ChapterPDF Available

Integrative Management of Disordered Impulse Control

February 2022

February 2022

DOI:10.1891/9780826185341.0015

In book: Tusaie & Fitzpatrick, Advanced Practice Psychiatric Nursing: integrating psychotherapy, psychopharmacology, & CAM approaches across the lifespan. (pp.pp1-42 preprint)
Chapter: 15
Publisher: Springer publishers

Authors:

Rony Blum

City University of New York - Hunter College

Prevention & early intervention of impulsive disorders. Postulated etiologies are discussed within genetic, parental, attachment (Siegel, Feldman), developmental, psychoneuroimmuno & endocrinological vulnerabilities that may increase "differential susceptibilities" (Bakermans-Kranenburg, Belsky). These vulnerabilities may be exacerbated & shaped by damaging currents within evolving family, peer, community, socioeconomic, sociocultural, sociopolitical collective behaviors. Assessment instruments are identified, with explanations of the earliest possible prevention, integrative treatments, & safest psychopharmacological approaches, to encourage clients to improve their own function, shape a more purposeful life, & contribute to the community.

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337

CHAPTER 15

Integrative Management of Disordered

Impulse Control

RONY BLUM

CHAPTER CONTENTS

Overview: Clarifying This Cluster of Disorders

Epidemiology of Impulsive or Disruptive Disorders

Vulnerabilities and Postulated Etiologies

Encoded Meanings of Aggression in the Adult

World

Assessment and Instruments

Early Prevention and Integrative Treatments

Psychopharmacology

Summary

Case Study

End-of-Chapter Resources

OVERVIEW: CLARIFYING THIS

CLUSTER OF DISORDERS

Gabrielle Carlson, head of the American Association for

Child and Adolescent Psychiatry (AACAP) Presidential

Taskforce, has focused upon understanding child and ado-

lescent emotional dysregulation. She rightly asks: “Are the

children irritable? Aggressive? Having a mood swing? A

meltdown? . . . Without an agreed upon term for the behav-

iors, we lack a treatment target. . . . with limited guidance

for what should be done” (Carlson, 2019). The reason for

this exceptional scrutiny is that the client’s health, families,

and communities suﬀ er profoundly without greater under-

standing of impulsive/disruptive disorders (Duﬀ y et al.,

2020; Carlson & Klein, 2018). They are also responsible for 12

times more disability-adjusted life years (DALYs) than either

attention deﬁ cit hyperactivity disorder (ADHD) or autism

spectrum disorder (ASD), both of which aﬀ ect so many lives.

The medical and socioeconomic impact of impulsive/

disruptive disorders is far beyond other mental health dis-

orders, and if not prevented or treated it can risk assault,

theft, property damage, sexual abuse, and mortality ( Frick

& Kemp, 2021 ). Around 50% of impulsive and disruptive

adolescents outgrow even moderately disruptive behav-

ior, but how can we encourage upstream prevention and

eﬀ ective treatment? These disorders require accurately

diﬀ erentiating the postulated etiology, assessing whether

responses are mostly reactively impulsive or deliberate-

ly antisocial, and applying the most comprehensive ap-

proach to lessen them. Exploring what is feasible to reduce

disruption and aggression in adult clients further requires a

nuanced understanding of how power and powerlessness

modulate the expression of disruptive aggressive behavior

within a matrix of shared meanings. Impulsive disruptive

behavior has a diﬀ erent meaning when deployed by people

in powerful or vulnerable positions, in rough or gentil mi-

lieux, and is diﬀ erently expressed in male or female worlds.

These factors all help explain why it has been diﬃ cult to

address without a suﬃ ciently clear grasp of a more com-

prehensive picture. Aggression originally was employed

to protect human beings—from environmental harm and

harm from one another—but also to acquire and protect

resources ( Weidler et al., 2019). The integrative General Ag-

gression Model (GAM), the most current paradigm, con-

siders developmental, biological, social, environmental,

cognitive, and personality factors on appraisal and decision

processes, which inﬂ uence aggressive behavior. The inter-

action of multiple individual, interpersonal, and social fac-

tors emerge over time within intersecting inﬂ uences of so-

ciocultural, socioeconomic, and political environments. The

etiology, expression, and meaning of aggression should be

individualized, with the holistic context in mind. In order

to encourage the client’s ability to ﬁ nd less harmful ways

of interacting, we must ﬁ nd out how power is deployed, or

abused, within the client’s world.

Children are socialized to ﬁ t into adult sociocultural, so-

cioeconomic, and political milieux, as they usually acquire

more capacities for self-regulation as they grow. Adoles-

cents, however, experience neurological and gonadal up-

heavals; as neuronal migration from the prefrontal cortex to

the occipital cortex occurs, life experiences shape neuronal

pruning, and sex hormonal upsurges transform body and

brain. Due to adolescent life preparation processes, risky be-

havior often overrides self-inhibition. By later adolescence

or young adulthood, when facing their initial life crossroads,

the balance between expression and inhibition often stabi-

lizes—unless adverse circumstances or unfortunate choic-

es upset this balance—so more clinician listening, training,

treating, and therapeutic adjustments are necessary.

Extremely anxious attachment, highly avoidant attach-

ment, and especially disorganized/fearful attachment

contribute to destabilizing the infant’s hypothalamic–

pituitary–adrenal (HPA) axis stress response. This may pre-

dispose clients to develop either “hot” (anxious/impulsive)

or “cold” (avoidant/disruptive) responses, although serious

cold response is sometimes not devoid of impulsivity. It has

long been established that secure attachment relations be-

tween the child and their mother is protective of the infant

psycho-neuro-immunologically, endocrinologically, physi-

ologically, and socioemotionally, helping them adjust base-

line autonomic stability and homeostasis (Shonkoﬀ et al.,

2012; Shonkoﬀ , 2017). Thus, here it is postulated that chronic

hyperarousal may partially be the result of early anxious

attachment expressed later as a “hot” response, while an

infant’s avoidant attachment may correspond with subse-

quent hypo-arousal as a “cold” response. Both may partially

be the result of the child’s early insecure attachment expe-

riences. The years of bonding entrainment during the early

years usually results in structural and functional neuronal

shaping and implications for the immune system, stress re-

sponses, homeostasis, neuroendocrine system, sleep, and

metabolism. A more devastating impact can be expected to

occur if there are parental medical conditions, addictions, or

socioeconomic disadvantages; familial instabilities; environ-

mental toxic exposures; congenital neurodevelopmental deﬁ -

cits and disabilities; and conﬂ icted nurturing responses as the

parent struggles to cope. Familial intergenerational patterns

can impact maternal interpersonal trauma responses, adding

to insecure attachment patterns. Interventions consisting of

maternal “reorganization” of coping with her traumatic life

events and parenting tools should be the ﬁ rst step in achiev-

ing a secure attachment with her child (Iyengar et al., 2019), at

the earliest age, to prevent compounding problems. Yet, the

usual trajectory and individual responses—especially with

unanticipated life events—may be shifted by anxious, avoid-

ant, or fearful attachment as life unfolds; this requires the de-

velopment of further capacities to anchor a feeling of security.

The examination of intergenerational transmission via

epigenetics was begun after the pioneers of epigenetics,

Howard Cedar and Aharon Razin, found in 1982 that

during embryonic development “genetic reprogramming”

corrects some parental methylation and acetylation pat-

terns. Yet, certain “environmentally-induced epigenetic

changes that occur in the parent are, for some aspects, “in-

herited by the oﬀ spring as a short-cut to evolution by way

of DNA-methylation-derived memory” (Cedar & Razin,

2017). Belsky’s thesis (Pluess et al., 2013) was that prenatal

stress programs post-natal environmental responsivity and

neurodevelopmental plasticity, even before nurture or na-

ture can modify the child (Hartman & Belsky, 2018).

The impact of early nurture is modulated at several stag-

es. Marian Bakermans-Kranenburg’s “Genetic Diﬀ erential

Susceptibility Model” underlines that infants are diﬀ er-

entially impacted by early nurture and their surrounding

environment, due to their own allelic variants and epigen-

etic methylation patterns (Bakermans-Kraneneburg & Van

IJzendoorn, 2015). Jay Belsky substantiated this model when

he found that children with at-risk alleles suﬀ ering from

adversities were, surprisingly, those who blossomed most

after the introduction of supportive, stimulating environ-

ments (Belsky & Van Ijzendoorn, 2017). Thus, interventions

targeting the earliest years’ neuroendocrine “mother–infant

synchrony” (Feldman, 2017) aim at prevention. By middle

childhood, twin studies show that while ventral striatal and

amygdala connectivity to the orbitofronta l cortex (OFC) has

high heritability, ventral striatal to thalamus connectivity

was mostly due to environmental factors (Achterberg et al.,

2018). So, we can better estimate what can, or cannot, be

modiﬁ ed depending upon the neurological area and ac-

companying behavioral expression of concern. Throughout

childhood, earlier intervention is best to prevent problems

from growing, from nursery school until the end of middle

school. During puberty, there is transformative neuronal

migration and myelination with emerging gonadal hor-

mones; accelerated growth; and immunological, epigenetic,

educational, and social role transformations, in addition to

a growing awareness of the adult world and possible future

roles in it. However, behavioral risks which may take indi-

viduals oﬀ track are also greater, due to wider social circles,

less overt parental oversight, intense adolescent peer bond-

ing while developing in semi-synchrony (Siegel, 2015), and

altered circadian patterns during brain remodeling (Deibel

et al., 2020). As the adolescent progresses to young adult-

hood, their own agency and life-changing decisions emerge

at crucial crossroads. If interventions were ineﬀ ective along

the way, this is the last best time to catch them before they

fall into the netherworld of an antisocial adulthood.

Thus, while 50% to 40% do fall into that netherworld, the

other half seemingly correct their impulsive/disruptive path

along the way. Some stop acting out after being diagnosed

with oppositional deﬁ ant disorder (ODD) before adoles-

cence, while others diagnosed with conduct disorder (CD)

by adolescence redirect their path during that time, since at

18 they risk being diagnosed with severe delinquency, anti-

social personality disorder (APD), and a poorer prognosis.

This chapter brieﬂ y outlines many of the key factors

of the psychoneuroimmunological and -endocrinological

models (Danese & Lewis, 2017). It points out key vulner-

abilities and developmental shapers that can transform

child, adolescent, and adult impulsive or disruptive be-

havior. These include parental health and behaviors, birth

factors, environmental exposures, genomic/epigenomic

factors, brain structure and function, genetic diﬀ erential

susceptibilities, mother–child neuroendocrine synchro-

ny and hormonal development, mother–child attachment

variations and epigenetics, family ecosystem, mentoring

“zone of proximal development,” education and peer dy-

namics, community dynamics, and young adult pathways.

Assessment tools are discussed, including Diagnostic

and Statistical Manual of Mental Disorders (5th ed.; DSM-5;

American Psychiatric Association, 2013) criteria and a man-

agement algorithm. Thematic assessment questions that

help guide evaluation include whether your young client

has more internalization or externalization, more impulsiv-

ity or disruptive behavior, more “hot” (reactive aggression)

or more cold (instrumental/predatory aggression), and

whether your client has demonstrated more prosocial/em-

pathic tendencies or antisocial (callous-unemotional [CU])

aspects? Together with your comprehensive psychiatric

assessment answers, these questions help give you a more

complete sense of the special emotional needs, psychoso-

matic responses, and coping processes of your client.

338 III: INTEGRATIVE MANAGEMENT OF SPECIFIC SYNDROMES

While APD clients are discussed in their own chapter, in

this one, adult clients with subclinical symptoms or asso-

ciated diagnoses with prominent impulsive or disruptive

symptoms are explored, such as intermittent explosive dis-

order (IED), which—although very familiar to all of us in

non- or subclinical clients who are fully functional except for

occasional, but notable, verbal or physical outbursts—lacks

a suﬃ cient research base as of yet, but clinicians frequently

want to know how to assist them. While the client with bor-

derline personality disorder (BPD) is often anticipated to be

the most challenging, the condition is highly treatable with

psychotherapy. Additional questions beyond those noted

previously for youth must be added for these two adult

diagnoses with notable impulsive/disruptive symptom

clusters. This can help the psychiatric-mental health ad-

vanced practice registered nurse (PMH-APRN) frame the

multiscale systems within which a client copes with their

unique context and life events for a more nuanced assess-

ment. Socioeconomic, sociocultural, and sociopolitical chal-

lenges present meso- to macroscale biopsychosocial contex-

tual matrices within which the client attempts to steer their

life. They may not feel a salutogenic “sense of coherence”

(Antonovsky, 1987), or be able to ﬁ nd meaning in their life

(Frankl, 1987), if that engagement results in a feeling of fail-

ure to meet what their life asks of them. Cultural “idioms of

distress” are discussed brieﬂ y, including notable or severe

impulsive or disruptive symptoms, usually without recog-

nized prior mental health issues, and larger questions of

sudden, unexpected acts of mass or homicidal-suicidal vi-

olence within complex family, socioeconomic, community,

sociocultural, and sociopolitical contexts.

After assessment, the most highly recommended parent–

child, individual, group, and multisystemic psychother-

apies, as well as current complementary and alternative

medicine (CAM) and conventional pharmacological aids to

facilitate client eﬀ orts to experience more coherency and a

more meaningful life, are brieﬂ y outlined.

EPIDEMIOLOGY OF IMPULSIVE

OR DISRUPTIVE DISORDERS

ODD prevalence is currently measured to be 3.3%, with

a ratio of 1.4:1 (boys to girls). For CD, the prevalence is

about 4% in schoolchildren ( Lochman et al. , 2019), with

2:1 gap from boys to girls (Fairchild et al., 2019). Estimated

lifetime prevalence rate of ODD may be as high as 65%

in clinical samples (Mikolajewski et al., 2017). A callous-

ness-unemotionality (CU) subset was added to the DSM-5

CD diagnosis, also called low prosocial emotions (LPE),

at a rate of 30% to 40% of those diagnosed with CD (Fair-

child et al., 2019). In rougher urban neighborhoods, acting

“tough,” joining a gang for protection, or seeking delin-

quent mentorship can be hard to refuse (Shatkin, 2015). In

the United States, the gender gap is 3:1 boys (6%–16%) to

girls (2%–9%), depending upon milieux (Lochman et al.,

201 9). There is frequent comorbidity and symptom overlap

between impulsive/disruptive disorders with bipolar I

and ADHD. It would make sense to treat the emotional

rollercoaster of bipolar I ﬁ rst, then secondarily try to mit-

igate antisocial behavior thereafter (Wozniak et al., 2019).

Impulsivity/disruptiveness can feature in other disorders,

particularly BPD, ADHD, mood disorders, substance abuse

disorders, eating disorders, obsessive-compulsive disor-

ders (OCD), and less frequently in anxiety disorders. In

about 60% of cases, impulsive/disruptive symptoms will

remit, but about 10% of children had symptoms at some

point (Fairchild et al., 2019). For IED in youth or adults,

the rate in community samples is 8.9%, although it is not

often paired with other disruptive disorders (Radwan &

Coccaro, 2020). BPD is among the most frequently seen

diagnoses clinically, with considerable symptom cluster

overlap with bipolar disorder (BP), which is discussed

in Chapter 9, “Integrative Management of Disordered

Mood.” Despite high comorbidity between these two dis-

orders and some clinician support for conceiving of them

along a bipolar spectrum, this chapter will not include

bipolar. The perspective here expressed is that while BP

is a rare disorder with a recognized genetic basis whose

treatment usually requires mood stabilizer pharmacother-

apy, the etiology of BPD appears to be often associated

with early sexual psycho-trauma in girls which destabiliz-

es aﬀ ect, identity, mood, and behavior, but, most impor-

tantly, their relationships. Thus, while BP should usually

be treated with mood stabilizers, BPD is often best treated

with psychotherapy within the framework of a trusting

long-term therapeutic relationship. However, there is no

expert consensus as to whether or not the disorders are

distinct or on a continuum; thus, the perspective adopted

here is not universally recognized (Sanches, 2019). Recent-

ly, after a meta-analysis of resting state functional magnet-

ic imaging (fMRI), BPD was proposed to be recognized as

a traumatic stress disorder instead of an enduring person-

ality disorder, since the symptoms can change over time

(Amad et al., 2019).

To what extent are these DSM-5 diagnostic criteria

valid socioculturally and politically across the globe, in

socioeconomically varied subcultural enclaves, and over

time? ODD and CD rates from 1987 to 2008 were evalu-

ated across minority subcultures in the United States to

determine validity, sensitivity, and speciﬁ city of the diag-

nostic categories, as well as across the globe. Rates were

not found to signiﬁ cantly vary geographically, but the

methodology did (Canino et al., 2010). Risk and protec-

tive factors balanced outcomes diﬀ erently. Cross-cultural

results across 16 areas of the world, using the Child Behav-

ior Checklist (CBCL) and a multivariate meta-regression,

indicated more internalizing than externalizing symptoms

in Asian regions versus Euro-American regions (Canino

et al., 2010). In the United States, from among a clinical

convenience sample of 1,173 youth in residential treat-

ment facilities, Caucasian youth were diagnosed with CD

at 24.4%, whereas Hispanic youth were at 43.3%, and Afri-

can American youth at 34.4% ( Fadus et al., 2020 ). The dis-

parities might indicate that clinicians’ mistakenly resigned

attitude perpetuates structural inequities and this may

be ameliorated by addressing them during mental health

15: INTEGRATIVE MANAGEMENT OF DISORDERED IMPULSE CONTROL 339

training. Use of the Cultural Formation Interview to know

discrepancies in parental reporting may also improve con-

sistency (Fadus et al., 2020 ).

VULNERABILITIES

AND POSTULATED ETIOLOGIES

Paul Frick’s multidisciplinary, multinational team em-

phasizes that the more serious CD is associated with low

HPA-axis reactivity to stress, neurocognitive impairment

(i.e., less grey matter in the amygdala, insula, and OFC),

functional abnormalities in emotion-processing and regula-

tion and decision-making, and lower autonomic reactivity

to stress. Increased responsiveness to perceived threat or so-

cial provocation may be due to altered amygdala responses

and/or structural deﬁ cits, but not due to frustration (Blair,

2018). However, twin studies show that about 50% of de-

veloping CD is due to environmental factors (Fairchild et

al., 2019). Before arriving at this stage where emotional and

cognitive circuits are functionally impaired, an integrative

systems view of development can help identify preventive

points of intervention.

Parental Health, Mental Health,

and Behavior

Parental medical, mental, social, or economic diﬃ culties

can put a child at risk for impulsivity or disruptive behav-

ior and other mental health issues. Young maternal age at

birth, low maternal education, history of parental antisocial

behavior, extreme family conﬂ ict, sparse socioeconomic re-

sources, and community violence can involve the infant or

child in multiple adverse childhood events (ACEs). Com-

bined adversities can lead to physical neglect at a rate of

65% and abuse at 35%, as well as sexual abuse and serial

foster home residence ( Seguin & Pilon, 2013 ; Shatkin, 2015;

Wozniak et al., 2019).

Maternal and Birth Complications

Infants exposed to some anesthetic agents, as well as pre-

natal tobacco, alcohol, prescription medications, illicit

substances, and often polysubstance misuse at once, can

experience withdrawal 48 to 72 hours postpartum after

discontinuation of the substance. Untreated newborns are

at risk for low birth weight (LBW), interuterine growth

restriction (IUGR), and placental anomalies in addition to

other maternal physiological, neurological, and behavioral

harms. Since 2016, the U.S. Food and Drug Administration

(FDA) has warned against the neurotoxic impact of the an-

esthetic agents isoﬂ urane, sevoﬂ urane, desﬂ urane, propo-

fol IV, and midazolam IV upon the fetal brain during the

third trimester of pregnancy, but also upon infants’ and

developing children’s brains. Strategies to circumvent this

impact are using nongamma-aminobutyric acid agonist

agents like opioids or dexmedetomidine when appropri-

ate, minimizing inhalation anesthetics during pregnancy,

beginning surgery promptly, and using intravenous toco-

lytics for uterine relaxation for fetal surgery instead of in-

halational anesthetics (Olutoye et al., 2018).

Many gestational and birth diﬃ culties can put the in-

fant at risk for developmental delays, social diﬃ culties,

and consequent behavioral diﬃ culties. IUGR was ex-

amined by Michael Meaney, who found that poor fetal

growth and catch-up growth were associated with child-

hood impulsivity and food fussiness—especially in girls—

alongside later risk for diabetes and metabolic syndrome

(Silveira et al., 2018). Early brain development begins with

the primary motor and sensory systems before cognitive

and executive systems, while well-matured newborns

display integrated connection patterns which are fur-

ther elaborated for higher cognitive functions. There are

multiple ways premature infants’ brains may have been

injured. The most well-known is encephalopathy of pre-

maturity (EP), but others include intraventricular hem-

orrhage (IVH), post-hemorrhagic hydrocephalus (PHH),

hypoxic-ischemic encephalopathy (HIE), and periventric-

ular leukomalacia (PVL). Due to technological advance-

ment in neuroimaging—diﬀ usion magnetic resonance

imaging (dMRI), resting state functional magnetic reso-

nance imaging (rs-fMRI), functional near infrared spec-

troscopy (fNIRS), diﬀ use optical tomography (DOT)—we

are now more aware of the extent to which these well-

known conditions damage structural and functional con-

nectivity in neonatal intensive care unit (NICU) babies

(Smyser et al., 2019). According to injury frequency, PVL

injury involves focal necrosis dorsal/lateral to the lateral

ventricles, with diﬀ use injury to focal necrotic lesions with

diﬀ use injury to pre-oligodendrocytes, astrogliosis, and

microgliosis, with less severe forms in 25% of premature

infants. These lesions result in spastic diplegia and cog-

nitive damage due to impaired oxygenation. IVH occurs

in 23% of very preterm infants (less than 32 weeks’ gesta-

tion) within the ﬁ rst 72 hours of life, and over 50% devel-

op neurodevelopmental disabilities spanning language,

cognitive, motor, and social ﬁ elds. Post-hemorrhagic

ventricular dilatation (PHVD) occurs in 50% of babies

who have IVH and develop PHH. Cognitive damage in

PHH is greater than +85% with cerebral palsy in 70% of

aﬀ ected infants (Matthews et al., 2018). For term infants,

25% to 80% of hypoxic–ischemic injuries (HIE) result in

deep nuclear grey matter damage to the basal ganglia and

thalamus. Watershed-type injury to white matter can ex-

tend to neuronal necrosis of the cortex for 15% to 45% of

HIE cases. Relative preservation of core connections, but

disruption of local connections, is also seen in preadoles-

cents of preterm birth, with neuromotor deﬁ cits still seen

at 6 months. Even diﬀ use impairments lead to neurode-

velopmental sequelae (Smyser et al., 2019). Preterm in-

fants have been strongly linked to impulsivity. The most

premature infants (very preterm [VP]/very low below

weight [VLBW]) were three times more likely to be diag-

nosed with ADHD than controls, and extremely preterm

(EP)/extremely below weight (ELBW) infants had four

times the risk. The explanatory hypothesis is that medical

problems, HPA-axis dysregulations, and perinatal system-

ic inﬂ ammation can cause structural and functional brain

diﬃ culties, which are expressed in increased impulsivity,

cognitive deﬁ cits, and emotional dysregulation, especially

340 III: INTEGRATIVE MANAGEMENT OF SPECIFIC SYNDROMES

if paired with parental/environmental adversities ( Franz

et al., 2018 ; Lee et al., 2021).

Parental Behavioral Risk Factors

Childhood aggression is most highly associated with to-

bacco inhalation (77%), maternal smoking (46%), alcohol

consumption (25%), chemical exposures (polychlorinated

biphenyls [PCBs], PCDFs; 15%), cognitive deﬁ cits, educa-

tional attainment, and genetic variation in the ﬁ rst mul-

ticountry meta-analysis of epigenome association study

(EWAS) with 15,324 participants from the Netherlands Twin

rotoxic to the fetal brain, fosters epigenetic changes in fetal

neuronal stem cells, and leads to postnatal neurobehav-

ioral disorders. It increases infertility, IUGR, miscarriage,

premature birth, sudden infant death syndrome (SIDS),

fetal pulmonary dysfunction, impaired hearing, damaged

infant cardiac and respiratory functions, and 1,000 deaths

annually (England et al., 2017; Sailer et al., 2019 ; Seguin &

Pilon, 2013 ). Maternal smoking in the United States has a

prevalence of 5.9%, while in Asia it is 25%, and in Ireland

it is highest at 38.4%. The FDA has listed 93 harmful and

potentially harmful constituents in tobacco ( Ashley, 2019 ).

Prenatal alcohol risk to the developing brain for

aggression was also a key variable in the same EWAS meta-

analysis (van Dongen et al., 2020). Around 25% of 18- to

34-year-olds binge drink and 7.3% of pregnancies were ex-

posed to alcohol, during which gastrulation and neurula-

tion can be disrupted, resulting in craniofacial dysmorphia

and brain abnormalities (Wozniak et al., 2019). Prevalence

rates for fetal alcohol spectrum disease (FASD) symptoms

in children due to maternal alcohol intake are estimated to

be 2% to 5% in the United States yet are believed to be vastly

underdiagnosed when not including facial dysmorphia, due

to social stigma (Domeij et al., 2018). FASD damages neu-

rodevelopment through oxidating injury, apoptosis, mod-

ulation of genetic expression, and disruption of neuronal

migration. Alcohol disrupts neural cell migration and ax-

onal pathﬁ nding by blocking cell adhesion and axonal

outgrowth mediated by the L1 neural cell adhesion mol-

ecule. Mutations in the L1 gene cause dysgenesis of the

corpus callosum, hydrocephalus, and cerebellar dysplasia.

Genetic, epigenetic, molecular, cellular, and physiological

interactions damage development and function. Apoptotic

death and impaired migration of neural crest cells leads to

brain and craniofacial malformations, while impaired pro-

liferation of neural stem cells contributes to microcephaly

by shrinking the pool of neural progenitor cells. In a study

of 65 infants who died within a year of FASD, 13% had

microcephaly, 8% had dysgenesis of the posterior corpus

callosum, and in 6% there was minor heterotopias, as com-

pared with MRIs of 5,000 typically developing children.

A systematic review of 18 qualitative studies discusses

children suﬀ ering from FASD, accompanied by executive

function deﬁ cits, emotional lability, somatic problems, high

pain tolerance, destructive behavior, hyperactivity, aggres-

sion, social diﬃ culties in friendships, school absences, in-

consistency at work, and a higher risk of addictions. Emo-

tional and behavioral dysregulation were severe enough to

be deemed a disability and impede schooling, risking de-

linquent behavior (van Dongen et al., 2020; Wozniak et al.,

2019). The death of proopiomelanocortin neurons in the

hypothalamic arcuate nucleus reduces HPA-axis function’s

stress mitigation and alters circadian rhythms through a

ﬂ atter cortisol response from the adrenals. Premeditated

aggression is associated with the late chronotype, perhaps

due to circadian misalignment and alteration of CLOCK,

SIRT1, BMALI, and PER2, which regulate monoamine oxi-

dase A (MAO-A; Deibel et al., 2020). Alcohol-induced endo-

crine dysfunction, disruption of morphogen signaling, and

activation of neuro-inﬂ ammation impact the developing

brain and immune system (Wozniak et al., 2019).

Maternal opioid abuse puts the fetus at risk for neona-

tal abstinence syndrome (NAS), to suﬀ er undue somatic,

neurological, cognitive, and emotional diﬃ culties (Haight

et al., 2018). The increase was more than ﬁ ve-fold from 2004

to 2014, increasing to 32,000 infants (Honein et al., 2019).

The American College of Obstetricians and Gynecologists

(ACOG) 2016 guidelines recommend that, to ensure they

are appropriate, the prescription of opioids should be pre-

ceded by a review of the Prescription Drug Monitoring Pro-

gram, that contraception counseling should be provided to

warn about the risks of opioid use during pregnancy, and

that medication-assisted therapy (MAT) be prescribed when

possible (Honein et al., 2019). A RAM literature review of

1,697 articles (including cohort and case studies) was win-

nowed to 75 articles to provide a national guidance docu-

ment for the Substance Abuse and Mental Health Services

Administration (SAMHSA) and Health and Human Ser-

vices (HHS) and found that pregnant mothers with opioid

misuse disorder should preferentially be treated with bu-

prenorphine (medication-assisted treatment) during preg-

nancy to reduce NAS severity, and this has better outcomes

than methadone. The Federal Steering Committee report

recommends longitudinal mother–infant surveillance, as it

appears that many developmental and physical disorders

have not yet been properly linked to polysubstance NAS,

yet those children usually need more special education and

early intervention services; this also is associated with gas-

troschisis and ASD (Klaman et al., 2017).

Environmental Toxins Affect

Neurodevelopment and Behavior

Exposomics has largely concluded that epigenetic mech-

anisms (genes X environment, or GxE) with a neuropsy-

chiatric impact following environmental exposures are

often due to synaptic dysfunction, microglia-immune alter-

ations, and gut–brain interactions (Hollander et al., 2020).

Impaired cognition is epidemiologically associated with

prenatal exposures to alcohol, polycyclic aromatic hydro-

carbons (PAHs), lead, methylmercury, organophosphate

pesticides (OPPs), and polychlorinated biphenyl ethers

(PBDEs). ADHD and autism are associated with prena-

tal exposure to the same, but not PAHs or OPPs (van de

Bor, 2019). Genetic factors are estimated to be only 30% to

40% of all causes of altered neurodevelopment, with envi-

ronmental factors accounting for 70% to 60% (Grandjean

15: INTEGRATIVE MANAGEMENT OF DISORDERED IMPULSE CONTROL 341

& Landrigan, 2014). The risk is greatest upon the devel-

oping brain in utero, infancy, and early childhood, since

low exposures from 200 chemicals pass from maternal to

fetal blood and breast milk; the fetal and neonatal blood–

brain barrier is highly vulnerable to intrusion (Grandjean

& Landrigan, 2014; van de Bor, 2019). Depending upon the

level of prenatal exposure, research has found that alcohol,

PAHs, lead, methylmercury (MeHg), OPPs, and PBDEs can

impair cognitive development partially via fetal microglia

activation, which itself is triggered by maternal immune

activation (Hollander et al., 2020). Chemicals can raise the

risk of ADHD, ASD, or disruptive disorder symptoms, es-

pecially alcohol, MeHg, OPPs, PBDEs, PCBs, and bisphenol

A (Bonmarito et al., 2017; van Dongen et al., 2020). Blood

lead levels from 5 micrograms/dL in early life have been

associated with aggression (Hollander et al., 2020). In the

United States, the murder rate decreased dramatically 20

years after lead was removed from gasoline (Grandjean &

Landrigan, 2014) and recently, high lead levels have been

found in shooters in South Africa (Naicker et al., 2018).

Methylmercury aﬀ ects neural stem cells and is moderately

associated with aggressive behaviors (Karatela et al., 2017).

A systematic review of the literature found that prenatal

exposures to fetal BPA were associated with higher lev-

els of anxiety, depression, aggression, and hyperactivity,

while children’s urine BPA metabolites (up to age 12) were

associated with the same symptoms, plus inattention and

conduct problems (Ejaredar et al., 2016). Phthalates have

been linked to neurodevelopmental deﬁ cits and behavioral

problems due to impaired attention and social interactions.

Pesticides inhibit cholinesterase function in the develop-

ing brain, harming the regulatory role of acetylcholine

before synapse formation (Grandjean & Landrigan, 2014).

A French cohort of 3,000 children were researched for ma-

ternal solvent exposure (e.g., nurse, chemist, cleaner, hair-

dresser, beautician), and exposure was reported to be tied

to dose-related hyperactivity and aggressive behavior. Pre-

natal exposure to organophosphate pesticides (like pyrifos)

measured in maternal urine results in dose-related micro-

cephaly at birth. Permethrine, a common delousing agent,

is associated with pediatric neurodevelopmental deﬁ cits

(Grandjean & Landrigan, 2014). A systematic review asso-

ciated the impact of prenatal phthalate exposure in boys

to lower cognitive scores, delayed psychomotor develop-

ment, and problem behavior ( Zhang et al., 2019 ). Yet the

most ubiquitous of all—prenatal air pollution and diesel

exhaust—also damages neural-glial activation, with mat-

urational delay. Gut–brain microbial dysbiosis aﬀ ects sero-

tonin and gamma-aminobutyric acid (GABA) production

and impacts immune processes (Hollander et al., 2020).

Genomic/Epigenomic Associations

With Impulsivity and Disruptive

Behavior

Irritability has been found to be 30% to 40% heritable from

twin studies, which increases in males, but decreases in fe-

males as they mature. It is associated with family and mater-

nal depression, and there is some genetic overlap. Amygdala

dysfunction impacts irritability in children, who can mistake

facial euthymia as threatening (Vidal-Ribas et al., 2016). CU

traits are the most concerning aspects of disruptive behavior

and can lead to severe violence. The heritability of CD with

CU traits is estimated to be 45% to 67% (Fairchild et al., 2019)

but Frick’s other study of 5,092 twin pairs age 16 in England

and Wales demonstrated 70% to 79% heritability ( Frick &

Kemp, 2021 ), while Moore’s study of 339 twin pairs ages 9

to 14 found it to be 39% to 47% (Moore et al., 2017). CU be-

havior in children was also measured in 339 twin pairs ages

9 to 14 years in two assessments with the Inventory of Cal-

lous-Unemotional Traits (ICU) to assess heritability, which

contributed 79% to CU traits. Altogether, 117 twin pairs were

monozygotic, while 120 were dizygotic, and 120 pairs were

opposite sex dizygotic. Heritability for exclusively monozy-

gotic twins might be surmised to be higher (sharing 100% of

their genes instead of 50%). The boys had a higher CU score

than the girls, yet in both cases, 53% could be accounted for

by parental inﬂ uence and family factors (Moore et al., 2017).

Bakermans-Kranenburg and van IJzendoorn found, in a key

twin study, that variances in amygdala-OFC connectivity

are 54% genetic (Achterberg et al., 2018).

Genetic studies have linked some genes and enzymes

to disruptive disorders: MAOA (the monoamine oxidase

A gene codes mitochondrial enzymes, which catalyze the

oxidative deamination of dopamine, norepinephrine, and

serotonin), COMT (rsrs4680 allele variant homozygous Met/

Met for slower catecholamine metabolism), 5-HTTLPR

(serotonin transporter polymorphisms) like 5-HT1B and

5-HT2A (the latter of which decreases the amygdala–OFC

connection), and 5-HT3 (alcoholism and APD-linked;

Moore et al., 2017; Rosell & Siever, 2015). MAOA has

been called the “warrior gene,” meaning it is associated

with aggression, and the aggression-linked variant allele

is X-linked (MAOA-VNTR), so the eﬀ ect is higher in men

(Rosell & Siever, 2015). Hollerbach’s research on a com-

munity sample of 2,796 Finnish twins supports low activ-

ity in the MAOA gene and the shorter polymorphism—if

there has been early childhood adversities—as key factors

in antisocial behavior, including CU traits (Lochman et al.,

2019) . A low activity allele in MAOA in the VNTR promot-

er, P2, is linked with epigenetic methylation, sensitizing

girls to childhood abuse, which, if combined, are risk fac-

tors for antisocial CD symptoms. But the protective eﬀ ect

of high activity in the MAOA gene only applies to Cauca-

sians ( Ling et al., 2019 ). Valproate (Depakote) upregulates

MAOA. Even in forensic legal proceedings in the United

States and Italy, the MAOA-L genotype has been presented

as a risk factor for criminality in 11 cases, yet the allele’s

eﬀ ect may increase concern about greater risk of recidivism

(McSwiggan et al., 2017).

The COMT enzyme metabolizes catecholamines (do-

pamine, norepinephrine, and epinephrine) primarily in

the prefrontal cortex (PFC), especially dopamine. The

Val/158Met COMT rsrs4680 allele variant thus results in

higher basal levels of dopamine, Val/Met has an interme-

diate level, while Met/Met has lower dopamine. Marian

Bakermans-Kranenburg decided that the Met/Met variant,

when subjected to childhood ACEs, experienced higher

342 III: INTEGRATIVE MANAGEMENT OF SPECIFIC SYNDROMES

psychosocial stress, anxiety, and pain, while the Val/Val al-

lele has been less sensitive (Crum et al., 2018). However,

the Met/Met allele variant responded positively to conceiv-

ing of stress as a challenge to meet; it improved cognitive

ﬂ exibility and increased happiness. The Val/Val variant was

less open to seeing stress as positive (Crum et al., 2018).

Belsky tested the Diﬀ erential Susceptibility Hypothesis and

found that Val/Val homozygotes, if subjected to childhood

adversity, expressed more aggression than those with Met/

Met. Yet, lacking those challenges, Val/Val had signiﬁ cant-

ly less aggression than those with Met/Met (Hygen et al.,

2015; Jager et al., 2020). They found geographical/cultural

linkages with frequencies as well: more COMT Val/Val al-

lele variants than Met/Met were found in Asians (43.9 vs.

13.3) and Black individuals (22 vs. 6.7), but Caucasians had

proportionally more Met/Met allele variants (40 vs. 24.4;

Crum et al., 2018). In Norway, Val/Vals were at 21.4%, Val/

Mets were 50.4%, and Met/Met was at 28.1% (Hygen et al.,

2015). These ﬁ ndings indicate that rather than a Stress-

Diathesis approach to early adversity, we should recognize

the importance of diﬀ erential susceptibilities toward envi-

ronmental challenges upon plasticity.

Other genes associated with CD have been the sodium-

dependent transporter (SLC6 A4), genes encoding the

oxytocin receptor (OXTR), and a polymorphism (single-

nucleotide polymorphisms [SNPs]: OXTR_rs237885AA

genotype) for UC traits. Vasopressin V1a receptor (AVPRIA)

has diﬀ erent loci for girls. Vasopressin inﬂ uences circadi-

an rhythms, and hyperactivity of AVPR1a polymorphisms

contributes to aggression (Deibel et al., 2020; Rosell & Siev-

er, 2015). Carriers of the D4 7R allele associated with pre-

natal stress had signiﬁ cantly more trait aggression (Rosell

& Siever, 2015). Genome-wide association studies (GWAS)

of RBFOX1 have found that it encodes the regulation of

neurodevelopmental processes. Canine and rodent aggres-

sion both have upregulated RBFOX1 (Fernandez-Castillo

et al., 2020). Another GWAS found C1QTNF7 (linked to

glucose metabolism and insulin signaling) With CD (Fair-

child et al., 2019). Genes associated with aggression in the

Dutch-Finnish EWAS meta-analysis point to associations

with 15 CpGs and 10 transcripts and their associations:

mostly of the AHRR (smoking), EXOC3, FLOT1 (schizo-

phrenia), TUBB (schizophrenia), RP4-647J21.1, SEMA7A,

and FAM60A gene expressions associated with CpGs

(van Dongen et al., 2020). For IED, a GWAS found that 27

methylation CpG site changes occur, but none reached ge-

nome-wide signiﬁ cance. With functional enrichment, these

genes are involved in the inﬂ ammatory/immune system,

the endocrine system, and GABAergic neuronal diﬀ erenti-

ation, which matches previous associations between inﬂ am-

matory cytokines like C-reactive protein (CRP), interleukin-6

(IL-6), and interleukin-1RAII protein and aggression. These

inﬂ ammatory pathways of the genes HTR1D, DAT, SLC63A,

AVPR1A, GRM5, NR3C1, and CRHBP are also associated

with maternal deprivation, child abuse, PTSD, and/or low

socioeoconomic status (Montalvo-Ortiz et al., 2018). Hypo-

or hyper-GABAergic tone increases aggression, thus empha-

sizing the importance of excitatory/inhibitory balance in the

OFC (Jager et al., 2020).

One in ten thousand children is born with XYY chro-

mosomes, with an even rarer genotype being a mosaicism

46,XY/47,XYY (Sood & Fuentes, 2020; van Rijn, 2019).

Around 85% of XYY boys have probably not been diag-

nosed, but typical physiognomy appears as tall stature,

macrocephaly, hypotonia, clinodactyly, hypertelorism, ﬂ at

feet, prognathic jaw, macrodontia, macro-orchidism, fertili-

ty problems like microphallus, hypoplastic scrotum, crypt-

orchidism, hypospadias, oligospermia, or sperm chromo-

somal abnormalities. Microdeletions in the long arm of the

Y chromosome, in the Yq11 region, the azoospermic factor,

may not permit the client to produce sperm (Sood & Fuen-

tes, 2020). Boys with Jacobs’ syndrome are at signiﬁ cant-

ly higher risk for seizure disorders, asthma, and tremors,

and have greater risk for developmental delays, behavioral

problems, diﬃ culties with impulse control, ASD, and an

average of 10 years less longevity. Incarcerated men with

high testosterone levels were aggressive, with increased

risk for criminal behavior. Bardsley found increased grey

brain matter with possibly reduced synaptic pruning (Sood

& Fuentes, 2020). Among Bardsley’s sample, 50% of the

boys had ADHD, as opposed to 16% in the general popu-

lation. ADHD has a global prevalence rate of 7.2%, but di-

mensional assessments of XYY boys found 69% had ADHD

symptoms. In a global study, language impairments for

XYY were near 80%, and executive functioning deﬁ cits

were over 23% to 57% with more externalizing problems,

social diﬃ culties, ASD symptoms, disorganized psychotic

thought, and ADHD symptoms (Sood & Fuentes, 2020).

Brain Structure and Function

in Impulsive/Disruptive Disorders

Frequent early symptoms seen in many children are anxiety or

irritability. Anxiety must be clearly distinguished from symp-

toms of irritability, which is an increased tendency to exhibit

anger toward peers. While both may generate negative aﬀ ect,

those with anxiety tend to ﬂ ee the source of danger, while

those with irritability tend to approach it. These symptoms

correlate with diﬀ erential neural activations. While anxiety

has been associated with increased amygdala connectivity to

the cingulate, thalamus, and precentral gyrus, irritability has

been associated with increased activity in the insula, caudate,

dorsolateral and ventrolateral prefrontal cortex, and inferior

parietal lobule ( Kircanski, Clayton, et al., 2018).

Via the cortico-basal ganglia-thalamo-cortical loop (CB-

GTC loop), disruptive clients were found to have increased

activity in the striatum (located in the basal ganglia). The

striatum is critical to motor, cognitive, emotional-process-

ing, inhibition or impulsivity, reward, decision-making,

planning, and motivational connectomes which connect

the limbic system (sense-interpreting, feeling, and memo-

ry-creating part of the brain) mainly to the OFC. Glutamate,

GABA, and dopamine neurotransmitters circulate within

the basal ganglia and its connections, partially composed of

the dopamine-producing substantia nigra, olfactory tuber-

cle, putamen and globus pallidus, subthalamic nucleus, and

the nucleus accumbens, which is stimulated by a rush of do-

pamine if a reward is attained. For impulsive behavior, the

15: INTEGRATIVE MANAGEMENT OF DISORDERED IMPULSE CONTROL 343

striatum is often enlarged and hyperactive (Ling et al., 2019 ).

Higher anxiety results from greater focus on the threat

(decreased amygdala connectivity to the cingulate, thala-

mus, and precentral gyrus), yet an irritable angry response

showed increased widespread neural activation (insula,

caudate, dorsolateral, and ventrolateral prefrontal cortex;

Kircanski, White, et al., 2018). There are 245 mitochrondrial

proteins linked to 800 other mitochondrial proteins associ-

ated with serious neuropsychiatric disorder, including BP.

Discovering more details about mitochondrial dysfunction,

glial-immune inﬂ ammatory response, and gut-brain con-

nections to antisocial behavior would expand our under-

standing (Zilocchi et al., 2020).

The Brain and Callous-Unemotional Traits

Underdevelopment and hyporesponsiveness of the limbic

system has been associated with more CU traits in child-

hood and instrumental/predatory spousal abuse, but not

reactive spousal abuse. The amygdala senses immediate

danger (generating fear or anger) and is the receiving sta-

tion for several sensory inputs before and as information

is categorized and remembered by the hippocampus and

thought through in the prefrontal cortex (Ling et al., 2019 ).

If the amygdala is impaired, the fear is blunted, and aggres-

sive and antisocial behavior may emerge due to lack of fear

of consequences and CU traits (Ling et al., 2019 ). Amygda-

lar intercalated masses contain GABAergic inhibitory neu-

rons which connect to the hypothalamus, bed nucleus of the

stria terminalis (BNST), and brainstem, and so are critical

for regulating amygdala activity. Lower amygdala volumes

have been found in trait aggressivity, especially the left

amygdala, but the right amygdala was linked to CU traits

and proactive aggression (Rosell & Siever, 2015). The stria-

tum integrates cortical input to modulate thalamocortical

activity through dopamine and serotonin. When serotonin

is low and involved in perceived interpersonal disadvan-

tage, impulsive aggression is more likely (Rosell & Siever,

2015). Children diagnosed with CD with CU traits (some-

times leading to increased psychopathy in maturity) have a

higher rate of cavum septum pellucidum (CSP), a structural

brain deviation. Notably, the degree of CU traits were found

to correspond to the measure of CSP deviation. Blair and

Zhang hypothesize that adult psychopathy can be preced-

ed by early neurodevelopmental limbic system disruption

and emotional hyporesponsiveness. This also helps explain

the association between CU traits, white matter tract abnor-

malities ( Blair et al., 2021 ), and reduced limbic grey matter.

Yet, in a large male adult incarcerated sample—mean age

33 and average intelligence quotient (IQ) of 96.96—CSP

was classiﬁ ed as being either present, or of three lengths up

to 6+mm. IQ, substance abuse, and severity of psychopathy

were assessed. CSP length was found to be associated with

aﬀ ective and interpersonal aspects of psychopathy, but CSP

was no more prevalent or larger in the incarcerated sam-

ple than in the control group. This indicates that disrupted

limbic development can contribute to dimensional aﬀ ective

and interpersonal deﬁ cits generally, but CSP is not a sensi-

tive or speciﬁ c sign of antisocial behavior, low IQ, or sub-

stance abuse. However, it can be higher in schizophrenia,

BP, and head trauma (Crooks et al., 2018). Antisocial indi-

viduals have been found to have reduced brain volumes,

impaired executive functioning, emotion regulation deﬁ -

cits which may impair decision-making, increased volume,

and abnormal function of the brain’s nucleus accumbens,

which is activated by pleasure or substance abuse. “Cold”

hypoarousal, especially when associated with CU traits,

is associated with a lesser amount of grey matter volume

across cortical and subcortical regions (amygdala, anterior

insula), reduced thickness in the ventromedial and OFC,

temporal cortex, fusiform gyrus, disrupted white matter

in the corpus callosum and uncinate fasciculus, and re-

duced functional connections in the default mode network

(linking the PFC and limbic system), but there is more

folding in the insula, ventromedial, and OFC (Fairchild

et al., 2019).

Genetic Differential Susceptibility Model:

Dandelion, Tulip, and Orchid Children

The Genetic Diﬀ erential Susceptibility Model found

that carriers of the DRD4-7R (Dopamine D4 receptor 7-

repeat allele) were the most vulnerable to adverse parental

inﬂ uences, but also demonstrated the most brilliant out-

comes when nurtured properly (Bakermans-Kranenburg &

Van Ijzendoorn, 2015), signifying a special developmental

capacity for plasticity. Greater capacity for socioemotion-

al plasticity has been found in the 5-HTTL-PR, serotonin

transporter-linked polymorphic region, which is a degen-

erate repeat of the polymorphic region in the SLC6 A4 gene

that codes for transporting serotonin from the synapse. The

long allele variant (G) transports more serotonin in the syn-

apse, while the short allele variant transports less serotonin

in the synaptic cleft. Ellis and Boyce referred to them as

the Dandelion (Maskrosbarn) child and the Orchid (Ork-

idebarn) child. Those with the long allele (G) were twice

as satisﬁ ed with their lives, and less sensitive to pain. But

newer research found that those with the short allele (A)

have greater reactive emotion to environmental stimuli

and greater sensitivity, higher cortisol reactivity, and great-

er physiological response to emotional stimuli, suﬀ ering

more during adversity, but blossoming more if carefully

scaﬀ olded, have supportive marriages, and live in empow-

ering communities ( Haase et al., 2015 ). Michael Pluess’s

research found three types of children: 29% being the least

sensitive Dandelion children, 40% being medium sensitive

Tulip children, with 31% being the most sensitive Orchid

children (Lionetti et al., 2018).

Mother–Child Synchrony: Oxytocin,

Vasopressin, Cortisol, Testosterone

Ruth Feldman’s Biobehavioral Synchrony Model identi-

ﬁ ed the key roles of oxytocin and vasopressin in establish-

ing mother–child synchrony, which extends to nurturing

fathers as well, to build the infant’s brain, drawing upon

close relationships to promote adaptability and resiliency

(Feldman & Bakermans-Kranenburg, 2017). High oxyto-

cin in women activates labor and maternal feelings and

counteracts motherly endogenous testosterone (Holtfrerich

344 III: INTEGRATIVE MANAGEMENT OF SPECIFIC SYNDROMES

et al., 2018). It also activates the breastmilk let-down re-

sponse, as well as prerequisite trust prior to pair-bonding

and lovemaking (Walum & Young, 2018). For both men and

women, oxytocin is protective of hippocampal neurons and

memory in both sexes (Matsushita et al., 2019), enhances

prosocial trust and empathy ( Grinevich & Neumann, 2021 ),

and infranasal oxytocin decreases task-related aggression

in healthy young males (Berends et al., 2019).

Low oxytocin levels are a marker of child abuse or ne-

glect in children, which correlates with low eye contact, not

responding to social cues, and a higher rate of socioemo-

tional problems ( Suzuki et al., 2020 ). Bakker-Huvenaars

found that a lower oxytocin to higher testosterone ratio are

correlates of the CU trait. Notably, they drew two-thirds

of their sample from ODD/CD boys from youth welfare

agencies (Bakker-Huvenaars et al., 2020). Additionally, Hu-

venaars found genetic variants of the oxytocin gene which

can lead to higher levels of aggression: single nucleotide

polymorphisms rs6770632 and rs1042778 of the oxytocin

gene are associated with persistent and extreme aggression

in males. There is a link between oxytocin rs237885 and

rs2268493 allele genotype and CU traits (Bakker-Huvenaars

et al., 2020). For men, oxytocin can activate pair-bonding and

lovemaking, yet when climaxing, vasopressin rises while

oxytocin decreases. For men, oxytocin is not merely the

“love hormone” as it has been popularized, since it may also

activate boundary-making behavior against other males or

unrelated outgroup members (Berends et al., 2019).

Underreactive, numbed-down systems and avoidant at-

tachment may well set the child up for CU unresponsive-

ness to others, and dampen the innate empathic response to

others’ suﬀ ering. Fonagy found temporary and chronic im-

pairments to understanding self and others’ mental states in

disruptive disorders, which may combine with other impair-

ments in cognition and valence systems (Fonagy & Luyten,

2018). Judith Solomon and Mary Main found that fearful/

disorganized/disoriented attachment presents as confusion

when the parent returns, going in circles, approaching, turn-

ing away, or “freezing” (Granqvist et al., 2017). For infants

who endured parental abuse or neglect, the percentage of

fearful/disorganized attachment is 70%, but after adoption

in nurturing homes, this impact was buﬀ ered (Fairchild

et al., 2019; Siegel, 2020). Children adopted in later child-

hood after maltreatment in group homes overseas were at

higher risk for insecure states of mind for other relation-

ships ( Raby & Dozier, 2019 ).

The child’s empathic response is the familial and so-

cial basis for collective life (Levy et al., 2019; Mafessoni

& Lachmann, 2019). Indeed, empathy is essential for in-

dividual and collective survival as a species, which Ervin

Staub, child Holocaust survivor, psychologist, and peace

researcher, has emphasized for 40 years. Preadolescents

previously exposed to wartime adversity, when shown

others in distress, activated overlapping aﬀ ective and cog-

nitive brain areas in their empathic response. Caregiving

patterns help shape the child’s interpersonal attunement,

temperament, and response to others' struggles (Levy et

al., 2019; Mafessoni & Lachmann, 2019). Complexity anal-

yses have found that species which favor individualistic

behavior over altruistic behavior tend to die oﬀ , while

those species with collective cooperation and mutual aid

usually survive and thrive. Human beings are clearly a so-

cial species, and we depend upon caring for each other for

survival. Learning and understanding each other’s minds

enables greater complexity of social organization. Our mir-

ror neuron system, which has both perceptual and motor

capabilities, facilitates feeling the pain of others intuitively

(Siegel, 2020).

Cortisol has been found to regulate the stress reaction in

acute situations requiring active solutions, but after which

the sympathetic nervous system (SNS) must be brought

back to a parasympathetic default baseline. Cortisol, along-

side serotonin, glutamate, epinephrine, norepinephrine,

orexin, leptin, testosterone, histamine, and blood pressure,

increases as one awakens and melatonin ceases, but then

descends into an afternoon slump hours later, when one’s

diurnal cortisol slopes downward. Cortisol helps regulate

aggression through modulating the amygdala-PFC fear/

threat circuitry (Rosell & Siever, 2015). Flatter cortisol

slopes are associated with adrenal exhaustion, disrupted

suprachiasmatic nucleus, and worse health and mental

health outcomes. Overwhelming allostatic load can result

in dysregulated central and peripheral circadian rhythms,

with disrupted metabolism and reduced capacity to main-

tain homeostasis. Rachel Yehuda found that Holocaust sur-

vivors have ﬂ at diurnal cortisol curves, yet their oﬀ spring

have high cortisol levels. Cortisol dysregulation is associ-

ated with later obesity, inﬂ ammatory/immune dysregu-

lation, cardiovascular disease, diabetes, cancer, mortality,

and depression. She also found that maternal and paternal

PTSD and ﬂ at cortisol levels can cause high cortisol lev-

els and epigenetic changes of the glucocorticoid receptor

(GR) gene in their oﬀ spring (Yehuda et al., 2016). Excessive

glucocorticoids during chronic stress can cause atrophy of

the hippocampus and reduce overall neuroplasticity in the

brain.

Jan Buitelaar’s team examined oxytocin, cortisol, and

testosterone in adolescent boys diagnosed with ODD/CD

versus typically developing controls. Oxytocin levels are

correlated with social cognition and aﬀ ection/boundaries,

cortisol levels are correlated with the acute stress response,

and testosterone is correlated with male reproduction,

dominance, and aggression. The team found that higher

cortisol and testosterone levels correlated with higher CU

traits (Bakker-Huvenaars et al., 2020).

Attachment and Epigenomic

Processes

ACEs were found to impact lifelong health, with or without

high-risk behavior, as Felitti discovered in a well-known

study done for the Centers for Disease Control and Pre-

vention (CDC) and Kaiser Permanente. As of now, ACEs

have been found to contribute to a premature closure of

the early window of plasticity, to delay or accelerate crit-

ical periods of development, reﬂ ecting GABA maturation,

brain-derived neurotropic factors (BDNF), and circadian

clock genes, in cross mammalian species inducing circadian

15: INTEGRATIVE MANAGEMENT OF DISORDERED IMPULSE CONTROL 345

misalignment, increasing health and mental health risks

(Cameron et al., 2017; Deibel et al., 2020; Felitti et al., 1998 ).

In 2005, Moshe Szyf teamed up with Michael Meaney (Mc-

Gill) to explore epigenetic programming according to dif-

ferential maternal behavior in rat pups ( Meaney & Syzf,

2005 ). Then, Meaney and psychiatrist Gustavo Turecki of

McGill teamed up to investigate the GR methylation in-

volved in HPA-axis alteration due to traumatic stress (Tu-

recki & Meaney, 2016). The bottom line of this research is

that maternal care can permanently alter physiology and

behavior, also partially mediated by epigenetic expression.

Early nurturing “programs” DNA methylation of GRs

in the hippocampus, through altered histone acetylation

and transcription factor binding to that receptor promoter,

which changes the HPA-axis response when coping with

stress. The HPA-axis is responsive to early adversity, induc-

ing methylation of exon I-7 promoter of GR (NR3C1) in rats,

and in humans at GR exon variant I-F. They note that 89%

of the human studies and 70% of the rat studies found in-

creased methylation of the variant out of 40 studies. Among

the suicide-completers, those with a history of child abuse

had decreased GR1-F expression in the hippocampus (Tu-

recki & Meaney, 2016).

Family Ecosystem: Family Life Cycle

and Zone of Proximal Development

Children mature by interacting within their family ecosys-

tem as a point of reference before expanding their social

world. The important point here is that family, communi-

ty, culture, and civilization are not merely contextual con-

structs. Parents and grandparents scaﬀ old the child’s devel-

opmental journey in life within evolving nested complex

relational systems, within which the infant is ﬁ rst nestled,

then inﬂ uences and sometimes transforms as they grow.

This evolution expands and enriches the child’s capacities

and options, helping them reach higher within their zone

of proximal development (ZPD), a concept developed by

Lev Vygotsky. This also means that “scaﬀ olding” is import-

ant for a child to develop an understanding of others and

reﬁ ne their empathic identiﬁ cation for others’ tribulations

in order to be able to respond sensitively. Parental recogni-

tion of their toddler’s state of mind and desires, as well as

reference to it, provides “stepping stones” for a child to ac-

cess other people’s states of mind. This intuitive education-

al scaﬀ olding of her child’s social learning via “mother–

child mental state talk” helps the child’s understanding of

others, allows greater emotional intimacy with them, and

signiﬁ es empathy for their struggles. For children with lan-

guage, communication, learning, or intellectual disabilities,

mother–child mental state talk is even more crucial for the

child to be able to integrate socially with siblings, cous-

ins, and typically developing peers (Yuill & Little, 2018).

Parents lacking suﬃ cient intuitive socioemotional insight

may set the child up for social diﬃ culties and being bullied

because his disabilities and educational trajectory will di-

verge from his peers. Even if the child was not oppositional

or angry by temperament, the frustration of dealing with

disabilities and their socioemotional sequelae, without at

least one parent with empathic insight, can lead to an ex-

acerbation of the child’s obstacles that could deepen op-

positionality. If the attitude of parents and other mentors

vis-à-vis the child’s being bullied or abused is minimized,

denied, or justiﬁ ed, this will increase the child’s sense of

being misunderstood. The child’s worldview becomes one

of foundational injustice against which they may rebel, be

resigned, or feel desperate to escape. If the child already

had impulsive or disruptive tendencies, this could harm

their coping and strengths.

Community Dynamics, Culture,

Education

Low income brings many dangers to developing children.

In disadvantaged rural areas, where prenatal care is not

always easily available or aﬀ ordable, there can be village

hierarchies of the dominating families, over generations,

while a few excluded and stigmatized families and/or

individuals are held up as “bad examples” since they do

not ﬁ t into the mainstream groove. Sometimes the bullying

can be severe when disabilities, cognitive deﬁ cits, or unre-

solved disputes between clans can result in vendetta-like

harm. Environmental exposures from toxic industries en-

demic near many poorer country communities and Native

American reservations—which cannot be chased away due

to needed paychecks—unhygienic conditions due to lack

of running water, and uneven access to safe electricity and

heating are diﬃ cult conditions in which to live, especially

for infants and children. In disadvantaged urban neigh-

borhoods, often disproportionally inhabited by minority

populations, residents can feel ghettoized by mainstream

society, lack psychosocial services, and may develop a re-

sentful subculture and distrust clinician assistance.

By middle childhood, exposure to socioeconomic disad-

vantages and numerous obstacles to socioeconomic ecosta-

sis is linked to diﬃ culties in emotion expression recognition,

due to chronic denial and/or unresolvable anger. In partic-

ular, angry facial expressions were identiﬁ ed less accurately,

especially high intensity anger. Lack of accurate emotion rec-

ognition and naming increases the likelihood of social diﬃ -

culties and behavior problems in school (Erhart et al., 2019).

Chronic denial or the numbing of one’s emotions as a reac-

tion to parents who have to manage negative emotions un-

der adverse circumstances may easily explode from chronic

and intense subsistence pressures, or individuals may resort

to self-medication with substances, which may be more

profound the more time the child has lived in poverty.

Unsafe neighborhood gangs and powerful criminal

models cause a dangerous lack of protection for neighbor-

hood girls, while bullying and powerful gangs vie for boys’

aﬃ liation. During communal disorganization, the paucity

of reasonably priced and accessible nutrition for families,

inadequate learning in resource-poor schools, the accessi-

bility of alcohol and drugs, and nightly gunﬁ re become the

child’s daily world. Delinquent impulsivity is rewarded by

small returns, defensiveness has become a way of life, and

early school drop-out and aggression may have been a com-

munal norm, inﬂ uencing the adolescent’s behavioral range.

346 III: INTEGRATIVE MANAGEMENT OF SPECIFIC SYNDROMES

However, children suﬀ ering from these environmental fac-

tors can have many diﬀ ering outcomes, with only those

with multiscale vulnerabilities and diﬃ culties as listed here

in systematic order susceptible to marginalized attitudes,

behavior, and aspirations. Raine’s neuromoral theory of

antisocial, violent, and psychopathic behavior traces some

neural circuitry impairment in areas responsible for moral

decision-making (Raine, 2019). However, this cannot ex-

plain why only malfunctioning neural circuitry would be

solely responsible for criminal responsibility, when exter-

nal shaping, modulating, and mentoring by parental, peer,

community, and cultural ﬁ gures have such powerful im-

pacts upon disadvantaged children and youth.

Young Adult to Adult Pathway

By young adulthood, about half of youth with CD with

less severe adolescent-onset drop delinquent friends and

improve their behavior as they acquire coping and reﬂ ec-

tive skills. Child disruptive mood dysregulation disorder

(DMDD) may be dealt with through treatment, or may

establish itself as closer to BP, in which case psychoedu-

cation and long-term mood stabilizers would be the path-

way to pursue, as elaborated on in Chapter 9, “Integrative

Management of Disordered Mood.” IED can continue into

adulthood through dysregulated bouts of anger while a

large proportion of those with IED should be diagnosed

carefully so as to identify where the psychodynamic source

of the dysregulation and trigger/re-triggering patterns lie.

Intermittent Explosive Disorder

For most adults on the milder and intermittent side of the

disruptive spectrum, their higher functioning lives diﬀ er

greatly from those with unremitting CD who, after the

age of 18, may be diagnosed with APD. Yet, those with

milder intermittent reactive outbursts without enduring

damage are often suﬀ ering from circumstances that have

overwhelmed their coping capacities, and usually work in

comfortable or moderate conditions. The resultant sequelae

may eventually cause profound impacts upon their closest

ones, as well as themselves. Reactive aggression occurs in

response to a social threat which is inescapable; thus, in

some clients, anger is activated rather than fear (Bertsch

et al., 2020). For adults with intermittent, or subclinical,

impulsive or disruptive symptoms such as IED along a

spectrum from mild to severe, their personal, social, study,

work, or community lives are disrupted by their own out-

bursts (Coccaro & McCloskey, 2019).

Borderline Personality Disorder

In a study of 11,900 maltreated children, emotional reactivi-

ty and dysregulation were found to be more prevalent than

the norm ( Lavi et al., 2019). Those suﬀ ering from BPD may

frequently act out impulsively and disruptively. Although

there are greater male rates of aggression than female, if

girls or women have been diagnosed with BPD, bouts of

anger are triggered by fears of abandonment or more abuse.

There is much internalization of anger, leading to self-harm

and suicidality, rather than other-harm, yet risky behavior

can lead to other harm as well. Symptoms include impul-

sive risky behavior like reckless driving, substance abuse,

excessive spending, and risky sexual activity, as well as in-

tense, but unstable, relationships. This diagnosis frequently

entails oscillating extremes of idealization or devaluation.

Accompanying symptoms are identity uncertainty, aﬀ ec-

tive instability, and temporary paranoia or dissociation,

which can entail derealization or depersonalization.

Although BPD symptoms may resemble BP symp-

toms, their etiologies are quite distinct, and their triggers

are well deﬁ ned. Bipolar is a genetically-based neurolog-

ical disorder, with extraordinary mood highs, lows, and

mixed states depending upon the rate of the client’s per-

sonal cycle phase. On the other hand, BPD depends upon

the quality of the early bonding experience; betrayals of

childhood trust, especially due to sexual abuse and/or in-

cest; or subsequent severe betrayals of trust including other

parental abuse, which can re-trigger those early responses.

An external and internal dynamic of idealization, followed

by hatred, can lead to extreme psycho-traumatic respons-

es leading to dissociation symptoms of derealization and

depersonalization. There is no mania per se in BPD, and

bipolar cycles take place over days and months, not hours

as in BPD. Impulsivity in BP is higher when screened. Brain

imaging indicates two distinct disorders as well. Whereas

in BP, decreased OFC volumes, decreased corpus callosum,

and enlarged amygdala and lateral ventricles are consistent

ﬁ ndings, in BPD there are decreased amygdala, anterior

cingulate, and volumes. There are also diﬀ erent neuropsy-

chological ﬁ ndings as well (Sanches, 2019).

Thus, instead of viewing BPD through the lens of the

frustrated therapists, we should regard it as a severe form

of relational trauma disorder closer to PTSD than a person-

ality disorder. There has been much controversy over the

decades regarding whether the nosologies have been in dis-

crete categories, yet many symptoms overlap. BPD itself has

been challenged as a nosological entity since the 1980s, as per

its psychodynamic etiology, and due to it not being a stable

diagnosis if the client experiences change (Sanches, 2019).

ENCODED MEANINGS OF

AGGRESSION IN THE ADULT

WORLD

Aggression is an interpersonal act that can have multiple

encoded meanings. The meaning of the aggressive act is in-

terpersonal, yet is conﬁ gured within a complex of shared

sociocultural, socioeconomic, and sociopolitical meanings

that may depersonalize it. This act also has wider repercus-

sions that impact not only those aﬀ ected but it is also part of

collective actions which shape the civilizational landscape.

We will touch brieﬂ y upon cultural “idioms of distress”

that include notable or severe impulsive or disruptive

symptoms, usually without recognized prior mental health

issues, and larger questions of sudden, unexpected acts of

mass or homicidal-suicidal violence within complex family,

socioeconomic, community, sociocultural, and sociopoliti-

cal contexts.

15: INTEGRATIVE MANAGEMENT OF DISORDERED IMPULSE CONTROL 347

Why More Men?

There is a biological foundation for male aggression. Me-

ta-analyses repeatedly ﬁ nd that males are much more likely

to act aggressively than women across the globe. The male

range of strength, height, weight, and being more likely to

act with physically aggressive force than women, at lower

provocation thresholds, has a higher range globally. Wom-

en, on the whole, are much more fearful, even under se-

vere repeated provocation, yet can more quickly identify

and express angry emotion, according to a recent German

meta-analyses (Weidler et al., 2019 ). Another meta-analysis

of testosterone level, with corresponding slightly higher

facial width-to-height ratio, has been found to be a robust

predictor of more aggressive male behavior in laboratory

conditions, especially with relatively disadvantaged social

status ( Haselhuhn et al., 2015). Thus, there is an underlying

biological element to male aggression to compete as well.

However, socioeconomic, sociocultural, and sociopolitical

norms channel this aggression to more acceptable, than ta-

boo, default targets.

Aggression: Outsiders Versus Insiders

Nevertheless, apart from relatively stable antisocial forensic

psychopathology, humans have largely employed aggres-

sion to defend and sustain the collective, including them-

selves. The way in which male aggression is conceived,

channeled, institutionally structured, and employed, by

whom, and for which reasons are developmentally, social-

ly, economically, culturally, and politically shaped. The mil-

itary, police, ﬁ reﬁ ghters, high-risk construction workers,

utilities installers, hunters, heavy industry workers, and

ﬁ eld electricians all require employing occupational strate-

gy and strength; the application of force has generally been

done by men, for the common good, and is highly honored

in most societies. Even when this involves employing force

against other people outside the mainstream community,

this is usually accepted and praised by the community or

country on whose behalf these structures of force protect

and defend.

Where the application of force has been generally unac-

ceptable in North American society, in our time, is in coun-

tering these interlocking oﬃ cial protective structures, with

the same community, or within the family, as broadly de-

ﬁ ned. In most communities, schools, and media, the deﬁ ni-

tion of who lies inside or outside those structures may have

blurrier edges when faced with disadvantaged distinct mi-

norities, immigrants, and refugees, and when viewed from

external countries’ perspectives.

Evolutionary and cultural geographical analyses have

yielded insights into the aggression rate, in civil conﬂ ict

and crime, being higher in southern rather than northern

latitudes ( Van Lange et al., 2017; Weick et al., 2017). In par-

allel, 18th- and 19th-century colonialism mostly impacted

countries closer to the equator ( Roscoe , 2017), as well as

spiritual and cultural norm diﬀ erentials under lands which

did not experience the increase in Native American-style

civil rights due to the North American growth of demo-

cratic governance, Scandinavian representative regimes,

the British Empire then Commonwealth, or improved civ-

il rights as a result of the French Revolution and empire

during peacetime. Thus, even today there are measurable

diﬀ erentials in attitudes toward mass aggression in many

southern latitudes, where the later type of exploitative co-

lonialism was historically rampant, leaving behind a trail

of socioeconomic devastation, greater tolerance for social

or military violence by formerly suppressed elites and dis-

sidents, and leaving more disadvantaged sectors behind.

In the Americas, the target of violence is quite diﬀ erent

in North America, as opposed to South and Central Amer-

ica. North America experiences periodic “random” mass

shootings from men with mental health or revenge issues

in a society characterized by anomie and extreme individ-

ualism, but the norm for spousal violence is about 20%. In

contrast, in South and Central America, women experience

spousal violence at rates ranging from 35% to 60%, but so-

ciopolitical violence is reserved for speciﬁ c economic and

political aims, while some social sectors have a high degree

of solidarity.

Violence Against Outsiders

Perpetrators and sites of serious violence in the United

States—such as mass shootings and school shootings—are

not easily predictable on the basis of prior CD or antisocial

assessments. Yet, they have been found to occur at a fairly

regular pace from 2005 to 2015, with mass shootings at a

rate of once every 2 weeks, while school shootings occurred

monthly ( Towers et al., 2015). After analyzing 323 mass

killings from 2006 to 2016 in the United States mathemat-

ically, each act appeared to be random, without emotional

contagion. Yet, when analyzed as a whole, there was a con-

tagion eﬀ ect across the country ( King & Jacobson, 2017 ). It

has been suggested that prevention would consist of infra-

structure-based deterrence, response system resiliency, and

the impeding of the event until law enforcement can arrive,

instead of higher identiﬁ cation of earlier stage disruptive be-

havior which did not lead clearly to antisocial delinquency.

There does not seem to be many analyses which can point ex-

clusively to APD psychopathology as the root cause, since a

range of mental disorders has emerged. Predictability is low.

Collective rioting or unoﬃ cially condoned violence can

throw communal protective structures into disarray and

threaten the sectors for which these structures were erected

to protect children, adolescent girls, pregnant women, se-

niors, and the ill.

Youth is a life stage during which impulsivity and dis-

ruption are often explored, even by those for whom this

is ego dystonic. Delinquent youth groupings exploit the

impulsivity and manipulability of disadvantaged and fos-

ter youth, and those who are socially marginal or with dis-

abilities. The leaders have some modus operandi similar to

paramilitary cells, who provide food, shelter, and attach-

ment ﬁ gures in exchange for teaching them to ﬁ ght. In the

West, life is a supreme value in itself. But for youth who join

gangs, paramilitary, or terror organizations, the borders be-

tween self and collective social needs are thin, submerging

one’s individual importance for group aims.

348 III: INTEGRATIVE MANAGEMENT OF SPECIFIC SYNDROMES

For Middle-Eastern, Western-born of Middle Eastern

heritage, or converted Westerners who are lured by the

promise of power, grievances unanswered, a vision of their

home culture, spiritual appeal, and a group purpose to ﬁ ll

their own sense of meaninglessness or lack of coherence,

the pull of gangs and paramilitary groups, for those testing

out their own disruptive notions, continues to ruin young

lives. Suicide-homicidal acts of terrorism during peacetime

are similarly planned by those who send youth to perpe-

trate them, in societies that cultivate honoring “martyrs”

( shaheed ) as heroic deaths (istishhad ), name streets and in-

stitutions after them, ﬁ lm them swearing in with a Koran

and kalashnikov assault riﬂ e to motivate others, and oﬀ er-

ing large posthumous rewards to the families of “martyrs.”

Demonization of their enemy target and Western culture is

generally done through social, educational, and religious

networks ( da’wah ). The directors of these operations are

well educated, yet hold radical views, and usually follow

extremist spiritual leaders, as do their home communities.

Some were pediatricians like Abd el-Aziz al-Rantisi (1947–

2004), the Hamas pediatrician who initiated the Second

Intifada against Israeli civilians in cities during peacetime.

He dispatched hundreds of children and youth—often

with disabilities or who were socially marginalized—as

human bombs and ﬁ eld operatives by brainwashing them

with visions of Paradise. These youth were further plied

with drugs, and then used as human bombs. The victims

believed they would ﬁ nally win approval from families

and become heroes in their communities. Although these

actions seem impulsive and disruptive, no prior impulsivi-

ty or disruptive behavior had been identiﬁ ed in these cases.

Vandevoorde, on the other hand, has found that self-ini-

tiated perpetrators of suicide-bombings in the West have

mixed grandiose and depressive symptoms ( Vandevoorde

et al., 2017 ).

Although very rare since most groups are composed

of male youth, female suicide bombers have often been

victims threatened by “family honor” murder threats and

conceive of this action as a method of redemption. Reli-

gious fanaticism, hatred, and “revenge” nationalism are

the communal incentives. But Iraqi-Jewish psychologist

Anat Berko, after years interviewing failed suicide-homi-

cide attempters, found BPD symptoms, a worldview which

splits the world into absolute good/bad categories, and

“identity fusion” with their group, due to transformative

group experiences ( Kavanagh et al., 2020). Related deper-

sonalization and dissociative trance-like symptoms after

the decision to commit the suicide-homicide (“sensation of

being uplifted”), sometimes with suicidal ideation and self-

harm, is propelled forward by heroic visions. If there is an

intervention during the trance-like state, the bomber might

change his mind ( Berko & Erez, 2007) .

Polygyny is characteristic of Fragile States fraught with

conﬂ ict (McDermott & Cowden, 2015). For youth born into

polygynous families, conﬂ icts, insecure attachment, early

trauma, and impulsive, disruptive, and borderline features

may stem from polygynous family dilemmas. First or later

wives, and their children, are forced to compete with one

other in order of seniority or patriarchal favoritism. This

aggravates intra-family jealousy, gossip, and conﬂ ict, where

daughters become contentious “family honor property.”

This type of socioeconomic hyper-hierarchization, with

a few wealthy, aged kingpins at its pinnacle, resplendent

with wives, children, and property, yet denies many young

males suﬃ cient wives to marry. The excess unmarried

youth and men result in higher rates of social disruption,

lower rates of girls’ education, lower girls’ age at marriage,

higher maternal mortality, higher rates of female genital

mutilation (FGM), more crime, kidnapping of females,

cousin marriage, sexual slavery, prostitution, and higher

defense expenditures (McDermott & Cowden, 2015).

On the other hand, after examining the wealth of liter-

ature on suicide terrorism in many cultures and political

settings, an Italian team concluded that there were no ﬁ xed

familial, educational, or socioeconomic factors accounting

for religious radicalization to commit suicide bombings.

Yet, they note most terrorists and handlers seem to have

core features of severely disruptive and APD traits. They

note callousness, lack of empathy, feelings of emptiness,

cold rationality, and a yearning for martyrdom and death as

a highly rewarding goal (Marazziti et al., 2018). Neurosci-

ence researchers note of terrorists’ neuropathology in struc-

tural and functional alterations in prefrontal, orbitofrontal,

and insular cortex, amygdala, and hippocampus responsi-

ble for controlling the archaic generators of aggression in

the hypothalamus and limbic system, which overlap with

regions generating prosocial traits like empathy. It is then

possible that there may be hedonistic reward in feeling su-

perior when in control of others’ lives (Bogerts et al., 2018).

Violence Against Insiders

Women throughout much of history, and in many places

across the world, have been perceived not only as people,

but also as material assets belonging to men. In some de-

veloping countries where women are still considered to be

somewhat akin to chattel, there is polygamy and strong

patriarchal privileges have remained or strengthened. In

places where the primary attachment remains with the

man’s mother, wives enter marriage as virgin assets, where

often worship to the Virgin Mary is popular. This pedestal

can quickly turn into a tomb if the former idealized virgin

does not conform to possessive male ( macho ) rules as wife.

The result is that throughout much of human history, and

in many regions around the world, there is less tendency

to view aggression against a feminine partner as indicative

of disruptive behavior or socially unacceptable. Even in

current United States terms, if violence against female part-

ners is “only” 20%, it is a weighty public health problem at

43 million adult women aﬀ ected, costing $3.6 trillion, and

potentially impacting multiple generations in its wake. A

2017 United States national study found that 55% of all ho-

micides of women from 2003 through 2014 were caused by

intimate partners (Adhia et al., 2019). Brieﬂ y, is this APD

behavior? Is this impulsive, disruptive, or BPD behavior?

Or is this normative behavior in some regions across the

globe? How then must a culturally sensitive PMH-APRN

view and treat the perpetrator, the victim, or the couple

with this problem, in the United States, with human rights

15: INTEGRATIVE MANAGEMENT OF DISORDERED IMPULSE CONTROL 349

and freedoms guaranteed by law? If treatable, can the fam-

ily and children reconcile after these events?

Female Partner, Daughter, or Sister Killings

”Honor killings” of daughters, wives, or sisters have oc-

curred across vast regions comprising half the globe, pre-

dominantly in the Middle East, South Asia, and the Maghreb

( Christianson et al., 2021). Especially in more conservative

rural areas, this is seen as enforcing the family’s honor within

the community and the expected masculine control of one’s

family within the community. Intimate partner violence of-

ten involves similar masculine control of family, yet within

interlinked intrapersonal (self-regulation) and interpersonal

friction across socioeconomic and cultural milieux ( Chester

& DeWall, 2018 ). Latin America has had intermittent femi-

cide epidemics by intimate partners, with the highest rates

in Honduras (6.2) and El Salvador (3.3) per 100,000 women,

with a sum of 4,640 out of 15 countries (Economic Commis-

sion for Latin America and the Caribbean [ECLAC], 2021).

In fact, 27% of women in Latin America suﬀ ered violence

at least once in their lives, while the rate in South America

is 33% (Organisation for Economic Co-Operation and De-

velopment [OECD], 2019). Prevention has focused upon

deconstructing machismo ideals, and legally reframing the

problem as “feminicide,” prohibiting the purchase of ﬁ re-

arms by perpetrators, using electronic surveillance devices

for oﬀ enders, and collecting attitude and murder data rath-

er than scouting out individual psychopathologies ( ECLAC,

2018 ). Even in English-speaking Jamaica within the larger

Latino Caribbean sphere, in seemingly impulsive male ho-

micide-suicides of female partners from 2007 to 2017, trig-

gers were obsession, sexual jealousy, and fear of separation,

with possible roots in childhood anxious attachment (Pot-

tinger et al., 2019). The coronavirus pandemic has exacer-

bated calls to hotlines in the region and elsewhere by 60% to

90%, which governments are ill-equipped to handle.

As the United States has become increasingly open to

diﬀ erent cultures and global immigration, we as clinicians

must become more aware of how to understand and treat

these phenomena with increasing nuance while adhering

to the goal of the client returning to function within their

own milieux, which is nonetheless inalienably nested with-

in U.S. mainstream norms and the law. This is how U.S.

courts have viewed speciﬁ c socioculturally shaped behav-

iors that have caused injuries. In American mainstream cul-

ture, murdering a sister, daughter, or wife on the pretext of

“unchaste” behavior is unacceptably sexist, and a felony in

legal terms. In North America, the British Commonwealth,

and European countries, hostile sexist attitudes are most

likely to be acted upon aggressively when males feel their

own relationship power to be low (Cross-Disorder Group

of the Psychiatric Genomics Consortium, 2019), and wors-

ening at the end of a relationship. According to the U.S. Na-

tional Violent Death Reporting System, homicide of current

or former girlfriends by adolescent males 11- to 18-years-

old were most commonly attributed to male possessive-

ness over rupturing ties (27.3%) and/or altercation (24.7%),

with some pregnancy-related and substance abuse issues.

Identifying prior impulsive behavior was not a factor, but

attachment insecurity issues were important. Limiting ac-

cess to ﬁ rearms by domestic violence perpetrators has re-

duced deaths previously, not even counting noncohabiting

partners. Successful interventions implemented in school

and community settings focused on preventing partner vi-

olence have addressed relationship skills, communication

strategies, recognizing abuse, safety planning, laws, and

prosocial bystanders. Adolescents could be better protected

with civil protection orders, which impact state-level rates,

since partner violence had been experienced by 71.1% of

females before age 25 (Adhia et al., 2019).

Wife Assault

Can partner abuse of women be said to be due to disruptive

delinquency when, unfortunately, it has been considered to

be relatively normative, or even a required husbandly duty,

across much of the globe? In other words, is aggression

against wives the result of psychopathology or is it due to

simply following behavioral norms shaped by sociocultur-

al, spiritual, and sociopolitical environments? It depends

upon which measure is used. If the measure is anthropo-

logical, it appears normative yet backward. If the measure

is public health, it appears pathogenic in any community

context. From a systems biology perspective, it appears as

mass species-destructive behavior. All of these perspectives

will inﬂ uence how we should assess and deal with clients

whose lives are unremarkable except concerning what may

be diagnosed as IED, BPD, BP, or APD. Partner abuse with

each of these diagnoses is best prevented and treated with

a tailored approach to the client’s unique symptom cluster

and psychosocial, socioeconomic, sociocultural, and socio-

political conﬁ gurations of meaning. It is within this mean-

ing crucible that the treatment can transform the client’s

self-conception, emotional responses, and behavior.

Social norms allowing husbands to attack their wives

greatly exacerbate the problem, so that this pandemic is

endemic in many locations across the globe (OECD, 2019) .

Prevalence rates range from 2% in Canada to 85% in Pa-

kistan. In low-income countries it is 40% (especially South

Asia), lower middle-income countries it is 32%, and it is 23%

in higher income countries (OECD, 2019). It is important

to realize that across the world, over 40% do not report or

seek treatment for this violence, particularly among Native

women, women with disabilities, and migrant women. In

areas of India, the percentage is as high as 86%. In 35 coun-

tries, less than 20% sought medical, law enforcement, or le-

gal assistance (OECD, 2019). In 11 national surveys in Arab

countries, violence against wives ranged from 6% to 59%

(physical), 3% to 40% (sexual), and 5% to 91% (emotional;

Elghossain et al., 2019). This impacts the ability to prevent

myriad forms of sporadic impulsive or calculated violence

from men seen otherwise as relatively normative in society

or provide assessment and treatment to them (OECD, 2019).

On the other hand, this is far from normative behavior in

the European Union. A multilevel Poisson regression anal-

ysis was done on a subsample of 39,269 women, and the

prevalence was only 4.2% (Sanz-Barbero et al., 2018).

350 III: INTEGRATIVE MANAGEMENT OF SPECIFIC SYNDROMES

Cultural Anger and Aggressive

Syndromes

The more aware mental health clinicians are of global

cultural “idioms of distress” that result in impulsive and

disruptive behavior, the better able they will be to pre-

vent, assess, and treat these syndromes (Cork et al., 2019).

What often are referred to as cultural “idioms of distress”

have evolved through historical events and cultural

re-adaptations. They are further modiﬁ ed by intertwined

socioeconomic changes, political reversals, Western and

traditional medicine interaction, and what the idiom sig-

niﬁ es. In America, as minorities, immigrants, or refugees,

they may embrace, reject, or partially identify with their

own cultures of origin. Additionally, the weight of histor-

ical events like colonialism and wars, their own ancestors

and elders, current socioeconomic and political realities,

the current status of their community or religion, hybrid-

ities, and metissages all modify how clinically relevant

impulsivity or disruptive disorders will be viewed. Thus,

incorporating or prioritizing traditional meanings within

treatments may enhance its eﬀ ectivity, if appropriate.

Gone and Kirmayer have recently outlined the past two

decades of Native north American mental health concerns,

focusing upon often discussed historical trauma (Brave

Heart, 1999), which later paired with Rachel Yehuda’s extant

evidence of intergenerational transmission of “trauma” via

epigenetic risks to health and mental disorders (Daskalakis

et al., 2021). They emphasize that an inordinate focus upon

historical trauma diverts energy from alleviating current

disadvantages, and further stigmatizes later generations

(Gone & Kirmayer, 2021). Yet, while intergenerational trau-

matic transmission involves damaging parent-child rela-

tions (Fearon & Roisman, 2017), multigenerational trauma

signiﬁ es an ongoing predicament in which endemic injury,

marginalization, or stigmatization occurs over generations

anyway (Blum, 2014).

The current mental health focus upon intergeneration-

al transmission of trauma via epigenetic processes must be

qualiﬁ ed. First, epigenetic markers, as already discussed,

may be modiﬁ able by early life nurture. Second, children are

diﬀ erentially susceptible. Third, epigenetic markers have

experimentally been reversed in nutrition, aging, and can-

cer research (Camillo & Quinlan, 2021; Gone & Kirmayer,

2021; Simpson et al., 2021). Fourth, in a comparison between

Holocaust survivors and the general Israeli population,

while the survivor cohort had higher comorbidities (3.3 to

2.7), longevity was improved for survivors (77.7 compared

to 81.7 years). This outcome was particularly remarkable

because the general population was noted as having twice

the economic resources of the survivors (Fund et al., 2019).

So, extreme ACEs may have notable health impacts, but, in

some cases, do not automatically determine plummeting

trajectories. This is due to the child’s catch-up attachments,

mentor scaﬀ olding, and own unique agency. Posttraumatic

growth is expressed in myriad lifeways (Blum, 2014).

Clinically important distinctions between dynam-

ic historical impacts, socioeconomic instabilities, and

sociocultural adaptations may not always be easy to tease

apart. Yet, we must be careful not to conﬂ ate social impacts

with medical conditions, or the reverse (Kirmayer et al.,

2014). Additionally, mistaking traumatization for cultural

expression, or the reverse, often happens when war refu-

gees from unfamiliar cultures arrive. Trying to understand

your client will require acquiring more background and

insider insights, while eﬀ ective treatments may demand

clinically and culturally creative bricolage.

Hwa-byung

Hwa-byung (HB) is a Korean cultural psychiatric “idiom

of distress” for a somaticized anger syndrome, produced

by long-term pent-up accumulated anger that produc-

es intractable psychiatric symptoms. Translated, it means

“illness from ﬁ re.” It refers to a familiar syndrome which

occurs when individuals have repressed feelings of anger

and perceived unfairness. There is an Oriental Medical

Evaluation for HB (IOME-HB) one can use to diagnose it

( Lee et al. , 2018). This anger internalization and somatiza-

tion syndrome has usually been recognized in middle-aged

women who suﬀ ered a history of abuse and aﬄ icted gener-

ations of Korean women during the Japanese invasions and

the division of Korea. It is unlike the usual male Western ty-

pology of externalizing anger. Although it is not impulsive,

it can lead to somatic symptoms of anger and depression.

Tensan (Tension)

“Tensan” (Tension) is a term used in ethnopsychological

literature to refer to a somaticizing North Indian idiom

of distress which had been studied in North Indian cities.

Symptoms are underlying irritation, rumination, frequent

anger, and insomnia, due to domestic conﬂ ict and urban

stressors, yet psychiatric care is not easily accessible and

has been stigmatized; thus, symptoms may persist when

unaddressed ( Weaver, 2017 ).

Pibloktoq

Pibloktoq (arctic hysteria) is a cultural psychiatric syn-

drome among circumpolar Inuit of Greenland. Its cluster of

hysterical symptoms includes alteration of consciousness,

seizures, amnesia, tearing oﬀ clothes, glossolalia, and run-

ning across the snow and rolling in it.

Windigo or Wendigo, Witiko, Chenoo

Windigo or Wendigo (Anishnaabe [or Chippewa, Ojibwa],

Ottawa, Algonquin, Potawatomi), Witiko (Cree) or Chenoo

(Mi’kmaq), in oral Algonquian tradition was most common

around the turn of the century until the 1980s. The creature

is an ice giant with a frozen human inside who possesses

the soul of a starved person during wintertime and can-

nibalizes his closest family. Albeit the above, Euro-Cana-

dian conceptions of “Windigo psychosis” and “Pibloktoq”

may reﬂ ect misunderstood mental states due to self-justi-

ﬁ cations that underlay policies of colonization, disposses-

sion, the plundering of children, and cultural destruction

(Waldram, 2015).

15: INTEGRATIVE MANAGEMENT OF DISORDERED IMPULSE CONTROL 351

La Bouffee Delirante

In West Africa and Haiti, La Bouﬀ ee Delirante is a disrup-

tive cultural “idiom of distress” characterized by sudden

agitation, aggression, confusion, auditory hallucinations,

and paranoia.

Running Amok

Running Amok is an Indonesian/Malaysian and Indian

cultural psychiatric term for a South Asian phenomenon.

The client often begins with rumination, then suddenly

breaks into a mass homicide spree, putting themselves at

risk for being killed or sometimes ending by suicide. It may

have begun with the cultural training for warfare of early

Japanese and Malaysians to frighten the enemy to ﬂ ight.

This term’s meaning and symptoms have evolved over

time, aﬀ ected by sociocultural currents, medical knowl-

edge, and the intent of those who employ the term. How-

ever, there have been variants found in Germany and the

United States, and is often mentioned by researchers as an

Islamic syndrome as well ( Imai et al ., 2019).

Ataque de Nervios

Ataque de nervios is a cultural psychiatric “idiom of dis-

tress,” which often occurs within acutely stressful situations

in Latinx cultures, as a sanctioned response to acute suﬀ er-

ing, chronic illness, grief, family conﬂ ict, external threats, or

the breakdown of social networks ( Ginzburg et al ., 2020).

There seems to be a cluster of symptoms (uncontrollable

shouting, aggression, crying episodes, trembling, heat in the

head and chest) with the overlapping meaning of ataque de

nervios according to diﬀ erent gender, age, or locational vari-

ations across Mexico, Puerto Rico, Honduras, Guatamala,

and Latinx communities in the United States ( Stein, 2019 ).

The Meaning of Aggression in Your

Adult Client

Country-wide or communal shared understandings are

part of the socialization and enculturation or accultura-

tion of children, learned from toddlerhood. Participating

in shared web of meanings, symbols, and metaphors of

their sociocultural milieux—while mediated through their

own early parent–child, family, and peer perceptions and

experiences—help shape their own behavior according

to the role in society they sense they have been expected

to play and provides a feeling of belonging and having

a home in the wider world. But developing children are

mostly dealing within their family world, while developing

adolescents are mostly dealing with their family and peer

worlds. Adults deal with their maternal and created fami-

lies, their study and work peers, their community, state, na-

tion, and the world at large, not only as it impacts them, but

as they impact it as an agent, within the limitations of their

position, yet with their own unique choices. Thus, success-

fully interpreting their conceptual world, relational world,

and behavior lies within a vaster repertoire.

The key is for the PMH-APRN to ascertain how the cli-

ent’s past and current cultural, social, economic, and polit-

ical signiﬁ cance impacts their understanding of their own

behavior. One must assess what kind of life they are liv-

ing. What role does anger and aggression play within it?

If in a dangerous neighborhood or high-powered job that

requires constant assertiveness bordering on aggression,

this behavior may be an eﬀ ort at self-protection, rather

than being merely dysfunctional. Consider to what degree

high environmental adversity is unavoidable, self-chosen,

or willingly accepted to assist others.

While many clients may have impulsive or disruptive

moments during times of collective transformations or high

distress, an individual subject to frequent, uncontrollable

bouts of impulsivity and seriously disruptive behavior with

consequences should seek clinical evaluation. The clinical

seriousness of this behavior depends upon its maladaptive

degree within the client’s self-coherence, his interpersonal/

sociocultural realms of family, social circles, studies, work,

and the degree to which partners have been harmed. Mis-

placed low expectations in more disadvantaged families,

milieux, and temporary situations may create a “sense of

incoherence” detrimental to physical and mental health. But

in the hardest conditions, during adolescence, at the weak-

est point of intergenerational transmission of trauma risk

factors, as the brain is being freshly remodeled and mean-

ingful life challenges appear, negative transmission factors

may be disrupted (Verhage et al., 2018). Antonovsky’s view

of the importance of salutogenic conditions aﬃ rms the lon-

gevity-relevant importance of coherence in one’s life, espe-

cially during periods of instability and traumatic life events

( Antonovsky, 1987 ). It is essential for a sense of self and

an optimistic developmental outlook regarding a positive

niche within society. This is why many child and adolescent

interventions—inserted at key developmental cusps to in-

sert fresh views and behavioral options into the child’s or

adolescent’s expectations, to optimize primary interactions,

and to re-scaﬀ old their learning contexts—can be so power-

fully transformative and provide hope. In order to ascend

beyond one’s apparent barriers, one must be oﬀ ered alterna-

tive scaﬀ olding and ladder steps up. Yet, the adult client has

employed their own agency to create a life path and at least

has a partial worldview. There are fewer developmental

cusps where transformation can jumpstart positive growth

than there are during childhood or adolescence In order to

change, the client must re-examine their mode of engaging

with the world and mature beyond their initial mode. They

must learn new skills to facilitate emotional self-regulation

and engage more eﬀ ectively, whether due to IED or BPD.

The development of APD is mostly from adolescents who

had CD, yet half of them shift into normative adult lives.

The remaining half develop APD (Sanches, 2019).

ASSESSMENT AND INSTRUMENTS

With regard to impulsive and disruptive disorders, it is

more accurate and helpful to review the symptom clusters

etiologically and dimensionally, rather than to think of the

DSM-5 categories as discrete and immutable. If the child

is young and has a lighter range of symptoms, attempting

to prevent more severe ones during development is the

most valuable treatment goal. Obtaining the most accurate

352 III: INTEGRATIVE MANAGEMENT OF SPECIFIC SYNDROMES

diagnostics possible involves a multidisciplinary team,

child, parental, and educational sources of information, as

well as a variety of instruments and labs, to home in on

the sources of the child’s diﬃ culties. Since many ODD and

CD clients have underlying medical and/or developmental

disorders (Benarous, Bury, et al., 2020; Benarous, Iancu, et

al., 2020), obtaining a sensitive and reliable diagnosis is the

key to constructing a collaborative treatment plan. Since

most of the aﬀ ected children or youth also have either some

cognitive diﬃ culties from ASD (20%) or learning disabili-

ties (around 25%), and many may develop socioemotional

diﬃ culties such as those of BP, IED, or DMDD (Bruno et

al., 2019), it is exceedingly important to understand how

this particular child’s symptoms developed over time in

order to provide an accurate diﬀ erential diagnosis. The eti-

ologies, attachment-based psycho-neuro-endocrinological,

biopsychosocial responses, and agency of the child, youth,

or adult ﬁ t better into ﬂ uid dimensions rather than into

sharply deﬁ ned DSM-5 categories. The understanding of

these disorders is in ﬂ ux, not only because of dimension-

ality constructs, new ﬁ ndings in neuropsychiatry, and ﬁ n-

er imaging, but also an expanded awareness of traditional

cultural/historical syndromes and how possible psychiat-

ric “idioms of distress” blend with current Western psy-

chiatric views as we become more aware of each other’s

mental health challenges across cultures. How we begin to

resolve and work with these new understandings and ﬁ nd-

ings will have an enormous import upon client trajectories.

Assessing Intersecting Dimensional

Spectrums

The key cross-cutting dimensional spectrums to consider

are:

1. Is the client’s underlying problem medical (i.e., genet-

ic, neurodevelopmental, pharmacological, or injury-

or toxin-caused)? How is the client’s cognition and

learning?

2. What is the quality of mother–child attachment as re-

ported by client?

3. If ACEs occurred, how many, and which kind, setting,

timing, duration, and severity of each?

4. Is there more internalization or externalization of nega-

tive emotion?

5. Is the presentation more impulsive or deliberately dis-

ruptive?

6. Does the behavior reﬂ ect a “hot” (reactive) response or

“cold” (instrumental) aggression?

7. If physiological coordinates can be measured or ob-

tained, this may help develop an accurate diagnosis.

8. Measure prosocial versus antisocial (CU) actions pro-

portionally one next to the other to determine degree of

CU traits. Correlates of these dimensions may point you

toward which are altering the client’s homeostasis, sense

of well-being, and actions more. A higher probability of

internalizing symptoms may signal adolescent eating

disorders or substance abuse associated with anxiety,

anxious emotional dysregulation, and physiological

hyperarousal; externalizing behavior is associated with

ADHD, inattention, avoidant emotional dysregulation,

and hypoarousal.

There is a distinction between reactive/impulsive ag-

gression (impulsive, rule-breaking, risk-taking) versus in-

strumental/predatory aggression (Pisano & Masi, 2020).

Reactive/impulsive aggression is “hot” and associated

with higher cortisol levels (Bakker-Huvenaars et al., 2020),

physiological hyperarousal, and quick skin reactivity. In

research conducted in a Boys Town of Omaha Nebraska,

reactive/impulsive aggression is correlated with a hyperre-

sponsive amygdala (for social threat), the striatum, and the

PFC, but the severity of psychopathology is associated with

the extent of the cavum septum pellucidum. Early neuro-

developmental disruption within the limbic system seems

to be the most probable neurological developmental eﬀ ect

( Blair & Zhang, 2020 ).

On the other end of the spectrum, “cold” calculation (in-

strumental aggression) is theorized to aid self-stimulation, and

has been associated with ﬂ atter cortisol diurnal curves, as well

as hypoactive physiological parameters like blood pressure,

pulse, and skin reactivity. Flatter cortisol curves have been as-

sociated with a dysfunctional suprachiasmatic nucleus (SCN).

Insomnia and metabolic ills may be seen with either. Despite

apparent physiological evidence, the interpretation of a dis-

tinction between instrumental versus impulsive aggression

has still been questioned in Fanning, Coleman, and Lee (2019).

The optimal order of the stepwise assessment begins

by obtaining medical and neurodevelopmental histories,

neurological labs, and, in some cases, a neuropsychological

battery of tests and/or genetic or genomic testing to disen-

tangle and elucidate the multiple layers of obstacles and

struggles the child faces. It is recommended to interview

the child ﬁ rst while observing his interactions with the play

milieu, while another therapist or social worker interviews

the parent(s), then observe the family interacting all togeth-

er, depending upon what can be said to the parent about

the child, as per Health Insurance Portability and Account-

ability Act (HIPAA) rules. Medical history should include

vital signs; genetic screens, if indicated; basic labs; brain im-

aging/EEG, if indicated; neurological referral, if indicated;

basic child, parent, and teacher screens (K-SADS, ASEBA,

BASC-C, SDQ); family genogram; contextual socioeco-

nomic, legal and cultural assessments; and more targeted

screens for impulsive-disruptive disorders. Disorder char-

acteristics and assessment for comorbidities are vital to the

formulation. If the client is adolescent, use the adolescent

formats, and, if adult, use the adult formats.

Collaboratively working with the child and parents is

key, but they often have clashing perspectives regarding op-

positional or aggressive behavior. The most well-meaning

parents can inadvertently exacerbate the child’s diﬃ culties,

since it can be hard for them to experience themselves from

their own child’s viewpoint, may have gunny-sacked their

frustrations, may feel guilty about the misbehavior, and

may be defensive about not knowing what to do. Teaching

the parents helpful skills to work with their child’s situation

15: INTEGRATIVE MANAGEMENT OF DISORDERED IMPULSE CONTROL 353

beneﬁ ts both and can improve symptoms, sometimes mark-

edly. It is best to avoid relying only upon parental reports

without child input and important to observe the child in

naturalistic family interactions, approaching and playing

within the therapeutic environment ﬁ lled with washable

toys, drawing utensils, doll families, little homes, trucks/

trains, balls, molded animals, puppets, and other play tools

set up in the room. The assessment should be supplement-

ed by collateral information from grandparents, teachers,

siblings, neighbors, school nurse, school principal, and ac-

ademic reports and tests, which a social worker can help

obtain when working conjointly.

For adolescents, obtaining earlier assessments, their

school documents, and any neuropsychiatric assessments,

or neuropsychiatric imaging, would be helpful. Try to ﬁ ll

out the maximum amount of information obtainable in the

Comprehensive Psychiatric Assessment. For adults, prior

assessments, imaging, academic documents, and medical

records, if available, are very helpful.

Physiological Assessment

Assessing Toxic Exposures

To assess fetal alcohol syndrome (FASD) or other toxic expo-

sures, comprehensive physical, sensory, occupational, and

neurological assessments are the best way to begin, so that

medical and physical problems can be treated ﬁ rst. A com-

prehensive neuropsychological evaluation of IQ, attention,

executive function, memory, and visual-motor coordination

are indispensable functional indicators, but after the medi-

cal assessments and treatments are arranged. For example,

for FASD, a neurological examination would include non-

speciﬁ c, cranial nerve abnormalities, dysarthria, hypotonia,

reﬂ ex changes, limb and gait ataxia, larger foot angles, in-

creased step width, and greater gait variability. In children

suﬀ ering from FASD, there are high epilepsy rates (5.9% vs.

0.5% normally), with more heterotopias or polymicrogyria.

Sometimes there are copy number variations or hypermeth-

ylation of cytosine-guanine dinucleotide sites in genes as-

sociated with neurodevelopmental disorders and epilepsy

(Wozniak et al., 2019). Physical therapists and occupational

therapists may see motor deﬁ cits in infants that may be dis-

cerned if walking is delayed, with gross and ﬁ ne motor deﬁ -

cits. For young children, there may be lower manual coordi-

nation scores and graphomotor skills, with strong pressure

and cross-thumb grasping style when attempting to write

or draw. Ophthalmological examinations may reveal optic

nerve hypoplasia and tortuosity of retinal vessels, while an

audiologist may ﬁ nd sensorineural hearing impairment.

Sleep disturbances of children with FASD are common

(58%) and exacerbate neurocognitive and behavioral deﬁ -

cits. If the suprachiasmatic nucleus (SCN), the central body

clock, is damaged, diurnal neuroendocrine secretions and

timing of functions in all the body’s cells can become dis-

rupted, period genes and circadian rhythms become altered,

melatonin levels are dysregulated (80%), and the child ex-

periences respiratory abnormalities and obstructions, which

worsen insomnia and parasomnias (Wozniak et al., 2019).

Assessing Congenital Genetic

Syndromes With Impulsive/Disruptive

Symptoms

Brunner Syndrome

5-HIAA (5-hydroxy-indoleacetic acid) is a serotonin me-

tabolite in the cerebrospinal ﬂ uid (CSF), and when low can

raise risks for aggression and suicide in humans (Shatkin,

2015), particularly if paired with variants of MAOA in what

is called Brunner syndrome. Symptoms of Brunner syn-

drome in male youth are mild intellectual disability, intro-

version, obsessive behavior, few friendships, but a history

of explosive aggression in childhood, with ﬂ ushing, head-

aches, and diarrhea. Diagnosis includes ﬁ nding high serum

serotonin, low urinary 5-HIAA, urinary metanephrines,

and vanillylmandelic acid (VMA). Serum and urine screen-

ing for metanephrine and serotonin measures, as well as

modifying the diet, may help, but psychopharmaceutical

MAOIs are contraindicated (Palmer et al., 2016).

22q11.2

The 22q11.2 deletion or duplication syndrome has pheno-

typic variability, yet is associated with neuropsychiatric

disorders like epilepsy, seizures, ADHD, ASD, IDD, anxi-

ety disorders, OCD, early-onset Parkinson’s disease, and

a quarter of those with schizophrenia (Olsen et al., 2018).

Both COMT and MAOA genes, associated with antiso-

cial behavior, are located in the 22q11 region. In addition,

22q11.2 duplication has been linked to aggression as well

via clinical anecdotes ( Vyas et al. , 2019). In this case, it has

been recommended to conduct genetic diagnosis early in

life, so prevention eﬀ orts may be started with early inter-

vention and monitoring ( Zinkstok et al. , 2019).

Sturge–Weber Syndrome

Sturge–Weber syndrome, a rare syndrome of 1:50,000, is a

vascular malformation after the division of a trigeminal cra-

nial nerve during the ﬁ rst trimester of fetal development.

This congenital condition predisposes the child to experience

high irritability, inattentiveness, and hyperactivity, and to

become oppositional. Neurologically, the child often suﬀ ers

from seizures. This syndrome creates leptomenigeal angio-

matoses, often in the posterior parietal and occipital lobes,

which causes atrophy, hypometabolism, and accelerated cal-

ciﬁ cation of brain arteries and veins. Signs and symptoms

are dermatological port wine stains on the face ipsilaterally

to the angiomatosis, with ocular disorders also appearing ip-

silaterally. Neuropsychological testing may ﬁ nd that if there

are seizures, the child may have learning disabilities and

borderline intellectual disabilities (Thome et al., 2013).

Tuberous Sclerosis

Tuberous sclerosis, a rare syndrome of 1:6,000–9,000, is an in-

herited or spontaneous genetic mutation in either the TSC1

or TSC2 gene, which normally suppresses tumors. The child

may have pervasive developmental disorder (PDD), ASD,

a disrupted attention span, aggression, emotional lability,

354 III: INTEGRATIVE MANAGEMENT OF SPECIFIC SYNDROMES

depression, anxiety, and sleep disturbances. Neurologically,

the child suﬀ ers from seizures. The syndrome facilitates the

formation of cortical tumors, cortical dysplasia, subcortical

heterotopias, white matter abnormalities, subependymal

nodules, and giant cell astrocytomas secondary to cell pro-

liferation, diﬀ erentiation, and migration abnormalities. The

child can have facial nevi around the nose/mouth area, or

impaired cardiovascular, renal, hepatic, and dermal func-

tions. Neuropsychological testing often shows IQ scores in

a bimodal distribution from just below the norm to severe-

ly impaired. With FASD, a child may have communicative,

receptive, and expressive language deﬁ ciencies; executive

function deﬁ cits; memory gaps; and/or ﬁ ne/gross motor

diﬃ culties (Wozniak et al., 2019).

Smith–Magenis Syndrome

Smith–Magenis syndrome is caused by a heterozygous de-

letion at chromosome 17 (17p11.2), which can result in de-

velopmental asynchrony and mild to moderate intellectual

disability, with distinctive facial features. They suﬀ er from

sleep disturbances, stereotypies, self-injurious behavior,

anxiety, frequent temper tantrums, aggression, opposition-

ality, and impulsivity. Prenatal or preimplantation diagno-

sis may be made for those at-risk using CMA or FISH on

fetal cells (Smith et al., 2019).

Thermoregulatory Fear of Harm

Thermoregulatory fear of harm (FOH) mood disorder is a

recently elaborated heritable disorder that entails symp-

toms which could be confused with impulsive or disrup-

tive symptoms, yet have physical thermodysregulation at

its core with a typical prodrome and symptoms cluster. It

occurs from thermoregulatory disruption, and results by

disturbing orexin levels and BDNF gene expression. The

child experiences overheating in mild ambient tempera-

ture, especially at night; the child is cold in the morning,

yet has extreme cold tolerance. This disorder also results

in frequent vivid REM sleep nightmares of pursuit, inju-

ry, death, and abandonment; parasomnias (night terrors

and hypnagogic hallucinations); enuresis; bruxism; sleep-

walking; sleep-talking; and morning state inertia. Defen-

sive behaviors develop due to fears, separation anxiety,

hypervigilance, perfectionism, and extreme reactive ag-

gression against oneself or others set oﬀ by limit-setting,

changes in routine, critique, loss, or threat—by mutilating

self, breaking objects, cutting, internal injury, fractures, loss

of teeth, or verbal violence. It is characterized by a nega-

tive self-concept, disrupted attachments, sad periods, and

brief manic-like states with increased goal-directed activi-

ty (“mission mode”). Individuals have diﬃ culty attending

school, lose their friends, and wind up on psychiatric ﬂ oors

(54%). While responses to anxiolytics, antipsychotics, and

mood stabilizers have obtained satisfactory results, robust

sustained outcomes (88%) have been obtained from intra-

nasal ketamine administered every 3 days. For diagnostics,

the Yale-Brown Obsessive Compulsive scale (YBOCS) and

the Overt Aggression Scale (OAS) are used. Proportionally,

this cluster may be a third of pediatric bipolar diagnoses

with extreme manias and depressions, which needs further

research of genetic mechanisms and acceptance in the

DSM-5 (Papolos et al., 2019).

Somatic Changes in Structure or

Function

Predatory/instrumental aggression has a diﬀ erent physi-

ological proﬁ le than reactive/impulsive aggression. Auto-

nomic arousal in proactive aggressors may be so tamped

down that initiating an act of violence generates little fear

of consequences. Meta-analyses have documented lower

baseline skin conductance rates as well (Lochman et al.,

2019 ). For reactive aggression, the opposite phenomenon

rules, especially in IED, DMDD, and BPD as their sympa-

thetic nervous system is usually physiologically aroused at

baseline during and after an emotional episode, with rela-

tive tachycardia and quick skin conductance, resulting in

impulsive outbursts.

Psychiatric Instruments

At the end of these usual measures, the American Psychi-

atric Association introduced new instruments which are

being tested for the impulsive/disruptive DSM-5 cluster

on its website. These distinctions also can help diﬀ er-

entiate this cluster from BP, which has cyclical episodic

irritability that is not chronic (Pisano & Masi, 2020). Ag-

gression does not exclusively imply a diagnosis of CD.

For adult clients, it is best to rule out mood disorders,

APDs, psychosis, and PTSD to be able to explore IED or

BPD further.

Impulsive/Disruptive Measures

• Alabama Parenting Questionnaire (see Paul Frick’s

Lab LSU.edu website)

• Anti-Social Personality Disorder (ASPD) —youth

version (free from Paul Frick’s Lab website)

• Anti-Social Process Screening Device (APSD): www

.mhs.com

• Balloon Analogue Risk Task (BART): Computerized

measure of risk-taking behavior, by client pumping

30 balloons until they either gain the worth of each

inﬂ ation or lose everything because the balloon

explodes. For each balloon, the maximum pumps

are diﬀ erent. If short on time, fewer balloons can be

done. Risk-taking declines with increased caution to

earn the reward. Studies show reliability and validity:

www.impulsivity.org/measurement/BART

• BIS-15—Barrett Impulsiveness Scale Short Form: 15

questions: scores + or greater than 11 are impulsive;

also available in Spanish and German

• BIS-11—Barrett Impulsiveness Scale: 30 questions on

a Likert scale. Optimal scoring done with breakdown

of attentional (attention and cognitive instability),

motor (motor and perseverance), and nonplanning

(self-control and cognitive complexity) components,

so the treatment plan can focus on the speciﬁ c deﬁ cits.

15: INTEGRATIVE MANAGEMENT OF DISORDERED IMPULSE CONTROL 355

Available in many languages: www.impulsivity

.org/measurement/bis11

• Brown-Goodwin Lifetime Aggression Scale: https://

dictionary.fitbir.nih.gov/portal/publicData/data

ElementAction!view.action?dataElementName=

BGLHATtlScoreLETBI&publicArea=true

• CAPE—Developed by Paul Frick of Louisiana State

University, 2019; Copyright Protected: https://sites01

.lsu.edu/faculty/pfricklab/wp-content/uploads/

sites/100/2015/11/CAPE-Manual.pdf

• Callous-Unemotional Traits (ICU-SR and ICU-TR),

Self-Version and Teacher Version: Measure the core

symptoms of psychopathy in children. http://labs

.uno.edu/developmental-psychopathology/ICU

.html; https://sites01.lsu.edu/faculty/pfricklab/wp

-content/uploads/sites/100/2019/05/ICU-T-score

-Table-PDF.pdf

• Clinical Evaluation of Emotional Regulation-9 (CEER-

9; Pylypow et al., 2020): Determines the threshold of

emotional lability

• Cultural Formulation Interview: Designed for children,

adoles cents, adults, and older adults, especially for

immigrants and refugees, caregivers, and to explore

spirituality and moral traditions (developed by Laurence

Kirmayer’s teams, McGill University/the Jewish

General Hospital. https://multiculturalmentalhealth

.ca/clinical-tools/cultural-formulation/; https://ny

culturalcompetence.org

• International Society for Research on Impulsivity:

Cued Go No-Go Task: Measures impulse control

through providing stop-start signals with pre-action

cues, which may be true or misleading. The speed or

quick inhibition of response is elicited and counted.

Slow inhibition 250 trials may be done in 15 minutes.

Good validity and reliability of this measure has been

studied in clinical and substance abusing clients: www

.impulsivity.org/measurement/cued-go-nogo/

• Disruptive Behavior Disorder Rating Scale

(DBD): https://ccf.ﬁ u.edu/research/_assets/dbd

-rating-scale.pdf

• ICU List of Translations: http://labs.uno.edu/

developmental-psychopathology/ICU/ICU%20

Translations.pdf

• Immediate and Delayed Memory Tasks (IMT/DMT):

Continuous performance test for impulsive behavior

by comparing consecutively presented numbers,

and responding when there is a match. Nontarget

responding can be caught in errors, because they

respond before information processing is completed:

www.impulsivity.org/measurement/IMTDMT

• KSADS for Assessing ODD, CD, DMDD, Other

Disorders and Suicide: www.kennedykrieger

.org/sites/default/ﬁ les/library/documents/faculty/

ksads-dsm-5-screener.pdf

• Peer Conﬂ ict Scale (PCS): Youth, Parent, and Teacher

versions, Paul Frick Lab, LSU.edu: https://sites01.lsu

.edu/faculty/pfricklab/wp-content/uploads/sites/

100/2015/11/Peer-Conﬂ ict-Scale-Youth-Version.pdf

• American Psychiatric Association Emerging Assess-

ment Measures: Pilot Instruments: www.psychiatry

.org/psychiatrists/practice/dsm/educational-resources/

assessment-measures

• Reward Dominance Task (see Paul Frick’s Lab website)

• International Society for Research on Impulsivity:

UPPS-P Impulsive Behavior Scale: Measures aspects of

impulsivity in negative urgency, lack of premeditation,

lack of perseverance, and sensation-seeking. The

instrument can be obtained for children (40 questions),

Short Adult version (20 questions), and Adult version

(59 questions) on a Likert scale: www.impulsivity

.org/?s=UPPS-P

Assessment Process

Assessment should occur in three layers or stages. The

ﬁ rst and second stages can be completed by an intake so-

cial worker before beginning a comprehensive psychiatric

assessment. Is the client aware of their own life goals and

purpose? They may be self-aware enough to know how to

distinguish the kind of life they live from the one they want

to live. If not, this will help guide them toward their life

goals. What do they aspire to do, within the realm of the

possible? What level of functioning? How do they see their

problem? Is there a sense of coherence?

The second stage is verifying to what extent the client

is living the kind of life with which their inner resources

can potentially cope, or to what extent and frequency they

get overwhelmed. Investing everything to cultivate greater

inhibitory capacities and balance may be less eﬀ ective if ev-

ery day the client walks out into chaotic contexts in which

deploying unpredictable, nondamaging eruptions may be

more protective of themselves and others.

The third stage is a comprehensive psychiatric assess-

ment which includes family history and medical history,

genogram, genetics, birth history, developmental history,

neurological, medical (includes injuries, surgeries, aller-

gies), and so on.

Mindfulness and emotional self-regulation work hand-

in-hand to prevent escalating anger from occurring. The

ﬁ rst involves an approach employing receptive awareness

grounded in the moment, while the second process occurs

during intense emotional responses ( Velotti et al., 2019 ).

Impairments in these capacities (e.g., alexithymia) are asso-

ciated with higher levels of aggression, in both community

and oﬀ ender populations (Velotti et al., 2019).

EARLY PREVENTION

AND INTEGRATIVE TREATMENTS

Assessing Which Treatment Is Suitable

Early preventive interventions are the key. Treatments for

impulsive and/or disruptive disorders should be diﬀ eren-

tiated according to the same factors that helped bring the

356 III: INTEGRATIVE MANAGEMENT OF SPECIFIC SYNDROMES

client’s unique diagnostic features into the light. Even with a

formal diagnosis that ﬁ ts within the parameters of the DSM-

5 , the PMH-APRN should ﬁ rst address medical vulnerabil-

ities, then try to understand how early the deepest source

of distress lies, then ﬁ nd out the twists and turns of life un-

folding through adverse events. With this background, the

clinician can focus upon the handling of emotions and life

choices. A further breakdown would look like this:

1. Are there underlying medical vulnerabilities—prematu-

rity, genetic, neurodevelopmental, mitochondrial, or in-

jury- or toxin-caused—which must be treated ﬁ rst or are

currently being treated? Are there recognized medical

disabilities? If in an outpatient clinic: does the clinician

have their medical chart?

2. Are there underlying cognitive or learning disabilities

not yet addressed, or being treated?

3. If ACEs: How many, which kind, duration, and severity

of each? How secure was the mother–infant attachment

or primary initial attachment to help the child cope?

If it was not secure, was the attachment conﬁ guration

avoidant, anxious, or fearful/disorganized? Was there

resilience, posttraumatic growth (PTG), or a bit of both?

Would more attachment-oriented therapy help?

4. Is there more internalizing or externalizing of negative

emotion? How intense?

5. Does the behavior reﬂ ect a “hot” (reactive) response or

“cold” (instrumental/predatory) aggression? Although

“hot” aggressive responses are associated with impul-

sivity, “cold” aggression can include “hot” temper, yet

with calculated “cold” actions. Do they have physiolog-

ical coordinates which correspond with “hot” or “cold”

responsiveness?

6. Is this handling of diﬃ cult emotions congruent with

their earlier attachment responses? In other words, is

their self-blaming, internalizing, “hot” aggressive tem-

per congruent with their younger anxiously attached

self? Do they express remorse? Or at the other end of

the spectrum, is their other-blaming, externalizing, in-

strumental “cold” aggressive behavior congruent with

their former avoidantly-attached self? Or are they oscil-

lating between inﬂ exible attachment extremes, as chil-

dren with fearful attachment responses do? Are reactive

attachment or disinhibited attachment comorbidities?

7. Is the presentation more unreﬂ ectively impulsive or de-

liberately disruptive?

8. Empathic or CU responses to others’ suﬀ ering is an

important spectrum coordinate to know. Do they re-

fuse self-blame, empathy, or lack remorse? Measure

prosocial/empathic versus antisocial attitudes and

actions proportionally one next to the other. Despite

other factors and possibly misleading mentorship, this

choice concerns both empathic and CU responses to

suﬀ ering. It also should be reviewed vis-a-vis their own

spiritual-cultural orientation and mentorship-guid-

ed ethical or unethical behavior. Previous avoidant or

fearful attachment conﬁ gurations will have entrained

less-responsive resonances. Yet, the client’s own agency

is still involved in initiating, or consent to act in, antiso-

cial ways, despite misguidance and unfavorable or con-

straining circumstances.

9. Ask and assess the degree of sense of coherence in their

life.

10. Ask and assess if they are still seeking meaning in their

life or what kind of meaning they have found: love, chil-

dren, work goals, study goals, meaning in their suﬀ er-

ing, or something else.

Rule of Thumb

The approach of social work is to try to improve client ex-

ternal circumstances. The approach of pastoral counseling

is to try to improve client moral strengths. The approach of

psychology is to try to improve client coping capacities. The

approach of psychiatry is to try to alter aﬀ ected brain mech-

anisms. Family and couple therapists approach individual

suﬀ ering as the result of family or dyadic dysfunction. Med-

icine and nursing aim to treat illness and nurse the client

back to health. But all of them depend upon basic health

promotion and common sense: good prenatal and prema-

ture infant care (Fleiss & Gressens, 2019), environmental

safety and hygiene, suﬃ ciently good quality nutrition and

hydration, enough good quality sleep in a peaceful dark

environment, space/area to safely exercise for general func-

tioning, neuronal sprouting, and preventing premature ag-

ing. Many people do not have these basics, yet therapies or

medications cannot be expected to work optimally without

endeavoring to ﬁ x these basics. PMH-APRNs would be wise

to integrate all these perspectives, so as to obtain a more

comprehensive and nuanced understanding of their clients.

For children, dyadic and family-based therapies will

be most helpful. As the child begins to gain more agency,

cognitive behavioral therapy (CBT) and dialectical behav-

ioral therapy (DBT), adjusted for age and traumatic ACEs,

are incorporated to some degree in many of the child and

youth therapies. This is not a stand-alone therapy, but is

joined with additional psychoeducational and behavioral

benchmarks, so the child or adolescent can be better adjust-

ed within their erstwhile psychosocial milieux, yet expand

their own agency to gain competence and acceptance with-

in larger mainstream society norms. This way, they will be

empowered to choose a psychosocial niche that matches

their own characteristics and aspirations more easily than

being required to conform within this initial primary sub-

cultural norm within the larger society.

In the case of foster children in kinship care who expe-

rienced early trauma, a systematic review was done ex-

amining randomized and quasi-randomized controlled

trials between 1990 and 2016. Generally, eﬀ ective inter-

ventions to improve behavioral issues had clear aims, tar-

geted domains, and developmental stages; used role-play

with coaching; and aimed at improving damage from

maltreatment and relationship disruption. These entailed

disciplinary consistency, positive reinforcement, trauma

psychoeducation, problem-solving, and parent training in

empathy, sensitivity, and attunement to their child (Kem-

mis-Riggs et al., 2018).

15: INTEGRATIVE MANAGEMENT OF DISORDERED IMPULSE CONTROL 357

Interactive Parent–Child Therapies

Play Therapies: The Incredible Years

The Incredible Years takes place in a small group format for

parents of children divided into age groups, from infant-

hood through age 12. The therapy lasts from 12 to 20 weeks.

It is a series of three distinct but modular evidence-based

programs to promote socioemotional understanding in

young children and prevent, as well as treat, disruptive be-

haviors. The Parenting Pyramid is built by strengthening

and nurturing parent–child attachment via child-directed

play and coaching the child’s growth and problem-solving,

increasing limits and rules, while reducing punishments

and criticism. The ﬁ rst is the basic parenting series with

ﬁ ve curricula versions for diﬀ erent ages. The emphasis is

upon age-appropriate parenting skills that assist children

in reaching crucial developmental milestones. The second

program trains teachers in 6 days for children aged 3 to 8

years and takes place monthly for 10 to 15 teachers. This

Teaching Pyramid promotes positive management skills

and relationships through socioemotional, academic, and

persistence coaching, as well as cultivating parent relation-

ships. The third program is Dina’s Dinosaurs social skills,

emotion, and problem-solving curriculum, in classroom

prevention or small group treatments. The latter takes place

across 20 sessions to groups of six children with conduct

problems or ADHD, often joined with the parenting cor-

relate (Reddy et al., 2016). The group format helps parents

see that they are not alone and learn what works for each

other as well. For the children, disruptive behavior can de-

crease, and prosocial behavior is encouraged to improve

(Webster-Stratton & Reid, 2017).

Parent–Child Interaction Therapy

Parent–Child Interaction Therapy (PCIT) is especially

good for 2- to 7-year-olds, and takes place across 14 to 17

sessions. It aims to teach an authoritative parenting style

that combines high nurturance with form control (Loch-

man et al., 2017). It begins with coaching the parent—via

an earpiece and one-way mirror—as child-directed play

with the parent unfolds. Parent responses to positive child

behavior, as well as diﬃ cult behaviors, are coached by the

PMH-APRN. This therapy nurtures positive child–parent

interactions for dyads whose relationship has already suf-

fered from being out of sync, with coercive incidents. The

use of labeled praise and eﬀ ective directions is used. This

parent beneﬁ ts from being personally coached by the ther-

apist, requiring each skill to be mastered before the next

step (Zisser-Nathenson et al., 2019). Long-term results have

been seen 6 years posttreatment (Lochman et al., 2017).

Oregon Model of Parent Management (PMT)

The Oregon Model of Parent Management (PMTO) is a

tried and true method supported by 40 years of research

(Forgatch & Gewirtz, 2017). Outcomes of reduction in be-

havioral problems in toddlers, children, and adolescents

has been well-documented, as it improved parents’ pos-

itive parenting, with positive eﬀ ects up to at least 9 years

posttreatment, with less delinquency and fewer arrests than

similar high-risk boys without the parents having under-

gone PTMO (Lochman et al., 2017). Parent Management

Training (PMT) is intended for 3- to 13-year-olds and their

parents. The therapist teaches and models key management

skills for challenging behaviors during 10 sessions. Families

then role-play these skills, practicing at home, with the use

of stars—which the child can then use to buy s omething

they desire. This treatment may not suﬃ ciently address

accompanying anxiety. It is often employed once children

age out of PCIT (2–7 years). However, if a young child has

underlying anxiety, extreme impulsivity, or explosive an-

ger, beyond merely being out of sync with their parents,

this therapy coaches the family to obtain skills to lessen the

child’s diﬃ culties. For high emotionally expressive (EE)

families (criticism, conﬂ ict, hostility, or emotional strife), pa-

rental guidance, as well as family therapy interventions, can

dramatically increase the child’s support system at home,

while beneﬁ ting the parents and family as a whole. PMT

with problem-solving skills training for child and adoles-

cents can boost cognition and creativity solving problems.

Triple P (PPP)

Positive Parenting Program (Triple P) boosts parenting in-

formation, skills, and behavior for a spectrum of mild to

severe parenting deﬁ cits, for toddler to adolescent children.

For mild problems, four sessions can suﬃ ce, but severe

diﬃ culties require 12 joint and individual child–parent

sessions, depending upon the client’s interactions and

problems (Sanders & Turner, 2017).

Problem-Solving Skills Training (PSST)

Problem-Solving Skills Training is a CBT training manual

for 7- to 13-year-olds, especially for disruptive behaviors.

It consists of 25 sessions and applies a ﬁ ve-step prob-

lem-solving model for challenging situations to assist cli-

ents in choosing prosocial responses in their lives. This is

accomplished through a combination of a 12-session pa-

rental training program of positive reinforcement, helping

explore more positive behaviors, accompanied by mild

punishments. Taken together, the programs reinforce stron-

ger eﬀ ects. Yet, even separately, each has had signiﬁ cant

reductions in disruptiveness while increasing the choice of

prosocial behaviors (Lochman et al., 2017) .

Coping Power Program

Coping Power Program (CPP) consists of separate parental

and child group treatments that take place simultaneously,

over the course of 16 to 18 months, to reduce opposition-

al, disruptive, and aggressive behavior in middle school

children (9–12 years). The 34 small group child sessions are

built upon the Anger Coping Program. Sessions are struc-

tured to teach CBT skills through games, role-playing, and

discussions, with individual monthly sessions for atten-

tion to each child. Behavior is managed through positive

reinforcement for prosocial behaviors, and consequences

for disruption, with rules and a regular agenda of goal

sheets, organizational skills, emotional awareness, anger

358 III: INTEGRATIVE MANAGEMENT OF SPECIFIC SYNDROMES

management, perspective taking, social problem-solving,

and peer relationships, using homework, extra points,

quizzes, small to larger prizes, and “strikes” for behavior-

al problems to withhold prizes. The parents hold 16 ses-

sions to learn more about academic support at home, stress

management, praise and ignoring, eﬀ ective instructions/

home rules, discipline and punishment, family cohesion,

problem-solving, communication, and long-term planning

(Lochman et al., 2017).

Deﬁ ant Teens

Deﬁ ant Teens is intended for 13- to 18-year-olds as outlined

by Russell Barkley and Arthur Robin in Your Deﬁ ant Teen .

At the ﬁ rst stage, the parent is taught skills to address de-

ﬁ ant behavior. The second stage involves teaching the ad-

olescent to alleviate the negative family dynamic. In the

third stage, both the adolescent and parents learn to dispel

unhelpful beliefs, and learn better communication, negoti-

ation, and problem-solving skills.

Foster Care Treatments: Multidimensional

Treatment Foster Care and Treatment Foster

Care Oregon

The predicament of foster children can often be due to

parental and community factors beyond the child’s own

control. In Britain, for example, the Oﬃ ce of National Sta-

tistics 20 years ago found a three to four times increase in

CD among children of socioeconomic “classes” D and E

as compared to class A, with 40% having been diagnosed

with CD (National Institute for Health and Care Excellence

[NICE], 2017 ). Multidimensional Treatment Foster Care

(MTFC) is a comprehensive community-based intervention

employed as a viable alternative to residential care or incar-

ceration for seriously disturbed adolescents. The youth is

placed with trained foster parents for 6 to 9 months, while

the child's own family is trained in parenting skills to help

the youth’s transition when they return home. The foster

homes are well-structured and supervised, while the client

receives individual therapy, psychiatric care, and school as-

sistance. Three randomized clinical trials have shown ben-

eﬁ ts compared to usual care for both boys and girls with

repeated delinquent behaviors, arrests, school absenteeism,

and teen pregnancies (Lochman et al., 2017).

Treatment Foster Care Oregon for adolescents (TFCO) is

a community-based model for adolescents who suﬀ er from

emotional problems, conduct problems, and severe and

chronic delinquency, as an outgrowth of MTFC. It is based

upon separately training parent and youth from mutual-

ly reinforcing one another’s diﬃ culties, weaknesses, and

engaging in intense downward spirals, so that when they

rejoin, they can reinforce one another positively. The treat-

ment team has a tight schedule of activities for the foster

family with a point system: activities of daily living (ADLs),

schooling, behavior, academic eﬀ ort, household chores, at-

titudes, volunteering, and healthy rising and bedtime. In-

tensive case management leaders have 10 families, with the

team composed of family therapists, individual therapists,

skills coaches, TFCO trainers, and a consulting psychiatrist.

Positive youth outcomes include reduced arrest rate, less

ﬂ eeing home, spending more time in foster homes, and less

violent oﬀ enses. The program also leads to separation from

deviant peers (Sanders & Turner, 2017).

Multisystemic Therapy

Multisystemic therapy (MST) has had some success for seri-

ous antisocial behavior including sexual assault, referred by

the justice system with high risk of out-of-home placement.

MST works intensively with the nested levels of emotional

ties that the child has in their family, school, and community.

This integration of all the child’s most important people, net-

works, and milieux involves driving toward the same goal

of lessening the child’s negativity toward self and others,

with improved inter-milieux communication and account-

ability. It employs a clinician supervising teams of master’s

level clinicians, who carry caseloads of four to ﬁ ve families.

They oﬀ er special education expertise, PMT, PSST, social

skills, family therapies, bullying prevention, and legal help.

It is ﬂ exibly applied and individualized, based upon how

the treatment “ﬁ ts” that client, with a constant circular ﬂ ow

of prioritizing, doing, measuring, and re-evaluating, much

like the nursing process. It has been validated extensively

and widely disseminated as evidence-based practice, which

has proved itself to be very eﬀ ective at reducing antisocial

behavior (Sanders & Turner, 2017).

Trauma Systems Therapy

This treatment, designed by the director of the New York

University Child Study Center, child psychiatrist Glenn

Saxe, is open to be modiﬁ able. It has been employed for med-

ical trauma, school-based treatment, foster care, residential

settings, refugee/immigrant groups, and substance-abusing

adolescents and lasts about 7 to 9 months. It is intended for

traumatized children, which may include impulsive/dis-

ruptive children, due to ACEs, chaotic family processes, so-

cioeconomic disadvantage, marginalized ethnic or minority

community environment, and association with deviant ag-

gressive peers in the background of impulsive/disruptive

behavior. The team insists upon ﬁ rst building the child’s and

family’s trust and treatment alliance, then requiring fami-

ly accountability by stopping drug abuse, legally restrain-

ing a violent partner, adherence in psychiatric medications,

participating in Social Services investigations, and allow-

ing a home-based team into the home. The treatment team

aims at leaving the child and family with skills to improve

their own situation, by building upon their own strengths

and helping them ﬁ x what is broken ( Saxe et al., 2015 ).

Adult Therapies

Therapies to treat adult clients involve assisting the client

to solve the situation themselves ﬁ rst, and then trying to

work with trait tendencies, moving stepwise from prevent-

able external stressors to internal functioning. To what level

of return to a functional life should the clinician aim?

It does not make sense to assist a client to adjust them-

selves and their behavior to “ﬁ t in” to a preventably dam-

aging milieu, when they have a viable option to switch

15: INTEGRATIVE MANAGEMENT OF DISORDERED IMPULSE CONTROL 359

to a milieu with a greater sense of coherence, meaning,

comprehensibility, and manageability for their own health

(Antonovsky, 1987). There is no milieu without limits or

diﬃ culties, but there should be a degree of compatible “ﬁ t”

if possible, since health can be compromised if unavoidable

stress levels raise markers of inﬂ ammation over time, pos-

ing cardiac and other health risks.

When considering which therapies and/or psychothera-

peutics might be suitable, collaborating with the client while

exploring the best options gives them some sense of agency

in their own treatment plan, and can help them to adhere

and make an eﬀ ort to improve their skills and self-eﬃ cacy.

Adults will usually have families and partners to consid-

er, who can become invaluable during treatment. As the

client changes, so will their close and other relationships:

spouse, children, parents, friends, coworkers, neighbors,

their children’s schoolmates, children’s parents, children’s

teachers, relatives, and many others. The family’s ecostasis

may change and require some family therapy to deal with

the changes. Especially with IED, or even more with BPD,

relationships can beneﬁ t from additional family therapies.

It should be noted that aiming at the clinician’s concep-

tion of the client’s own cultural norm may miss the mark.

While one should strive to be open and responsive to the

client’s cultural variations, it might not be a good idea to

encourage the client to isolate themselves exclusively with-

in cultural norms which, in the United States, may mar-

ginalize them or even put them in prison. Begin where the

client is. Pay attention to any cultural messages from their

country of origin that may be contradictory to those from

which he suﬀ ers in the United States. Aim to help them ﬁ nd

an individual combination of acculturation and encultura-

tion which ﬁ t them best, within their present milieu, so they

can deal with immediate challenges. Yet even this can be

insuﬃ cient without a life direction.

On the other hand, if one cannot change one’s cir-

cumstances, then accepting those limits while changing

attitudes and behavior to embrace the best aspects may

be attempted. In particular, as Viktor Frankl emphasiz-

es, one’s purpose in life is driven by meaning seeking,

even if less manageable than desired. Love, purposeful

work, and/or courage in the face of adversity are the

three life experiences wherein meaning is often found

(Frankl, 1987). It is best to help the client aim for the po-

tential of what the grounded client aspires to, considering

their strengths and potential, rather than merely to per-

ceive weaknesses and faults. Frankl classically called this

Height Psychology—focused on reaching one’s spiritual

potential—as opposed to Depth Psychology—focused

only on uncovering one’s past like Freud. Frankl’s aim

was to encourage and scaﬀ old clients to be capable of be-

coming what they can be, rather than what they are at

present. If the goals are low to begin with, the initially

disruptive “Orchid Child” adolescent or young adult in

particular will not easily envision the extent of their own

blossoming while moving beyond their disadvantaged

childhood milieu, unless they can ﬁ nd meaning in their

own previous suﬀ ering. Much adversity, suﬀ ering, and

sacriﬁ ce can be shouldered if there is a meaning to it. This

is particularly true for adolescents and young adults in

North America, facing the challenges of solving the larg-

er problems in the world, with their life ahead of them.

Their contribution to solving them, rather than expecting

life to entertain or exclusively fulﬁ ll them, will demon-

strate greater maturity in their approach to meaning. The

development and growth of a mature soul who strives to

meet those larger challenges, accompanied by emotional

and/or behavioral skills to learn, may go beyond the un-

sustainable goal of satisfying themself.

An easy, comfortable life is easier to cope with emotion-

ally and behaviorally than one which is ﬁ lled with fewer

resources, greater dangers, and concrete fears with which

to cope. Yet, if there is meaning in these larger challenges,

there can also be greater growth or maturation of the client’s

own agency, applied ethics, altruistic action, greater sense

of coherence in life, and a motivation to evolve through

ﬁ nding meaning in meeting those larger challenges.

Adult Psychotherapies

and Complementary and Alternative

Therapies

Tailoring one’s approach to a client’s agitation can help

avoid ill-matched pharmaceuticals that are designed to mit-

igate agitation without regard for what triggered the client.

Aggressive states occur when a threat is perceived by the

amygdala, locus ceruleus, anterior insula, hypothalamus,

bed nucleus of the stria terminalis, and periaqueductal gray

to trigger stress hormone release. Perceptions may overes-

timate or misinterpret the threat, and BPD conditions have

notably hypoactive cortical inhibition, so negative agitated

appraisals and reactions are more frequent than more ﬂ exi-

ble responses. A hyperactive HPA-axis can cause copious re-

lease of norepinephrine, glutamate, dopamine, and acetyl-

choline while tamping down serotonin and GABA, both of

which otherwise could inhibit negative responses. Increased

activation occurs in mania, acute psychosis, and stimulant

intoxication, which increase fear or paranoia while reducing

the ability to think clearly and modulate responses. In par-

ticular, low serotonin metabolite 5-hydroxyindoleacetic acid

in cerebrospinal ﬂ uid has been found in suicide attempters

by violent means and aggressive traits (Miller et al., 2020).

Preventing this agitation upstream is better than over-

managing it once it has occurred. Thus, most IED and

mild-to-moderate BPD suﬀ erers, if high functioning, can

beneﬁ t from regular diaphragmatic breathing and mind-

fulness, and meditation practice can increase awareness of

their own emotional pulse. Emotional self-regulation tech-

niques can be tried to see what works for them. Mindfulness

practice includes cognitive reappraisals, articulating associ-

ations between internal and external stimuli with thoughts

and feelings, emotional reappraisal of an emotionally

charged situation or memory, and expressive suppression.

Diaphragmatic breathing, progressive muscle relaxation

(PMR), somatic experiencing (SE), mindfulness, dialectical

behavior therapy (DBT), Schema Therapy (ST), mentaliza-

tion-based therapy (MBT), and/or group anger manage-

ment sessions should be ﬁ rst choices, since these maximize

360 III: INTEGRATIVE MANAGEMENT OF SPECIFIC SYNDROMES

self-awareness and behavioral choice within myriad social

and cultural contexts. Once clients are hyperaroused and

aware of it, deep breathing will not work in acute situations.

Only if they have daily entrainment of their vagal nerves

at the rate of 20 abdominal breaths, three times daily, for

at least 2 weeks, will their parasympathetic system return

slowly to default mode, even under external life pressures.

PMR only facilitates this eﬀ ect, but does not speed it up,

since physiological changes take place slowly. Somatic ex-

periencing (SE) increases awareness to one’s physiological

expression of emotions and response to others, thus alert-

ing the client of building tension. CBT gives tools to reason

out what emotional responses are beyond what matches

the actual stimulus to reduce catastrophizing. DBT is an

evidence-based treatment for BPD. It helps the client rec-

ognize overwhelming fear or anger responses, even when

matched proportionally to extreme external pressures. It

helps the client keep tabs upon their own moods and labil-

ity by constantly checking their own emotional pulse. This

involves daily measures of mood, mindfulness, emotion

regulation, and distress tolerance to develop greater skills

in all. Emotional self-regulation practice involves aware-

ness and understanding of emotional responses, eﬀ ective

coping with negative emotions, distress tolerance, and ef-

fective inhibition of impulsivity. MBT was formulated by

Peter Fonagy of the Anna Freud Center speciﬁ cally for

BPD. This evidence-based therapy focuses upon a deﬁ cit in

“mentalization,” meaning understanding others’ and your

own perspectives (Vogt & Norman, 2018). In treatment for

BPD, when MBT and DBT outcomes were compared, DBT

was more eﬀ ective in lessening BPD severity, self-harm, and

psychosocial functioning; however, MBT was more success-

ful in countering self-harm and suicidality. Both proved to

signiﬁ cantly improve BPD severity (Storebo et al., 2020).

Trauma-focused CBT-anger therapy focuses upon redirect-

ing anger expression and learning how to modulate anger.

For discrete times when the client cannot manage their

distress anxiety or anger, it is best to redirect the excess en-

ergy by moderately quick walking; running; doing jump-

ing jacks; dancing; hiking; performing Tai Chi (redirecting

their energy power into a mindful movement ﬂ ow); playing

hockey, bowling, volleyball, or ping-pong; boxing a punch-

ing bag; kickboxing; playing drums; playing a horn instru-

ment; pillow-ﬁ ght simulation; screaming at a deserted loca-

tion—see what works for them. To allow more steam to blow

oﬀ in an inescapable environment at work or home, they

may recuperate from excess stimulation by lowering work

and interpersonal pressure through more frequent “time-

outs” with decreased stimulation and enhanced soothing

(e.g., warm bubble baths, soothing music, carpentry, home

repairs, herbal teas or warm low-sodium soup cupped be-

tween both hands, touching base with family or friends,

gardening, cooking/baking, cleaning clothes or ﬂ oors).

Symptoms of Korean Hwa-byung (HB) were successfully

treated in a pilot randomized controlled trial of 26 clients

by semi-individualized acupuncture that took into account

the client’s character and kind of emotional distress. Fol-

low-up was at 4 and 8 weeks, with positive outcomes (Lee

et al., 2018 ).

For BPD, the most important key is a therapeutic re-

lationship which stands the test of time to be a salutary

corrective for disrupted trust during parental or men-

tor bonding when the client was young. BPD, despite its

stigmatic reputation and alarming symptoms, is highly

treatable, with good clinical recovery without psychophar-

maceuticals (Campbell et al., 2020). The central approach

will invest in the therapeutic relationship, with application

of DBT or ST, or psychodynamic work. While DBT will

work best if there are severe self-harm attempts, Schema

Therapy may work well if there is avoidance (Fassbinder

et al., 2018). ST employs limited reparenting, imagery and

Gestalt dialogue, cognitive restructuring, and behavioral

pattern-breaking.

In the case of moderate to more extreme BPD, PTSD

with dissociation, or IED, upping the treatment level may

improve results. Onno van der Hart of the University of

Utrecht and former past president for the Society for Trau-

matic Stress Studies, compiled the key steps needed to deal

with clients suﬀ ering from dissociation. Phase 1 consists

of the therapeutic relationship, assessment, case formula-

tion, treatment planning, working with child parts of the

client, approaches to shame, working with angry and hos-

tile parts, and unsafe behavior. Phase 2 consists of working

with traumatic memory. Then phase 3 integrates dissocia-

tive parts into a cohesive personality and beyond (Boon

et al., 2017). DBT combined with psychodynamic therapy

can be especially good for BPD ( Stone, 2019 ), since both the

failure of early bonding and trust requires psychodynamic

work, while DBT focuses upon skill-building in emotional

self-regulation.

Couple Therapy With Borderline

Personality Disorder

If working with a couple, where one of the individuals suf-

fers from BPD, it is best to ﬁ rst work with the BPD client

separately, so that they become more cognizant of early

trust issues and why they oscillate emotionally and during

cognitive appraisal of the spouse, while working on emo-

tional regulation skills simultaneously. At some point there-

after, Imago Relationship Therapy, developed by Harville

Hendrix and Helen Hunt, can improve their relationship

by accessing and caring for the inner “wounded child,”

aiming to transform conﬂ ict into mutual growth. Thus, in-

stead of the therapist facilitating interaction with the “good

mother,” this therapy is used (Hendrix & Hunt, 2021). An-

other option is an oﬀ shoot from Richard Schwartz’s In-

ternal Family Systems Therapy, called Intimacy from the

Inside Out (IFIO), that recognizes the self “parts,” about

which individuals have ambivalent feelings, although they

nonetheless bring them to their couplehood. The therapy

aims at having clients heed their inner dialogue with more

detachment and compassion, so as not to constantly try to

eliminate them, so that the suppressed part interferes with

the couple connection. The therapy consists of unblending

and reinforcing diﬀ erentiation with connection between

the partners, so they can connect through their strengths

(Herbine-Blank & Sweezy, 2021).

15: INTEGRATIVE MANAGEMENT OF DISORDERED IMPULSE CONTROL 361

For more usual IED, while Satir Family Therapy is de-

signed to facilitate loving communication between the cou-

ple and within the family, Bowenian Family Therapy places

emphasis upon the multigenerational aspects of repeating

chronic problems within the expanded family system. Both

therapies have benefits for IED, while for BPD, Satir Family

Therapy provides many skills to support authentic loving

communication.

Two creative arts therapies are highly recommended for

many different disorders and have a powerfully positive

impact upon the client’s symptoms. Music therapists have

found that clients suffering from BPD have greater difficulty

with interpersonal synchronized improvisation due to their

foundational attachment difficulties (Foubert et al., 2017).

With psychodrama therapy, BPD clients with limited insight

and verbal skills have much to gain and learn from this ther-

apy, whose results are powerful (Olsson, 2018). Drama ther-

apy is a very powerful route to bring underlying issues to

the fore and work through them with others, in reassuring

surroundings, with safety in having the clinician near.

PSYCHOPHARMACOLOGY

Psychopharmacological medications should never be the

first-line treatment, but may be helpful for short-term ad-

justment of unmanageable symptoms, or to accompany

parent, family, parent–child, group, or individual psycho-

therapies. Although they may be able to adjust attention,

hyperexcitation, impulsivity, cognition, alertness, and other

points of concern, the client and their family, plus the school

and social milieux, must work in synergy to improve their

life, scaffold them to ameliorate dysfunctional coping tools,

and assist them to reinforce their strengths. Medications

alone only can facilitate, albeit with numerous potential ad-

verse effects. The main goal of the psychotherapy will be

working daily on this multiscale self and life improvement

project to alleviate symptoms and dysfunction, and pre-

venting further deterioration into more severe diagnoses.

The algorithm depicted in Figure 15.1 should guide treat-

ment for impulsive/disruptive symptoms in children and

adolescents. The PMH-APRN will need to actively consider

if these pathways fit their client’s dimensional symptoms,

neuroscientific profile, and multiscale sociocultural, socio-

economic, and sociopolitical concerns.

No FDA medications are currently approved for DMDD

and only a few studies have been done. Psychotherapeutic

treatments for anxiety and ADHD often work for DMDD:

CBT, DBT, PMT (Barkley, Russell & Robin, Arthur, Defiant

Teens 13-18), and computer-based programs. Medications

often used are stimulants to calm the irritability, or anti

depressants (citalopram with methylphenidate) to reduce

irritability in DMDD. Second-generation neuroleptics

(SGAs) have been used occasionally if other medications

have not been effective.

Children and youth: Try to make an accurate primary diagnosis, identify possible comorbidities, and rule out other poss ible diagnoses

If etiology caused by medical problem,

medication, or substance abuse, refer to

pediatrician or substance abuse detox,

treatment, and prevention

Evaluate/reevaluate

Milder Diagnostic Dimension

Impulsivity and oppositional defiant disorder (ODD)

in early childhood

Moderate Diagnostic Dimension

Disruptive behavior and moderate “hot”

aggress ion (ODD, DMDD, CD) during middle

childhood

Severe Diagnostic Dimension

Disruptive behavior and moderate/severe

impulsive “hot” or instrumental “cold”

aggress ion (CD) during early adolescence

Asses s parents and family

Identify if child, parent(s), sibling, or other source is

main problem and/or school, social, or community

onsider cultural, economic, s piritual, political forces

Consider child-directed play therapy, parent training,

family therapy, PCIT

If insufficient, consider adjuvant clonidine or

guanfacine or stimulant if comorbid with ADHD

Recheck medical and pharm agents; consider

neuropsychological testing and labs to identify

developmental, cognitive, learning problems

Identify if child, parent(s), sibling, or other

source is main problem, academic difficulties,

social bullying, cultural difficulties, or tough

community milieu

Consider parent training, family therapy, DBT,

trauma-focused CBT, creative arts therapies

If weaker cognition, consider stimulants or

atomoxetine for better cognitive focus

Do thorough labs, neuroimaging,

neuropsychological testing

Identify if child, parent(s), sibling, or other

source is main problem, s chool, social,

cultural milieu(x), or community milieux

Consider TST or MST and/or changing

schools, neighborhood

Consider adding low dose risperidone

If insufficient, consider adding low dose

chlorpromazine PRN for aggressive episode

If less emotion regulation, consider short-term

low dose risperidone to reduce aggression

FIGURE 15.1 Treat ment of impulsive/disruptive disorders in children and adolescents.

ADHD, attention deficit hyperactivity disorder; CBT, cognitive behavioral therapy; CD, conduct disorder; DBT, dialectical behavioral therapy;

DMDD, disruptive mood dysregulation disorder; MST, multisystemic therapy; ODD, oppositional defiant disorder; PCIT, Parent–Child

Interaction Therapy; PRN, as needed; SGA, second-generation antipsychotics; TST, trauma systems therapy.

362 III: INTEGRATIVE MANAGEMENT OF SPECIFIC SYNDROMES

The National Institute of Mental Health (NIMH) oﬀ ers

participation in clinical trials as a way to ﬁ nd more eﬀ ective

medications for the child at www.nimh.nih.gov/research/

research-conducted-at-nimh/join-a-study. Find local clin-

ical trials at www.clinicaltrials.gov (NIH publication No.

20-NH-8119).

Adolescents with CD episodic irritability, impulsive ag-

gression, suicidal or self-harm ideation, or behavior with

comorbid BP may beneﬁ t from lithium; however, BP should

be ruled out.

Mutations that cause the misfolding of monoamine trans-

porters (DAT/SLC6A3, NET/SLC6A2, and SERT/SLC6A4)

have led to mental and physical problems. Pharmacological

research has assisted in the correct folding and delivery to

the proper locations within the brain for dopamine, norepi-

nephrine, serotonin, glycine, and GABA. These are called

pharmaco-chaperones (small molecules assisting mono-

amine transporters to fold correctly and get them unstuck

from the endoplasmic reticulum [like atypical ligands and

partial releasers] to deliver them to cells). DAT has been

rescued by bupropion, modaﬁ nil, and ibogaine (Pygmie in-

digenous medication undergoing research, but too toxic in

its tree bark form; Bhat et al., 2019).

Adults suﬀ ering from IED, if not seen earlier in life,

should begin with anger management training and DBT.

Family psychoeducation and therapy may be necessary to

help understanding and resolve symptom impacts upon

family members. There is currently no medication which is

approved for this disorder, but a trauma-focused CBT-anger

treatment had a high success rate in a post-conﬂ ict scenario

(Hewage et al., 2018). Adults suﬀ ering from APD are cov-

ered in Chapter 9, “Integrative Management of Disordered

Mood.” Adults suﬀ ering from BPD, if not seen earlier in life,

should begin psychodynamic psychotherapy in the context

of a trusting, attentive, and supportive relationship with the

clinician. The PMH-APRN should prepare to treat this client

for several years, despite possible intermittent skittishness

on the client’s part, as it may take them some time to val-

ue that support and mentoring. Remember that their early

attachment, or later attachments, may have had traumatic

disruptions or low quality of trust. Keep in mind that this

relationship, once well-established, should go hand-in-hand,

at about 6 months or so, with a separate commitment to DBT

therapy, to enable them to become more self-aware and de-

velop greater behavioral options, to manage emotions and

their comportment.

Adult Complementary and

Alternative Medicine and

Psychopharmacotherapy

Despite frequent polypharmacy for BPD, no medication

has received FDA approval, nor any British authorization,

since this disorder is often foundationally based upon ear-

ly relational psycho-trauma. Yet, omega-3 fatty acids taken

on a regular basis may facilitate neuronal communication,

which may help rewire old patterns. A range of medications

may be useful if symptom clusters are targeted instead of

the diagnosis. Bozzatello has listed oxytocin, clonidine,

opiate antagonists, antidepressants, mood stabilizers, and

antipsychotics that target key symptom clusters (Bozzatello

et al., 2019). But in the last year or two, more meta-analyses

and systematic reviews of psychotherapies have signiﬁ -

cantly improved BPD symptoms of psychosocial function-

ing, severity, reducing self-harming, and suicidal behav-

ior, while the ﬂ uoxetine control group had a signiﬁ cantly

higher rate of suicide attempts. Quetiapine (Seroquel) is the

most frequently prescribed medication given to BPD clients

in the hospital (Stoﬀ ers-Winterling et al., 2020).

For acute agitation in either IED or BPD, which has

passed the point of reasoning and/or CAM, the PMH-

APRN should always consider if this activation is due to

medical causes like hypoxia, hypoglycemia, seizure attacks,

stroke, delirium, other conditions, or medication side ef-

fects. The ﬁ rst-line medication class which will enhance

the GABAergic tone includes benzodiazepines, particularly

lorazepam (Ativan). This must be for clients without sub-

stance abuse and only used as an emergency remedy, due

to this medication’s addictive properties, unless alcohol has

been used, in which case Project BETA (Best Practices in the

Evaluation and Treatment of Agitation) recommends halo-

peridol (Haldol). However, in the case of older adults with

delirium or dementia, since antipsychotics have a black box

warning of higher mortality with use in seniors, a low dose

may be warranted only if absolutely necessary (Miller et al.,

2020; Roppolo et al., 2020). Improving the management of

acutely agitated clients in the emergency department occurs

through implementation of Project BETA.

SUMMARY

Disruptive and impulsive aggression is a signiﬁ cant pub-

lic health problem, especially as our world expands to

necessarily become more interdependent and cooperative.

Upstream prevention is advocated in prenatal and early

life, since epigenetic modiﬁ cations can become heritably

transmitted in response to environmental factors, diet, and

toxicant exposures (Xavier et al., 2019). This chapter pro-

poses a developmental multiscale systems approach. The

chapter begins by highlighting neuroanatomical ﬁ ndings

about alterations in the amygdala’s GABAergic inhibition

role in the amygdala-prefrontal pathway, including key

deﬁ cits in the serotonergic system, dopamine, oxytocin,

vasopressin, cortisol, and testosterone (Rosell & Siever,

2015). There is also a crucial developmental role for nur-

ture. Extremely anxious attachment or highly avoidant at-

tachment, but especially disorganized/fearful attachment,

destabilizes the infant’s homeostasis, increases inﬂ am-

mation, alters immune function, and lowers the thresh-

old of tolerating allostatic load. Destabilizing the infant’s

HPA-axis stress response contributes to destabilizing an

already fragile neurodevelopmental constitution in many

fragile infants. It may predispose responses into respective

“hot” (anxious attachment)—impulsive and physiologi-

cally hyperaroused—or “cold” (avoidant attachment)—

disruptive and physiologically hypoaroused—dimensions.

These dimensions run along a spectrum, and do not easi-

ly ﬁ t into discrete categories. The “hot” attachment proﬁ le

15: INTEGRATIVE MANAGEMENT OF DISORDERED IMPULSE CONTROL 363

is associated with a hyperactive amygdala and insula,

and predispose the child psycho-neuro-immunologically,

endocrinologically, socioemotionally, and, in terms of car-

diac health, toward baseline autonomic hyperarousal, in-

ternalizing emotions, higher oxytocin, higher cortisol, and

physiological hyperarousal. This is correlated mostly with

internalizing negative emotions in ODD, yet for DMDD

and IED, it can erupt with reactive violence due to a cur-

tailed capacity to regulate negative emotions. On the other

hand, especially when associated with child-onset CD with

CU traits, avoidant—or especially disorganized attached—

children may have “cold” reduced volume and hypoac-

tive prefrontal cortex, amygdala, folded insula, low default

mode connections and activity, autonomic hypoarousal,

externalizing instrumental/predatory aggression, low em-

pathy or remorse, and antisocial attitudes and actions and

may be at risk for economic insecurity and social distress.

Approximately 20% of children in the United States are

considered to be highly vulnerable, due to lack of adequate

care and protection. Approximately 40% of children with

developmental disabilities have mental health diagnoses,

often with ADHD and/or impulsive/disruptive disorders.

Around 90% of children in residential centers have experi-

enced adverse childhood life events (ACEs). Half of chil-

dren in foster care have been given nominal psychiatric di-

agnoses, and 65% of children in juvenile detention centers

have been given psychiatric diagnoses (Stahl, 2019). Thus,

it is vitally important to seek early prevention beginning

prenatally, to prevent deviation from a child’s normative

prosocial development, which is a key part of healthy and

happy development for the client, yet this also depends

upon reinforcing “fragile families” so each can support

their closest family member. Prosocial attitudes and actions

beneﬁ t the family, youth, and the community (Staub, 2016).

Forensics are beyond our scope, but it would be “biolog-

ical reductionism” to imagine that one’s inherited biological

equipment is the only factor that counts as an “explanation”

for aggression against others. Parental and community re-

sponsibility would be neglected if psychoeducation and pre-

vention were not attempted whenever possible. Although

some biological diﬀ erences and deﬁ cits may demarcate dif-

fering risk factors, they cannot in themselves constitute a

“complete explanation” for behavior. There are multiscale

factors: environmental exposures, prenatal parental behav-

ior, mother–child attachment, epigenetic alterations, dyadic

partner or friendship bonding, family, social, community,

spiritual, cultural, economic, and political responsive shap-

ing and modulations. Socioemotional inﬂ uences like abusive

or negligent parenting and deviant peers have long been rec-

ognized as cardinal inﬂ uences in the development of antiso-

cial behavior since they can shepherd the child’s underlying

biological vulnerabilities in a harmful direction (Osofsky &

Lieberman, 2011).

Second, it would be a logical fallacy to say that some

socioeconomic or sociocultural risk factors inﬂ uence the

emergence of developing CD, then argue, in legal set-

tings, that CD is a neurodevelopmental disorder. This

logical fallacy is called a non sequitur. It also misappre-

hends the scientiﬁ c consensus regarding neuropsychiatric

pleiotropic epigenetics. Due to the extensive multicenter, multi

country, genomic, and genome-wide association study

(GWAS) investigations on numerous disparate disorders, it

would be rash to declare an exclusive association of neuro-

developmental diﬀ erences with only one disorder cluster.

Pleiotropy is the rule and developmental issues are associ-

ated with many nonaggressive, innocuous disorders.

Third, it is indisputable that individuals with disabili-

ties are 2.5 times more frequently manipulated, exploited,

or abused by people without disabilities, with rates soaring

much higher for under 24 and over 65 years (Harrell, 2017).

In fact, a high proportion of exploiters know the victim or

are their relatives. Frequently, the social dynamic has been

that older manipulators with more serious antisocial behav-

ior have coerced younger, more vulnerable individuals with

disabilities, including self-regulation diﬃ culties, to carry

out the older ones’ objectives. This way, the manipulators

avoid consequences. Those with disabilities are often afraid

of being victimized if they do not comply (Harrell, 2017). In

the United States, radical extremist groups and gang lead-

ers have similar tactics, oﬀ ering destructive mentorship and

hate indoctrination and missions of self-destructive behav-

ior, in exchange for shelter, food, and a sense of belonging

to marginalized youth, those with cognitive disabilities, and

vulnerable foster children. Can we as a society, and as clini-

cians, not oﬀ er better?

Fourth, a salutogenic “sense of coherency” is encouraged

when clinicians take the time and eﬀ ort to listen regularly to

a client’s struggles, instead of writing a prescription without

listening. As the child client plays, as the adolescent reveals

emotion they may not have been aware of, and as the adult

begins to piece together a life narrative they may not have

been able to articulate before, clients begin to perceive their

own picture through the lens of the shared, safe relationship.

A sense of coherency is clariﬁ ed bit by bit, at the client’s pace,

especially with key queries that further open up a more co-

herent map for them to assess and decide how to proceed.

Fifth, within one’s limited circumstances and capacities, a

human being has the agency to deploy his free will and be-

come more grateful of others' contributions. The founder of

the Third Viennese School of Psychiatry and Holocaust survi-

vor, Viktor Frankl, has always emphasized that “everything

can be taken from a man but one thing: the last of the human

freedoms—to choose one’s attitude in any given set of cir-

cumstances.” As children and youth grow and mature, and

as adults continue to shape their own lives, choosing one’s

own approach, and giving back contributions to the commu-

nity, provide mature ways to not only function, but to thrive.

PEDIATRIC POINTERS

Stephen Stahl has pointed out that highly vulnerable chil-

dren receive two- to ﬁ ve-times more medications than all

other Medicaid-enrolled children, for whom there is 75%

to 90% polypharmacy. A child/youth and parent/guardian

collaborative treatment plan should begin with joint or mul-

timodal psychotherapies, and only include psychopharma-

cology as necessary for the direct beneﬁ t of the developing

child or youth and/or to ensure safety for others due to

364 III: INTEGRATIVE MANAGEMENT OF SPECIFIC SYNDROMES

immediate threats. Treating aggression in these vulnerable

children as a tranquilizer and not for their direct beneﬁ t is

not “best medical practice” (Stahl, 2019). Choose low and

slow. Children often have more frequent side eﬀ ects, with

faster hepatic and renal metabolism and excretion. Quicker

pharmacokinetics can lead to faster absorption, higher peak

drug levels, and peak dose side eﬀ ects. Children may need

to be given drugs in smaller doses several times a day. Chil-

dren’s physiology can access biologically active pharma-

ceuticals more quickly than adults since their bodies have a

greater percentage of water, yet cannot store lipid-binding

drugs, so smaller doses at more frequent intervals may

help. If several nonpharmacological therapies have failed

for high violence, try risperidone before chlorpromazine.

Administer medications only if needed by targeting the cli-

ent’s symptoms with the lowest eﬀ ective dose. To switch,

slowly cross-titrate over 6 to 8 weeks to avoid overload-

ing or rebounding. Avoid polypharmacy. Ampoules and

vials contain sulﬁ tes, which can cause allergic reactions.

Monitor increasing side eﬀ ects, or less eﬀ ectiveness, as the

child grows and develops into adolescence (Stahl, 2019).

The FDA recommends that when using stimulants for all

ages, heart rate and blood pressure should be monitored for

changes (FDA, TSI#114: Safety - 000114).

AGING ALERTS

CD prevalence is less than 1% in adults (Fairchild et al.,

2019). Medication use by older adults has several pre-

cautions, with a stepwise approach recommended by the

American Geriatric Society. The Beers Criteria list of med-

ications lists what medications to avoid in older adults,

due to adverse eﬀ ects (American Geriatrics Society Beers

Criteria Update Expert Panel, 2019). Polypharmacy is more

common and/or accompanied by the use of client-initiated

CAM therapies, which are often undiscussed with their pro-

viders. The standardized pharmacokinetics, upon which

dosage is based, and pharmacodynamics can be altered due

to aging, which can lead to adverse events, especially when

polypharmacy is used (Rochon et al., 2020).

CASE STUDY

A 9-Year-Old Foster

Boy With Behavior Issues

CASE STUDY

A 9-Year-Old Foster

Boy With Behavior Issues

CLIENT DESCRIPTION

The client TS was a Caucasian 9-year-old foster boy,

previously diagnosed with ADHD and mild speech

misarticulation. He had been interrupting class by

running laps around his desk to generate laughter,

throwing airplane notes to annoy classmates, and

climbing unsafely onto the high windowsills. He was

currently living with a foster single mother and three

other children. He was brought in by the school coun-

selor, since his foster mother rarely replied to calls

from school. His mother had died of triple negative

breast cancer when he was 2 years old. His father was

absent, so his maternal grandmother cared for him

until he was 5, at which point she had a stroke and

became unable to care for him.

Notable observation room highlights were that

TS was hypervigilant and underweight, looking

around with frightened eyes. His eye contact was

good but brief with the PMH-APRN, his clothes

were worn but clean, his hair was tousled but not

greasy without scratching, and he replied brief-

ly. More relaxed, he ran about the comprehensive

psychiatric emergency program (CPEP) pediatric

observation room to look at all the games and toys,

with high startle reaction when one fell on the ﬂ oor.

Another foster girl who was 11 years old began run-

ning about with him, playing distractedly with the

toys, and they drew animals together with the PMH-

APRN’s crayons. They became friendly and the little

girl hugged him sometimes. When she was about to

be discharged to a children’s facility, she was upset

about going. She embraced and clung to the little

boy and did not want to leave him. After 15 minutes

of clinging onto one another, she was led away. Then

he began bonding with the PMH-APRN who had

been watching them. He denied intent to self-harm,

act aggressively against others, or that he had been

having hallucinations, and did not seem to have any

delusions.

When the foster mother arrived 6 hours later, her

thoughts seemed disorganized, her hair was streaked

in circus colors, she had long colored nails, and she

was dressed in a frilly short skirt and low collar. She

seemed irritated, impatient, and resisted cooperation

before taking him back to her home. During the last 6

months, he deﬁ ed, or passively did not comply with,

her directives, sometimes deliberately annoying the

older foster boy, blaming the older boy for poking

him, and bullying the youngest girl; he has been

“touchy,” and “only wants his peanut butter and jam

sandwich” even when she packs them all oﬀ to school

with cheese sandwiches since the school does not al-

low peanut butter due to other children’s allergies.

When asked if TS seemed more hyperactive or deﬁ -

ant, she aﬃ rmed the latter.

CURRENT SYMPTOMS/PROBLEMS

TS’s behavior during the ﬁ rst interview was initial-

ly distracted eye contact focused upon the pediatric

toys, psychomotor agitation, attention span brief,

verbal ﬂ uency slightly slow, speech was abbreviated

with misarticulation, neglected dental care, holes in

his shoes, and a right knee scrape. He reported re-

peated nightmares of searching for his mother and

not ﬁ nding her, and another one about being chased

by a big dog. He had no notable current medical prob-

lems, was taking no medications, and had no aller-

gies. He spoke about his school activities, indicating

15: INTEGRATIVE MANAGEMENT OF DISORDERED IMPULSE CONTROL 365

frequent hyperactivity, distraction, and desire to play

more than learn, with fair insight for age. The teacher

sent in his mildly low verbal and mathematics scores,

as well as his low New York State Common Core

3–8 English Language Arts and Mathematics testing.

During recess, he was disruptive by intruding upon

others’ games, for which children complained, as per

the school counselor.

The Administration for Children and Families

(ACF) reported notable medical history was that

he was born prematurely at 35 weeks, at 2.4 kg and

45 cm. He was in the NICU for a few days and had

hyperbilirubinemia, treated with phototherapy. The

rest of his records were skimpy; since he was born in

another state, they had not gotten complete access to

his early medical records, so it was unknown if there

were any sequelae or other conditions. His medical

records noted that all his vaccinations were up to

date, and at age 7, he had received stitches on his leg

after inadvertently running into a barbed wire fence

while escaping from an older bully after school.

At home, there were three other foster children: an

11-year-old boy, an 8-year-old girl, and another 7-year-

old girl. He felt closest to the 7-year-old girl, whom he

protected from the others when they bullied her. He

did not feel very close to his foster mother, whom he

said was always at work; he liked his teacher, although

she complained about his impulsivity and disruptive

behavior in class. The foster mother had arrived with

him. This time, her thoughts seemed disorganized,

her hair still streaked in circus colors, and she seemed

bored and again resisted cooperation. She aﬃ rmed

that she observed car seat safety and sports safety, but

did not take him swimming or bike-riding so she did

not observe those safety precautions. She reported that

there were no ﬁ rearms at home to store safely. She re-

lated that she was getting tired of getting called from

his school, with reports of his hyperactivity, since she

did not want to “bother with medications” for any

of the foster children in her home. As per her report,

none of the children have had injuries, but they have

engaged in pushing, shoving, annoying, unwanted

tickling, and other mildly disruptive tactics.

Notable vitals and labs included heart rate 90

bpm, respiration rate 28, 80% of boy’s growth chart

percentile weight/height, high creatine phosphoki-

nase (CPK) of 360 mcg/L. Repeat labs 2 months

later revealed CPK of 150 mcg/L (slightly high), so

pathological muscular processes were ruled out, and

thyroid-stimulating hormone (TSH) was normal, so

hyperthyroid was ruled out. Labs were sent for genet-

ic testing for BRCA1 and BRCA2. His Barrett Impul-

siveness Scale indicated moderate impulsivity, but

his Conners and Vanderbilt scores from both parent

and teacher were mildly negative for ADHD.

His provisional diagnoses are 313.89 Posttraumat-

ic Stress Disorder, 313.81 Mild Oppositional Deﬁ ant

Disorder, V61.8 Upbringing Away From Parents.

Rule/out secondary diagnoses were V61.21 En-

counter for Mental Health Services for Victim of Non-

parental Neglect, ISD-10-CM H90 Unspeciﬁ ed Hearing

Loss, 307.9 Unspeciﬁ ed Communication Disorder,

Attention-Deﬁ cit/Hyperactivity Disorder (ADHD).

POSSIBLE EXPLANATIONS

TS seems to be suﬀ ering from nonparental mismatch

and possible medical neglect, since his foster mother

did not arrive promptly to the CPEP and arrived an-

noyed and impatient. Although he has no medications,

she will not consider medications for any of her foster

children since this would be “too much of a bother.”

He does not feel close to his foster mother, his dental

care is not up to date, his clothes are worn, his hair is

not freshly washed, and his toes reach the very end of

his gym shoes, which have two holes. ACF will be noti-

ﬁ ed, so they can determine about his treatment, as well

as that for the other three children. (It was important not

to be inﬂ uenced by the initially inappropriate impression she

made upon most of the CPEP staﬀ , but to carefully listen

to her speciﬁ c actions and attitudes regarding TS, and her

impact upon TS.) Being raised away from a deceased

mother and grandmother with limited mobility is a

tragic situation, which has a more harmful impact

when paired with somewhat neglectful care by a pos-

sibly schizotypal single mother, who is caring for other

foster children of varying traumas and conditions.

For the last 6 m onths, TS seems to be overaroused

and hypervigilant (allowing for the setting eﬀ ect),

with intrusion episodes of repeated nightmares

(unresolved problems), insomnia (fear of the night-

mares), and avoidance. He displays previous stitch-

es and knee scrapes he received while running away

from bullies (who may be represented by the angry

dog in his nightmares). There may be an overlap

of symptoms with ODD. He has been deﬁ ant and

noncompliant with adult directives, and has episodes

of acting out in anger when annoying and sparring

with his older foster brother; he blames those older

and bigger than he, and although this may be mostly

true, he does seek out older boys to model. He seems

to provoke anger deliberately for attention, and imi-

tate it himself to scare oﬀ the bullies, but for now, he

does fulﬁ ll all the criteria for ODD.

He may have allowed the foster girl to hug him, in-

stead of not allowing her, because he largely has an anx-

ious/impulsive attachment proﬁ le. This kind of proﬁ le

may be easier to work with than other proﬁ les, since he

still desires to bond, although he must be placed in an

environment of greater safety for this to happen. This

also indicates that he may have been attached to his

366 III: INTEGRATIVE MANAGEMENT OF SPECIFIC SYNDROMES

mother and grandmother, until it was no longer possi-

ble to remain at home. He suﬀ ers from the absence of

his father as well. He is afraid of larger boys because

of having been bullied in the past, which is why pres-

ently he is learning how to become more aggressive

and deﬁ ant. He already was thought to have ADHD,

a usual diagnosis given for a hyperactive child of trag-

ic circumstances, but often their hyperactivity lessens

with improved circumstances, and the stimulants giv-

en are often to relieve caregiver irritation. Due to his

adverse life events, PTSD is a more likely diagnosis as

per his speciﬁ c symptoms, with mild ODD beginning

to surface due to trying to meet the challenges of bul-

lying and the untrustworthy adult he deals with daily.

It is worthwhile to check out his hearing, since he

does not pronounce “r” correctly, which may be a re-

sult of congenital hearing loss, hearing loss from an

aminoglycoside antibiotic, NSAID, or neglected ear

infection during his early years with a seriously ill

single mother or an older grandmother who may not

have noticed or misinterpreted symptoms. Another

possibility is medical neglect from anyone, including

his foster mother. In any case, his suspected commu-

nication disorder may merely be the result of uncor-

rected hearing loss, which may become corrected

once the hearing is corrected or may indicate a more

neurodevelopmentally based learning disorder.

ADAPTIVE FEATURES/STRENGTHS

TS has endured the most devastating trauma of los-

ing his mother, then being removed from his grand-

mother. Despite his possible PTSD at the time, he

adapted his behavior to face threats to his well-being

and security from older boys who required him to be

tougher and challenged him to ﬁ ght. He has deﬂ ected

actual ﬁ ghting with them to demonstrating his fear-

lessness by defying the teacher in front of the entire

class, which may deter school bullies from harming

him. Yet, his inner strength is his ability to embrace

those who show him aﬀ ection, as he allowed the little

foster girl to do in the CPEP.

PLAN FOR TREATMENT

In consultation with the multidisciplinary team, the

possibility was explored of kinship care with the cli-

ent’s aunt in a village near the grandmother upstate.

Due to the grandmother’s mobility and medical

problems, she also has not been able to encourage her

other daughter, who lives 3 hours away upstate, to

adopt her sister’s son. Previously, the sister had been

busy caring for newborn twins, but as they are now 5

years old, the aunt is open to the idea of adopting TS.

The social worker was occupied with arranging this.

TS’s clinician treatment plan entails trauma-

focused play therapy (Eliana Gil’s approach) integrated

with adopted parent, and some family psychoeduca-

tion, play participation, and adopted parent support

groups for the parents. To facilitate TS’s adaptive

working with intermittent strong negative emotions,

TS will have short-term DBT sessions for 6 months,

then reassess treatments after 6 months.

DESCRIPTION OF TREATMENT AND

CLIENT’S RESPONSE

TS seemed to love his play therapy sessions and could

really express his fear of the older boys and unfamil-

iar men through playing with plastic wolves and ti-

gers preying on rabbits and birds. He responded well

to DBT, and usually did not forget his homework.

Most importantly, he loved his new family, his aunt

was aﬀ ectionate and warm, and he ﬁ nally had a fa-

ther. He had moved to another school upstate, where

the children and parents were less ambitious and

aggressive than in the city, yet not so small-town to

exclude him initially for being an outsider. Although

between 10 and 13, middle school children tend to

cling to their previous social standing and groups and

outsiders may be mistreated, he worked assiduously

on his skills and acquired good insight into his PTSD.

He did not truly lose his fear of the bigger boys, so

he engaged in soccer, which helped him become

stronger and alleviate his excess energy, reducing his

prior hyperactivity. His ODD symptoms diminished

to none by 13, ADHD was eventually ruled out, his

hearing improved with inconspicuous hearing aids,

his speech articulation improved, and labs for BRCA1

and BRCA2 were negative, as were his aunt’s, who

rushed to get tested upon recommendations to do so.

By the time TS entered high school, his scores had

risen to moderately above normal. He became pop-

ular with the girls, who found him to be more emo-

tionally aware than most other boys at that age. This

caused the boys to treat him respectfully. He also be-

came known as a swift soccer player, which boosted

his social standing as well. He also developed a love

for music, so he played a guitar with his friends, too.

It was not easy for teachers to discern his rocky path-

way to his current condition.

SUMMARY OF TREATMENT

This multiprofessional team treatment plan was luck-

ily very eﬀ ective in setting TS along a salutogenic life

pathway which had meaning for him. Instead of TS

becoming trapped in an untenable foster home situa-

tion and school situation where he would increasing-

ly become labeled as the “ODD child,” then possibly

worsen into being perceived as the “CD boy” as he

would be transferred from transient home to home, he

found stability. One must actively seek loving adop-

tive parents to replace a deceased one, and a secure

15: INTEGRATIVE MANAGEMENT OF DISORDERED IMPULSE CONTROL 367

home environment whenever possible. This would

preferably be within the framework of kinship care,

but there have also been instances of maltreatment

from being stigmatized as the “poorer cousin’s delin-

quent kid” or someone landing upon relatives who

have some harmful dysfunction, as many motherless

girls have experienced in the hands of uncles or older

male cousins, which puts a child again at risk. The

team tried to get the child back in the driver’s seat of

his life, with loving adult scaﬀ olding and guidance.

For TS to experience catharsis and get more insight

into his early psycho-traumatic life event of losing his

mother and grandmother’s home all before age 5,

play therapy expanded to a participatory family ther-

apy that involved the twins as well, so they could in-

tegrate TS’s early life into their conceptual worlds as

well, and look up to their new older brother. DBT was

extremely helpful for TS to have the requisite skills to

avoid negative emotional overﬂ ow, which is a useful

skill in any family or social framework. Overall, the

team was satisﬁ ed and proud of TS’s capacities and

achievements.

DISCUSSION QUESTIONS

1. How does an insecure family situation propitiate

the development of defenses which eventually

may become more aggressive?

2. How would you distinguish between a child

suﬀ ering from ODD and PTSD? If these comor-

bidities can coexist, then how does one distinguish

between the primary diagnosis and the secondary

one?

3. Why was it a good idea for TS to experience ca-

tharsis and insight with play therapy, but also to

learn new emotion-regulation skills with DBT?

4. Can children really catch-up developmentally af-

ter they have had a devastating setback?

END-OF-CHAPTER RESOURCES

Client Resources

Parent Resources

• Parent’s Guide to Their Child’s Medication: www

.parentsmedguide.org

• National Alliance for the Mentally Ill (NAMI) Handbook

for Parents: www.aacap.org/App_Themes/AACAP/

docs/member_resources/toolbox_for_clinical_

practice_and_outcomes/sources/NAMI_Handbook

.pdf

Infant and Toddler Mental Health Resources

• AACAP: Resources for Primary Care: www.aacap

.org/AACAP/Resources_for_Primary_Care/

Practice_Parameters_and_Resource_Centers/Practice_

Parameters.aspx

• Zero to Three (also in Spanish): www.zerotothree.org/

espanol/infant-and-early-childhood-mental-health

• Parent–Child Interaction Therapy for Toddlers: www

.pcit-toddlers.org/index.html

• Healthy Families New York: www.healthyfamiliesnew

york.org

• Incredible Years: http://incredibleyears.com

• Center for the Developing Child, Harvard University—

Resources: https://developingchild.harvard.edu/

resources/#

Learning Videos for Children to Manage

Emotions

• For the Birds: Think Before You Act: www.youtube

.com/watch?v=LI92DLRdKYE&list=PLKCADPfFtO

AuIED2TP5x_3LGUy 7XbVnOH&index=1

• My Life on YouTube: Kids Mindfulness: Four Calm

Compilations: Bulldog Finds His Quiet Place, Butterﬂ y

Body Scan, Rock-a-Bye, Imaginary Hugs and Peaceful

Place: www.youtube.com/watch?v=iEEJT9cYsm0

• We Do Listen Foundation: The Wiggle Tales (5–8 years):

• Anger Management Lesson: www.youtube.com/

watch?v=9wC2XqCW64k

• Controlling Anger: www.youtube.com/watch?v=

QxSKKtUdAjU

• Listen Better Lesson: www.youtube.com/watch?v=

HH0rQiwKtSs

• Broadway Kids Against Bullying: www.youtube.com/

watch?v=cRB4e_aEces

• Kids Bullying—Children’s Literature Story—Howard

Wigglebottom: https://www.youtube.com/watch?v=

VQgSwhD2ug0

• How to Get Along With Others: www.youtube.com/

watch?v=KQKOILOFSg4

• What to Do When Angry: www.youtube.com/watch?

v=W2B6L4a7YjU

• Sesame Street: Name That Emotion: www.youtube

.com/watch?v=ZxfJicfyCdg

• Sesame Street: Elmo Shows Emotions With Zoe, Bert,

and Big Bird: www.youtube.com/watch?v=dO_

I0harbQg

• Sesame Street: Common and Colbie Caillat—Belly

Breathe: www.youtube.com/watch?v=_mZbzDOpylA

• Sesame Street: Cookie Monster—First Time I Ate a

Cookie: www.youtube.com/watch?v=L2_MUD16EIk

368 III: INTEGRATIVE MANAGEMENT OF SPECIFIC SYNDROMES

• Sesame Street: Dave Matthews and Grover Sing About

Feelings: www.youtube.com/watch?v=_mZbzDOpylA

• Sesame Street: Cookie Monster—Me Want It But Me

Wait: www.youtube.com/watch?v=9PnbKL3wuH4

• Sesame Street: Cookie Monster—Share It Maybe: www

.youtube.com/watch?v=-qTIGg3I5y8

• NPR, Life Parenting Kit: Cookie Monster Practices Self-

Regulation: www.youtube.com/watch?v=j0YDE8_jsHk

• The Wolf Who Learned Self-Control: www.youtube

.com/watch?v=TLUGycJSS-Q

Psychiatric-Mental Health Nurse

Practitioner Resources

• Psychodynamic Play Psychotherapy (PDPT): www

.aacap.org/AACAP/Member_Resources/How-to

-use-the-Psychodynamic-Play-Psychotherapy-Train

-the-Trainer-Tool.aspx

• The Kids We Lose documentary: www.thekidswelose

.com/

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ResearchGate has not been able to resolve any citations for this publication.

Cellular reprogramming and epigenetic rejuvenation

Article

Full-text available

Sep 2021

Ageing is an inevitable condition that afflicts all humans. Recent achievements, such as the generation of induced pluripotent stem cells, have delivered preliminary evidence that slowing down and reversing the ageing process might be possible. However, these techniques usually involve complete dedifferentiation, i.e. somatic cell identity is lost as cells are converted to a pluripotent state. Separating the rejuvenative properties of reprogramming from dedifferentiation is a promising prospect, termed epigenetic rejuvenation. Reprogramming-induced rejuvenation strategies currently involve using Yamanaka factors (typically transiently expressed to prevent full dedifferentiation) and are promising candidates to safely reduce biological age. Here, we review the development and potential of reprogramming-induced rejuvenation as an anti-ageing strategy.

Reduced Neural Responsiveness to Looming Stimuli is Associated with Increased Aggression

Article

Full-text available

May 2021
SOC COGN AFFECT NEUR

Background: While neuro-cognitive work examining aggression has examined patients with conditions at increased risk for aggression or individuals self-reporting past aggression, little work has attempted to identify neuro-cognitive markers associated with observed/recorded aggression. The goal of the current study was to determine the extent to which aggression by youth in the first three months of residential care was associated with atypical responsiveness to threat stimuli. Method: This functional MRI study involved 98 (68 male; mean age = 15.96 [sd = 1.52]) adolescents in residential care performing a looming threat task involving images of threatening and neutral human faces or animals that appeared to be either loom or recede. Results: Level of aggression was negatively associated with responding to looming stimuli (irrespective of whether these were threatening or neutral) within regions including bilateral inferior frontal gyrus, right inferior parietal lobule, right superior/middle temporal gyrus and a region of right uncus proximal to the amygdala. Conclusions: These data indicate that aggression level is associated with a decrease in responsiveness to a basic threat cue-looming stimuli. Reduced threat responsiveness likely results in the individual being less able to represent the negative consequences that may result from engaging in aggression, thereby increasing the risk for aggressive episodes.

A ride through the epigenetic landscape: aging reversal by reprogramming

Article

Full-text available

Apr 2021

Aging has become one of the fastest-growing research topics in biology. However, exactly how the aging process occurs remains unknown. Epigenetics plays a significant role, and several epigenetic interventions can modulate lifespan. This review will explore the interplay between epigenetics and aging, and how epigenetic reprogramming can be harnessed for age reversal. In vivo partial reprogramming holds great promise as a possible therapy, but several limitations remain. Rejuvenation by reprogramming is a young but rapidly expanding subfield in the biology of aging.

Factors associated with neurodevelopment in preterm infants with systematic inflammation

Article

Full-text available

Mar 2021
BMC Pediatr

Background Several studies have suggested that adverse neurodevelopment could be induced by systemic inflammation in preterm infants. We aimed to investigate whether preterm infants with systemic inflammation would have impaired neurodevelopment and which biomarkers and neurophysiologic studies during inflammation are associated with poor neurodevelopment. Methods This prospective cohort study enrolled infants born before 30 weeks of gestation or with birth weight < 1250 g. Infants were grouped according to the presence of systemic inflammation: Control (no inflammation, n = 49), I (systemic inflammation, n = 45). Blood and cerebrospinal fluid samples for markers of brain injury and inflammation were collected and amplitude-integrated electroencephalography (aEEG) was performed within 4 h of septic workup. We evaluated aEEG at 35 weeks postmenstrual age (PMA), head circumference at 36 weeks PMA, and brain MRI at discharge. The Bayley Scales of Infant and Toddler Development III (Bayley-III) was performed at a corrected age (CA) of 18 months. Results The I group had more white matter injuries (2 vs. 26.7%, Control vs. I, respectively) at the time of discharge, lower brain functional maturation (9.5 vs. 8), and smaller head size (z-score − 1.45 vs. -2.12) at near-term age and poorer neurodevelopment at a CA of 18 months than the control ( p < 0.05). Among the I group, the proportion of immature neutrophils (I/T ratios) and IL-1 beta levels in the CSF were associated with aEEG measures at the day of symptom onset (D0). Seizure spike on aEEG at D0 was significantly correlated with motor and social-emotional domains of Bayley-III ( p < 0.05). The I/T ratio and CRP and TNF-α levels of blood at D0, white matter injury on MRI at discharge, head circumference and seizure spikes on aEEG at near-term age were associated with Bayley-III scores at a CA of 18 months. Conclusions Systemic inflammation induced by clinical infection and NEC are associated with neurodevelopmental impairment in preterm infants. The seizure spike on aEEG, elevated I/T ratio, CRP, and plasma TNF-alpha during inflammatory episodes are associated with poor neurodevelopment.

Intergenerational trauma is associated with expression alterations in glucocorticoid- and immune-related genes

Article

Full-text available

Nov 2020

Offspring of trauma survivors are more likely to develop PTSD, mood, and anxiety disorders and demonstrate endocrine and molecular alterations compared to controls. This study reports the association between parental Holocaust exposure and genome-wide gene expression in peripheral blood mononuclear cells (PBMC) from 77 Holocaust survivor offspring and 15 comparison subjects. Forty-two differentially expressed genes (DEGs) were identified in association with parental Holocaust exposure (FDR-adjusted p < 0.05); most of these genes were downregulated and co-expressed in a gene network related to immune cell functions. When both parental Holocaust exposure and maternal age at Holocaust exposure shared DEGs, fold changes were in the opposite direction. Similarly, fold changes of shared DEGs associated with maternal PTSD and paternal PTSD were in opposite directions, while fold changes of shared DEGs associated with both maternal and paternal Holocaust exposure or associated with both maternal and paternal age at Holocaust exposure were in the same direction. Moreover, the DEGs associated with parental Holocaust exposure were enriched for glucocorticoid-regulated genes and immune pathways with some of these genes mediating the effects of parental Holocaust exposure on C-reactive protein. The top gene across all analyses was MMP8, encoding the matrix metalloproteinase 8, which is a regulator of innate immunity. To conclude, this study identified a set of glucocorticoid and immune-related genes in association with parental Holocaust exposure with differential effects based on parental exposure-related factors.

Mitochondria under the spotlight: On the implications of mitochondrial dysfunction and its connectivity to neuropsychiatric disorders

Article

Full-text available

Sep 2020

Neuropsychiatric disorders (NPDs) such as bipolar disorder (BD), schizophrenia (SZ) and mood disorder (MD) are hard to manage due to overlapping symptoms and lack of biomarkers. Risk alleles of BD/SZ/MD are emerging, with evidence suggesting mitochondrial (mt) dysfunction as a critical factor for disease onset and progression. Mood stabilizing treatments for these disorders are scarce, revealing the need for biomarker discovery and artificial intelligence approaches to design synthetically accessible novel therapeutics. Here, we show mt involvement in NPDs by associating 245 mt proteins to BD/SZ/MD, with 7 common players in these disease categories. Analysis of over 650 publications suggests that 245 NPD-linked mt proteins are associated with 800 other mt proteins, with mt impairment likely to rewire these interactions. High dosage of mood stabilizers is known to alleviate manic episodes, but which compounds target mt pathways is another gap in the field that we address through mood stabilizer-gene interaction analysis of 37 prescriptions and over-the-counter psychotropic treatments, which we have refined to 15 mood-stabilizing agents. We show 26 of the 245 NPD-linked mt proteins are uniquely or commonly targeted by one or more of these mood stabilizers. Further, induced pluripotent stem cell-derived patient neurons and three-dimensional human brain organoids as reliable BD/SZ/MD models are outlined, along with multiomics methods and machine learning-based decision making tools for biomarker discovery, which remains a bottleneck for precision psychiatry medicine.

Current Understanding of the Neurobiology of Agitation

Article

Full-text available

Jul 2020

Introduction: Managing agitation in the clinical setting is a challenge that many practitioners face regularly. Our evolving understanding of the etiological factors involved in aggressive acts has better informed our interventions through pharmacologic and behavioral strategies. This paper reviews the literature on the neurobiological underpinnings of aggressive behaviors, linking psychopathology with proposed mechanisms of action of psychiatric medications shown to be effective in mitigating agitation. Methods: We performed a review of the extant literature using PubMed as a primary database. Investigation focused on neurobiology of agitation and its relation to the current evidence base for particular interventions. Results: There are well-established pathways that can lead to increased autonomic response and the potential for violence. Psychopathology and substance-induced perceptual distortions may lead to magnification and overestimation of environmental threat, heightening the potential for aggression. Additional challenges have arisen with the advent of several novel drugs of abuse, many of which lead to atypical clinical presentations and which can elude standard drug screens. Our interventions still lean on the evidence base found in Project BETA (Best Practices in Evaluation and Treatment of Agitation). Although not a new drug and not included in the Project BETA guidelines, ketamine and its use are also discussed, given its unique pharmacology and potential benefits when other protocoled interventions have failed. Conclusion: Aggression can occur due to manifold reasons in the clinical setting. Having an informed understanding of the possible determinants of agitation can help with more tailored responses to individual patients, limiting the unnecessary use of medications or of interventions that could be deemed forceful.

Prescriber's Guide – Children and Adolescents: Stahl's Essential Psychopharmacology

Book

Oct 2018

Stephen M. Stahl

Child and adolescent psychopharmacology is a rapidly growing field with psychotropic medications used widely in the treatment of this patient group. However, psychopharmacological treatment guidelines used for adults cannot simply be applied for children or adolescents, thus presenting clinicians and nurse practitioners with assessment and prescribing challenges. Based on the best-selling resource Stahl's Prescriber's Guide, this new book provides a user-friendly step-by-step manual on the range of psychotropic drugs prescribed for children and adolescents by clinicians and nurse practitioners. Reviewed by expert child and adolescent psychiatrists, the medications are presented in the same design format in order to facilitate rapid access to information. Each drug is broken down into a number of sections, each designated by a unique color background thereby clearly distinguishing information presented on therapeutics, safety and tolerability, dosing and use, what to expect, special populations, and the art of psychopharmacology, and followed by key references.

Conduct Disorders and Empathy Development

Article

Dec 2020

Childhood conduct disorders, a serious mental health concern, put children at risk for significant mental health problems throughout development. Elevations on callous-unemotional (CU) traits designate a subgroup of youth with conduct disorders who have unique causal processes underlying their problem behavior and are at a particularly high risk for serious impairment relative to others with these disorders. As a result, these traits have recently been integrated into major diagnostic classification systems for conduct disorders. Given that CU traits are partly defined by deficits in empathy, we review research on empathy development in typically developing children and use this research to ( a) advance theories on the specific emotional deficits that may be associated with CU traits, ( b) explain the severe pattern of aggressive behavior displayed by children with elevated CU traits, and ( c) suggest possible ways to enhance prevention and treatment for children with conduct disorders and elevated CU traits. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 17 is May 7, 2021. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Revenge of the Windigo: The Construction of the Mind and Mental Health of North American Aboriginal Peoples

Book

Dec 2004

James Waldram

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