In recent years, there has been a huge increase in the prescribing of psychiatric medication to treat aggression in children.
Specifically, atypical antipsychotic and mood stabilizing drugs, originally developed for schizophrenia and bipolar disorder in adults, are now routinely prescribed to treat the aggression that occurs in a variety of childhood psychiatric disorders.
Prescriptions for atypical antipsychotics increased sixfold between 1993 and 2002, and the majority were prescribed to treat non-psychotic aggression, according to a task force that recently published guidelines on how to treat aggression in kids.
But these drugs carry the risk of serious side effects, notably severe weight gain and metabolic changes that can lead to Type 2 diabetes. Critics, including many in the medical community, have said they are over-prescribed.
At the same time, we’re in the midst of a collective national hand-wringing over how to reduce childhood bullying. Might drugs that curb aggression be the answer?
The Wrong Kind of Aggression
The question raises the unsettling specter of medicalizing ordinary but undesirable childhood behavior, a criticism that’s been lobbed for years at doctors, parents and teachers who endorse stimulant medications for hyperactive children with ADHD.
But putting aside the ethical concerns for a moment, is it even possible for the drugs in question to reduce bullying?
The simple answer is probably not – unless the child has other underlying psychiatric problems that are the source of the bullying.
The reason is that bullying falls under a subtype of aggression – called “proactive” or “predatory” aggression – that’s purposeful and premeditated. In contrast, “reactive” or “impulsive” aggression occurs when kids lash out because they feel threatened in some way or when they have a low tolerance for frustration.
I found very few studies testing how well medications work in different subtypes of aggression in children, but one that tested the mood stabilizer lithium found it was only effective in reducing impulsive aggression, not predatory aggression.
In general, experts seem to agree that kids who exhibit predatory/proactive aggression – which includes bullying – have control over their behavior. Therefore, behavioral therapies are thought to be most appropriate and effective. And because bullying has a substantial social component and often occurs in groups, many interventions are now focusing on addressing it at the school or group level.
Kids with impulsive aggression, in contrast, generally have less control over their behavior. Often they are super-sensitive to stimuli in the environment. Medications – or psychosocial therapies – that reduce their level of arousal, anxiety, or anger can therefore also reduce their aggression.
When Bullies Have A Psychiatric Disorder
However, it’s very common for bullies to have an underlying psychiatric disorder that causes other symptoms. It’s also common for bullies to be bullied themselves.
One large, population-based study of Finnish children born in 1981 found that of kids who were both bullies and victims of bullying, 97 percent had psychiatric symptoms as rated by their parents or teachers. Of those who were only bullies, 80 percent had psychiatric symptoms.
It’s possible, then, that if clinicians treat the underlying problem, resolving the child’s ADHD, depression, anxiety or bipolar symptoms, for example, that the child may be calmer, happier and less inclined to pick on others.
Medication is far from the only way of treating childhood psychiatric illness, but in many cases it can be effective, especially when it is part of suite of interventions that also includes cognitive, behavioral or other therapy, school accommodations and parent skills training.
So in bullies without psychiatric problems, “pro-social” skills training and school interventions are probably best. But in those who have coexisting psychiatric issues, therapies that target other symptoms, including impulsive aggression, may result in a better-adjusted, less aggressive child who’s less likely to take out his or her own pain and frustration on others by bullying them. Medications are one such treatment.
Share Your Stories
Do you have a child who bullies others, or were you a bully yourself? Are you considering medication for your child, or do you think taking medication would have helped you be less of a bully? Are you a clinician who treats children with aggression? If you did try medication for your child, yourself or a patient, what was its effect on the bullying?
Or are you concerned that in the rush to medicate aggression, doctors might be pushing drugs on run-of-the-mill bullies whose behavior would be better dealt with through other means?
Please feel free to comment!