseeifresolves;Decreasedose;SwitchAP

Endocrine Galactorrhea Decreasedose;Obtainprolac3nlevels;Endocrineconsult SwitchAP

Gynecomas3a(males) Obtainprolac3nlevels;Endocrineconsult SwitchAP

Hyperprolac3nemia Noac3onneededunlessclinicalsignsorsymptoms,orPRL≥280mg/mL Prolac3nlevelsdon't needtobeobtainedinabsenceofsymptoms

Akathisia¹ Decreasedose;Slowswitch Addbetaadrenergicantagonist;SwitchAP

Extra- Akinesia² Decreasedose Addan3cholinergic;SwitchAP

pyramidal Dystonia² Addan3cholinergic(IM);Addlorazepam(IM);Addan3histamine(IM) Decreasedose;SwitchAP

Symptoms MuscleRigidity²,³ Addanitcholinergic;Decreasedose Adddopamineagonist;SwitchAP

TardiveDyskinesia³ Neurologyconsult;Discon3nueAP;Increasedose SwitchAP

Tremor² Decreasedose Addan3cholinergic;SwitchAP

Medically Agranulocytosis Discon3nueAPimmediately;Emergencyinternalmed/pediatricconsult;Labs SwitchAPonceagranulocytosisresolves

Life- Gra nulocyto penia Di scon3nue AP;Pedi atricconsult;Repeatla bs SwitchA Po nceANC+ WBCreturn sto normal

threatening LFTsIncrease Internalmed/pediatricconsult;Repeatlabs;Considerdiscon3nuingAP Discon3nueAP;SwitchtodifferentAPonceLFTsarenormal

Decreasedlibido;Erec3ledysfunc3on Decreasedose;Discon3nuemedica3onswithsexualside-effects SwitchAP

E nu re si s Vo id b efor e sl ee p; D ec re as e flu id s in e ve ni ng s; D ec re as e do se ; Gi ve m ed s earl y U se b eh av io r in te rv en 3o n; S wi tc h APintheevening;Wakeyouthtovoidatnight

Hypersaliva3on Decreasedose;TeachPt.tosleepinlateraldecubitusposi3on;Puttowelover SwitchAP;IfcausedbyEPS,addan3cholinergic;Ifcausedby

Other pillow Clozapine,addalphaagonist(eg.Guanfacine)

I ns om ni a Ev al ua te f or d ep re ssi on o r an xi et y di so rd er a nd tre at u nd er ly in g co nd i3o n; Sw itc h AP

GivetotalorlargerAPdoseatbed3me;Addhypno3csleepaid;Ifdueto

AP,considerdecreasingdose

Nausea/Vomi3ng Wait1-2days;Decreasedose;Addtemporaryan3eme3c SwitchAP

Rash Discon3nueAP;Dermatologyconsultifsevere SwitchAP/MSoncerashresolves

Modifiedfrom:2004.TRAAY:TreatmentRecommenda3onsfortheUseofAn3psycho3csforAggressiveYouth.APocketReferenceGuideforCliniciansinChildandAdolescentPsychiatry.NewYorkStateOfficeofMentalHealth,ResearchFounda3onforMental

Hygiene,Inc.andtheTrusteesofColumbiaUniversity.

Notes:UseofmorethanoneAPincreasesriskforAP-relatedside-effects.Forfurtherrecommenda3ons,pleaseseeAppendixforhandouts,ra3ngscalesandaddi3onalguidelinesforthemanagementofside-effects.

FOOTNOTES:

¹=BarnesAkathisiaRa3ngScale AP=An3psycho3c

²=SimpsonAngusScale MS=MoodStabilizer

³=AbnormalInvoluntaryMovementScale

22



23

MEDICATIONMAINTENANCE+DISCONTINUATION

MINIMIZINGSIDEEFFECTSWHENSWITCHINGPSYCHOTROPICMEDICATIONS

Startlow!Goslow!Andstopslowly!Avoidabruptstopping,starting,and/orswitchingtoreduceriskofreboundandwithdrawalphenomena.

Donotswitchuntil theprimarydisorderhas been treatedaccordingto targetdisorderguidelines at

adequatedoseandduration.

Onlystopand/or switch abruptly if a serious adverse effectnecessitates it (i.e. severe neutropenia;

agranulocytosis; diabetic ketoacidosis; neuroleptic malignant syndrome; acute pancreatitis; lithium

toxicity;StevensJohnsonSyndrome;etc.).

Slowswitchusingcross-titrationisthepreferredmethod;anevenslowerswitchcanbedoneusingthe

plateau-crosstitrationmethod,withtherapeuticdoseoverlapofmedications(whenswitchingtoaless

sedatingorcholinergicmedication,oronewithamuchlongerhalf-life).

Iftimepermits,donotreducethefirstmedicationbymorethan25-50%per5half-lives.

ADDITIONALCONSIDERATIONS

Whenswitchingmedications, themoredifferentthebindingaffinityfor thesamereceptor(between

the two drugs), the greater the risk for side effects and rebound and withdrawal phenomena (esp.

sedating;anti-cholinergic;dopaminergic).

The more different the half-life of the medications with the same physiological effect (desired or

undesired), the greater the risk for rebound and withdrawal phenomena; withdrawal and rebound

phenomenaaremostlikelywhendiscontinuingfromashorthalf-lifemedication.

Withdrawalandreboundphenomenaaremostlylikelytooccurwhenswitchingfromastronglyanti-

histaminergic (sedating)or anti-cholinergic medication (i.e.,Clozapine,Olanzapine, Quetiapine), to a

less strong binding medication (i.e., haloperidol, molindone, peridone, paliperidone, aripiprazole,

Ziprasidone);orfromastronglybindinganti-dopaminergic(i.e.FGAAP,RisperidonePaliperidone)toa

less strongly binding antipsychotic (i.e., clozapine, quetiapine, clozapine); or a full antagonist, to a

partialagonist(aripriprazole).

Insufficientefficacyorincreasedsideeffectsmayoccurduringaswitchwhenmedicationsmetabolized

bycytochromeP450liverenzymesarepairedwithamedicationthataffectsthatsameenzyme.

Never discontinue Lithium or Clozapine abruptly to avoid potentially severe rebound of mania or

psychoses.

Quetiapine and Mirtazapine can lead to more sedation at lower doses (below 250-300 mg for

Quetiapine,andbelow30mgforMirtazapine).

CLINICALPEARLSOFSIDEEFFECTMANAGEMENT

Followguidelines forprimarydisorder (whenavailable);initialmedicationtreatmentshouldtargetthe

underlyingsymptom(s)/disorder.

Ifinadequate response, add anAP, try a different AP, oraugmentwitha MS; use the recommended

titrationschedule+deliveranadequatemedicationtrialbeforeadjustingmedication. Conduct side effect and metabolic assessments and laboratory tests that are clinically relevant,

comprehensive,andbasedonestablishedguidelines.

Provideaccessibleinformationtoparents/guardiansaboutidentifying+managingsideeffects.

Useevidence-basedstrategiestopreventorminimizesideeffects.

Collaboratewithmedicalormentalhealthspecialistsasneeded.

Followgeneralrulesandclinicalpearlsforswitchingpsychotropicmedications(seebelow).



24

APPENDIX

AlgorithmfortheTreatmentofADHDwithComorbidAggression

AlgorithmfortheTreatmentofDepression/AnxietywithComorbidAggression

ActionPlans:ATemplatetoDevelopCreatingShort-Term,Intermediate,andLong-termAction

Plans

ActionPlans:TipsforFamilies

DietaryandPhysicalActivityRecommendations

APSideEffectsChecklist

ClinicalGlobalImpressions(CGI)

BriefPsychiatricRatingScaleforChildren(BPRS-C-9)

ModifiedOvertAggressionScale(MOAS)

YoungManiaRatingScale



ALGORITHMFORTHETREATMENTOFADHDWITHCOMORBIDAGGRESSION

THOROUGHEVAL,DIAGNOSTIC

STAGEO ASSESSMENTANDFAMILY

CONSULTATIONRE:

TREAT MENT ALT ERNAT IV ES NON‐MEDICAT IO N

Par6alorNon‐ TREATMENTResponsetoAggression ALTERNATIVES

ESTABLISHPRESENCEOFADHD,

STAGE1 BEGINADHDALGORITHM

Par6alorNon‐ ImprovementofADHD+Aggression CONTINUATION

ResponsetoAggression

ADDABEHAVIORAL

STAGE2 INTERVENTION*⁺



ADDANTIPSYCHOTIC**

STAGE3 TOTHE

STIMULANT***⁺



ADDLITHIUMOR

STAGE4 DIVALPROEXSODIUM

TOTHEREGIMEN⁺



ADDAGENTNOT

STAGE5 USEDIN

STAGEFOUR⁺

ImprovementofADHD+Aggression CONTINUATION

CLINICALCONSULTATION

MAINTENANCE

FOOTNOTES:

*Evaluateadequacyofbehaviortreatmentaerinadequateresponseatanystage.

**RisperidonehasthemostefficacyandsafetydataforanyAP(anZpsychoZc)inchildren.

***IfpaZentisanimminentthreattoselforothers,anZpsychoZcsmaybestartedwithbehavioraltreatment.

⁺Primarycarephysicians(PCP)smaychoosetoobtainpsychiatricconsultaZon(eitheratthisstep,orpriorto),dependingonlevelofexperience,trainingandcomfortability.

Note:Anystagecanbeskippeddependingontheclinicalpicture.

Adaptedfrom:Pliszka,SR,Crismon,M.L.,Hughes,CW,ConnorsCKetal.2006. 25



ALGORITHMFORTHETREATMENTOFDEPRESSION/ANXIETYWITHCOMORBIDAGGRESSION

THOROUGHEVAL,DIAGNOSTIC

STAGEO ASSESSMENTANDFAMILY

CONSULTATIONRE:

TREATMENTALTERNATIVES NON‐MEDICATION

TREATMENT

ALTERNATIVES

GIVENDXOFMDDORANXD/O,

STAGE1 BEGINALGORITHM

(INCLUDINGCBTAND/ORSSRI)

ImprovementofAggression CONTINUATION

ADDABEHAVIORAL

STAGE2 INTERVENTION*⁺

(INADDITIONTOCBT&SSRI)

ImprovementofAggression(andMDD/ANX) CONTINUATION

ADDLITHIUM

STAGE3 ORDIVALPROEXSODIUM

TOTHESSRI⁺


ADDANTIPSYCHOTIC

STAGE4 TOTHE

SSRI**⁺ImprovementofAggression(andMDD/ANX) CONTINUATION

STAGE5 ALTERNATECLASS

(VEN,BUP,MRT,DXT⁴)


STAGE6 REASSESSTREATMENT

GUIDANCE


ADDAGENTNOT

STAGE7 USEDINSTAGEFOUR⁺


CLINICALCONSULTATION

FOOTNOTES MAINTENANCE

¹Evidence‐basedpsychotherapycanbeusedatanystageinthealgorithm.

²FLX(Fluoxe_ne)istheonlyan_depressantwithanFDA‐approvedindica_onfordepressioninyouth.

³SSRI=Selec_veSerotoninReuptakeInhibitor(includes:FLX(Fluoxe_ne);CIT(Citalopram);SRT(Setraline);EST(Escitalopram);Paroxe_ne(notrec.forpre‐adolescents);

⁴VEN=Venlafaxine;BUP=Buproprion;DXT=Duloxe_ne,MRT=Mirtazapine

⁺Primarycarephysicians(PCP)smaychoosetoobtainpsychiatricconsulta_on(eitheratthisstep,orpriorto),dependingonexperience,trainingandcomfort,level

Note:Anystagecanbeskippeddependingontheclinicalpicture.

Adaptedfrom:HughesCW;EmslieGJ;CrismonM.L.;BosnerK;etal.ConferencePanelonMedica_onTreatmentofChildhoodMajorDepressiveDisorder.J.Am.Acad.ChildAdolesc.Psychiatry,46:6.26

Paralornon‐responseofaggression










ACTIONPLANS:PSYCHO-SOCIALTREATMENTPLANNING+MANAGEMENTOFOVERTAGGRESSIONFORFAMILIESANDCLINICIANS

ATemplatetoDevelopShort-,Intermediate-andLong-termAc9onPlanstoManageandMonitorTreatmentofOvertAggression

CHILD'SNEEDS WHAT? WHO? WHERE? WHEN? HOWMUCH? WHY?

Whyistheac9onimportant?

ADDRESSING Ho w will t he n ee d( s) b e W ho is th e ac9v e ag en t? I s tr ea tm ent loca9 on - W ha t is t he 9 me -f ra me ? H ow m an y se ss io ns o f Ta rg e9 ng w hich

NEEDS+IDENTIFYING addressed?Whatresources Whoisaccountable? and9mespecific? Howfrequentaresessions? therapyaresuggested? symptom(s)?

RESOURCES areavailable? Whowillassistyou? Typeofenvironment? HowoenisRxdistributed? WhatistheRxdose? Short-termgoals?

Objec9ves?

SOCIAL+EMOTIONAL: WHAT? WHO? WHERE? WHEN? HOWMUCH? WHY?

Developingaskillorhobby

canincreaseinterest,

IMPROVING dedica9on,feelings

SELF-ESTEEM ofaccomplishment,andaposi9vesenseofself-worth.

Havingfriendsbuilds

self-esteem,andcreates

MAKING moreposi9vesocial

FRIENDS interac9ons.Consider

planningac9vi9es

withotherstudents.

MEDICALNEEDS: WHAT? WHO? WHERE? WHEN? HOWMUCH? WHY?

Findingthebesttypeand

doseofmedica9onwill

MAKINGTHEMOST resultinfewerorno

OFMEDICINE side-effects,andimprove

overallphysical,social

andmentalwell-being.

Monitoringside-

MONITORING effectswillhelpyou

SIDE-EFFECTS todiscernwhetheror

notmedica9onisworkingforyourchild.

EDUCATIONALNEEDS: WHAT? WHO? WHERE? WHEN? HOWMUCH? WHY?

Understandingyour

child'sapprehension,

PERFORMANCE perceivedhardships,and

INSCHOOL a\tudestowardlearning

canhelpyoufindnewways

tomakelearningmorefun.

Doingandfinishinghomework

DOING prepareschildformore

HOMEWORK successthenextdayat

school,andontestsand

finalgrades.

27



FAMILYNEEDS: WHAT? WHO? WHERE? WHEN? HOWMUCH? WHY?

Raisingachild

CHILDIN thatrequiresspecial

TREATMENT a]en9onandaddi9onal

9me,especiallywhenthere

areotherchildrenin

thefamily,canbe

difficultoneveryone.

PARENTS

Strongintra-family

communica9oniskey

tomaintenance+progress.

IncludingeveryoneintheSIBLINGS ac9onplans,spending

individual9mewith

familymembers,andtaking

9meforyourself,

iskeytodecreasing

conflictsinthehome,

FAMILYAS andpreven9ngfeelingsof

AWHOLE negligence,burnout

orburden.

Modifiedfrom:PeterS.Jensen,MD(2004).MakingtheSystemWorkforYouandYourChildWithADHD.GuilfordPress.PP.51and254.

Note:Thischartishelpfulinthatitprovidesexamplesofhowtoestablishshort-term,intermediate,andlong-termoutcomesandgoalswiththechildandfamily.Thisformcanbecopied

forrepeateduse.

28



29

ACTIONPLANS:TIPSFORFAMILIES

Fartoooften,thesystemsinplacetohelpchildrenwithaggressionfallshort,largelybecausetheuniqueproblems

ofanindividualchildrequirecostly,time-consumingattention,andthenumberofindividualkidsneedingsuch

careexceedsthecapacityofavailableresources.ThetemplateforActionPlansprovideaframeworkusefulfor

bothyoungerandolderchildren;thistemplatecanbeusedtogetherwithpsychosocialinterventions,andcanbetailoreddependingontheneedsofyourchildandtheenvironmentinwhichtheActionPlantemplateisbeing

used.

PRINCIPLESOFACTIONFORTHEPARENT

Evenwith a relatively treatable condition such as asthma, inaddition to carefully monitoring your child’s

medications,youmustensurethatbabysitters,teachersandrelativesknowwhattodoifyourchildhasan

“attack”andyouarenotthere.Now,thinkaboutthekindsofstepsyoumusttaketopreventyourchild’s

exposuretopotential triggersthatcansetoff anattack (housedust,pollens, orpets). The samekindof

planningisneededtoanticipateorpreventyourchild’sreactionstoaggression“triggers”.

Showwarmthandacceptanceto yourchild despitehis/her flaws,identifyavailableresources tohelpyou,

prioritize short, intermediate and long-term goals, plan action steps that are truly feasible, and commit

yourselftosmallchangesfirst,thenbuildinguponthem.

Remember when you are feeling overwhelmed by the lack of available resources, time pressures and

conflictingpriorities,takeintoaccountthechild’scapabilitiesandinput,andyourstrengthsandweaknesses

asaparent.Don’tbehardonyourself…oryourchild.Patient,long-termapproacheswillusuallysucceed,but

demandsforbigresultsimmediatelywilloverwhelmbothyouandyourchild.

Asaparent,thinkofyourselfastheskipperonasailingvessel.Atthebeginningofavoyage,yourcraftshould

atminimumbeoutfittedwithsails,a rudder,acompass,map,aradio,aknowledgeablecrew,andadequate

provisions.Evenwithallofthesenecessitiesonboard,anddespitethatyouchartedathoughtfulcourseatthe

outset,anysignificantchangeinweatherislikelytodictateachangeinplans.Adaptingtoprevailingwindsand

adjustingcourseareminimumrevisions,butmoredramatically,youmayneedtoweighanchortemporarilyin

asafeharbor,returntoport,orevenradioforhelp!Rememberthatflexibilitywillassistyouinfindingthe

mostperfectsolution.Don’tsetyourselfupforfailure;rather,recognizethatthoughmisstepsarelikelyto

happen,youcaneventuallyachievesuccessifyoukeepatit,workingyourplan,andpatientlyrevisingitwhen

needed.

Developingandimplementingaplanforyourchild(andforyourselfandfamily)willhelpyoutobeableto

stepbackandreflectasoftenasneeded,givingyoutheabilitytoexplorenewoptionsandmakenecessary

mid-coursecorrections.

Planningwon’tsolveallofyourproblems,butitcertainlywillhelpyoubepreparedforthechallengesahead;

it’sbettertoempoweryourselfbytakingcharge,ratherthanlettingyourselfbecomeoverwhelmedbyyour

child’saggressionorbythechallengesingettinghelpfromyourchild’sschoolorhealthcaresystem.



DIETARYANDPHYSICALACTIVITYRECOMMENDATIONSFORCHILDRENANDADOLESCENTSONPSYCHOTROPICAGENTS

TARGET MANAGEMENTSTRATEGIES

AgeGroup Pediatricpa7ents<18yearsreceivingpsychotropicmedica7onsassociatedwithweightgain.

Paren7ngStyle Allowchildtoself-regulatemeals;encouragingauthorita7veparen7ngstylesuppor7ngincreasedphysicalac7vityandreducedsedentarybehavior,

providingtangibleandmo7va7onalsupport;discourageoverlyrestric7veparen7ngstyle.

FamilyInvolvement Yes;Itisveryimportanttohavesupport.

Sugar-sweetenedBeverages Replacesugar-sweeteneddrinks,including“diet”drinks,withwater,ormoderateamountsofunsweetenedteaorlow-fatmilk(nosugar-sweetenedbeveragesif

overweightorobese),assessforexcessiveconsump7onof100%fruitjuice.

MealFrequency Assessformealfrequency(includingquality),aimfor3tolessthan6separatemealsperday,withnomorethan1mealintheeveningoratnight.

Breakfast Dailybreakfast.

MealPor7ons Assessforconsump7onofexcessivepor7onsizesforage,promoteservingsmallmealpor7ons.

PacingofFoodConsump7on Eatslowlyandtakesecondhelpingsonlya[eradelayof15-20minutes.

SugarContent Assessforexcessiveconsump7onoffoodsthatarehighinenergydensity,preferen7allyeatfoodwithalowglycemicindex.

Dietwithbalancedmacronutrients(caloriesfromfat,complexcarbohydrates,andproteininpropor7onsforagerecommendedbyDietaryReferenceIntakes);Reduce

saturatedfatintake,butavoidextensiveconsump7onofprocessedfat-freefooditems.

FiberContent Diethighinfiber(25-30grams/day);fiveormoreservingsoffruitsandvegetablesperday(avoidfruitjuice).

Assessforsnackingpa`erns(includingquality);Avoidsnackinginasa7etystate,replacinghigh-fat,high-caloriesnackswithfruitandvegetables.

OutsideMeals/FastFood Limitmealsoutsidethehome,especiallyinfast-foodrestaurants(nomorethanonceperweek);familymealsatleast5-67mes/week.

SedentaryBehavior Twoorfewerhoursofscreen7meperday,andnotelevisionorvideogamesintheroomwherethechildsleeps.

Exercise Performmoderatelevelphysicalac7vityforatleast30-60minutes/day.

Modifiedfrom:AmericanMedicalAssocia7on200.ExpertCommi`eeRecommenda7onsontheAssessment,Preven7on,andTreatmentofChildandAdolescentOverweightandObesityrecommenda7onsfortreatmentofpediatricobesity

Modifiedfrom:CorrellCU,CarlsonHE.200.Endocrineandmetabolicadverseeffectsofpsychotropicmedica7onsinchildrenandadolescents.JAmAcadChildAdolescPsychiatry2006;45:1-91.aAuthorita7veparentsarebothdemandingandresponsive.

30

FatContent

Snacks



31

APSIDE-EFFECTSCHECKLIST

Patient:Date:

Rater:

INSTRUCTIONS

Ratetheseverityofthefollowingside-effectsfrom0(notpresent)to3(severe).

Side-effectsmarkedwitha†shouldbescoredusingonly0(notpresent)or1(present).

ANCHORS

0=None1=Mild2=Moderate3=SevereN/A=NotAssessedLIFE-THREATENINGWEIGHTANDDIABETES†NMS*________CurrentHeight________inches

DecreasedANC*________BaselineWeight________pounds

†Agranulocytosis________CurrentWeight________pounds

MarkedIncreaseinLFTs*________WeightGain________pounds

BaselineBMIPercentile________

EPSCurrentBMIPercentile________

TardiveDyskinesia ________ElevatedGlucose________Akathisia________ElevatedCholesterol________

Akinesia________ElevatedTriglycerides________

Tremor________

MuscleRigidity________ENDOCRINE†Dystonia________†Amenorrhea________

TardiveDyskinesia________†Galactorrhea________

†Gynecomastia________

COGNITIVEEFFECTSExcessThirst________

Confusion ________UnexplainedWeightLoss________

MemoryProblems________

Sedation ________ANTICHOLINERGICHypersomnia________DryMouth________

Insomnia________BlurredVision________

Headache________Constipation________

CARDIACOTHERQTcProlongation ________Irritability________

Tachycardia ________Nausea/Vomiting________

Hypotension________SexualDysfunction________

DecreasedLibido________

*Abbreviations Dermatological________

NMS=Neurolepticmalignantsyndrome Hypersalivation________

LFTs=LiverfunctiontestsEnuresis________

ANC=Absoluteneutrophilcount



32

CLINICALGLOBALIMPRESSIONS(CGI)

Patient:Date:

Rater:

INSTRUCTIONS

TheCGIhelpsquantifytheoverallseverityandimprovementofapatient’scondition.

Ratethepatient’sseverityofillnessandglobalimprovementusingtheanchorsbelow.

SEVERITYOFILLNESSHowillisthepatientatthistime?

1=Normal,notatallill

2=Borderlinementallyill

3=Mildlyill

4=Moderatelyill

5=Markedlyill

6=Severelyill

7=Amongthemostextremelyillpatients

GLOBALIMPROVEMENT

Comparedtothepatient’sconditionpriortotreatment,howillishe/shenow?

1=Verymuchimproved

2=Muchimproved

3=Minimallyimproved

4=Nochange

5=Minimallyworse

6=Muchworse

7=Verymuchworse



33

BRIEFPSYCHIATRICRATINGSCALEFORCHILDREN(BPRS-C-9)*

Patient:Date:

Rater:

DESCRIPTIONTheBPRS-C(9-itemversion)canbeusedtoscreenforandmonitoravarietyofpsychiatricsymptoms.Item

descriptionsarepresentedbelow,alongwithanchorstoguidehowtheseverityofeachitemisrated.

ANCHORSItemsareratedusingthefollowingscale:

0=NotPresent1=VeryMild2=Mild3=Moderate4=Moderate-Severe5=Severe6=VerySevere

___1.UNCOOPERATIVE:NEGATIVE,UNCOOPERATIVE,RESISTANT,DIFFICULTTOMANAGE

NotPresent:Cooperative,pleasant.

Mild:Occasionallyrefusestocomplywithrulesandexpectations,inonly1situation/setting.

Moderate-Severe:Persistentfailuretocomplywithrules/expectationsinmorethan1setting.Causes

frequentimpairmentinfunctioning.

ExtremelySevere:Constantlyrefusestocomplywithrulesandexpectations,delinquentbehaviors,

runningaway.Causessevereimpairmentinfunctioninginmostsituations/settings.

___2.HOSTILITY:

ANGRYORSUSPICIOUSAFFECT,BELLIGERENCE,ACCUSATIONSANDVERBALCONDEMNATIONOFOTHERS

NotPresent:Cooperative,pleasant.

Mild:Occasionallysarcastic,loud,guarded,quarrelsome.Causesmilddysfunctioninonesituationorsetting.

Moderate-Severe:Causesfrequentimpairmentinseveralsituations/settings.

ExtremelySevere:Assaultive,destructive.Causessevereimpairmentinfunctioninginmost

situations/settings.

___3.MANIPULATIVENESS:

LYING,CHEATING,EXPLOITIVEOFOTHERS

NotPresent:Notatall.

Mild:Occasionallygetsintroubleforlying,maycheatonoccasions.

Moderate-Severe:Frequentlylies/cons/manipulatespeopleheknows.Causesfrequentimpairmentin

functioninginseveralsituations/settings.

ExtremelySevere:Constantlyrelatestoothersinanexploitive/manipulativemanner,consstrangersout

ofmoney/situations.Causessevereimpairmentinfunctioninginmostsituations/settings.

___4.DEPRESSIVEMOOD:

SAD,TEARFUL,DEPRESSIVEDEMEANOR

NotPresent:Occasionally/quicklydisappears.

Mild:Sustainedperiods/excessiveforevent.

Moderate-Severe:Unhappymosttime/noprecipitant.

ExtremelySevere:Unhappyalltime/psychicpain.Causessevereimpairmentinfunctioning.

___5.FEELINGSOFINFERIORITY:



34

LACKINGSELF-CONFIDENCE/SELF-DEPRECIATORY

NotPresent:Feelsgood/positiveaboutself.

Mild:Occasionallyfeelsnotasgoodasothers/deficitsin1area.

Moderate-Severe:Feelsothersarebetterthantheyare.Givesnegative,blandanswers,can’tthinkof

anythinggoodaboutthemselves.

ExtremelySevere:Constantlyfeelsothersarebetter.Feelsworthless/notlovable.

___6.HYPERACTIVITY:

EXCESSIVEENERGYEXPENDITURE,FREQUENTCHANGESINPOSTURE,PERPETUALMOTION

NotPresent:Slightrestlessness,fidgeting.Noimpactonfunctioning.

Mild:Occasionalrestlessness,fidgeting,frequentchangesofposture.Noticeable,butdoesnotcause

impairmentinfunctioning.

Moderate-Severe:Excessiveenergy,movement,cannotstaystillorseated.Causesdysfunctionon

numerousoccasions/situations.Seekshelpforbehaviors.

ExtremelySevere:Continuousmotorexcitement,cannotbestilled.Causesmajorinterferencein

functioningonmostoccasions/situations.

___7.DISTRACTIBILITY:

POORCONCENTRATION,SHORTENEDATTENTIONSPAN,REACTIVITYTOPERIPHERALSTIMULI

NotPresent:Performanceconsistentwithability.

Mild:Occasionallydaydreams,easilydistracted.Isabletofocuswithprompting.

Moderate-Severe:Frequentlyhastroubleconcentrating,avoidsmentaltasks,disruptive.Needsfrequent

assistancetostayfocused.Causesdecreasedperformance.

ExtremelySevere:Constant,needs1:1assistancetostayfocused.

___8.TENSION:

NERVOUSNESS,FIDGETINESS,NERVOUSMOVEMENTSOFHANDSORFEET


Mild:Occasionallyfeelsnervousorfidgets.Canberelaxedorreassured.

Moderate-Severe:Mostdays/timefeelsnervous/fidgety.Causesmentalorphysicaldistress.

ExtremelySevere:Pervasiveandextremenervousness,fidgeting,nervousmovementsofhandsand/orfeet.

___9.ANXIETY:

CLINGINGBEHAVIOR,SEPARATIONANXIETY,PREOCCUPATIONWITHANXIETYTOPICS,FEARSORPHOBIAS


Mild:Occasionallyworries(atleast3timesaweek)aboutanticipated/currentevents,separation,fears,

orphobias.Theseworriesappearexcessiveforsituation.

Moderate-Severe:Mostdays/timeworriesaboutatleast2lifecircumstances,oranticipated/currentevents.

ExtremelySevere:Pervasiveandextremeworryaboutmosteverything,realorimagined.

____TOTALSCOREFORALL9ITEMS

*Reprintedwithpermissionfromtheauthor(Hughesetal.,2003–2004).



35

MODIFIEDOVERTAGGRESSIONSCALE(MOAS)*

INSTRUCTIONSANDSCORINGSUMMARY:CATEGORYSUMSCOREWEIGHTSWEIGHTEDSUM

TheMOAShelpsclinicalinterviewerstrackaggressiveincidentsinoutpatientsettings.

Ratethepatient’saggressivebehavioroverthepastweek.Selectasmanyitemsasareappropriate.1)Additemswithineachcategory;2)Inthescoringsummary,multiplysumbyweightandaddalltheweighted

sumsfortotalweightedscore.Usethisscoretotrackchangesinlevelofaggressionovertime.VERBALAGGRESSION:VERBALHOSTILITY,STATEMENTSORINVECTIVESTHATSEEKTOINFLICTPSYCHOLOGICAL

HARMONANOTHERTHROUGHDEVALUATION/DEGRADATION,ANDTHREATSOFPHYSICALATTACK

___0.Noverbalaggression

___1.Shoutsangrily,cursesmildly,ormakespersonalinsults

___2.Cursesviciously,isseverelyinsulting,hastemperoutburstsordeliberately(e.g.,togainmoneyorsex)

___3.Impulsivelythreatensviolencetowardothersorself

___4.Threatensviolencetowardothersorselfrepeatedly

____SUMVERBALAGGRESSIONSCOREAGGRESSIONAGAINSTPROPERTY:WANTONANDRECKLESSDESTRUCTIONOFWARDPARAPHERNALIAOR

OTHERS’POSSESSIONS

___0.Noaggressionagainstproperty

___1.Slamsdoorangrily,ripsclothing,urinatesonfloor

___2.Throwsobjectsdown,kicksfurniture,defaceswalls

___3.Breaksobjects,smasheswindows

___4.Setsfires,throwsobjectsdangerously

____SUMPROPERTYAGGRESSIONSCOREAUTOAGGRESSION:PHYSICALINJURYTOWARDONESELF,SELF-MUTILATION,ORSUICIDEATTEMPT

___0.Noautoaggression

___1.Picksorscratchesskin,pullshairout,hitsself(withoutinjury)

___2.Bangshead,hitsfistsintowalls,throwsselfonfloor ___3.Inflictsminorcuts,bruises,burns,orweltsonself

___4.Inflictsmajorinjuryonselformakesasuicideattempt

____SUMAUTOAGGRESSIONSCORE

PHYSICALAGGRESSION:VIOLENTACTIONINTENDEDTOINFLICTPAIN,BODILYHARM,ORDEATH

___0.Nophysicalaggression

___1.Makesmenacinggestures,swingsatpeople,grabsatclothing

___2.Strikes,pushes,scratches,pullshairofothers(withoutinjury)

___3.Attacksothers,causingmildinjury(bruises,sprains,welts,etc.)

___4.Attacksothers,causingseriousinjury(fracture,lossofteeth,deepcuts,lossofconsciousness,etc.)

____SUMPHYSICALAGGRESSIONSCORE

*ModifiedfromKay,S.R.,Wolkenfeld,F.,&Murrill,L.M.(1988).Profilesofaggressionamongpsychiatricpatients:I.Nature

andprevalence. JournalofNervousandMentalDisease,176(9),539–546.

CATEGORY SUMSCORE WEIGHTS WEIGHTEDSUM

VerbalAggression X1

AggressionAgainstProperty X2

Autoaggression X3

PhysicalAggression X4

TOTALWEIGHTEDSCORE



36

YOUNGMANIARATINGSCALE*Patient:Date:

Rater:

INSTRUCTIONSThepurposeofeachitemistoratetheseverityofthatabnormalityinthepatient.Whenseveralkeysaregivenfor

thegradeofseverity,thepresenceofonly1isrequiredtoqualifyforthatrating.

Thekeysprovidedareguides.Onecanignoretheanchorsifthatisnecessarytoindicateseverity,althoughthis

shouldbetheexceptionratherthantherule.Thisisparticularlyusefulwhentheseverityofaparticularitemina

patientdoesnotfollowtheprogressionindicatedbytheanchors.

ELEVATEDMOOD

0=Absent

1=Mildlyorpossiblyincreasedonquestioning

2=Definitesubjectiveelevation;optimistic,self-confident;cheerful;appropriatetocontent3=Elevated,inappropriatetocontent;humorous

4=Euphoric;inappropriatelaughter;singing

INCREASEDMOTORACTIVITY/ENERGY

0=Absent

1=Subjectivelyincreased

2=Animated;gesturesincreased

3=Excessiveenergy;hyperactiveattimes;restless(canbecalmed)

4=Motorexcitement;continuoushyperactivity(cannotbecalmed)

SEXUALINTEREST

0=Normal;notincreased

1=Mildlyorpossiblyincreased

2=Definitesubjectiveincreaseonquestioning

3=Spontaneoussexualcontent;elaboratesonsexualmatters;hypersexualbyself-report

4=Overtsexualacts(towardpatients,staff,orinterviewer)

SLEEP

0=Reportsnodecreaseinsleep

1=Sleepinglessthannormalamountbyuptoonehour

2=Sleepinglessthannormalbymorethanonehour

3=Reportsdecreasedneedforsleep

4=Deniesneedforsleep

IRRITABILITY0=Absent

2=Subjectivelyincreased

4=Irritableattimesduringinterview;recentepisodesofannoyanceorangeronward

6=Frequentlyirritableduringinterview;short,curtthroughout

8=Hostile,uncooperative;interviewimpossible



37

SPEECH(RATEANDAMOUNT)

0=Noincrease

2=Feelstalkative

4=Increasedrateoramountattimes,verboseattimes

6=Push;consistentlyincreasedrateandamount;difficulttointerrupt

8=Pressured;uninterruptible;continuousspeech

LANGUAGE/THOUGHTDISORDER

0=Absent

1=Circumstantial;milddistractibility;quickthoughts

2=Distractible;losesgoalofthought;changestopicsfrequently;racingthoughts

3=Flightofideas;tangentiality;difficulttofollow;rhyming,echolalia

4=Incoherent;communicationimpossible

THOUGHTCONTENT

0=Normal

2=Questionableplans,newinterests

4=Specialprojects;hyperreligious

6=Grandioseorparanoidideas;ideasofreference

8=Delusions,hallucinations

DISRUPTIVE/AGGRESSIVEBEHAVIOR

0=Absent,cooperative

2=Sarcastic;loudattimes,guarded

4=Demanding;threatsonward

6=Threatensinterviewer;shouting;interviewdifficult

8=Assaultive;destructive;interviewimpossible

APPEARANCE

0=Appropriatedressandgrooming

1=Minimallyunkempt

2=Poorlygroomed;moderatelydisheveled;overdressed3=Disheveled;partlyclothed;garishmakeup

4=Completelyunkempt;decorated;bizarregarb

INSIGHT

0=Present;admitsillness;agreeswithneedfortreatment

1=Possiblyill

2=Admitsbehaviorchange,butdeniesillness

3=Admitspossiblechangeinbehavior,butdeniesillness

4=Deniesanybehaviorchange

TOTALSCORE _______________(0–13=minimalseverity;14–20=mild;21–26=moderate;27–38=severe)

*ReprintedfromYoung,R.C.,Biggs,J.T.,Ziegler,V.E.,&Meyer,D.A.(1978).Aratingscaleformania:Reliability,validity,and

sensitivity.BritishJournalofPsychiatry,133(5),429–435.



BIBLIOGRAPHY

AmericanMedicalAssociation2007.ExpertCommitteeRecommendationsontheAssessment,Prevention,and

TreatmentofChildandAdolescentOverweightandObesityrecommendationsfortreatmentofpediatricobesity:

http://www.ama-assn.org/ama/pub/category/11759.html,accessed11.25.2007

Correll,CU:Reallifeswitchingstrategieswithsecond-generationantipsychotics.JClinPsychiatry 2006:67:160-161.

CorrellCU:Antipsychoticuseinchildrenandadolescents:Minimizingadverseeffectstomaximizeoutcomes. JAm

AcadChildAdolescPsychiatr y2008;47:9-20.

CorrellCU:Balancingefficacyandsafetyinthetreatmentwithantipsychotics.CNSSpectr .2007;12(Suppl17):12-

20,35.

CorrellCU:Fromreceptorpharmacologytoimprovedoutcomes:individualizingtheselection,dosing,and

switchingofantipsychotics.EuropeanPsychiatry.–inpress

CorrellCU,CarlsonHE.Endocrineandmetabolicadverseeffectsofpsychotropicmedicationsinchildrenand

adolescents.JAmAcadChildAdolescPsychiatry2006;45:771-791.

CorrellCU,SchenkEM.AssessingandTreatingPediatricBipolarDisorder.InOxfordAmericanPsychiatryLibrary.In

preparation.

HughesCW,EmslieFH,CrismonML,PosnerK,BirmaherB,RyanN,JensenPS,CurryJ,VitielloB,LopezM,ShonSP,

PliszkaS,TrivediMH,andtheTexasConsensusConferencePanelonMedicationTreatmentofChildhoodMajor

DepressiveDisorder:TheTexasChildren'sMedicationAlgorithmProject:UpdatefromtheTexasConsensus

ConferencePanelonMedicationTreatmentofChildhoodMajorDepressiveDisorder.JAmAcadChildAdol

Psychiatry,2007:46:667-686.

Jensen,PeterS.MakingtheSystemWorkforYourchildwithADHD.TheGuilfordPress.NewYork:2004.

Kay,S.R.,Wolkenfeld,F.andMurrill,L.M.Profilesofaggressionamongpsychiatricpatients:I.Natureand

prevalence.JNervMentDis1988:176:539-546.

PliszkaSR,CrismonML,HughesCW,ConnersCK,EmslieGJ,JensenPS,McCrackenJT,SwansonJM,LopezM,Texas

ConsensusConferencePanelonPharmacotherapyofChildhoodAttentionDeficitHyperactivityDisorder.The

TexasChildren’sMedicationAlgorithmProject:ARevisionoftheAlgorithmforMedicationTreatmentofChildhood

AttentionDeficitHyperactivityDisorder(ADHD).JAmAcadChildAdolescPsychiatry2006:45:520-6.

Pliszka,SR,Crismon,M.Letal.TexasDepartmentofStateHealthServices.PsychotropicMedicationUtilization

ParametersforFosterChildren.2007.

TreatmentRecommendationsfortheUseofAntipsychoticMedicationsforAggressiveYouth(TRAAY)–Pocket

ReferenceGuide(2004).JensenPS,PappadopulosE(Eds).NYSOfficeofMentalHealthandCenterforthe AdvancementofChildren’sMentalHealthatColumbiaUniversity,NewYork,NY.

YoungRC,BiggsJT,ZieglerVE,MeyerDA.Aratingscaleformania:reliability,validityandsensitivity.BritJ

Psychiatry 1978:133:429-435.

Documents

TREATMENT OF MALADAPTIVE AGGRESSION IN YOUTH