Assessment and Treatment of Aggressive Behavior in Children

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Assessment and Treatment of Aggressive Behavior
in Children

• John 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 resources
• 2.) to protect personal/familial safety and
  resources
• 3.) to defend and build ones 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 threatened
• 3.) the benefits exceed the cost/risk
• 4.) social status increases as a result of
  aggression

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• Aggression also often accompanies psychiatric
  disorders

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Reasons include

• 1.) 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 Aggression

• 1.) Proactive/instrumental
• 2.) Reactive/affective

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Proactive

• 1.) Has a goal
• 2.) Is controlled and directed
• 3.) 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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Reactive

• Reactive 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 includes

• A.) Impulse control
• B.) Disinhibition
• C.) Predominant affect - Temperament

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Assessment(cont.)

• D.) Degree of affective reactivity and capacity
  for modulation of affect
• E.) Predominant parenting style
• F.) Parent-child Relationships

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Assessment(cont.)

• G.) Presence of abuse and neglect
• H.) Whether the aggression achieves a goal
• I.) Whether one observes useful aggressiveness

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Assessment(cont.)

• J.) Language ability
• K.) 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 Algorithm

• 1.) Identify diagnoses present
• 2.) Identify environmental targets for
  intervention
• 3.) Seriously consider treatment for primary
  underlying problem (e.g. ADHD)

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Treatment Algorithm (cont.)

• 4.) Change only 1 thing at a time
• 5.) Pursue psychosocial interventions organize
  day, establish bedtime, ensure adequate food
  intake, increase daily structure

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Treatment Algorithm (cont.)

• 6.) Pursue psychosocial therapies
• 7.) Consider antiaggression medication
• 8.) 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 Stabilizers
• Lithium has mixed data
• Divalproex 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 risperidone
• if 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 care
• May be a relapsing and remitting course often
  associated with contextual variables