assessment and treatment of aggressive behavior in children

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Assessment and Treatment of Aggressive Behavior in Children. John 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 resources - PowerPoint PPT Presentation

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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 ones prestige, status or power

  • Aggression is more likely when1.) the victim is in an out group/ depersonalized2.) 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 include1.) 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 Aggression1.) Proactive/instrumental2.) Reactive/affective

  • Proactive1.) 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

  • ReactiveReactive 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 affectE.) 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 AggressionADHDConduct DisorderOppositional Defiant DisorderDepressionHead Injury

  • Common Diagnoses Associated with Aggression (cont.)Mental RetardationPervasive Developmental DisorderBipolar DisorderPTSDDyslexia

  • Get best history of context/antecedents, outcomes, frequency, severity of aggression

  • Treatment Algorithm1.) 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 TreatmentsParent Management TrainingParent-Child Interaction TherapyMultisystemic TherapyStructural Family TherapyTrauma Focused Cognitive Behavioral Therapy

  • Specifically these interventions render aggressionIrrelevantIneffective

    Inefficientby changing antecedentsby changing consequencesby developing alternatives

  • Putting aggressive children and youth together (groups, detention) make aggression worse

  • PsychopharmacologyStimulants if warranted (ADHD)Antipsychotics most usedRisperdal 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 dataBenzodiazepines 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

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