This is a literature review discussing previous studies on the associations between impulsive aggression and the serotonergic system in adults, adolescents, and children. The review demonstrates that there is a clear association between low cerebrospinal fluid serotonin and impulsive aggression. However, studies on neurotransmitter receptor profiles, functional imaging, genetics, and epigenetics reviewed in this article suggest a more complicated picture that includes consideration of gene vs. environment in the evaluation of risk. Serotonin supplementation studies suggest that selective serotonin reuptake inhibitors may reduce impulsive aggression in some adults but are less effective in adults with pathological aggression and also in children and adolescents. Child and adolescent studies are less conclusive, in part due to the heterogeneous physiologic and psychosocial changes occurring over the course of development. The author thus concludes that psychiatrists can reduce risk in these special patient populations by creating safer environments in the form of changes in policy and increased support services.

Attention-deficit/hyperactivity disorder (ADHD) is a common, symptomatically heterogeneous, neurodevelopmental disorder. It’s symptoms first appear early in life and evolve as the brain matures and reorganizes over the lifespan. Cognitive dysfunction is a key feature of adult ADHD and typically manifests as a dysregulation of executive control of attention, working memory, inhibitory control, and emotion regulation rather than as a defining deficit in a specific cognitive domain. The heterogeneity of presentation, changing clinical manifestations across development, and variability in functional impairment associated with ADHD contribute to the difficulty of obtaining a “snapshot” diagnosis using a single assessment or representative battery. Careful history-taking of information across raters and settings generally reveals a pattern of symptoms beginning in childhood. Manifested impairment required for diagnosis depends on a variety of supportive or mitigating versus contributory factors. In adulthood, persisted or untreated ADHD may predispose to a variety of other conditions, including low educational and/or academic attainment, decreased earning potential, substance use or abuse, parenting and marital problems, poor health practices, a variety of risky behaviors, and a variety of comorbid Axis I and Axis II psychiatric disorders. High-functioning adults who have not previously come to clinical attention may present for care because of academic underattainment, suboptimal performance in the workplace, or behavioral or mood dysregulation. In addition, ADHD may be discovered as part of a more comprehensive workup of other disorders. A range of psychosocial and psychopharmacological treatments are available; response is often good to excellent once the disorder is properly identified.

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