Neurobehavioral Treatment of Aggressive Youth: A Neuropsychiatric Approach

Neurobehavioral treatment is an evidenced-based, neuropsychiatric treatment approach designed specifically for youth with impulsive                       aggression (irritable or explosive, not premeditated).

A vast scientific literature has shown that impulsive aggression is more biological than premeditated aggression and more responsive to medication (Volavka, 2002; Haller & Kruk, 2006). “The distinction between impulsive and premeditated aggression appears to be a valid one.” (Citrome, Nolan & Volavka, 2004). When a child or adolescent shows recurrent episodes of aggression that is disruptive and maladaptive, that juvenile may be described as showing pathological aggression (Coccaro, 2003). Aggression of this type is the most common reason for referral to mental health services and the most difficult to manage (Damon, 2009). Premeditated aggression can be understood in psychosocial terms, such as the antisocial behavior of Conduct Disorder, but for impulsive aggression there is often a biological or brain basis to the problem (Lieberman, 2007).

What is Neuropsychiatry?

The term’ neuropsychiatry’ has served as successor to the former term ‘organic psychiatry’ and is contrasted with notions of psychodynamics…” (Oldham & Riba, 2004). Neuropsychiatry has become a medical specialty committed to the care of individuals with neurologically-based disturbances of cognition, behavior, and mood (Coffey, Brumback & Rosenberg, Eds., 2005). The American Neuropsychiatric Association now provides board examinations for certification in this specialty (www.anpaonline.org, 2006). Neuropsychiatry treats psychiatric patients who have additional disorders of brain function from problems during pregnancy, premature or difficult birth, head injury, developmental disorders, or genetic disorders (Coccaro, 2003). Neuropsychiatric youth are described as over-reactive to minor provocation, out of control, highly emotional, and more responsive to medication (Haller, & Kruk, 2006).

What is involved in a neuropsychiatric assessment?

A neuropsychiatric assessment includes a neuropsychiatric physical examination, neuropsychological assessment, and neurophysiological testing, with laboratory testing, genetic markers, and neuroimaging techniques as indicated by the initial assessment (Chen et al., 2007; Fisher, et al., 2011). “Over the last decade advances in key areas of basic and laboratory science (including molecular biology, cell biology, genetics, neuroscience, neuropathology, and neuroimaging) have helped to establish new and meaningful links between neurobiologic abnormalities and neuropsychiatric disorders” (Yudofsky & Kim, 2004).

Why is neuropsychiatric assessment needed for youth with impulsive aggression?

Abuse, neglect, harsh discipline, and absent or inadequate parenting are all risk factors for antisocial and premeditated aggressive behaviors (Connor, 2002), but impulsive pathological aggression is generally associated with brain disorders (Lieberman, 2007; Matthews et al., 2013). Individuals who show impulsive aggression are different in neurocognitive abilities and psychophysiology measures, and are unique in their response to pharmacological intervention (Barratt, Stanford, Kent & Felthous, 1997). “Consistent evidence supports a neurocognitive vulnerability in some youth with early-onset, chronic aggression.” (Connor, 2002).

Residential neuropsychiatric treatment of impulsive aggression includes a Neurobehavioral Milieu (e.g.; positive discipline and a quiet, non-confrontational environment) to minimize aggressive responses and promote more positive social behaviors.

A “milieu” is the environment surrounding one during psychiatric residential treatment. The likelihood of impulsive aggression can be decreased by environmental factors, and the proper social environment can discourage aggressive responding (Daffern & Howells, 2002). Therapeutic communities foster pro-social behaviors such as cooperation, empathy, and responsibility, and result in reductions in the number of serious incidents in a facility (Dolan, 1998). The Neurobehavioral Milieu is designed for brain impairments and is more structured, less confrontational, more positive in orientation, and less prone to over-stimulation than traditional psychiatric environments (Matthews, et al., 2011).

Neurobehavioral treatment follows the conventional wisdom that medications should be targeted to the underlying diagnosis and pathophysiology, and not just used for sedation.

A large number of case reports as well as randomized double-blind studies have supported the practice of targeting medication to a particular diagnosis (Coccoro, 2003). “Although sedation can be used to control acute agitation, sedation per se is suboptimal in reducing agitation in the long term because of its negative impact on overall functioning. Longer term management requires treatment of the underlying disorder.” (Crome, Noland & Volavka, 2004; Matthews et al., 2012). The Neuropsychiatric approach goes even further by targeting medications to brain areas showing abnormal activity that may underlie pathological impulsive aggression (Matthews et al., 2009).

REFERENCES

American Neuropsychiatric Association website. Retrieved 3/27/2006 from www.anpaonline.org.

Barratt, E.S., Stanford, M.S., Kent, T.A. & Felthous, A., (1997). Neuropsychological and cognitive psychophysiological substrates of impulsive aggression. Biological Psychiatry, 41, 1045-1061.

Chen, T., Blum, K., Matthews, D., Fisher, L., et al. (2007). Preliminary association of the TaqA1 allele of the Dopamine D2 Receptor Gene and the Dopamine Transporter (DAT1) 480 bp Allele with Pathological Violent Behavior in Adolescents. Gene Ther. Mol. Bio., Vol. 11, 93-112.

Citrome, L., Nolan, K. & Volavka, J., (2004). Science-Based Treatment of Aggression and Agitation, in Chapter 11, Vol. II, of The Science, Treatment and Prevention of Antisocial Behaviors, Fishbein, D. (Ed.), New Jersey, Civic Research Institute.

Coccaro, E. F. (2003). Aggression: Psychiatric Assessment and Treatment, Marcel Dekker, New York.

Coffey, Brumback & Rosenberg (Eds.), (2005). Pediatric Neuropsychiatry. Lippincott, Williams & Wilkins, Baltimore.

Connor, D., (2002). Aggression and Antisocial Behavior in Children and Adolescents, Chapter 6, New York, The Guilford Press.

Damen, I.M., (2009). The effectiveness of a restraint reduction policy implemented to reduce the use of physical restraint with children and adolescents in a residential care facility. Ph.D. dissertation, University of Tennessee.

Daffern, M. & Howells, K., (2002). Psychiatric inpatient aggression: A review of structural and functional assessment approach. Aggression and Violent Behavior, 7, 477-497.

Dolan, B., (1998). Therapeutic community treatment for severe personality disorders. Millon, Simonsen, Birke-Smith & Davis (Eds.), Psychopathology: Antisocial, Criminal and Violent Behavior, New York, Guilford Press.

Fisher, W., Ceballos, N., Matthews, D., & Fisher, L. (2011). Event-Related Potentials in Juveniles with Impulsive Aggression: A Retrospective Chart Review Study. Psychiatry Research, 187, 409-413.

Haller, J. & Kruk, M.R. (2006). Normal and abnormal aggression: human disorders and novel laboratory models. Neurosci Biobehav Rev, 30 (3), 292-303.

Lieberman, M. D. (2007). Social cognitive neuroscience: A review of core processes. Annual Review of Psychology, 58, 259-89.

Matthews, D., Fisher, W., Ceballos, N., and Fisher, L. (2009). Event Related Potentials in Juveniles with Impulsive Aggression. Presentation at the American Neuropsychiatric Association, San Antonio, TX.

Matthews, D., Fisher, L. & Matthews, G. (2012). Explosive Juveniles: Medical Management Without Antipsychotic Medication. ANPA Abstracts at J Neuropsychiary Clin Neurosci, 24, 2, 256.

Matthews, D., Fisher, L., & Matthews, G. (2013). Medical Management of Explosive Aggression. Paper presented at the American Neuropsychiatric Association, April,Boston.

Oldman, J. & Riba, M., (2004). Introduction to the review of psychiatry series. Neuropsychiatric Assessment, Yudofsky & Kim (Eds.), Washington, D.C., American Psychiatric Association Publishing.

Volavka, J., (2002). Neurobiology of Violence, (2nd Ed.), Washington, D.C., American Psychiatric Association Publishing.

Yudofsky, Stuart & Kim, H.F. (Eds.), (2004). Neuropsychiatric Assessment. Washington, D.C., American Psychiatric Association Publishing.