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
2.) to protect personal/familial safety and
resources
3.) 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 threatened
3.) the benefits exceed the cost/risk
4.) social status increases as a result of
aggression
Aggression also often accompanies
psychiatric disorders
Reasons include
1.) 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 Aggression
1.) Proactive/instrumental
2.) Reactive/affective
Proactive
1.) Has a goal
2.) Is controlled and directed
3.) Not necessarily planned, may be
opportunistic
Proactive (cont.)
Proactive aggression includes group
antisocial activity and callous/unemotional
aggression
Reactive
Reactive 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 includes
A.) Impulse control
B.) Disinhibition
C.) Predominant affect - Temperament
Assessment…(cont.)
D.) Degree of affective reactivity and
capacity for modulation of affect
E.) Predominant parenting style
F.) Parent-child Relationships
Assessment…(cont.)
G.) Presence of abuse and neglect
H.) Whether the aggression achieves a goal
I.) Whether one observes useful
aggressiveness
Assessment…(cont.)
J.) Language ability
K.) 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 Algorithm
1.) Identify diagnoses present
2.) Identify environmental targets for
intervention
3.) Seriously consider treatment for primary
underlying problem (e.g. ADHD)
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
Treatment Algorithm (cont.)
6.) Pursue psychosocial therapies
7.) Consider antiaggression medication
8.) 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 Stabilizers
Lithium has mixed data
Divalproex 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 risperidone
if 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 care
May be a relapsing and remitting course
often associated with contextual
variables