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06. First- and Second-Generation Antipsychotics for Managing Explosive Behavior

Published on June 1, 2022 Expired on June 1, 2025

Carrie A. Vaudreuil, M.D.

Psychiatrist, Massachusetts General Hospital Instructor, Harvard Medical School - Massachusetts General Hospital

Key Points

Risperidone and aripiprazole have the most evidence for treating aggression in children and adolescents.
SGAs can cause side effects and require regular monitoring.

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Slides and Transcript

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In this next section, we’re going to go more in depth into the first and second-generation antipsychotics and their use for managing explosive behavior.

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So as mentioned in the previous section, the first-line treatment for explosive behavior that hasn’t responded to other interventions are the second-generation antipsychotics which have the most evidence for treating explosive behavior across a number of psychiatric diagnoses.

References:

Vaudreuil, C., Farrell, A., & Wozniak, J. (2021). Psychopharmacology of treating explosive behavior. Child and Adolescent Psychiatric Clinics of North America, 30(3), 537-560.

First- and Second-Generation Antipsychotics for Managing Explosive Behavior Slide 2 of 12

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Slide 3 of 12

The medication with the most evidence for treating explosive behavior is risperidone which is typically prescribed at a dose between 0.5 mg and 4 mg daily. The second-generation antipsychotic with the second most evidence supporting its use in the treatment of explosive behavior is aripiprazole which is typically used at a dose of 2 to 15 mg daily.

References:

Vaudreuil, C., Farrell, A., & Wozniak, J. (2021). Psychopharmacology of treating explosive behavior. Child and Adolescent Psychiatric Clinics of North America, 30(3), 537-560.

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When starting a second-generation antipsychotic, start at the lowest dose possible and titrate as slowly as possible increasing the dose no faster than every two days but slower again if possible. Before deciding that a medication is ineffective, it should be tried for at least two weeks.

References:

Vaudreuil, C., Farrell, A., & Wozniak, J. (2021). Psychopharmacology of treating explosive behavior. Child and Adolescent Psychiatric Clinics of North America, 30(3), 537-560.

First- and Second-Generation Antipsychotics for Managing Explosive Behavior Slide 4 of 12

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Slide 5 of 12

When using second-generation antipsychotics, the side effects can include weight gain, sedation, elevated cholesterol, increased risk of developing type 2 diabetes, and metabolic syndrome.

References:

Vaudreuil, C., Farrell, A., & Wozniak, J. (2021). Psychopharmacology of treating explosive behavior. Child and Adolescent Psychiatric Clinics of North America, 30(3), 537-560.

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Because of these risks, lab work should be obtained prior to starting the medication and at regular intervals while the patient is taking the medication. So specifically, you’ll always want to obtain a hemoglobin A1c and a fasting lipid panel prior to starting the medication and then approximately every six months. Weight should be monitored while the patient is on the medication again at regular intervals of at least once every six months.

References:

Vaudreuil, C., Farrell, A., & Wozniak, J. (2021). Psychopharmacology of treating explosive behavior. Child and Adolescent Psychiatric Clinics of North America, 30(3), 537-560.

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Slide 7 of 12

In children with cardiac concerns or a family history of cardiac concerns or in children who are on a number of other medications that can increase QT interval, you may want to obtain an ECG prior to starting the medication and again once the patient is stabilized on the medication because second-generation antipsychotics can also increase the QT interval.

References:

Vaudreuil, C., Farrell, A., & Wozniak, J. (2021). Psychopharmacology of treating explosive behavior. Child and Adolescent Psychiatric Clinics of North America, 30(3), 537-560.

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If the patient has undergone a trial of both risperidone and aripiprazole with no benefit or if there is an adverse reaction to these medications or if there is a contraindication to their use, it is reasonable to consider the use of other second-generation antipsychotics. However, the evidence to support the use of other antipsychotics is significantly more scarce.

References:

Vaudreuil, C., Farrell, A., & Wozniak, J. (2021). Psychopharmacology of treating explosive behavior. Child and Adolescent Psychiatric Clinics of North America, 30(3), 537-560.

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Slide 9 of 12

First-generation antipsychotics can also be considered for the treatment of explosive behavior. However, they are generally avoided due to the risk of side effects including sedation, extrapyramidal side effects, tardive dyskinesia, and neuroleptic malignant syndrome.

References:

Vaudreuil, C., Farrell, A., & Wozniak, J. (2021). Psychopharmacology of treating explosive behavior. Child and Adolescent Psychiatric Clinics of North America, 30(3), 537-560.

First- and Second-Generation Antipsychotics for Managing Explosive Behavior Slide 9 of 12

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Of the first-generation antipsychotics, haloperidol has the most data supporting its use for agitation and aggression in children and adolescents, with a starting dose of 0.5 mg daily and a maximum dose that is weight based of 0.05 to 0.075 mg/kg/day divided every 8 to 12 hours.

References:

Vaudreuil, C., Farrell, A., & Wozniak, J. (2021). Psychopharmacology of treating explosive behavior. Child and Adolescent Psychiatric Clinics of North America, 30(3), 537-560.

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Slide 11 of 12

The key points for this section are: Second-generation antipsychotics and specifically risperidone and aripiprazole have the most evidence supporting their use in the treatment of aggression in children and adolescents across psychiatric disorders. Second-generation antipsychotics carry the risk of a number of side effects and require regular monitoring of lab values and vital signs.

First- and Second-Generation Antipsychotics for Managing Explosive Behavior Slide 11 of 12

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First- and Second-Generation Antipsychotics for Managing Explosive Behavior Slide 12 of 12

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Next Section

07. Antidepressants and Mood Stabilizers for Managing Explosive Behavior

Learning Objectives:

After completing this activity, the learner will be able to:

Perform a thorough evaluation of explosive behavior in children and adolescents.
Differentiate explosive behavior from other common diagnoses in children and adolescents.
Identify the recommended treatments for explosive behavior and prescribe them accordingly.

Release Date: June 1, 2022

Expiration Date: June 1, 2025

Expert: Carrie Vaudreuil, M.D.

Medical Editor: Paz Badía, M.D.

Relevant Financial Disclosures:

None of the faculty, planners, and reviewers for this educational activity have relevant financial relationships to disclose during the last 24 months with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

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