A substantial proportion of psychiatric and mental health services is devoted to the treatment of severely aggressive, disruptive, and defiant children and adolescents. Aggressive behavior, which is usually thought of as a physical behavior with the potential to harm or damage a living being or inanimate object,⁶is highly distressing to witness, poses a significant threat to self and others, and is a leading cause of psychiatric hospitalization.^7–9 Despite a growing awareness that maladaptive aggression can be a debilitating psychiatric symptom,^10,11 developing and evaluating treatments for aggression has been difficult, as aggressive behaviors occur in a variety of environmental and psychiatric contexts.¹²

While most aggressive youth are diagnosed with a disruptive behavior disorder—conduct disorder (CD) or oppositional defiant disorder (ODD)—aggression also occurs with many other sub-threshold or primary psychiatric conditions, such as attention deficit hyperactivity disorder (ADHD), post-traumatic stress disorder (PTSD), and mood and anxiety disorders.^13,14 Moreover, methodological problems, such as reliably defining and assessing aggression and maintaining pediatric subjects in studies with long baseline periods,6 have restricted the scientific study of aggression. As a result of limited research in this area, interventions for aggressive youth are largely based on heuristic clinical practices, the adult literature, and case reports.¹² Efforts to reduce the costs of mental health treatment by rationing psychosocial approaches and limiting hospitalization have further complicated treatments for aggression, leading standard clinical practices to coincide with increasing financial and social pressures rather than rigorous scientific data.¹² Children and adolescents with maladaptive aggression often receive a combination of medication and psychotherapy, depending on diagnosis, age, and symptom severity.^11,12 Although a variety of medications— including atypical antipsychotics, mood stabilizers, and stimulants—show substantial efficacy in reducing aggression associated with different primary conditions,^{12,15–21} these pharmacological approaches are generally adjunctive to comprehensive psychosocial, community, and psychoeducational interventions, as the underlying neurobiological mechanisms involved in aggression responding remain largely unknown.22 Moreover, recent increases in prescribing to pediatric populations, often on an off-label basis,^23,24 have led parents, educators, and service providers to increasingly explore non-medication treatment options. This article therefore reviews current psychosocial treatments for managing maladaptive aggression in children and adolescents.

Multimodal Treatment
To date, multimodal treatment approaches, which involve parent training, structural family therapies, and child skill-building treatments, have demonstrated the greatest efficacy in managing persistent aggressive behaviors in children and adolescents. These multifocused approaches show a medium to large effect (ranging from 0.4 to 0.9) on conduct problems and aggression in at-risk youth, and demonstrate sustained effects after treatment completion.^{22,25–29}

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