Hostname: page-component-cd9895bd7-8ctnn Total loading time: 0 Render date: 2024-12-25T18:50:18.409Z Has data issue: false hasContentIssue false
  • English
  • Français

Closing the gap: unmet needs of individuals with impulsive aggressive behavior observed in children and adolescents

Published online by Cambridge University Press:  31 March 2020

Adelaide S. Robb ,
Daniel F. Connor ,
Birgit H. Amann ,
Benedetto Vitiello ,
Azmi Nasser ,
Welton O’Neal ,
Stefan Schwabe ,
Gianpiera Ceresoli-Borroni ,
Jeffrey H. Newcorn  and
Shawn A. Candler
...Show all authors
Adelaide S. Robb*
Affiliation:
Department of Psychiatry and Behavioral Sciences, Children’s National Medical Center, Washington, DC, USA
Daniel F. Connor
Affiliation:
Department of Psychiatry, University of Connecticut Medical School, Farmington, Connecticut, USA
Birgit H. Amann
Affiliation:
Behavioral Medical Center—Troy, Troy, Michigan, USA
Benedetto Vitiello
Affiliation:
Department of Public Health and Pediatric Sciences, University of Turin, Turin, Italy
Azmi Nasser
Affiliation:
Supernus Pharmaceuticals, Inc., Rockville, Maryland, USA
Welton O’Neal
Affiliation:
Supernus Pharmaceuticals, Inc., Rockville, Maryland, USA
Stefan Schwabe
Affiliation:
Supernus Pharmaceuticals, Inc., Rockville, Maryland, USA
Gianpiera Ceresoli-Borroni
Affiliation:
Supernus Pharmaceuticals, Inc., Rockville, Maryland, USA
Jeffrey H. Newcorn
Affiliation:
Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, USA
Shawn A. Candler
Affiliation:
Supernus Pharmaceuticals, Inc., Rockville, Maryland, USA
Jan K. Buitelaar
Affiliation:
Department of Cognitive Neuroscience, Donders Institute for Brain, Cognition, and Behaviour, Radboud University, Nijmegen, The Netherlands
Robert L. Findling
Affiliation:
Department of Psychiatry and Behavioral Sciences, Johns Hopkins University, Baltimore, Maryland, USA Department of Psychiatry, Virginia Commonwealth University, Richmond, Virginia, USA
*
Author for correspondence: Adelaide S. Robb, Email: AROBB@childrensnational.org
Get access Rights & Permissions [Opens in a new window]

Abstract

Impulsive aggressive (IA, or impulsive aggression) behavior describes an aggregate set of maladaptive, aggressive behaviors occurring across multiple neuropsychiatric disorders. IA is reactive, eruptive, sudden, and unplanned; it provides information about the severity, but not the nature, of its associated primary disorder. IA in children and adolescents is of serious clinical concern for patients, families, and physicians, given the detrimental impact pediatric IA can have on development. Currently, the ability to properly identify, monitor, and treat IA behavior across clinical populations is hindered by two major roadblocks: (1) the lack of an assessment tool designed for and sensitive to the set of behaviors comprising IA, and (2) the absence of a treatment indicated for IA symptomatology. In this review, we discuss the clinical gaps in the approach to monitoring and treating IA behavior, and highlight emerging solutions that may improve clinical outcomes in patients with IA.

Keywords

ADHDassessment toolimpulsive aggressionmaladaptive aggressionunmet needs
Type
Perspective
Information
CNS Spectrums , Volume 26 , Issue 5 , October 2021 , pp. 448 - 456
Copyright
© The Author(s) 2020. Published by Cambridge University Press

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

Jensen, PS, Youngstrom, EA, Steiner, H, et al. Consensus report on impulsive aggression as a symptom across diagnostic categories in child psychiatry: implications for medication studies. J Am Acad Child Adolesc Psychiatry. 2007;46(3):309–322.CrossRefGoogle ScholarPubMed
Blair, RJ. The neurobiology of impulsive aggression. J Child Adolesc Psychopharmacol. 2016;26(1):4–9.CrossRefGoogle ScholarPubMed
Connor, DF. On the challenge of maladaptive and impulsive aggression in the clinical treatment setting. J Child Adolesc Psychopharmacol. 2016;26(1):2–3.CrossRefGoogle ScholarPubMed
Saylor, KE, Amann, BH. Impulsive aggression as a comorbidity of attention-deficit/hyperactivity disorder in children and adolescents. J Child Adolesc Psychopharmacol. 2016;26(1):19–25.10.1089/cap.2015.0126CrossRefGoogle ScholarPubMed
Connor, DF, Newcorn, JH, Saylor, KE, et al. Maladaptive aggression: with a focus on impulsive aggression in children and adolescents. J Child Adolesc Psychopharmacol. 2019;29(8):576–591.10.1089/cap.2019.0039CrossRefGoogle ScholarPubMed
Robb, AS, Schwabe, S, Ceresoli-Borroni, G, et al. A proposed anti-maladaptive aggression agent classification: improving our approach to treating impulsive aggression. Postgrad Med. 2019;131:1–9.CrossRefGoogle ScholarPubMed
Vitiello, B, Behar, D, Hunt, J, Stoff, D, Ricciuti, A. Subtyping aggression in children and adolescents. J Neuropsychiatry Clin Neurosci. 1990;2(2):189–192.Google ScholarPubMed
Raine, A, Dodge, K, Loeber, R, et al. The reactive–proactive aggression questionnaire: differential correlates of reactive and proactive aggression in adolescent boys. Aggress Behav. 2006;32(2):159–171.CrossRefGoogle ScholarPubMed
Young, AS, Youngstrom, EA, Findling, RL, et al. Developing and validating a definition of impulsive/reactive aggression in youth. J Clin Child Adolesc Psychol. 2019;25:1–17.CrossRefGoogle Scholar
American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Publishing; 2013.Google Scholar
Coccaro, EF. Intermittent explosive disorder as a disorder of impulsive aggression for DSM-5. Am J Psychiatry. 2012;169(6):577–588.10.1176/appi.ajp.2012.11081259CrossRefGoogle ScholarPubMed
Kashdan, TB, Elhai, JD, Breen, WE. Social anxiety and disinhibition: an analysis of curiosity and social rank appraisals, approach-avoidance conflicts, and disruptive risk-taking behavior. J Anxiety Disord. 2008;22(6):925–939.CrossRefGoogle ScholarPubMed
Hollander, E, Chaplin, W, Soorya, L, et al. Divalproex sodium vs placebo for the treatment of irritability in children and adolescents with autism spectrum disorders. Neuropsychopharmacology. 2010;35(4):990–998.CrossRefGoogle ScholarPubMed
Perroud, N, Baud, P, Mouthon, D, Courtet, P, Malafosse, A. Impulsivity, aggression and suicidal behavior in unipolar and bipolar disorders. J Affect Disord. 2011;134(1–3):112–118.CrossRefGoogle ScholarPubMed
Soloff, PH, Abraham, K, Burgess, A, Ramaseshan, K, Chowdury, A, Diwadkar, VA. Impulsivity and aggression mediate regional brain responses in Borderline Personality Disorder: an fMRI study. Psychiatry Res Neuroimaging. 2017;260:76–85.CrossRefGoogle Scholar
Blair, RJ, Leibenluft, E, Pine, DS. Conduct disorder and callous-unemotional traits in youth. N Engl J Med. 2014;371(23):2207–2216.CrossRefGoogle ScholarPubMed
Bidzan, L, Bidzan, M, Pachalska, M. Aggressive and impulsive behavior in Alzheimer's disease and progression of dementia. Med Sci Monit. 2012;18(3):CR182–CR189.10.12659/MSM.882523CrossRefGoogle ScholarPubMed
Tufan, E, Topal, Z, Demir, N, et al. Sociodemographic and clinical features of disruptive mood dysregulation disorder: a chart review. J Child Adolesc Psychopharmacol. 2016;26(2):94–100.CrossRefGoogle ScholarPubMed
Fontenelle, LF, Mendlowicz, MV, Versiani, M. Impulse control disorders in patients with obsessive–compulsive disorder. Psychiatry Clin Neurosci. 2005;59(1):30–37.CrossRefGoogle ScholarPubMed
James, LM, Strom, TQ, Leskela, J. Risk-taking behaviors and impulsivity among veterans with and without PTSD and mild TBI. Mil Med. 2014;179(4):357–363.10.7205/MILMED-D-13-00241CrossRefGoogle ScholarPubMed
Leclerc, M, Regenbogen, C, Hamilton, R, Habel, U. Some neuroanatomical insights to impulsive aggression in schizophrenia. Schizophr Res. 2018;201:27–34.CrossRefGoogle Scholar
Mosti, C, Coccaro, EF. Mild traumatic brain injury and aggression, impulsivity, and history of other- and self-directed aggression. J Neuropsychiatry Clin Neurosci. 2018;30(3):220–227.CrossRefGoogle ScholarPubMed
Coccaro, EF, Fridberg, DJ, Fanning, JR, Grant, JE, King, AC, Lee, R. Substance use disorders: relationship with intermittent explosive disorder and with aggression, anger, and impulsivity. J Psychiatr Res. 2016;81:127–132.CrossRefGoogle ScholarPubMed
Wright, A, Rickards, H, Cavanna, AE. Impulse-control disorders in gilles de la tourette syndrome. J Neuropsychiatry Clin Neurosci. 2012;24(1):16–27.CrossRefGoogle ScholarPubMed
Gurnani, T, Ivanov, I, Newcorn, JH. Pharmacotherapy of aggression in child and adolescent psychiatric disorders. J Child Adolesc Psychopharmacol. 2016;26(1):65–73.CrossRefGoogle ScholarPubMed
Scotto Rosato, N, Correll, CU, Pappadopulos, E, et al. Treatment of maladaptive aggression in youth: CERT guidelines II. Treatments and ongoing management. Pediatrics. 2012;129(6):e1577–e1586.CrossRefGoogle ScholarPubMed
Connor, DF. Aggressive and Antisocial Behavior. In: Hopkins, B, Geangu, E, Linkenauger, W, eds. The Cambridge Encyclopedia of Child Development. 2nd ed. Cambridge, UK: The Cambridge University Press; 2017:443–448.Google Scholar
Connor, DF. Aggression and Antisocial Behavior in Children and Adolescents: Research and Treatment. New York, NY: The Guilford Press; 2002.Google Scholar
Barratt, ES, Stanford, MS, Dowdy, L, Liebman, MJ, Kent, TA. Impulsive and premeditated aggression: a factor analysis of self-reported acts. Psychiatry Res. 1999;86(2):163–173.CrossRefGoogle ScholarPubMed
Dodge, KA, Lochman, JE, Harnish, JD, Bates, JE, Pettit, GS. Reactive and proactive aggression in school children and psychiatrically impaired chronically assaultive youth. J Abnorm Psychol. 1997;106(1):37–51.CrossRefGoogle ScholarPubMed
Kempes, M, Matthys, W, de Vries, H, van Engeland, H. Reactive and proactive aggression in children--a review of theory, findings and the relevance for child and adolescent psychiatry. Eur Child Adolesc Psychiatry. 2005;14(1):11–19.CrossRefGoogle ScholarPubMed
Wortzel, HS, Arciniegas, DB. A forensic neuropsychiatric approach to traumatic brain injury, aggression, and suicide. J Am Acad Psychiatry Law. 2013;41(2):274–286.Google Scholar
Yudofsky, SC, Silver, JM, Hales, RE. Pharmacologic management of aggression in the elderly. J Clin Psychiatry. 1990;51(Suppl:22–28):29–32.Google ScholarPubMed
Potegal, M. Temporal and frontal lobe initiation and regulation of the top-down escalation of anger and aggression. Behav Brain Res. 2012;231(2):386–395.CrossRefGoogle ScholarPubMed
Connor, DF, McLaughlin, TJ. Aggression and diagnosis in psychiatrically referred children. Child Psychiatry Hum Dev. 2006;37(1):1–14.CrossRefGoogle ScholarPubMed
Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD). General Prevalence of ADHD; 2017. http://www.fdanews.com/articles/156467-corepharma-wants-investigation-into-endo-8217-s-moban-withdrawal?v=preview. Cited April 17, 2017.Google Scholar
Pastor, P, Reuben, C, Duran, C, Hawkins, L. Association between diagnosed ADHD and selected characteristics among children aged 4–17 years: United States, 2011–2013. NCHS Data Brief. 2015;201:201.Google Scholar
MTA Cooperative Group. A 14-month randomized clinical trial of treatment strategies for attention-deficit/hyperactivity disorder. Arch Gen Psychiatry. 1999;56(12):1073–1086.CrossRefGoogle Scholar
Connor, DF, Chartier, KG, Preen, EC, Kaplan, RF. Impulsive aggression in attention-deficit/hyperactivity disorder: symptom severity, co-morbidity, and attention-deficit/hyperactivity disorder subtype. J Child Adolesc Psychopharmacol. 2010;20(2):119–126.CrossRefGoogle ScholarPubMed
Dowson, JH, Blackwell, AD. Impulsive aggression in adults with attention-deficit/hyperactivity disorder. Acta Psychiatr Scand. 2010;121(2):103–110.CrossRefGoogle ScholarPubMed
Mathias, CW, Stanford, MS, Marsh, DM, et al. Characterizing aggressive behavior with the Impulsive/Premeditated Aggression Scale among adolescents with conduct disorder. Psychiatry Res. 2007;151(3):231–242.CrossRefGoogle ScholarPubMed
Tsiouris, JA, Kim, SY, Brown, WT, Cohen, IL. Association of aggressive behaviours with psychiatric disorders, age, sex and degree of intellectual disability: a large-scale survey. J Intellect Disabil Res. 2011;55(7):636–649.CrossRefGoogle ScholarPubMed
Jurewicz, M, Takakura, A, Augello, A, et al. Ischemic injury enhances dendritic cell immunogenicity via TLR4 and NF-kappa B activation. J Immunol. 2010;184(6):2939–2948.CrossRefGoogle ScholarPubMed
Kaat, A, Farmer, C, Gadow, K, et al. Factor validity of a Proactive and Reactive Aggression Rating Scale. J Child Fam Stud. 2015;24(9):2734–2744.CrossRefGoogle ScholarPubMed
Romans, L, Fresan, A, Senties, H, et al. Validation of the Impulsive/Premeditated Aggression Scale in Mexican psychiatric patients. Nord J Psychiatry. 2015;69(5):397–402.CrossRefGoogle ScholarPubMed
Knoedler, DW. The Modified Overt Aggression Scale. Am J Psychiatry. 1989;146(8):1081–1082.Google ScholarPubMed
Ceresoli-Borroni, G, Liranso, T, Brittain, ST, et al. A novel assessment tool for impulsive aggression in children with attention-deficit/hyperactivity disorder. J Child Adolesc Psychopharmacol. 2019;29(8):592–598.CrossRefGoogle ScholarPubMed
Ceresoli-Borroni, G, Liranso, T, Brittain, ST, et al. Application of the impulsive aggression diary in adolescents with attention-deficit/hyperactivity disorder. J Child Adolesc Psychopharmacol. 2019;29(8):599–607.CrossRefGoogle ScholarPubMed
Malone, RP, Bennett, DS, Luebbert, JF, et al. Aggression classification and treatment response. Psychopharmacol Bull. 1998;34(1):41–45.Google ScholarPubMed
Pappadopulos, E, Macintyre Ii, JC, Crismon, ML, et al. Treatment recommendations for the use of antipsychotics for aggressive youth (TRAAY). Part II. J Am Acad Child Adolesc Psychiatry. 2003;42(2):145–161.CrossRefGoogle ScholarPubMed
Felthous, AR, Stanford, MS. A proposed algorithm for the pharmacotherapy of impulsive aggression. J Am Acad Psychiatry Law. 2015;43(4):456–467.Google ScholarPubMed
Knapp, P, Chait, A, Pappadopulos, E, Crystal, S, Jensen, PS, Group TMS. Treatment of maladaptive aggression in youth: CERT guidelines I. Engagement, assessment, and management. Pediatrics. 2012;129(6):e1562–e1576.CrossRefGoogle ScholarPubMed
Neuroscience Based Nomenclature (NbN). NbN Glossary. Utrecht, The Netherlands; 2017.Google Scholar
Stocks, JD, Taneja, BK, Baroldi, P, Findling, RL. A phase 2a randomized, parallel group, dose-ranging study of molindone in children with attention-deficit/hyperactivity disorder and persistent, serious conduct problems. J Child Adolesc Psychopharmacol. 2012;22(2):102–111.CrossRefGoogle ScholarPubMed
Campbell, M, Small, AM, Green, WH, et al. Behavioral efficacy of haloperidol and lithium carbonate. A comparison in hospitalized aggressive children with conduct disorder. Arch Gen Psychiatry. 1984;41(7):650–656.CrossRefGoogle ScholarPubMed
Pollock, BG, Mulsant, BH, Rosen, J, et al. Comparison of citalopram, perphenazine, and placebo for the acute treatment of psychosis and behavioral disturbances in hospitalized, demented patients. Am J Psychiatry. 2002;159(3):460–465.CrossRefGoogle ScholarPubMed
Aman, MG, Binder, C, Turgay, A. Risperidone effects in the presence/absence of psychostimulant medicine in children with ADHD, other disruptive behavior disorders, and subaverage IQ. J Child Adolesc Psychopharmacol. 2004;14(2):243–254.CrossRefGoogle ScholarPubMed
Findling, RL, Townsend, L, Brown, NV, et al. The treatment of severe childhood aggression study: 12 weeks of extended, blinded treatment in clinical responders. J Child Adolesc Psychopharmacol. 2017;27(1):52–65.CrossRefGoogle ScholarPubMed
Krakowski, MI, Czobor, P. Depression and impulsivity as pathways to violence: implications for antiaggressive treatment. Schizophr Bull. 2014;40(4):886–894.CrossRefGoogle ScholarPubMed
Owen, R, Sikich, L, Marcus, RN, et al. Aripiprazole in the treatment of irritability in children and adolescents with autistic disorder. Pediatrics. 2009;124(6):1533–1540.CrossRefGoogle ScholarPubMed
Scahill, L, McCracken, JT, King, BH, et al. Extended-release guanfacine for hyperactivity in children with autism spectrum disorder. Am J Psychiatry. 2015;172(12):1197–1206.CrossRefGoogle ScholarPubMed
Bearss, K, Taylor, CA, Aman, MG, et al. Using qualitative methods to guide scale development for anxiety in youth with autism spectrum disorder. Autism. 2016;20(6):663–672.CrossRefGoogle ScholarPubMed
Zanarini, MC, Frankenburg, FR, Parachini, EA. A preliminary, randomized trial of fluoxetine, olanzapine, and the olanzapine-fluoxetine combination in women with borderline personality disorder. J Clin Psychiatry. 2004;65(7):903–907.CrossRefGoogle ScholarPubMed
Schneider, LS, Frangakis, C, Drye, LT, et al. Heterogeneity of treatment response to citalopram for patients with Alzheimer's disease with aggression or agitation: The CitAD Randomized Clinical Trial. Am J Psychiatry. 2016;173(5):465–472.CrossRefGoogle ScholarPubMed
Malone, RP, Delaney, MA, Luebbert, JF, Cater, J, Campbell, M. A double-blind placebo-controlled study of lithium in hospitalized aggressive children and adolescents with conduct disorder. Arch Gen Psychiatry. 2000;57(7):649–654.CrossRefGoogle ScholarPubMed
Mattes, JA. Oxcarbazepine in patients with impulsive aggression: a double-blind, placebo-controlled trial. J Clin Psychopharmacol. 2005;25(6):575–579.10.1097/01.jcp.0000186739.22395.6bCrossRefGoogle ScholarPubMed
Mattes, JA. Levetiracetam in patients with impulsive aggression: a double-blind, placebo-controlled trial. J Clin Psychiatry. 2008;69(2):310–315.CrossRefGoogle ScholarPubMed
Keppel Hesselink, JM, Kopsky, DJ. Phenytoin: 80 years young, from epilepsy to breast cancer, a remarkable molecule with multiple modes of action. J Neurol. 2017;264(8):1617–1621.CrossRefGoogle ScholarPubMed
Stanford, MS, Houston, RJ, Mathias, CW, Greve, KW, Villemarette-Pittman, NR, Adams, D. A double-blind placebo-controlled crossover study of phenytoin in individuals with impulsive aggression. Psychiatry Res. 2001;103(2–3):193–203.CrossRefGoogle ScholarPubMed
Hammond, FM, Bickett, AK, Norton, JH, Pershad, R. Effectiveness of amantadine hydrochloride in the reduction of chronic traumatic brain injury irritability and aggression. J Head Trauma Rehabil. 2014;29(5):391–399.CrossRefGoogle ScholarPubMed
Allan, ER, Alpert, M, Sison, CE, Citrome, L, Laury, G, Berman, I. Adjunctive nadolol in the treatment of acutely aggressive schizophrenic patients. J Clin Psychiatry. 1996;57(10):455–459.CrossRefGoogle ScholarPubMed
Risperdal Prescribing Information. Janssen Pharmaceuticals, Titusville, NJ. 2007.Google Scholar
Seeman, P. Atypical antipsychotics: mechanism of action. Can J Psychiatry. 2002;47(1):27–38.10.1177/070674370204700106CrossRefGoogle ScholarPubMed
Aman, MG, Bukstein, OG, Gadow, KD, et al. What does risperidone add to parent training and stimulant for severe aggression in child attention-deficit/hyperactivity disorder? J Am Acad Child Adolesc Psychiatry. 2014;53(1):47–60.CrossRefGoogle ScholarPubMed
Kronenberger, WG, Giauque, AL, Lafata, DE, Bohnstedt, BN, Maxey, LE, Dunn, DW. Quetiapine addition in methylphenidate treatment-resistant adolescents with comorbid ADHD, conduct/oppositional-defiant disorder, and aggression: a prospective, open-label study. J Child Adolesc Psychopharmacol. 2007;17(3):334–347.CrossRefGoogle ScholarPubMed
Aman, MG, Smith, T, Arnold, LE, et al. A review of atomoxetine effects in young people with developmental disabilities. Res Dev Disabil. 2014;35(6):1412–1424.CrossRefGoogle ScholarPubMed
Gadow, KD, Brown, NV, Arnold, LE, et al. Severely aggressive children receiving stimulant medication versus stimulant and risperidone: 12-month follow-up of the TOSCA trial. J Am Acad Child Adolesc Psychiatry. 2016;55(6):469–478.CrossRefGoogle ScholarPubMed
Greenhill, LL, Solomon, M, Pleak, R, Ambrosini, P. Molindone hydrochloride treatment of hospitalized children with conduct disorder. J Clin Psychiatry. 1985;46(8 Pt 2):20–25.Google ScholarPubMed
Ganguli, R. Weight gain associated with antipsychotic drugs. J Clin Psychiatry. 1999;60(Suppl 21):20–24.Google ScholarPubMed
Kroeze, WK, Hufeisen, SJ, Popadak, BA, et al. H1-histamine receptor affinity predicts short-term weight gain for typical and atypical antipsychotic drugs. Neuropsychopharmacology. 2003;28(3):519–526.CrossRefGoogle ScholarPubMed
Seeman, P, Tallerico, T. Antipsychotic drugs which elicit little or no Parkinsonism bind more loosely than dopamine to brain D2 receptors, yet occupy high levels of these receptors. Mol Psychiatry. 1998;3(2):123–134.CrossRefGoogle ScholarPubMed
Sikich, L, Frazier, JA, McClellan, J, et al. Double-blind comparison of first- and second-generation antipsychotics in early-onset schizophrenia and schizo-affective disorder: findings from the treatment of early-onset schizophrenia spectrum disorders (TEOSS) study. Am J Psychiatry. 2008;165(11):1420–1431.10.1176/appi.ajp.2008.08050756CrossRefGoogle ScholarPubMed
Ceresoli-Borroni, G, Nasser, A, Adewole, T, et al. A double-blind, randomized study of extended-release molindone for impulsive aggression in ADHD. J Atten Disord. 2020 (in press).Google ScholarPubMed
Ceresoli-Borroni, G, Adewole, T, Liranso, T, Findling, R. Efficacy and Safety of Extended-Release Molindone (SPN-810) to Treat Impulsive Aggression in Children Being Optimally Treated for Their Attention-Deficit/Hyperactivity Disorder: Phase 2b and Open-Label Extension Results. Poster presented at the Children and Adults with Attention-Deficit/Hyperactivity Disorder (CHADD) 29th Annual International Conference on ADHD. Atlanta, Georgia; November 9–12, 2017.Google Scholar
ClinicalTrials.gov. Pilot Trial of Neural Correlates of Response to Treatment of PTSD-Associated Impulsive Aggression; 2006.Google Scholar
ClinicalTrials.gov. Neurokinin (NK) 1 Antagonist for Pathological Aggression for Harmful, Impulsive, and Self-/Aggressive Behaviour (AHIMSA-1); 2019.Google Scholar