What Does Risperidone Add to Parent Training and Stimulant for Severe Aggression in Child Attention-Deficit/Hyperactivity Disorder?

Journal of the American Academy of Child and Adolescent Psychiatry (Impact Factor: 7.26). 01/2014; 53(1):47-60.e1. DOI: 10.1016/j.jaac.2013.09.022
Source: PubMed


Although combination pharmacotherapy is common in child and adolescent psychiatry, there has been little research evaluating it. The value of adding risperidone to concurrent psychostimulant and parent training (PT) in behavior management for children with severe aggression was tested.
One hundred sixty-eight children 6 to 12 years old (mean age 8.89 ± 2.01 years) with severe physical aggression were randomized to a 9-week trial of PT, stimulant (STIM), and placebo (Basic treatment; n = 84) or PT, STIM, and risperidone (Augmented treatment; n = 84). All had diagnoses of attention-deficit/hyperactivity disorder and oppositional-defiant disorder (n = 124) or conduct disorder (n = 44). Children received psychostimulant (usually Osmotic Release Oral System methylphenidate) for 3 weeks, titrated for optimal effect, while parents received PT. If there was room for improvement at the end of week 3, placebo or risperidone was added. Assessments included parent ratings on the Nisonger Child Behavior Rating Form (Disruptive-Total subscale was the primary outcome) and Antisocial Behavior Scale; blinded clinicians rated change on the Clinical Global Impressions scale.
Compared with Basic treatment (PT + STIM [44.8 ± 14.6 mg/day] + placebo [1.88 mg/day ± 0.72]), Augmented treatment (PT + STIM [46.1 ± 16.8 mg/day] + risperidone [1.65 mg/day ± 0.75]) showed statistically significant improvement on the Nisonger Child Behavior Rating Form Disruptive-Total subscale (treatment-by-time interaction, p = .0016), the Nisonger Child Behavior Rating Form Social Competence subscale (p = .0049), and Antisocial Behavior Scale Reactive Aggression subscale (p = .01). Clinical Global Impressions scores were substantially improved for the 2 groups but did not discriminate between treatments (Clinical Global Impressions-Improvement score ≤2, 70% for Basic treatment versus 79% for Augmented treatment). Prolactin elevations and gastrointestinal upset occurred more with Augmented treatment; other adverse events differed modestly from Basic treatment; weight gain in the Augmented treatment group was minor.
Risperidone provided moderate but variable improvement in aggressive and other seriously disruptive child behaviors when added to PT and optimized stimulant treatment. Clinical trial registration information-Treatment of Severe Childhood Aggression (The TOSCA Study), URL:, unique identifier: NCT00796302.

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    • "The comorbidity of ADHD + ODD is important because of its treatment implications. The current evidence-based approach for treating significant ADHD with affective aggression involves maximizing treatment for ADHD with medication and parent training and adding other anti-aggressive or moodstabilizing medication if the child has not sufficiently improved (Aman et al., 2014;Blader et al., 2010). This is not the treatment for ODD alone. "
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    ABSTRACT: Background: This study explores the relationship of irritability to tantrums and loss of temper in a community and clinical sample. Methods: The community sample, recruited via commercial mailing lists, consisted of 462 6-year-olds whose parents completed the Child Behavior Checklist (CBCL), and Preschool Age Psychiatric Assessment (PAPA). Tantrums were assessed in the oppositional defiant disorder (ODD) section of the PAPA. Irritability was assessed in the depression section to identify persistently irritable and/or angry mood. The clinic sample, drawn from a child psychiatry clinic, included 229 consecutively referred 6-year-olds from 2005 through 2014 whose parents completed the CBCL and Child and Adolescent Symptom Inventory (CASI). Temper loss and irritability items came from the ODD and depression sections of the CASI, and tantrum description was taken from an irritability inventory. Children's Global Assessment Scale (CGAS) and the CBCL Dysregulation Profile were examined in both samples. Logistic and multiple regression were used to compare rates of diagnosis, CBCL subscales, CGAS, and tantrum quality between children with tantrums only and tantrums with irritability. Results: Almost half (45.9%) of clinic children had severe tantrums; only 23.8% of those were said to be irritable. In the community, 11% of children had tantrums, but 78.4% of those were called irritable. However, irritability in the clinic, although less common, was associated with aggressive tantrums and substantial impairment. In contrast, irritability was associated with only a relatively small increase in impairment in the community sample. Conclusions: Irritability may have different implications in community versus clinic samples, and tantrums assessed in the community may be qualitatively different from those seen in clinics.
    No preview · Article · Jan 2016 · Journal of child and adolescent psychopharmacology
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    • "Specifically, we include parent management training (PMT) and cognitive-behavioral therapy (CBT) because these modalities have received extensive empirical support as stand-alone interventions that are provided in the format of outpatient psychotherapy (Sukhodolsky et al. 2004; Dretzke et al. 2009). There is also evidence that these behavioral interventions can be helpful in conjunction with medication management for severe aggression (Aman et al. 2014) and as part of multimodal interventions for serious conduct problems that address multiple risk factors (Sukhodolsky and Ruchkin 2006). First, we provide an overview of anger/irritability and aggression as the treatment targets of behavioral interventions followed by a discussion of the general principles and techniques of these treatment modalities. "
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    DESCRIPTION: Review of behavioral interventions for anger, irritability and aggression in children and adolescents
    Full-text · Research · Sep 2015

  • No preview · Article · Jan 2014 · Journal of the American Academy of Child and Adolescent Psychiatry
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