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 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 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 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 Treatments

• Parent Management Training• Parent-Child Interaction Therapy• Multisystemic Therapy• Structural Family Therapy• Trauma Focused Cognitive

Behavioral Therapy

Specifically these interventions render

aggression• Irrelevant

• Ineffective

• 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