New Guidelines for Treating Maladaptive Aggression in Youth

A child rests her chin on her knee.2012 Recommendations for the Treatment of Maladaptive Aggression in Youth (T-MAY), developed by the T-MAY Steering Committee, organized and coauthored by investigators at the Rutgers University Center for Education and Research on Mental Health Therapeutics (CERT)

By Shelley Norden Barnes


A 15-year-old boy repeatedly breaks into fistfights with classmates who, he describes, "drive me so crazy that I just snap." A 10-year-old girl has frequent unprovoked outbursts with her teachers and peers while at school. Such episodes are common among 10 to 25 percent of American youth who suffer from aggressive behavior.1

Impulsive maladaptive aggression, or unplanned and poorly controlled aggressive behavior, is not in itself a psychiatric disorder. It is a symptom of several common child psychiatric conditions such as attention deficit hyperactivity disorder (ADHD) and mood/anxiety disorders. If left untreated, maladaptive aggression can undercut academic functioning, disrupt relationships, and lead to substance abuse, expulsion from school, and incarceration. It is also among the most expensive childhood conditions to treat.2

More and more often, clinicians are prescribing psychotropic medicines such as second-generation antipsychotics and mood stabilizers on an off-label basis to treat overtly aggressive behavior. This practice, however, falls outside the indications approved by the U.S. Food and Drug Administration (FDA) for prescribing antipsychotic medications since there are limited efficacy and safety data regarding their use in children. While other treatment options are available, evidence-based practices to help clinicians assess, treat, and manage pediatric impulsive aggression, particularly in outpatient settings, are limited.

To address these issues, the Rutgers Center for Education and Research on Mental Health Therapeutics (CERT) collaborated with the REACH (Resource for Advancing Children’s Health) Institute and other organizations to create evidence-based treatment recommendations for maladaptive aggression in youth. The goal was to optimize treatment effectiveness and safety by creating a framework that clinicians could use in outpatient settings to diagnose and treat maladaptive impulse aggression in youth, manage side effects of pharmacologic therapies, and coordinate psychosocial interventions. The resulting recommendations, Treatment of Maladaptive Aggression in Youth: CERT Guidelines I and II (known as the T-MAY guidelines), were published in the June 2012 issue of the journal Pediatrics.3,4 Access the PubMed abstracts:

  • Treatment of Maladaptive Aggression in Youth (T-MAY): CERTs Guidelines I.  Family Engagement, Assessment & Diagnosis, and Initial Management.
  • Treatment of Maladaptive Aggression in Youth (T-MAY): CERTs Guidelines II.  Psychosocial Interventions, Medication Treatments, and Side Effects Management.

Role of the Rutgers CERT in the T-MAY Recommendations

"This T-MAY project is a wonderful example of how you get more leverage from resources, more impact, and better work by having a center that brings together the research, education, and stakeholder engagement around the use and outcomes of psychotropic medications," says Stephen Crystal, Ph.D., coauthor of the T-MAY guidelines and the principal researcher at the Rutgers CERT, which provided funding, organized, and oversaw the T-MAY Steering Group, in collaboration with the REACH Institute and other partners.

"Through our preliminary research, it became apparent that the effort to manage impulsive aggression, which is a symptom and not a diagnosable condition, was behind much of the extraordinarily large prescription rates for antipsychotics in kids," Crystal says. While medication can be a key component of a treatment plan for aggressive behavior, Crystal emphasizes that it is only part of a comprehensive strategy that includes psychosocial interventions and individualized assessment.

Two of the most critical recommendations, according to Crystal, are to conduct a comprehensive psychosocial diagnostic and risk assessment evaluation of the child and the caregiver prior to starting medications and provide evidence-based skills training to parents, children, and caregivers during all phases of treatment.

"If these recommendations were put into practice consistently, it would be a huge shift in treatment," Crystal notes. "It's part of the process of recognizing the risks as well as the benefits of taking psychotropic medications. Medication should not be the first step but rather the last recourse."

Another key recommendation is to target treatment to the primary underlying disorder rather than to the symptom of aggressive behavior, an approach not always taken, says Crystal. For example, evidence shows that using ADHD-specific medications to treat aggression in kids who have ADHD is often effective without having to add antipsychotic medication in an effort to impact aggressive behavior.

"The risk of long-term, deleterious outcomes with antipsychotics—especially metabolic problems and the risk of diabetes—are higher than with drugs for some underlying problems," says Crystal. "In the case of ADHD, the ADHD-specific drugs have a lot better risk profile. It’s important to treat the underlying disorder first."

Results: Turning Research into Policy

Although the T-MAY guidelines were published earlier this year, they already are affecting both local and national health care initiatives.

Many states have adopted elements of the T-MAY research in their own treatment recommendations. Crystal and his team recently worked with the State of Texas to review its guidelines for prescribing psychotropic medicines to foster youth, who are prescribed these medicines at a significantly higher rate than the general youth population. "Those guidelines have been quite influential because most states haven't been quite as specific about having written guidelines," Crystal points out. "In providing our recommendations to the State of Texas, we really drew on and referenced our T-MAY research."

Crystal's team also worked with CalOptima, a public health plan that serves Orange County, California, to develop prescribing guidelines that included several elements of the T-MAY research, particularly the need for metabolic monitoring.

The T-MAY research has had an impact on a national scale as well. The CERTs team was asked to meet with the U.S. Children’s Bureau to inform development of an Information Memorandum that was sent to all states mandating that they develop plans for medication monitoring. The team also drew on the T-MAY work in its presentation to the U.S. Department of Health and Human Services’s recent Psychotropics and Child Welfare Summit, where 300 representatives of State agencies came together to grapple with the issue of psychotropics for foster youth, says Crystal.

In addition, the U.S. General Accounting Office and the Administration for Children and Families also referenced the CERTs research in their reports on psychotropic use in foster children. The latter report can be accessed on Administration for Children and Families Web site.

"Our CERT funding allowed us to pull this all together and provide the direction and core. But we were able to leverage a lot of effort from our partners," Crystal explains.
It’s the only way something like this could happen."

Learn more about and download the Treatment of Maladaptive Aggression in Youth (T-MAY) Toolkit (PDF, 3.3 MB).

The Center for Education and Research on Mental Health Therapeutics at Rutgers University is one of six nationwide CERTs funded by the Agency for Healthcare Research and Quality. The mission of each CERT is to conduct research and provide education that will advance the optimal use of drugs, medical devices, and biological products; increase awareness of the benefits and risks of therapeutics; and improve quality while cutting the costs of health care.


  1. Loeber R, Farrington DP, eds. Child delinquents: development, intervention, and service needs. Thousand Oaks, CA: SAGE Publications; 2001.
  2. Soni A. The Five Most Costly Children's Conditions, 2006: Estimates for the U.S. Civilian Noninstitutionalized Children, Ages 0–17. Statistical Brief 242. Rockville, MD: Agency for Healthcare Research and Quality; April 2009. Available at
  3. Knapp P, Chait A, Pappadopulos E, Crystal S, Jensen P, and the T-MAY Steering Group.  Treatment of Maladaptive Aggression in Youth (T-MAY): CERTs Guidelines I.  Family Engagement, Assessment & Diagnosis, and Initial Management.  Pediatrics 129(6):e1562-1576, June 2012 PMID:22641762.
  4. Scotto Rosato N, Correll C, Pappadopulos E, Chait A, Crystal S, Jensen P, and the T-MAY Steering Group.  Treatment of Maladaptive Aggression in Youth (T-MAY): CERTs Guidelines II.  Psychosocial Interventions, Medication Treatments, and Side Effects Management.  Pediatrics 129(6):e-1577-1586, doi 10.1542/peds.2010-1361, June 2012. PMID: 22641763
Page last reviewed March 2017
Page originally created March 2017
Internet Citation: New Guidelines for Treating Maladaptive Aggression in Youth. Content last reviewed March 2017. Agency for Healthcare Research and Quality, Rockville, MD.
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