Research Activities January 2013, No. 389

New guidelines help clinicians assess and treat maladaptive aggression in youth

Child/Adolescent Health

Maladaptive aggression in youth can have devastating consequences on the child and the family. It can lead to violence, expulsion from school, broken relationships at home, and run-ins with the juvenile justice system. Recently, a team of national experts from the Center for Education and Research on Mental Health Therapeutics (CERTs) at Rutgers University, working with the REACH Institute, several States, and other stakeholders, convened national experts to review available evidence to develop evidence-based consensus treatment recommendations for youth with maladaptive aggression. The team's first published report (part I of the guideline) describes the literature review process and establishes nine recommendations to help health care providers engage families, assess youth, and effectively evaluate and manage maladaptive aggression. In the second report (part II), guideline developers offer 11 recommendations to help primary care and specialty providers select appropriate psychosocial interventions and medication treatments. Both guideline publications were funded in part by grants from the Agency for Healthcare Research and Quality (HS16097) to the Rutgers University CERT. For more information on the CERTs program, visit

Knapp, P., Chait, A., Pappadopulos, E., and others (2012, June). "Treatment of maladaptive aggression in youth: CERT guidelines I: Engagement, assessment, and management." Pediatrics 129(6), pp. e1562-e1576.

This guideline report highlights the absolute necessity for clinicians to use intensive "engagement procedures" focused on the patient and the family during the initial evaluation and diagnostic workup in order to obtain families' "buy in" and co-participation in the initial treatment plan. Effective engagement also tends to increase families' trust in and alliance with the health care provider, which further aids in a more complete assessment of the child's emotional and behavioral problems, as well as families' strengths and challenges. Intensive psychoeducation and support to both parents and youth is essential right from the outset, and youth at risk for harming themselves or others should be referred to a psychiatrist for evaluation. Guidelines further recommend that standardized measures be used to evaluate aggression at baseline and throughout treatment, with continuous monitoring to ensure treatment strategies are effective over time. Also, because clinical interventions alone are often insufficient to fully address maladaptive aggression, clinicians must ensure that parents are connected to community agencies that can assist them in obtaining the full range of supports needed to return youth to healthier developmental life pathways. Similarly, providers' ongoing consultation with teachers and school systems is often required to effectively help patients and families manage maladaptive aggression in and outside the home.

Rosato, N.S., Correll, C.U., Pappadopulos, E., and others (2012, June). "Treatment of maladaptive aggression in youth: CERT guidelines II: Treatment and management." Pediatrics 129(6), pp. e1577-e1586.

The second guideline report details 11 treatment recommendations to guide the initial and ongoing therapies. Importantly, for the overall management of maladaptive aggression, the child and family need to take active and continuing roles in treatment planning. In terms of treatment selection, the literature review and resulting guideline indicate that children and youth with maladaptive aggression benefit greatly from a range of therapeutic interventions that include cognitive behavioral therapies (CBT) and appropriate medication treatments. Younger children benefit from psychosocial interventions that include programs teaching parents positive parenting skills, effective classroom management by teachers, and interpersonal skills building for the child. In contrast, older children tend to benefit from brief strategic family therapy and CBT. Regardless of age, continued followup and maintenance of psychosocial interventions is critical, as learned skills tend to dissipate over time. The recommendations emphasize treating the underlying disorder first, as well as beginning with psychosocial interventions before pharmacological treatment because of the lower risk. Considerations for the appropriate selection of psychotropic treatments, and balancing risks with benefits, are reviewed. When aggression cannot be adequately managed with alternative interventions, use of antipsychotics had the greatest efficacy in addressing these symptoms, followed by stimulants, while mood stabilizers tended to yield poorer or mixed results. The guideline advises clinicians to avoid using more than two psychotropic medications simultaneously, and emphasizes the importance of giving parents information on how to identify and manage medication side effects in order to assist compliance and produce better therapeutic outcomes.


Page last reviewed January 2013
Page originally created January 2013
Internet Citation: New guidelines help clinicians assess and treat maladaptive aggression in youth. Content last reviewed January 2013. Agency for Healthcare Research and Quality, Rockville, MD.