Assessment and Treatment of Aggressive Behavior in Children
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Assessment and Treatment of Aggressive
Behavior in ChildrenJohn Sargent, MD
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Aggression is behavior that is unwanted and is perceived by the person that receives it as intrusive
and harmful
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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
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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
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Aggression also often accompanies psychiatric disorders
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Reasons include1.) High negative emotionality
leading to low threshold for anger or tolerance for frustration
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Reasons include (cont.)2.) Distorted cognitions may lead to
unwarranted alarm or erroneous beliefs
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Reasons include (cont.)3.) High anxiety can lead to harmful
escape or avoidance behaviors
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Reasons include (cont.)4.) Inadequate impulse control can
lead to use of disinhibited aggressive behaviors
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Reasons include (cont.)5.) Delayed cognitive or
communicative development may lead to aggressive behaviors as a method of communicating emotions or desires
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Reasons include (cont.)6.) Significant maltreatment may
lead to both a decrease in empathy and modeling of aggressive behavior
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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
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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
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This progresses to continued fighting and also bullying and teasing – 8% of boys fight frequently, 15-20%
engage in bullying
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Aggression is a common cause for requesting mental health
assistance
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Violence (as distinct from aggressive behaviors) among adolescents is often a group activity and most
often is perpetrated by adolescents upon adolescents
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Two Types of Aggression1.) Proactive/instrumental2.) Reactive/affective
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Proactive1.) Has a goal2.) Is controlled and directed3.) Not necessarily planned, may be
opportunistic
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Proactive (cont.)Proactive aggression includes group
antisocial activity and callous/unemotional aggression
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ReactiveReactive aggression is behavior that
responds to a perceived hurt, slight or violation
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Reactive (cont.)Often includes hitting, biting, kicking
and self-injurious behavior. Often accompanied by shouting and verbal outbursts
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Reactive (cont.)Appears instantaneous and
unplanned, often with significant negative consequences for the aggressive child
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Aggression can be overt or covert and can be direct or indirect
(cyberbullying)
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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
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Aggression is often multifactorial and reflects the reality that risk
factors often occur together: poverty, modeled aggression, poor
verbal skills, abuse, etc.
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Assessment of children brought for treatment of
aggression includesA.) Impulse controlB.) DisinhibitionC.) Predominant affect -
Temperament
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Assessment…(cont.)D.) Degree of affective reactivity
and capacity for modulation of affect
E.) Predominant parenting styleF.) Parent-child Relationships
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Assessment…(cont.)G.) Presence of abuse and neglectH.) Whether the aggression
achieves a goalI.) Whether one observes useful
aggressiveness
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Assessment…(cont.)J.) Language abilityK.) IQ
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Common Diagnoses Associated with
Aggression• ADHD• Conduct Disorder• Oppositional Defiant Disorder• Depression• Head Injury
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Common Diagnoses Associated with
Aggression (cont.)• Mental Retardation• Pervasive Developmental Disorder• Bipolar Disorder• PTSD• Dyslexia
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Get best history of context/antecedents, outcomes, frequency, severity of aggression
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Treatment Algorithm1.) Identify diagnoses present2.) Identify environmental targets
for intervention3.) Seriously consider treatment for
primary underlying problem (e.g. ADHD)
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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
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Treatment Algorithm (cont.)
6.) Pursue psychosocial therapies7.) Consider antiaggression
medication8.) Always utilize rating scale or
episode calendar
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Evidence Based Psychosocial Treatments
• Parent Management Training• Parent-Child Interaction Therapy• Multisystemic Therapy• Structural Family Therapy• Trauma Focused Cognitive
Behavioral Therapy
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Specifically these interventions render
aggression• Irrelevant
• Ineffective
• Inefficient
by changing antecedents
by changing consequences
by developing alternatives
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Putting aggressive children and youth together (groups, detention)
make aggression worse
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Psychopharmacology• Stimulants if warranted (ADHD)• Antipsychotics – most used
Risperdal has most data and has an FDA indication for use in children with autism
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Psychopharmacology (cont.)
• Mood StabilizersLithium has mixed dataDivalproex has some positive results in treating aggression in irritable youth
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Psychopharmacology (cont.)
• Clonidine is used but there is limited data
• Benzodiazepines can be disinhibiting
(not indicated)
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Psychopharmacology (cont.)
Psychopharmacology is aimed at target symptoms – arousal, excitability, irritability, not aggression itself
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Psychopharmacology (cont.)
JS choice: low dose risperidoneif needed add divalproex
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Psychopharmacology (cont.)
Discontinue meds after 6 months of improvement, taper one at a time
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Refer early, maintain long term availability, actively involve
parents in careMay be a relapsing and remitting
course often associated with contextual variables