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Assessment and Treatment of Aggressive
Behavior in ChildrenJohn Sargent, MD
Aggression is behavior that is unwanted and is perceived by the person that receives it as intrusive
and harmful
Aggression generally has 3 purposes:
1.) to gain resources2.) to protect personal/familial
safety and resources3.) to defend and build one’s
prestige, status or power
Aggression is more likely when
1.) the victim is in an out group/ depersonalized
2.) the perpetrator feels threatened3.) the benefits exceed the cost/risk4.) social status increases as a
result of aggression
Aggression also often accompanies psychiatric disorders
Reasons include
1.) High negative emotionality leading to low threshold for anger or tolerance for frustration
Reasons include (cont.)
2.) Distorted cognitions may lead to unwarranted alarm or erroneous beliefs
Reasons include (cont.)
3.) High anxiety can lead to harmful escape or avoidance behaviors
Reasons include (cont.)
4.) Inadequate impulse control can lead to use of disinhibited aggressive behaviors
Reasons include (cont.)
5.) Delayed cognitive or communicative development may lead to aggressive behaviors as a method of communicating emotions or desires
Reasons include (cont.)
6.) Significant maltreatment may lead to both a decrease in empathy and modeling of aggressive behavior
Aggression may also be a common and acceptable means of resolving
conflict or managing behavior in some families/ contexts. Thus it
may be adaptive in those environments
Aggression commonly begins in childhood: 27% of parents of 3
year olds report that the child hits at least sometimes. 58% of
preschool children demonstrate some aggressive behavior
This progresses to continued fighting and also bullying and teasing – 8% of boys fight frequently, 15-20%
engage in bullying
Aggression is a common cause for requesting mental health
assistance
Violence (as distinct from aggressive behaviors) among adolescents is often a group activity and most
often is perpetrated by adolescents upon adolescents
Two Types of Aggression
1.) Proactive/instrumental2.) Reactive/affective
Proactive
1.) Has a goal2.) Is controlled and directed3.) Not necessarily planned, may be
opportunistic
Proactive (cont.)
Proactive aggression includes group antisocial activity and callous/unemotional aggression
Reactive
Reactive aggression is behavior that responds to a perceived hurt, slight or violation
Reactive (cont.)
Often includes hitting, biting, kicking and self-injurious behavior. Often accompanied by shouting and verbal outbursts
Reactive (cont.)
Appears instantaneous and unplanned, often with significant negative consequences for the aggressive child
Aggression can be overt or covert and can be direct or indirect
(cyberbullying)
2 longitudinal courses of antisocial behavior are seen – early
childhood onset, which commonly persists to adulthood, and
adolescent onset with an end in early adulthood
Aggression is often multifactorial and reflects the reality that risk
factors often occur together: poverty, modeled aggression, poor
verbal skills, abuse, etc.
Assessment of children brought for treatment of
aggression includesA.) Impulse controlB.) DisinhibitionC.) Predominant affect -
Temperament
Assessment…(cont.)
D.) Degree of affective reactivity and capacity for modulation of affect
E.) Predominant parenting styleF.) Parent-child Relationships
Assessment…(cont.)
G.) Presence of abuse and neglectH.) Whether the aggression
achieves a goalI.) Whether one observes useful
aggressiveness
Assessment…(cont.)
J.) Language abilityK.) IQ
Common Diagnoses Associated with
Aggression• ADHD• Conduct Disorder• Oppositional Defiant Disorder• Depression• Head Injury
Common Diagnoses Associated with
Aggression (cont.)• Mental Retardation• Pervasive Developmental Disorder• Bipolar Disorder• PTSD• Dyslexia
Get best history of context/antecedents, outcomes, frequency, severity of aggression
Treatment Algorithm
1.) Identify diagnoses present2.) Identify environmental targets
for intervention3.) Seriously consider treatment for
primary underlying problem (e.g. ADHD)
Treatment Algorithm (cont.)
4.) Change only 1 thing at a time5.) Pursue psychosocial
interventions – organize day, establish bedtime, ensure adequate food intake, increase daily structure
Treatment Algorithm (cont.)
6.) Pursue psychosocial therapies7.) Consider antiaggression
medication8.) Always utilize rating scale or
episode calendar
Evidence Based Psychosocial Treatments
• Parent Management Training• Parent-Child Interaction Therapy• Multisystemic Therapy• Structural Family Therapy• Trauma Focused Cognitive
Behavioral Therapy
Specifically these interventions render
aggression• Irrelevan
t• Ineffectiv
e
• Inefficient
by changing antecedents
by changing consequences
by developing alternatives
Putting aggressive children and youth together (groups, detention)
make aggression worse
Psychopharmacology
• Stimulants if warranted (ADHD)• Antipsychotics – most used
Risperdal has most data and has an FDA indication for use in children with autism
Psychopharmacology (cont.)
• Mood StabilizersLithium has mixed dataDivalproex has some positive results in treating aggression in irritable youth
Psychopharmacology (cont.)
• Clonidine is used but there is limited data
• Benzodiazepines can be disinhibiting
(not indicated)
Psychopharmacology (cont.)
Psychopharmacology is aimed at target symptoms – arousal, excitability, irritability, not aggression itself
Psychopharmacology (cont.)
JS choice: low dose risperidoneif needed add divalproex
Psychopharmacology (cont.)
Discontinue meds after 6 months of improvement, taper one at a time
Refer early, maintain long term availability, actively involve
parents in careMay be a relapsing and remitting
course often associated with contextual variables