Aggression by Children and Adolescents



Aggression by Children and Adolescents


Robert J. Hilt MD

William P. French MD



Introduction

The evaluation of aggression in children and adolescents is complex because aggression and violence by themselves are not necessarily pathologic behaviors. Aggression may be adaptive and serve important social and biologic goals, such as when a child (hereafter “child” means a child or an adolescent up to age 18 years) is rough-housing with a sibling or aggressively defends himself or herself from an attacker. Adaptive aggression is normal, has a place in society, and does not require treatment. Maladaptive aggression, on the other hand, is a dysfunctional behavior, which is ultimately harmful to the individual. As Connor notes, compared to adaptive aggression, maladaptive aggression is often inappropriate to the social context; is more intense, frequent, or long-lasting than its apparent cause warrants; and often, but not always, appears to be impulsive and unregulated.

Families of children with these types of behaviors can easily become overwhelmed and often need assistance from primary care providers, mental health professionals, or other community supports. Because types and causes of aggression vary, the evaluation and treatment of these behaviors is complex and often requires multidimensional strategies ranging from the simple to the extreme. This chapter will clarify these complexities and present a suggested approach to the clinical management of maladaptive aggression. The use of the term aggression in this chapter will hereafter denote maladaptive aggression unless otherwise noted.


Background

Historically, socially unacceptable aggression in children has been addressed both by the justice and by the mental health systems. The American justice system’s formal involvement with child aggression began with the establishment of the first juvenile court in Chicago in 1899. The court originally began as an outgrowth of a broad urban reform movement, which viewed maladaptive behaviors in children as the product of poverty and other negative social forces typically found in large, industrialized urban cities. Such a view contributed to juvenile courts historically operating under the doctrine of parens patriae, or parent of the people. When a child’s welfare appeared at risk, the court tried to facilitate rehabilitation through referral to social service agencies. In focusing on the child’s welfare, the juvenile court system has generally promoted the distinction between juvenile and adult offenders. In the last 50 years, there have been legal challenges to this policy, which have led to modifications of how juvenile offenders are treated. The first of these challenges occurred in the 1960s through suits that claimed the juvenile system, by operating separately from the adult justice system, denied due process to child offenders by limiting their access to legal protections available to adult offenders.. More recently, in the 1980s and 1990s, increased juvenile crime and attendant media coverage have led to modifications of juvenile law codes allowing juveniles, under certain circumstances, to be tried as adults in criminal courts.


Like the justice system model, the mental health model also developed out of progressive reforms of the early twentieth century. Psychiatrists, psychologists, and social workers, operating as members of clinical teams in newly formed child guidance clinics, intervened with maladjusted children in local communities. Initially the child guidance movement concentrated on efforts of prevention as a means of social reform; over time, however, the clinics shifted toward individual treatment of identified children. As this shift occurred, there was a change in the recognized typical social characteristics of the maladjusted child away from poor, immigrant children of lower social classes toward increasing numbers of children from higher income, better educated families.

In contemporary American society, the juvenile justice and mental health systems continue to have intersecting roles in interventions with aggressive children; for example, as Teplin and colleagues found in 2002, up to 75% of juvenile offenders have at least one diagnosable psychiatric disorder. In order to address such needs, there have been efforts to place mental health professionals in correctional facilities, but these services remain underdeveloped and inadequately funded and staffed.


Clinical Features

Aggression is not a diagnosis but rather a behavior pattern that has a variety of presentations and determinants. Adaptive aggression can be a normal aspect of early social development (i.e., a toddler hitting someone to get back a toy) or be needed to preserve one’s safety. Aggression is maladaptive when it occurs with inappropriate intensity, duration, or frequency. Although a wide variety of subtypes of pathologic aggression have been postulated, two dichotomous subtypes appear to the authors to be the most clinically relevant categorizations: (1) hot versus cold aggression and (2) direct versus indirect aggression.


“Hot” and “Cold” Aggression

“Hot” aggression refers to impulsive, aggressive, and defensive behaviors that arise in response to an actual or perceived attack or provocation. This type of aggression is best conceptualized as a defensive fear-driven response to threat and frustration. It is associated with high central nervous system (CNS) autonomic arousal and irritability due to activation of the fight, flight, and freeze response; behaviorally there is an uncoordinated, poorly modulated response to the threat with high risk of self-harm and low probability of successful outcome or reward. Children with “hot” aggression often display biases that, in the setting of socially provocative or ambiguous situations, lead them to make exaggerated, inappropriate, and aggressive responses to peers and adults, whom they may inappropriately believe to have hostile intentions toward them. “Hot” aggression is associated with a history of developmental disturbances, physical abuse, social instability, or neuropsychiatric problems, such as inattention and impulsivity.

Children with “cold” aggression are commonly described as having callous-unemotional traits and appear to have little CNS autonomic arousal or visible signs of fear, irritability, and anger when engaged in aggressive acts. This type of aggression is pursued in order to obtain a desired goal or favorable outcome such as food, property, social status, or pleasure in inflicting harm. Unlike in “hot” aggression, the execution of “cold” aggressive acts occurs in an organized, patterned, goal-directed, and controlled manner, which increases the likelihood of successful outcome. “Cold” aggression theories in humans postulate that this behavior can be reinforced in the context of social environments that provide social role modeling and external reinforcements for such behavior, such as gangs or violence-prone communities. “Cold” aggression has a later age of onset than does “hot” aggression, and is felt to be quite unresponsive to medication treatments.



Direct and Indirect Aggression

Both the cold and hot forms of aggression may manifest in either physical or nonphysical ways. Physical aggression and violence are easily recognized behaviors—they constitute a “direct” form of aggression in which the individual is directly physically manipulating or harming another individual. Nonphysical expressions of aggression, often termed “indirect” aggression, are only recently becoming recognized clinically as aggressive acts.

Indirect aggression, as described by Vaillancourt, is a form of maladaptive behavior that involves manipulating social relationships in aggressive ways to intentionally hurt target victims. In contrast to direct aggression, which peaks at around 30 months of age in the general population, indirect aggression increases in its occurrence throughout childhood and may peak, for females at least, somewhere in late adolescence or young adulthood. Examples of indirect aggression include motivating others to dislike a person, betraying others’ trust by divulging their secrets, using subtle speech or body language to convey derogatory interpersonal messages, and spreading rumors about others, as for example, with regard to promiscuous sexual behavior, frigidity, or sexual orientation. Indirect aggression is more commonly seen in females compared to males, and when accounted for in community samples, it narrows the gender gap in terms of the overall prevalence of aggression in children.

Children who utilize indirect aggression often gain status and popularity within certain peer circles, but at the same time they are likely to be disliked by their victims, other lowerstatus individuals, and their larger peer networks. Thus, in terms of social adaptation, indirect aggression has features of both competence and impairment. Clinical referral of children who utilize indirect aggression is not very common. What is more common is to receive referrals on children who themselves are victims of indirect aggression and therefore experience anxiety and depression, or may plan out “cold” aggressive actions as a response to feeling victimized. As interest, knowledge, and research on the effects of indirect aggression grow, especially as regards the occasional serious negative outcomes that occur from it, schools and other community organizations have begun taking this type of aggression very seriously by enacting rules and punishments to attempt to limit its use.


Epidemiology

Aggression in infants and toddlers is common, contributes to healthy social adaptation, and usually does not continue to be a significant concern for children as they mature. Conflicts naturally arise in normal interactions, and assertiveness is one way infants and toddlers learn to establish relationships and boundaries in their evolving social lives. In a random community sample of 572 toddlers aged 17 months, 72% could be classified as having either modest or high aggression. When followed up to 42 months of age, these initially aggressive toddlers showed greater persistence of aggression when compared to the 28% of the sample rated as having “little or no physical aggression.” As children age further, however, most learn nonphysical forms of conflict resolution so that by the time they enter first grade, the rates of aggression in community samples are much lower.

School-aged children who participate in aggressive acts tend to repeat their aggression and are consistently rated by their teachers through their school years as being more aggressive than their peers. Outcomes for this subset are concerning: data from an original birth cohort of 1265 subjects studied over a period of 25 years found that the children who displayed the highest levels of aggression between age 7 and 9 years had, as adults, significantly worse criminal, mental health, substance-abuse, and relational outcomes compared to their less aggressive counterparts, with rates between 1.5 and 19 times higher than the least disturbed 50% of children studied. This association of conduct problems with poor adult outcomes was similar for females and males.


Combined rates of indirect and direct aggression are similar for males and females until around age 7. After this, the data indicate that males are about 3.5 times as likely as females to commit direct physical violence, while females are more likely to utilize indirect forms of aggression. The median age for onset of significant antisocial behaviors has been estimated at about 7 years in males and 13 years in females. African American children are about 1.5 times as likely as Caucasian American children to commit violent acts—other ethnicities have not been compared nationally. According to “Youth Violence: A Report of the Surgeon General”, child violence is fairly common in that 30% to 40% of males and 16% to 32% of females have committed at least one seriously violent act (aggravated assault, robbery, gang fights, or rape) by age 17. The peak age of onset of seriously violent offences is 16.

US criminal levels of aggression in juveniles, such as murder and aggravated assault, peaked in the mid-1990s after a period of rapid increase from the mid-1980s. Since then, violent crime in juveniles has decreased by half. Despite this overall improvement, there have been a number of highly publicized crimes, such as the school shootings at Columbine in 1999, which have reminded the public of the seriousness of child aggression and violence. Individuals who continue their violence through adulthood are more likely to have had an early onset of violent acts (before puberty), and are more likely to be engaged in a risky lifestyle involving drug use, precocious sex, and gun involvement.


Etiology

Historically, there has been considerable debate between nativist perspectives, on the one hand, and social learning perspectives, on the other, as to the causes of aggression. From a nativist view, aggression is an innate drive and natural behavioral consequence of a biologically driven competition for limited resources. From a social learning view, however, aggression is not innate but is learned through the modeling of other people’s aggressive behaviors, whether in the home, at school, or as portrayed in the media.

The approach of much contemporary work on aggression synthesizes these two perspectives through elaborating current understandings of the role gene-environment interactions play in the development and expression of aggression. According to this view, while an individual begins the developmental process with certain species-wide innate propensities like the potential for aggression, the direction and development of these propensities depend in large part on the interactions between these innate factors and the individual’s environment. Some children, due to both genetic and environmental factors, have a more difficult time compared to others in learning functional alternative strategies to aggression when faced with certain environmental conditions. Childhood maltreatment and exposure to aggressive adults, for instance, are potent environmental factors shown in the work of Dorothy Lewis to favor the development persistent aggressive behavior. Lewis’s work also stresses, however, how innate vulnerabilities can modulate the expression of aggressive behaviors in individuals exposed to maltreatment. For example, in children with pre-existing CNS dysfunction, exposure to maltreatment is particularly potent in promoting aggression.

In the following discussion of risk factors for the development of aggression, it will be helpful to keep in mind this dynamic and complex interplay between individual and environmental factors. It is also important to note that while the risk factors presented later in the text are predictive of an increased probability of aggression, in most cases they represent associations rather than known causal factors.


Risk/Resilience Factors

A number of individual factors have been identified as predisposing children to aggressive behavior, as summarized in Table 22-1. Prenatal alcohol exposure is associated with antisocial behavior and impulsive aggression, while prenatal nicotine exposure is associated with
attention-deficit/hyperactivity disorder (ADHD), conduct disorder (CD), and other adverse behavioral outcomes. Certain inborn temperaments have also been linked to aggressive behaviors in young people. According to Connor, children with temperaments described as “difficult,” “novelty seeking,” or “sensation seeking” in preschool are at increased risk for later psychopathology including CD and aggression. This association is more often seen in males versus females, and when associated with concomitant environmental stressors such as family dysfunction.








TABLE 22-1 Essential Risk Factors for Aggression and Related Behaviors







  • Individual risk factors


    Genetic susceptibility


    Prenatal toxin exposure


    “Difficult” temperament


    Cognitive deficits


    Affect dysregulation



  • Family risk factors


    Maltreatment and neglect


    Inadequate (i.e., coercive) parenting


    Family dysfunction and marital conflict



  • Community factors


    Peer rejection


    Antisocial peer group affiliation


    Neighborhood violence and poverty


    Media violence exposure


Deficits in cognitive function and performance have also been identified as important markers of increased risk of antisocial behavior. Deficits in prefrontal cortex-mediated executive functioning leading to impairments in impulse control and behavioral regulation have been associated with chronic aggression. Additional cognitive factors associated with conduct problems and aggression include low verbal and performance IQ and academic underachievement. Children with impairments in mood regulation often display chronic irritability, easy frustration, anger, dysphoria, and aggression. Children with high mood reactivity and sustained negative mood may have social information processing deficits that bias them to “hot” aggression defensive responses to perceived threats from others.

Maltreatment is an important source of increased risk of aggression in children. In an influential paper in 1989, Widom reported that children exposed to maltreatment and neglect are at a significant increased risk of the development of aggressive behaviors. Other factors that influence the relationship between maltreatment and aggression include the type of maltreatment exposure, the age of occurrence, and IQ level. Genetics also plays a role in how one responds to maltreatment. For example, Caspi and colleagues have been able to demonstrate that whether or not a child exposed to maltreatment develops problems with significant aggression as an adult depends in part on which of two different forms of the gene monoamine oxidase A (MAOA) the individual has.

Inadequate parenting practices are another important family risk factor. Patterson’s Coercive Family Process links the development of conduct problems to a pattern of inconsistent disciplining and follow-through, which leads to conflict and inadvertent reinforcing of childhood aggressive behavior through parents being either overly punitive or acquiescing to their child’s demands as a way to end the conflict. Additional parenting factors associated with the development of behavioral problems include insufficient supervision, poor delineation of boundaries, and low levels of parent positive praise and involvement. Bidirectional influences are also important. Children with difficult temperaments and disruptive behaviors are likely to elicit negative responses from their parents and other adults with whom they have contact. Additional family risk factors include family stressors such as marital conflict,
domestic violence, separation, and divorce; parent psychopathology and criminality; single parenting without sufficient supports; and family poverty.

Negative community factors, such as unfavorable school, neighborhood, and social environments, also increase the risk of aggression. Neighborhoods with high resident turnover and limited community resources lack collective efficacy, placing children from families with low socioeconomic status (SES) at risk for delinquent behaviors. Chronic exposure to neighborhood violence is strongly correlated with increased aggression, especially during adolescence. Connor notes that early childhood social rejection by peers and a later congregation of aggressive children into groups promote further learning of antisocial behaviors and impede the development of prosocial skills, especially during adolescence. Ameliorating factors for these negative peer influences include supportive family relationships and academic competence. One last important community factor is children’s exposure to media violence (MV). Singer and colleagues have reported that the amount of time elementary school children watched television was closely correlated with their self-reported levels of violent behavior. Children who have emotional and behavioral disorders, live in homes where violence is permitted, or witness violence in their neighborhood appear to be at greater risk to be influenced by MV. Suggested causal mechanisms of MV promoting aggressive behaviors in children include the following: (1) MV increases “hot” aggression through sensitization of the threat response system, (2) MV increases “cold” aggression through loss of empathy and habituation to the suffering of others, and (3) MV encourages the use of violence as an acceptable method of working through conflicts and problems.


Diagnostic Considerations

The clinical assessment and treatment of aggression often occur in mental health settings where treatments rely on assigning Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) psychiatric diagnoses and initiating interventions based on those diagnoses. This is frequently not ideal for several reasons. First, most maladaptive juvenile aggressive behaviors occur in individuals who are not psychiatrically ill, and therefore nonpsychiatric theories of etiology and intervention are usually required. Second, an aggressive act may be an adaptive behavioral response to a threatening encounter (such as a child pushing away a peer who is teasing them); therefore, even in a child with a previous DSM-IV diagnosis, aggression may be developmentally or situationally appropriate. Lastly, the presence of aggressive behavior is not very diagnostically helpful because the presentations of a number of DSM-IV illnesses can include aggression as a clinical feature. However, with these caveats in mind, if aggression occurs in the setting of a treatable DSM-IV psychiatric illness, as summarized in Table 22-2, then treating that underlying illness has a good chance of impacting the degree of occurrence of aggression. The following section summarizes the associations between aggression and a number of DSM-IV disorders as noted by Connor.

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Jul 5, 2016 | Posted by in PSYCHIATRY | Comments Off on Aggression by Children and Adolescents

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