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	Florida Best Practice Guidelines for Chronic Impulsive Aggression in Children and Adolescents The expert panel did also take up the issue of aggression and treatment of aggression based on earlier work by Jensen and colleagues to create the treatment of aggressive youth. The expert panel did agree to support four of the initial TRAAY recommendations: 1. For all new cases, clinicians should conduct or review the results of comprehensive, psychiatric, diagnostic interviews with the patients and parents or guardians before prescribing, changing, or discontinuing medication. 2. Standardized symptom and behavior rating scales with proven reliability and validity should be used to measure the severity and frequency of target symptoms before treatments are initiated at regular intervals throughout treatment during acute episodes, and when treatments are changed or discontinued. 3. Structured psychosocial and educational intervention should be the first-line of treatment and should be continued, even if subsequent medications are initiated to manage aggression. 4. Symptoms of aggression are common in a wide range of psychiatric conditions. Aggressive patients who also present with persistent and clinically significant symptoms of hyperactivity, anxiety, depression, or mania should receive at least one adequate trial of a first-line agent for these primary disorders. The expert panel agreed that there are different types of aggression that have been described in literature and have been discussed in expert panel meetings. The panel noted that aggression is a complex phenomenon and that the chronicity of the aggression needs to be taken into account. There are also many subtypes of aggression, including affective and impulsive subtypes, and also instrumental and predatory aggression. There are many individuals who may have both. The group most apt to benefit from treatment with medications will most likely have affective impulsive aggression, whereas predatory aggression is much more difficult to treat. The expert panel recommended that it is important for clinicians to differentiate affective impulsive aggression from instrumental and/or predatory aggression as part of their diagnostic assessment or evaluation, and then, from that point, select interventions based on the type of aggressive syndrome. Level I: The panel thought an atypical antipsychotic could be used with multiple iterations of monotherapy consistent with the recommendations in the TRAAY guidelines. Level II: Lithium, valproic, carbamazepine, and typical antipsychotics could be used as an adjunctive medication, however the panel noted that mood stabilizers have not been shown to be successful in pervasive developmental disorders and, therefore, clinicians should be aware of these data. Level III: Mood stabilizer combination could be attempted with antipsychotics if not attempted in the past. Child & Adolescent    » ADHD    » Depression    » Bipolar Disorder    » Tourettes Syndrome    » Aggression Adults    » Schizophrenia    » Bipolar Disorder