Current community practice emphasizes use of second-generation antipsychotic agents for children with impulsive aggression. While risperidone has proven effective for irritability associated with pervasive developmental disorders [25,26] and second-generation antipsychotics have been effective in pediatric bipolar disorder, these agents are associated with significant weight gain and other metabolic effects. Use of these medications is associated with decreased utilization of psychosocial interventions. Given the relationship of SMD with ADHD, anxiety, and unipolar depression, investigations of drugs from other classes with targeted effects and better side effect profiles, such as mood stabilizers, antidepressants, and stimulants, are certainly warranted. In fact, the DSM-5 Workgroup has specifically called for clinical trials stating it is "critically important" to assess whether stimulants and SSRIs should be first line treatments in SMD-affected youth. The only published medication trial in SMD youth is a double-blind placebo controlled study of lithium conducted by the intramural group at NIMH, which failed to demonstrate effects. Other informative investigations include small positive studies of methylphenidate versus placebo for ADHD plus oppositional defiant disorder and aggression, open-label stimulant followed by adjuvant divalproex vs. placebo for ADHD and aggression, and stimulant augmentation with double-blind risperidone versus placebo in ADHD with treatment resistant aggression. These studies are notably heterogeneous in design and choice of outcome measures. No clear predictors of response have been reported.