Validation of the Interview Module for Intermittent Explosive Disorder (M-IED) in children and adolescents: a pilot study

Evidence-Based Assessment of DSM-5 Disruptive, Impulse Control, and Conduct Disorders

The assessment of oppositional defiant disorder, conduct disorder, antisocial personality disorder, and intermittent explosive disorder-the Disruptive, Impulse Control and Conduct Disorders-can be affected by biases in clinical judgment, including overestimating concerns about distinguishing symptoms from normative behavior and stigma associated with diagnosing antisocial behavior. Recent nosological changes call for special attention during assessment to symptom dimensions of limited prosocial emotions and chronic irritability. The present review summarizes best practices for evidence-based assessment of these disorders and discusses tools to identify their symptoms. Despite the focus on disruptive behavior disorders, their high degree of overlap with disruptive mood dysregulation disorder can complicate assessment. Thus, the latter disorder is also included for discussion here. Good practice in the assessment of disruptive behavior disorders involves using several means of information gathering (e.g., clinical interview, standardized rating scales or checklists), ideally via multiple informants (e.g., parent-, teacher-, and self-report). A commitment to providing a full and accurate diagnostic assessment, with careful and attentive reference to diagnostic guidelines, will mitigate concerns regarding biases.

Finding a Needed Diagnostic Home for Children with Impulsive Aggression

Aggressive behavior is one of the most common reasons for referrals of youth to mental health treatment. While there are multiple publications describing different types of aggression in children, it remains challenging for clinicians to diagnose and treat aggressive youth, especially those with impulsively aggressive behaviors. The reason for this dilemma is that currently several psychiatric diagnoses include only some of the common symptoms of aggression in their criteria. However, no single diagnosis or diagnostic specifier adequately captures youth with impulsive aggression (IA). Here we review select current diagnostic categories, including behavior and mood disorders, and suggest that they do not provide an adequate description of youth with IA. We also specifically focus on the construct of IA as a distinct entity from other diagnoses and propose a set of initial, provisional diagnostic criteria based on the available evidence that describes youth with IA to use for future evaluation.

Prevalence of DSM-IV intermittent explosive disorder in Black adolescents: Findings from the National Survey of American Life, Adolescent Supplement

Little is known about the epidemiology of Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM–IV) intermittent explosive disorder (IED) in adolescents, and no information is currently available regarding the relationship between race/ethnicity and IED among Black youth in the United States. Using the World Health Organization World Mental Health Composite International Diagnostic Interview (Adolescent Version), we estimated the prevalence, severity, and disability of IED in a national, probability sample of African American and Caribbean Black youth (ages 13–17) from the National Survey of American Life, Adolescent Supplement. Face-to-face surveys of 810 African American and 360 Caribbean Black youth were conducted between 2001 and 2003. We calculated lifetime and 12-month diagnoses of IED using diagnostic algorithms based on DSM–IV and assessed IED disability using a modified Sheehan Disability Scale. Overall findings indicated lifetime and 12-month IED prevalence rates of 9.2% and 7.0%, respectively. Lifetime prevalence rates of IED were 9.0% for African American and 12.4% for Caribbean Black teens. Within the past 12 months, 6.7% of African American and 11.5% of Caribbean Black adolescents met diagnostic criteria for IED. Lifetime and 12-month IED were associated with anxiety disorders. In addition, few teens with lifetime IED received any treatment. Findings are consistent with recent evidence that intermittent explosive disorder may be more common than previously considered, especially among adolescents. Significant acts of aggression and impairment are associated with IED, and low treatment rates indicate that more research on this disorder and intervention options is warranted.

Attention deficit hyperactivity disorder and sensory modulation disorder: a comparison of behavior and physiology

Children with attention deficit hyperactivity disorder (ADHD) are impulsive, inattentive and hyperactive, while children with sensory modulation disorder (SMD), one subtype of Sensory Processing Disorder, have difficulty responding adaptively to daily sensory experiences. ADHD and SMD are often difficult to distinguish. To differentiate these disorders in children, clinical ADHD, SMD, and dual diagnoses were assessed. All groups had significantly more sensory, attention, activity, impulsivity, and emotional difficulties than typical children, but with distinct profiles. Inattention was greater in ADHD compared to SMD. Dual diagnoses had more sensory-related behaviors than ADHD and more attentional difficulties than SMD. SMD had more sensory issues, somatic complaints, anxiety/depression, and difficulty adapting than ADHD. SMD had greater physiological/electrodermal reactivity to sensory stimuli than ADHD and typical controls. Parent-report measures identifying sensory, attentional, hyperactive, and impulsive difficulties varied in agreement with clinician's diagnoses. Evidence suggests ADHD and SMD are distinct diagnoses.

Disentangling impulsiveness, aggressiveness and impulsive aggression: an empirical approach using self-report measures

There is confusion in the literature concerning the concept of impulsive aggression. Based on previous research, we hypothesize that impulsivity and aggression may be related, though not as closely as to consider them the same construct. So, our aim was to provide empirical evidence of the relationship between the impulsivity and aggressiveness constructs when considered as traits. Two widely used questionnaires [Barratt's Impulsiveness Scale (BIS) and Aggression Questionnaire-Refined (AQ-R)] were administered to 768 healthy respondents. Product-moment and canonical correlations were then calculated. In addition, a principal components analysis was conducted to explore whether impulsive aggression can be defined phenotypically as the expression of a single trait. The common variance between impulsivity and aggressiveness was never higher than 42%. The principal components analysis reveals that one component is not enough to represent all the variables. In conclusion, our results show that impulsivity and aggressiveness are two separate, although related constructs. This is particularly important in view of the misconceptions in the literature.

[Intermittent explosive disorder: current status]

BACKGROUND

Intermittent Explosive Disorder (IED) is a recently reported mental disorder. It was introduced in the edition of the Diagnostic and Statistical Manual of mental disorders. Since then, the clinical criteria have developed, but some ambiguity has remained.

LITERATURE FINDINGS

In fact, the utility of excluding this diagnosis in the presence of some personality disorders (antisocial and borderline personalities) is being discussed. On the one hand, the recurrence of violent behaviour is not always found among these personalities and, on the other, to accept both diagnoses of personality disorder and IED would permit one to distinguish a subgroup of patients to whom it would be possible to offer appropriate treatment. However, some criteria could be introduced among those needed for the diagnosis. These criteria include signs of tension, immediately preceding the assaults, as well as signs of release, or even pleasure, after performing the act. These symptoms are frequently reported by IED patients and they are still found in the diagnosis criteria of other impulse control disorders. IED starts during adolescence and it is more frequent among boys. Due to the criteria restrictions, its prevalence is considered as low. However, violent behaviour and impulsivity among psychiatric patients are frequent. The comorbidity of IED has been studied without taking these restrictions into account. A high level of comorbidity is noted with mood disorder. Some reports agree with the hypothesis of a disorder included in the spectrum of a mood disorder. The other psychiatric disorders, frequently associated with IED, are cluster B personality disorders and anxious disorders. There are few studies on the etiopathogeny of IED. However, some results warrant more attention. They concern the deregulation of the serotoninergic system and mild brain injuries. The etiopathogenic hypotheses have influenced the choice of the drugs offered to IED patients, which are mainly selective serotonin reuptake inhibitors, mood stabilisers, and beta-blockers. The efficacy of these treatments was determined essentially by case reports. Some controlled trials are needed to confirm the utility of these molecules in this disorder. In spite of the frequency and the seriousness of violent impulsive behaviour, it is still studied much less than mood or anxious symptoms.

CONCLUSION

We believe that IED diagnosis permits the categorization of such violent behaviour in many psychiatric pathologies. The evolution of IED diagnostic criteria should permit psychiatrists to recognise and handle recognition and management of violent behaviour better.

Characteristics of aggression in clinically referred children

OBJECTIVE

We investigated the phenomenology of aggression in a group of psychiatrically referred children and in a comparison group of children.

INTRODUCTION

Children (N=275) were evaluated at a pediatric psychopharmacology clinic in an academic medical center and compared with 100 non-referred children from the community. To assess the influence of several predictors on the child's level of clinical impairment we conducted stepwise regression analyses.

RESULTS

Aggression occurred across many different psychiatric diagnoses in psychiatrically referred children. Aggression in referred children was more frequent, physical, intense, lasted for a longer duration per episode, was more resistant to intervention, and occurred at an earlier age of onset in contrast with comparison children. Controlling for psychiatric diagnosis and demographic variables, family income and number of aggressive episodes in the last 6 months were the only significant predictors of child impairment.

DISCUSSION

Phenomenologically, aggression may be more maladaptive in children with a psychiatric disorder compared with non-referred youths. These phenomenological differences in characteristics of aggression support the concept of an aggressive syndrome in psychiatrically referred children.

CONCLUSION

Results support the need for development of specific treatment interventions for excessive maladaptive aggression independent of psychiatric diagnosis in referred children and adolescents.

Intermittent explosive disorder: epidemiology, diagnosis and management

Intermittent explosive disorder (IED) is characterised by discrete episodes of aggressive impulses that result in serious assaultive acts towards people or destruction of property. IED causes severe impairments in daily function. The diagnosis of IED should be made only after a thorough medical work-up. A structured or semi-structured diagnostic interview is helpful to ensure that comorbid and pre-existing conditions are considered. There is a lack of controlled trials of agents for the treatment of patients with IED, but there is evidence that mood stabilisers, antipsychotics, beta-blockers, alpha(2)-agonists, phenytoin and antidepressants may be useful. Behavioural interventions may be valuable as part of the overall treatment of IED.