Aggression Management Guidelines

Introduction to Aggression Management

The American Academy of Child and Adolescent Psychiatry recommends divalproex sodium, lithium, or atypical antipsychotics, such as risperidone, as evidence-based mood stabilizers for aggression management, excluding lamotrigine from these recommendations 1, 2

For patients with ADHD and aggression, the American Academy of Child and Adolescent Psychiatry suggests optimizing stimulant medication, such as methylphenidate or amphetamine, as first-line therapy to reduce both ADHD symptoms and aggressive behaviors 2
For patients with conduct disorder and aggression, intensive psychosocial interventions, such as multisystemic therapy or family-based therapy, combined with treatment of comorbid conditions, are recommended 1
Divalproex sodium is the preferred adjunctive mood stabilizer for aggressive outbursts, with a 70% reduction in aggression scores after 6 weeks at therapeutic levels 1, 2
Risperidone has the strongest controlled trial evidence for reducing aggression when added to other treatments, at a dose of 0.5-2 mg/day 1, 2

When using divalproex, regular monitoring of liver enzymes and maintenance of therapeutic blood levels are necessary 2
When using risperidone, monitoring for metabolic syndrome, weight gain, movement disorders, and prolactin elevation is required 1, 2
A minimum of 6-8 weeks at therapeutic doses/levels should be allowed before declaring treatment failure with divalproex or lithium 1

The American Academy of Child and Adolescent Psychiatry advises against using lamotrigine off-label for aggression due to its lack of antimanic and anti-aggressive properties 1, 2
Avoiding polypharmacy by trialing one medication class thoroughly before switching is recommended 1, 3
Benzodiazepines should not be used for chronic aggression due to the risk of paradoxical rage reactions and dependence 4, 3