1. A Meta-Analysis of Non-stimulant Medication Effects on Overt Aggression-Related Behaviors in Youth with SED by Daniel F. Connor, R. Thomas Boone, Ronald J. Steingard, Ivan D. Lopez, & Richard H. Melloni, Jr. Presented by: Tzu Min Lee Radford University

2. Purpose To determine the effect size for non-stimulant medications on symptoms of overt aggression- related behaviors in referred children and adolescents with serious emotional and behavioral disturbances. - Prevalence of pharmacological interventions - Overall efficacy of medications to treat aggression unclear - A literature review back to 1955 revealed no other meta-analysis except one in 2002 to assess the effects of stimulant medications on overt and covert aggression in youth with ADHD

3. Issues to Consider How is medications determined? - used to treat aggression-related behaviors in youth with developmental delay, ADHD, CD, depression, schizophrenia, anxiety disorders, bipolar disorder and tic disorders How is aggression-related behaviors defined? - why overt aggression - defined broadly to be consistent with the multiplicity of aggression problems faced by clinicians in practice

4. Literature Review 1970-2001 medical & behavioral science Methods - Electronic Sources * Medline * PsycInfo * Pub Med - Journal bibliographies Studies - 41 were found - 33 met the inclusion/exclusion criteria

5. Studies to Include Report quantitative data on independent drug effects (neuroleptics, atypical antipsychotics, mood stabilizers, antidepressants and adrenergic agents) Published in peer-reviewed scientific journal Use a placebo control either in cross-over or parallel-group methodological design Have a mean sample age of 19 years or younger Use a valid rating scale or method of observation to assess aggression-related behaviors Open studies, case reports and review articles are excluded.

6. Dependent Measures Overt aggression-related behaviors - physical assault, verbal threats, oppositional and defiant behavior, noncompliance, rule defiance, malicious teasing of others, conduct problems, disruptive behavior, poor self-control, explosive outbursts of property destruction, temper tantrums, hyperactivity/impulsivity, explosive rage attacks, hostility, and/or irritability

7. Dependent Measures Clinician Rating - Brief Psychotic Rating Scale (BPRS) - Children’s Psychiatric Rating Scale (ChPRS) - Rating Scale of Abnormal Behavior Checklist (RSABC) Parent Rating - Conners Parent/Teacher Rating Scale (CPRS & CPRS) Teacher Rating - Teachers Self-Control rating Scale (TSCRS) Overall Rating - Average of effects for all reporters in each given study

8. Results * p <.0001 for all ratings EFFECTS OF DRUGS ON OVERT AGGRESSIVE BEHAVIOR 95% CIFile- drawer X Criteria N d L U Clinician Rating 560.75.27 2.20 146 Parent Rating 496.77 -.10 4.08 315 Teacher Rating 835.63.27 2.33 430 Overall Rating 1221.68.57 2.36 1047

9. Potential Moderators Mean sample age Percentage of boys in the sample Drug group - neuroleptics, atypical antipsychotics and mood stabilizers - antidepressants and adrenergic agents Study design - within-subjects - between-subjects Interaction between drug type & study design

10. Results – Moderators Drug Group, Study Design and their Interaction DRUG GROUP STUDY DESIGN Within-subjectsBetween-subjects Antipsychotic.78 1.03 Antidepressant 3.05.44

11. Study Limitations Limitations of the extant published literature - small sample sizes, absence of drug use means and standard deviations Grouping medications to increase statistical power diminished the precision of analysis Risk of inflating Type 1 error by combining diverse ratings within an individual study into a single rating Haloing effects of medication improvements on core features of psychiatric disorders

12. Clinical Implications Results support the continued use of medication therapy as part of a multimodal treatment plan. Parent ratings of their children did not entirely endorse medication interventions as always effective Benefits of medical interventions must be balanced with their potential risks. Need for a thorough, multidisciplinary psycho- educational evaluation since overt aggression is heterogeneous in etiology. Treatment plans must consider diverse psychosocial family, individual, community, educational, and psychopharmacological treatment interventions.

13. Future Research A need for continued, comprehensive research Define aggressive behavior explicitly Examine drug effects on certain types of aggression - physical assault, reactive aggression, proactive aggression, covert aggression, CD/ODD Investigate social validity measures - effects of drugs on quality-of-life measures for child and family