Doi:10.1016/j.jadohealth.2003.10.009

JOURNAL OF ADOLESCENT HEALTH 2004;35:260 -277 Recent Research Findings on Aggressive and ViolentBehavior in Youth: Implications for ClinicalAssessment and Intervention NANCY RAPPAPORT, M.D. AND CHRISTOPHER THOMAS, M.D.
Abstract: Assessing children and adolescents for po-
tential violent behavior requires an organized approach
that draws on clinical knowledge, a thorough diagnostic
interview, and familiarity with relevant risk and protec-
tive factors. This article reviews empirical evidence on
risk factors, the impact of peers, developmental path-
Although arrest rates for serious violent crimes and ways, physiological markers, subtyping of aggression,
juvenile homicides have fallen from an all-time high and differences in patterns of risk behaviors between
in the mid-1990s, many adolescents and children sexes. We explore these determinants of violence in
remain involved in aggressive delinquent and vio- children and adolescents with attention to the underly-
ing motivations and etiology of violence to delineate the
lent behaviors such as physical fighting, bullying, complexity, unanswered questions, and clinical rele-
using weapons, verbal threats of harm to others, and vance of the current research. Interventions, including
chronic impulsive aggression In 1999, juveniles cognitive behavioral therapy, psychopharmacological
accounted for 16% of all violent crime arrests, and treatment, and psychosocial treatment, are reviewed with
homicides committed by youth under 18 accounted acute recognition of the need to use multiple modalities
for 10.1% of all homicides Although this homi- with, and to expand research to define optimal treatment
cide rate is lower than in previous years, the overall for, potentially violent children and adolescents. The
prevalence of other violent behaviors among youth information considered for this review focuses on vio-
remains high. These figures are the culmination of a lence as defined as physical aggression toward other
tragic trajectory of violence that has an alarming individuals. Other studies are included with wider def-
impact on the physical safety and emotional well- initions of violence because of their relevance to assess-
ing the potential for violent behavior. Society for
Adolescent Medicine, 2004
Youth violence often emanates from multiple risk factors: biologic vulnerability inconsistent,overly permissive, or harsh discipline commu- KEY WORDS:
exposure to violence Violent behavior rarely appears spontaneously; it typically has a long devel- opmental pathway In certain instances, ag-gression may be a response to stress that occursduring a vulnerable period, and an individual maynot respond in the same volatile way at a different From the Harvard Medical School, Cambridge, Massachusetts (N.R.) and University of Texas Medical Branch, Houston, Texas (C.T.). time in their life However, there is usually a Address correspondence to: Nancy Rappaport, M.D.,Cambridge strong continuity in violence between childhood, Hospital, 1493 Cambridge St., Macht Building, Cambridge, MA 02139. adolescence, and adult life. Aggressive behavior, Manuscript accepted October 6, 2003. conduct problems, and antisocial behaviors generate Published by Elsevier Inc., 360 Park Avenue South, New York, NY 10010 one-third to one-half of all child and adolescent the evaluation of youth violence. These research psychiatric clinic referrals, and clinicians are fre- findings are grouped into the areas of individual quently asked to provide evaluation and treatment factors (gender, physiological markers, and social recommendations for these patients In the con- cognitive risk factors), social and environmental fac- text of disruptive disorders, extensive reviews exam- tors (family, peer and environmental factors), fol- ine the primary risk factors and developmental path- lowed by sections addressing conceptual models ways while also recognizing that there is still a level (cumulative risk factors and aggression subtypes), of complexity that warrants further research to en- considerations in risk assessment, and prevention/ hance our understanding of aggression and to in- intervention approaches (cognitive behavioral ther- apy, psychopharmacological treatment and psycho- Even though many clinicians specializing in ado- social treatment). Special emphasis is devoted to lescent medicine may not have the expertise to reports from areas that have not received consider- conduct this type of psychiatric diagnostic assess- ation in previous general reviews but expand our ment and to choose treatment modalities, it is helpful clinical awareness and provide a better framework to be exposed to the relevant research about aggres- for understanding youth violence, such as aggression sive youth and to appreciate the practical limitations of our knowledge and possible areas of intervention.
The role of the evaluating mental health clinician iscritical in providing a diagnostic assessment that is based on a sophisticated clinical formulation. The Research literature on youth aggressive and violent initial steps are to carefully identify and understand behavior was reviewed after a systematic search of the cumulative effects of risk and protective factors PsycInfo and Medline. Also, manual review of arti- on the patient; assess acute safety considerations; cles' reference lists identified additional pertinent evaluate the onset, severity, and course of the violent studies. The review focuses on important findings in behavior; identify comorbidity; and determine the youth violence and topics that have not been covered motivation for change and self-reflection. Currently, in previous general reviews, including gender differ- no validated screening instruments or protocols exist ences, conduct disorder, subtypes of aggression and for the prediction of juvenile aggression. Although risk factors, with emphasis on areas of current re- several assessment instruments appear promising, no single screening instrument has been establishedor generally accepted for predicting youth aggres-sion.
The success in predicting treatment outcomes and violence for these high-risk patients is variable, and it is useful for clinicians to continue to assess these Most of the research on youth violence focuses on patients and to look for opportunities for preventive men and boys with relatively little attention given to interventions. Offering the perspective of a commu- aggressive females, primarily because a much larger nity practitioner rather than that of an individual percentage of males, as compared with females, practitioner is crucial because these aggressive chil- commit violent acts Typically, gender differ- dren usually need coordinated efforts drawing on ences were difficult to discern, as many studies resources from their family, medical, and mental (particularly those examining conduct disorder) in- health care providers, educators and other commu- cluded only male participants In the past, to nity members. These assessments may occur in emer- understand the characteristics, history, and symp- gency rooms, court clinics, schools, outpatient psy- toms of girls with illegal or aggressive behavior, the chiatric clinics, or inpatient psychiatric units. In this most frequently implemented design relied on un- review, we will present the salient information rele- controlled follow-up and cross-sectional studies with vant to clinicians who may be asked to identify and/or assess violent children and adolescents, and the last 10 years, researchers have generated more to determine the capacity for intervention. Because empirical studies of girls' aggression in several dif- there is extensive recent research on youth violence, ferent disciplines (developmental psychology, child particular attention is therefore focused on topics psychiatry, and criminology), with more attention to that have special relevance to clinicians. Most impor- prospective longitudinal studies and more diverse tant are studies that provide information critical to participants However, there is still a long JOURNAL OF ADOLESCENT HEALTH Vol. 35, No. 4 way to go until the research on female youth violence subsequently evolve into serious psychopathology and aggression provides the same depth of work as but does not necessarily reflect overt patterns of on boys, particularly with respect to longitudinal aggression. In a longitudinal study of 2251 girls entering kindergarten, who were examined over a Most epidemiological studies have identified con- period of 7 years with a 3-year follow-up, the duct disorder as one of the most severe mental DSM-IV diagnostic criteria of conduct disorder failed disorders in adolescent girls, with prevalence rates to identify the most impaired, persistently antisocial varying from 4% to 9% Criminal statistics girls They suggested that the criteria for girls and diagnostic criteria of conduct disorder can be might need to be different from those used for boys, viewed as identifying adolescent females with the whether in reducing the number or type of symp- same underlying disruptive behaviors of concern.
toms. Crick expanded the criteria of female aggres- The Office of Juvenile Justice showed in national sion from an emphasis on physical and overt aggres- statistics on adolescent female violent crime arrests sion to verbal, indirect, and relational aggression an increase of 23% as compared with an 11% increase Relational aggression refers to gaining control in the arrests of male juveniles It is unclear if through manipulative behavior that affects peer sta- this marked increase in female arrests is owing to tus and that is recognized by girls as motivated by increased detection of females by the juvenile justice intent to harm and "meanness." Later studies dem- system and previous reluctance to arrest girls. The onstrated that relational aggression in females pre- severity of adolescent female crime has also in- dicts concurrent psychosocial adjustment problems Girls may have different ways than boys of ex- Separate criteria for identifying conduct disorder pressing aggression that are affected by biological, in females and males have not been developed. This dispositional, and contextual factors. The challenge issue was considered during the development of the is to unravel the interaction of causal factors, the DSM-IV but was not pursued because there was heterogeneity of risk factors, and the identification of insufficient information available to support gender- different developmental trajectories to determine specific criteria for identifying conduct disorder precise mechanisms of variable outcomes of female By developing accurate and useful criteria that ex- aggression. There is recognition that girls are often amines a broad range of behavior for assessing exposed to the same biological insults (e.g., prenatal female aggression, it may be ascertained that there is maternal cigarette smoking) as boys, but that this an unrecognized continuity between persistent trou- exposure has a minimal effect on girls' relative risk bling behavior (not the same type of disruptive (RR) of conduct disorder In contrast, there is an behavior that is seen in males) that increases the association of prenatal smoking with psychiatric probability of developing life-long impairment in morbidity specific to antisocial behavior in males females There may be gender-specific levels and types of behavior that identify girls as disruptive that ological limitations owing to a reliance on cross- are at low risk according to males' standards but sectional studies and because there is difficulty mea- predict subsequent impairment in girls. This identi- suring prenatal exposure with precision and fication may be useful in developing reliable clinical separating risk factors that may have confounded the tools to provide early detection and support to those results. However, this study highlights the increased young girls who are at risk of developing late onset vulnerability of males to peri and postnatal stresses of dysfunction in multiple areas. Several longitudinal It would be clinically useful to delineate why studies show that adolescent girls with conduct females are less vulnerable to prenatal nicotine ex- disorder predictably suffered in multiple adult out- posure and subsequent associated severe antisocial comes after adolescence. Their dysfunction unfolded over time and included poor physical health The majority of developmental studies do not increased mortality rates, increased criminality rates, differentiate physical aggression and verbal aggres- high rates of psychiatric comorbidity, and participa- sion and the studies tend to examine the exter- nalizing observable behaviors that are more consis- Antisocial adolescent females are often more vul- nerable to family dysfunction and have a later onset confrontational verbal threats and physical assaults of aggressive behavior than males Some prelim- Existing classification methods of girls with inary evidence connects girls' depression and family conduct disorder may overlook behavior that may discord to later antisocial behavior Expanding the analysis of behavior linked to aggression is One peripheral measure, salivary cortisol concen- reflected in one of the first studies of an ethnically tration, may reflect alterations in the hypothalamic- diverse group of adolescent female offenders that pituitary-adrenal axis. In a longitudinal study of 38 showed a link between trauma, psychopathology, clinic-referred school-age boys, low salivary cortisol and violence An examination of 96 incarcerated levels were associated with persistent and early adolescent girls found that they were 50% more onset of aggression Boys with low cortisol likely to show symptoms of posttraumatic stress concentrations (measured at Year Two and Four in disorder (PTSD) than male juvenile delinquents the study) had three times the number of aggressive The difficulty with the study was that the sample symptoms than did boys with higher cortisol levels.
was small and the researchers did not consider other Continually restricted (low) cortisol levels may be comorbid pathology. Causality was not established more relevant to predicting continuous aggression because cross-sectional data were collected. The rec- than an isolated low concentration of cortisol at a ognition of PTSD and subsequent aggression in single point in time. This finding was correlated to incarcerated females may lead to focusing on this often unidentified association between PTSD and Boys who bully often have low anxiety and show aggression. Such research also highlights the impor- low cortisol levels In contrast, affective aggres- tance of screening and early intensive intervention sive boys with high arousal show high cortisol levels.
This study was limited by a relatively small sample Any antisocial behavior (including violence) in consisting only of males and by the failure to control girls should alert clinicians to the possibility of for time of the day in measuring cortisol, because comorbid psychiatric disorders because girls with salivary cortisol levels show diurnal/circadian vari- antisocial behaviors are at much greater risk than ability The mechanism linking persistent ag- boys for suffering from a wide range of psychiatric gression and low cortisol concentration is not yet illnesses In a recent study examining violence elucidated. Yehuda et al examined the alteration in exposure, violent behaviors, psychological trauma, cortisol levels (lowered) in patients with posttrau- and suicide risk in a community sample of danger- matic stress disorder (PTSD) There may be some ously violent adolescents, one in five females was at overlap with aggressive patients that have lowered a high risk for suicide compared with significantly cortisol levels. The brain plasticity of the developing lower percentages in all other comparison groups child suggests that prenatal and early developmental The distinctive vulnerabilities of violent females stress (maternal prenatal smoking, abuse, and ne- and their pattern of clinical presentation remain to be glect) can change the hypothalamic-pituitary-adrenal axis permanently Another hypothesis postu- Clinicians must be vigilant about screening for lates that attachment behaviors regulate arousal ac- aggressive behavior in females, particularly between tivity in the hypothalamic-pituitary-adrenal axis.
the female and intimate partners and/or family Disorganized attachment relationship in infants is members. Practitioners must also consider that an correlated with elevated cortisol levels The later assaultive adolescent girl may have had some under- correlates of disorganized attachment strategies can lying trauma and may need further counseling. If the manifest in preschool years as disturbed and aggres- clinician sees an aggressive adolescent female for a sive interactions with parents and teachers recent injury or routine examination, it is particularly However, clinically, these physiological markers relevant to screen for suicide risk, as they are at a cannot be used as predictors of violence, as many children with disorganized attachment histories andelevated salivary cortisol levels do not become ag-gressive. Some studies have shown that it is not Physiological Markers
merely the basal level of cortisol that is key to Recently, researchers have attempted to identify bi- understanding disruptive and aggressive behavior ological markers that may be relevant to the further but rather the hypothalamic axis response to stress- subtyping of aggression. Environmental stressors ful stimuli Consequently, further studies are can affect hormone production, and experiences can needed to fully understand these interactions.
affect physiological states that can, in turn, affect Researchers have postulated that the inhibitory behavior. Aggressive behavior in both children and neurotransmitter serotonin (precursor 5ЈHT) may adults is associated with abnormalities in peripheral modulate aggressive behavior in youths. Several methods of measuring indirect serotonin activity in JOURNAL OF ADOLESCENT HEALTH Vol. 35, No. 4 the brain are employed, as serotonin cannot be that treatment for adults cannot be indiscriminately directly, economically, or easily quantified: metabo- lites in the cerebrospinal fluid and platelet receptorsindirectly demonstrate the neuronal functioning asdo measurements of whole blood serum The Social Cognitive Risk Factors
hypothesized relationship between lowered CSF se- Social cognitive research has identified differences in rotonin precursors and higher levels of aggression is the way that aggressive children process information supported by two longitudinal studies; however, there is not a simple inverse relationship cognitive variables in aggressive and nonaggressive Challenge studies use drugs such as dl-fenfluramine boys at preadolescent and early adolescent develop- as a way to indirectly assess the CNS serotonin levels. These challenge studies of prepubertal boys children often misread interpersonal cues and inter- suggest that there may be developmental changes in pret ambiguous or prosocial communication as hos- serotonin function. Prepubertal aggressive boys ini- tile and react aggressively. The children also often tially may have increased serotonin functioning as have heightened sensitivity to rejection derived from compared with nonaggressive boys This en- early experiences of physical abuse or emotional hanced serotonin may decrease with the onset of neglect that then triggers anxiety or angry states adolescence If this hypothesis is substantiated in This tendency to identify affect arousal as future studies, it could have direct clinical implica- anger can also lead to overlooking verbal solutions in tions in terms of avoiding selective serotonin re- favor of frequent and intense aggressive behavior.
uptake inhibitors in aggressive prepubertal boys Trauma-related emotions can trigger severe ag- It is a more complex picture with youths, gression in response to minor or trivial disappoint- possibly because developmental fluctuations with ments. Slaby and Guerra elaborated on the cognitive serotonin confound the results. Further research profile of these aggressive adolescents who believe needs to delineate the relationship of the develop- that there are limited consequences for aggression, ment of neurobiological systems and specific vulner- that aggression has concrete benefits, and that it is a abilities in response to stressful environmental legitimate response These findings are exceed- ingly important for clinicians working with aggres- Gender differences in the rates of aggressive be- sive children and their parents. Understanding the haviors have naturally focused on the potential role impact of impaired social communication can assist of androgens, especially testosterone, in the develop- families in understanding violent outbursts and ment of violence. Numerous studies have found a serve as the basis for developing potential interven- correlation between higher levels of testosterone and tions. This insight can also assist clinicians in recog- nizing how distorted social cognition in patients and studies describing this relationship are with boys their families impedes their efforts for intervention.
after the onset of puberty, suggesting that the acti-vating effect depends on physical maturation There is also some evidence to suggest that testosterone is specifically related to provoked ag-gression, but not unprovoked aggression, in adoles- Family Factors
The family environment is the intimate system There are no definitive mechanisms delineated to wherein development is shaped. There is ample understand the hypothesized association between empirical evidence (longitudinal designs, random- aggression in youth and fluctuations in testosterone, ized controlled clinical trials, and cross-sectional cortisol, or neurotransmitters. This is the new fron- studies) demonstrating the pivotal role of consistent tier as researchers attempt to further elucidate how parental discipline in preventing early patterns of neurobiology and hormones play out differently in aggressive versus nonaggressive individuals while Dishion et al and Patterson et al developed a still acknowledging the impact of environmental model of coercion that starts with family practices stressful events. Whereas selective serotonin re- beginning in early childhood In this typical uptake inhibitors are used in the adult population to scenario, when an oppositional child is aggressive, dampen aggression by increasing serotonin the parents fail to intervene early and to set reason- preliminary findings in prepubertal boys suggest able standards for behavior. Instead, parents may respond inconsistently by withdrawing, giving a Gangs may be a special case in peer relationships neutral response, or overreacting with excessively and violence. Numerous studies report an associa- harsh punishment or exaggerated negative affect. A tion between gang involvement and increased vio- reciprocal escalation of behavior may ensue with lence and delinquency The result of Thorn- increasingly coercive parent-child interactions. The berry's analysis of gang members supports a child learns that aggressive reactions to parental facilitation model where the norms and group pro- requests often lead to parental abdication and with- cesses of the gang exacerbate the behavior patterns of drawal. Thus, the child uses aggressive behavior to the individual gang members Interestingly, be- effectively terminate parental aversive requests, and fore and after gang membership, these individuals in turn, the aggressive behavior is reinforced (escape do not have significantly different risk factors or conditioning). Often, the same parents may overlook profiles than nongang members. Also, gang mem- or respond inappropriately to the prosocial behavior bers are disproportionately responsible for delin- their children may occasionally demonstrate. The quent crime, particularly serious and violent offenses insights on family interaction reinforce the impor- tance of clinician attention to parent-child interac- The Seattle Social Development Project also found tions in dealing with aggressive behavior. Parents that the influence of gangs was greater than just are often frustrated in their attempts to manage associating with deviant peers Parents can mod- aggressive behavior in their offspring and may be ify the effect of deviant peers, with a positive parent- unaware of how their responses may unwittingly child relationship providing protection for adoles- sustain or even exacerbate behavior. This explana- cents Another important peer influence on tion does not mean that responsibility for violent acts the development of aggression may be social ostra- by youth should be incorrectly placed on the parents, cism, as seen in recent school shootings. In early but rather points to the need for families to find more childhood, both peer group rejection and victimiza- effective means to resolve the issues that contribute tion are associated with increased risk for aggressive to aggressive behavior. In terms of assisting parents, behavior It is not clear whether this rejection ready information about how parents can use appro- and victimization are prompted by early aggressive priate discipline methods, attend to positive rein- behaviors or by some other individual risk factor, forcement, and encourage conflict resolution is use- such as impulsivity. Certainly, social ostracism re- ful. Consistent parental discipline, increased positive sults in youth having fewer opportunities to learn parental involvement, and increased monitoring of and practice socially acceptable behaviors through the child's activities were accompanied by significant positive peer relationships. To curtail bullying by reductions in a child's antisocial behavior.
aggressive children, Olweus designed systemic inter-ventions in schools to increase monitoring and estab-lish consequences for bullying Twemlow et alexamined how coercive power dynamics in school Peers and Gangs
are critical to understanding how bullying can be As with the development of other social behaviors, sustained in school settings By analyzing the peers have an impact on aggression and violence in school climate, the power dynamic can be rebalanced adolescence. Studies with different age groups indi- so as to decrease the potential for violence cate that the influence of deviant peer behavior on Whereas the negative effect of antisocial peers is a the development of aggression is most pronounced risk factor for aggressive behavior in youth, clini- during adolescence. Associating with delinquent cians should recognize the heightened impact of peers was predictive of self-reported adolescent vio- gangs and their recent spread throughout American lence in several studies In addition, associat- communities. It is important to learn not only about ing with peers who disapprove of antisocial behavior the patient's peer group, but also if there is gang appears to reduce the likelihood of later violent acts Unfortunately, in mixed groups of children,nonaggressive children are more likely to becomeaggressive than are aggressive children to become Gangs and Females
nonaggressive Despite the contribution of devi- The finding that male gang involvement is associated ant peers to the onset of adolescent aggression, the with a disproportionate amount of serious and vio- mechanism of the causal influence of peer networks lent crime holds true with girl gangs as well Surveys have demonstrated that female gang mem- JOURNAL OF ADOLESCENT HEALTH Vol. 35, No. 4 bers are more likely to be violent than non-gang- erational support, were more often identified in close involved boys Although female gangs represent proximity to other stable neighborhoods An- a small proportion of gang members, the numbers on other factor that adds to the vulnerability of the females in gangs vary widely depending on whether neighborhood occurs when youth are exposed to data are drawn from official law enforcement violence, as this exposure increases the risk for sources or self-report surveys. The law enforcement data may underestimate the presence of girls because Access to a potentially lethal weapon, usually a of the law enforcement's limited capacity to get firearm, increases the likelihood that a lethal event accurate internal information from the gangs and will result from an aggressive or violent altercation because of the extensive confusion around how to The relatively easy access to firearms for youth define a gang National surveys of law enforce- increases the risk of youth violence Weapon- ment agencies over two decades, covering 61 police carrying for some adolescents is relatively common, departments, show a total of 992 female gang mem- as identified in a 2001 Center for Disease Control and bers comprising approximately 4% of the gang pop- Prevention study, Youth Risk Behavior Surveillance ulation In a multisite, multistate cross-sectional System In that national study of high school survey of a public school sample of eighth grade students, 17.4% of adolescent boys carried a weapon students (not a random sample), 237 girls out of 623 (a knife, gun, or club) at some point during the gang members in an ethnically diverse group of 6000 month before the survey The rate was higher in students identified themselves as gang members some areas (e.g. one survey that was conducted in inner-city middle schools found that 25% of male The re-examination of the role of female gang students and 11% of female students reported carry- members has redefined the earlier bias by male ing a gun with gun-carrying strongly linked to researchers who relied on interviews with male gang aggressive delinquency rather than to self-protec- tion) Boys most likely to carry handguns were tially seen as playing an auxiliary role in the gang those with the most aggressive behaviors (i.e., initi- and primarily acting as weapon bearers, sexually ating fights), who believed that shooting someone is exploited members, or girlfriends The trajec- justifiable under certain circumstances and who per- tory of female gang involvement may be different ceived their peers as accepting violence and more complex than originally posited. Ethno- Pittel used clinical evaluations to describe some of graphic fieldwork has highlighted that the adoles- the beliefs of students carrying weapons and catego- cent girls' participation in gangs may reflect frustra- rized them as "deniers," "innocents," "fearfuls," and "defenders" For example, deniers claim Females were more likely to look to the gang as a ignorance of how the weapon came into their pos- refuge than males and they often came from more session. They insist that they did not knowingly troubled families than the male gang members carry the weapon into school and claim an unknownculprit planted it in their book bag or locker. Inno-cents admit to possessing a weapon but claim they Environmental and Situational Factors
were holding it for someone else or found it. It is Studies of communities and individuals confirm the important to further elucidate the reasons that ado- popular impression that youth violence is more lescents carry weapons, as it will inform clinical common in urban and impoverished neighborhoods Certainly the impact of poverty on the family A moderate relationship exists among illicit drug system contributes to the risk for violence and ag- use, alcohol, and violence Alcohol can stir gression, but the analysis of neighborhood character- aggression by reducing threat-related inhibition and istics offers a more complex understanding. Collec- increasing arousability. Alcohol also decreases high- tive efficacy (assessed by cross-sectional surveys of er-order cognitive functioning by altering the adoles- 8782 Chicago adult residents) shows that active cent's ability to communicate and judge the degree of engagement by adults to supervise and maintain threat in a social situation A study on youth order, neighborhood residential stability, and con- violence in schools demonstrated that 40% of the centrated affluence decreases the likelihood of vio- students who drank alcohol at school reported car- lence in a community Additionally, adults rying a weapon to school, as compared with 4% of sharing relevant information and providing supervi- youth who did not drink alcohol at school sion for informal social control, known as intergen- Aggression predicts substance use and substance use predicts aggression An extended longitudinal The central design of effective preventive efforts is study found that aggressive behavior in childhood is twofold: (a) the examination of risk and protective predictive of substance use in adolescence This factors at critical developmental periods, and (b) the research also indicated that the relationship appears understanding of the mechanisms through which to be influenced by the presence of associated symp- these risk factors impair youth behavior. In the toms of depression and impulsivity. Other factors context of assessing violent/aggressive children, the that may affect the association between aggression principal questions are whether children are "hard- and substance use in youth include family history of wired" and genetically primed to be aggressive, alcoholism and drug abuse and involvement with whether the environment is shaping the vulnerable peers or gangs using drugs Clinicians must be child, or both. Raine's research showed substantial aware of the vicious cycle that exists between sub- empirical evidence to support the interaction be- stance use and violence in youth, as with adults.
tween biological and environmental variables to spe- These findings on specific environmental factors cifically explain violent behavior Raine drew contributing to youth violence enable clinicians to comparisons from a large birth cohort (4269 male assess the individual patient's potential risk, as well children in Denmark) and classified the children as current behavior patterns, in greater detail. Such according to two variables. If children had birth understanding can provide the basis for a more complications or neurological impairment, they had tailored and individualized approach to developing about the same chance of becoming criminally vio- prevention and intervention plans. Public health lent 18 years later as those children with no risk efforts can also be directed to address these defined factors. The group of children with both early child- risks within the broader community to reduce and hood rejection and birth complications (4.5% of pop- ulation) accounted for 18% of all violent crimescommitted by the collective sample of 4269 subjects.
Raine's study defines early childhood rejection asmaternal rejection of the infant (unwanted preg- Cumulative Risk Factors
nancy and attempt to abort the fetus) and disruption Numerous factors contribute to the relative risk for of the mother-infant bond (public institutional care the development of violence and no single factor is of the infant). Significantly, the interaction effect was associated with all aggression or provides absolute found to be specific to violent offending and did not prediction. Studies utilizing multiple factors provide generalize to nonviolent crimes or recidivism, per se.
stronger prediction of violence and demonstrate the A different example of the critical interaction be- interaction and increased cumulative risk of these tween genetic risk and environmental influence was influences Evidence indicates that the impact provided from the Dunedin longitudinal study of risk factors depends upon their presence during Physically abused boys with a variant of the mono- amine oxidase A (MAOA) gene were twice as likely Specific models describing distinct pathways in to develop aggressive behaviors and three times as the development and progression of aggressive be- likely to be convicted of a violent offense as an adult havior that incorporate multiple risk factors have in comparison with abused boys without the MAOA been proposed based on longitudinal research variant. In the absence of a history of abuse, boys As part of an overall model of the develop- with the variant MAOA gene were at no greater risk ment of antisocial behaviors, Loeber et al describe a for later aggressive behaviors than other nonabused specific course of development of aggressive and violent acts. Minor fights and bullying characterize This research provides specific information about the early stage, progressing to the later stages of some of the very early risk factors for violent behav- more serious assaults, weapon use, rape, and rob- ior and has major policy implications and clinical bery Although many children will exhibit entry relevance supporting intensive early intervention.
level behaviors, fewer progress to each successive Effective early interventions with nurse visitation in stage of antisocial acts. The further a youth the home environment for high-risk families (aver- progresses in development of aggressive behaviors, age of 30 visits spanning from prenatal to the child's the more likely that other antisocial behaviors will 2nd birthday and focusing on maternal functioning) also appear. Therefore, youth with the most severe have shown a significant reduction in adolescent behaviors will often exhibit the widest variety of antisocial behavior including arrests and convictions, in comparison to a control group This type of JOURNAL OF ADOLESCENT HEALTH Vol. 35, No. 4 intervention can compensate for negative birth com- aggressive behavior over time, and to recognize that plications and promote positive parenting, thereby a small portion of adult violent offenders had short- preventing the more serious forms of antisocial be- term escalation of aggression at late onset It is havior leading to arrests and convictions critical that clinicians not interpret the relative stabil-ity of aggression as equivalent to aggression beingrelatively intractable as a fixed and predetermined Aggression Subtypes
behavior. Although there is a consistent finding in From a clinical perspective, research on subtypes of the stability of aggression, this finding has not trans- aggression may be helpful in understanding and lated into an understanding of patterns of aggressive treating aggression. Clinical observation, experimen- behavior within individuals. Nor has this categoriza- tal paradigms in laboratories, and cluster/factor an- tion generated an understanding about the large alytic studies show subtypes of aggression that may individual differences in the stability of aggression; have implications for the management and treatment which individuals may replace aggression with bet- ter adaptive behavior, which individuals are at tively distinct forms of aggression in youth may greater risk for persistent aggression, and which affect more tailored prevention and intervention youth are intermittently aggressive.
approaches to help predict treatment response.
There are several limitations with childhood-onset One subtype of antisocial behavior is classified and adolescent-onset subtyping. The problem with according to time of onset: childhood-onset (prepu- the term "childhood-onset" is that it implies a fixed, determined behavior, and does not seem to reflect gations primarily examined longitudinal groups of the ongoing exposure to risk factors and cumulative males at different intervals utilizing direct observa- insults that shape and reinforce persistent aggres- tion, peer nomination (wherein peers identify the sion. The variability in aggression or antisocial be- most aggressive peers), or teacher/parent ratings of havior suggests that different ways of measuring disruptive behavior. The results are usually pre- aggression may result in different indices of stability sented in terms of variance (percentage) or stability or discontinuity This type of measurement coefficient (correlating individuals from one time to does not capture the periodicity of aggression, and another time with certain behaviors present). Child- high correlation does not demonstrate the change in hood-onset antisocial behavior is rarer than adoles- severity level of aggression with age. The inade- cent-onset, typically 5- 6% in the general population quacy of the categories was further illustrated when of young males, but it is associated with more Tolan and Thomas' examined early- and late-onset seriously persistent violent behavior and worse out- offenders and showed that both populations looked comes Childhood-onset antisocial behavior is surprisingly similar in their cumulative risk factors more likely associated with neuropsychological def- In creating onset curves in a longitudinal icits (e.g., impaired language and intellectual func- sample of 500 males from the Pittsburgh Youth tioning, attention deficit hyperactivity disorder Group Study, the age of onset of aggression gradu- [ADHD]) and inconsistent discipline by parents ally increased for each level of aggression and there was no bimodal distribution that would support Investigations about aggression and conduct dis- order-like behavior demonstrate aggression as a rel- The most empirical research analyzing distinct atively stable trait, often compared with intelligence patterns of aggressive antisocial and delinquent be- Olweus carefully reviewed 16 longitudinal haviors relates to the trajectory of overt and covert studies of subjects 2 to 18 years of age and showed high stability coefficients (.81 in males). Subsequent of aggression were developed almost exclusively on studies, with varying methods of assessment, also males, and non-Anglos were underrepresented.
demonstrated high rates of stability of aggression in Despite the limitation, a temporal sequence of clinically referred samples and community samples escalating aggressive behaviors was proposed by with a range from 32% to 81% of children continued examining the Pittsburgh Youth Study of 1500 males with their disruptive, aggressive behavior in adoles- in three cohorts, ranging from ages 7 to 13 years at cence Although these studies emphasized high the first sampling time, with 6-month intervals be- stability of aggression over time, it is critical to tween assessments followed over 10 years The enhance the understanding about the significant cohorts were chosen so as to cover the age-range of proportion of aggressive youth that do not maintain development under investigation (7 years to young adulthood), but the three cohorts do not represent vation is fear-induced and leads to irritability and separate pathways, just separate age groups. In the hyperarousability In animal models, stimula- "overt" pathway, males start by annoying and bul- tion of the ventromedial hypothalamus reproduces lying others, followed by physical fighting, then by (simulates) an affective type of aggression assaultive behavior and forced sex. The "covert" Predatory aggression involves minimal levels of au- pathway entails sneaky acts such as stealing and tonomic activation and the information processing is lying, followed by property damage, vandalism, and fire setting; culminating in fraud, burglary, and seri- In a small clinical sample, Vitiello et al provided ous theft. The third proposed developmental path- preliminary evidence of the clinical validity of sub- way involved those males with "authority conflict." types of aggression A scale was constructed This research highlights how identifying common with items that demonstrated good internal consis- clusters of aggression and sequences of behaviors tency, reliability, and stability for identifying preda- may improve early identification. When this theoret- tory and affective aspects of aggression. The instru- ical framework was applied to the National Youth ment was used to differentiate the types of Data of a nationally representative sample, a larger aggression of 73 aggressive boys and girls aged 10 proportion of serious and violent youth offenders through 18 years who were inpatients or enrolled in followed the overt developmental sequence than the a partial hospitalization program. Most of the pa- general population The initial step of detailing tients had either predominantly affective or mixed the developmental patterns of aggression over time predatory-affective scores. Vitiello's findings suggest and identifying the probable trajectory of serious and that those children who are purely proactive/pred- violent offenders may allow a clinician to identify atory aggressors are not as frequently treated or patients at risk when they have a progression of admitted to psychiatric hospitals. Patients with a behavior and not by the presence of a specific behav- high affective aggression score had a higher inci- ior. Although the cumulative acts of aggression are dence of psychotic symptoms and a higher likeli- detailed, the mechanism of how individuals begin hood of receiving lithium or neuroleptics.
with minor aggressions, progress to more severe Distinguishing whether adolescents' aggression is forms of violence, and how individuals with similar primarily reactive or proactive may suggest the behavior will follow these predictable trajectories, therapeutic direction of prevention and treatment, as remain to be elucidated. Winnicott's essays on depri- well as prognosis If adolescents have reactive vation and delinquency or Aichhorn's observa- aggression, they most likely have impaired social tions on Wayward Youth still provide insight about cognitive processing that misinterprets information the inner experience and psychic turmoil These and can be responsive to cognitive behavioral ther- authors illuminate the meaning of the outward man- apy that provides an alternative approach to fearful ifestations of behavior through insightful interviews of individual patients, often overlooked in the pop- types of patients may also benefit from medications that alter their hyperaroused state. Proactive aggres- Another subtype of aggression emanates from sive youth are more likely to progress to externaliz- multicultural studies that assessed proactive aggres- ing behaviors and subsequent criminal behavior than sion and reactive aggression Children initi- males assessed as having reactive aggression in ad- ate proactive aggression to obtain specific rewards olescence and followed into adulthood Proac- and establish social dominance. Proactive aggression tive boys have the expectation of positive outcomes involves a minimal level of physiological arousal and from aggressive behavior and thus the emphasis is relates to predatory aggression. Conversely, reactive on systematic interventions, increased monitoring, aggression or affective aggression involves the de- fensive use of force against a perceived threat orprovocation. This defensive stance is triggered byactivation of the fight-or-flight response, with a highlevel of physiologic arousal.
Different neuroanatomical chemical pathways un- Assessing children and adolescents for potential vi- derlie these forms of aggression. Affective/reactive olence requires an organized approach that draws on aggression is characterized by impulsive/explosive clinical knowledge, a thorough diagnostic interview, anger and decreased levels of serotonin metabolites and familiarity with relevant risk and protective in cerebrospinal fluid The autonomic acti- factors. Even with guidelines and checklists for iden- JOURNAL OF ADOLESCENT HEALTH Vol. 35, No. 4 Table 1. Assessment Guidelines for Clinicians
cians, and to get details of past treatment attempts.
These clinicians may note what has already been 1. What are the capabilities and skills of the parents?2. Is there any evidence of disorganized attachment to the done for the patient. When a clinician has enough information to make a preliminary formulation, it is 3. Are there any other medical problems that suggest useful to explain to the patient the clinician's current abnormalities with regulation of behavior or affect? understanding in addition to exploring the patient's 4. Does the patient's aggression fall into predatory aggression or 5. What is the range, severity and frequency of the aggressive Essential to the diagnostic interview is for the clinician to clarify whether the child or adolescent 6. Is there a clear precipitant to the aggression, (predictable wants to change and is willing to work to change his/her assumptions, behavior patterns, denial of 7. Has the patient been traumatized, and could that lead to responsibility, and lack of trust. It is important to 8. Is there a past history of violent episodes? identify whether the child or adolescent who enjoys 9. What are the parents' attitudes towards violence? hitting or hurting the victim has any empathy orunderstanding of the distress inflicted on anotherperson.
tifying risk factors, there is the possibility of errors: If the patient expresses no motivation to change false positives, false negatives, or both. False posi- and does not have any desire to control aggression or tives are children and adolescents who may have risk homicidal ideation, the assessment has reached a factors but do not act violently, whereas false nega- critical juncture. At this point, it is the clinician's tives are youth who are overlooked but who subse- responsibility to provide feedback to the adults (e.g., quently act violently. In the absence of validated and parents, court personnel, school staff) who have reliable screening instruments or effective protocols, initiated the assessment. If the patient poses a very we propose a rational approach to the clinical inter- high violence risk, preventive action needs to be view, conducted by a mental health practitioner, that will help in evaluating individual children or ado- Coercive measures such as hospitalization and the lescents for potential violence Unfortunately, question of warning potential victims also need to be there are practical barriers regarding some adoles- addressed. Although risk factors can indicate the cents that practitioners would ideally like to refer, potential for violence, it is still difficult to determine such as time lag, financial limitations, and family or why some children are on a chronic trajectory of patient distrust of practitioners. If the patient makes aggressive behavior and others manage to compen- explicit verbal threats or appears to have prominent sate despite exposure to many of the cumulative risk symptoms suggestive of a comorbid state (exacerbat- factors that lead to violence. Violence is rarely ran- ing his/her aggression), the treating clinician is ad- dom, yet the dynamic and situational variables can change so quickly that an assessment is extremely The starting point of an evaluation is a general time-sensitive. Developing a rational strategy for diagnostic psychiatric interview to determine if the evaluating adolescents and children at risk for vio- young patient has a major mental illness, medical lence leads to the development of a treatment plan/ disorder, or substance abuse that could be contribut- program to contain and reduce the risk.
ing to his or her aggressive behavior. A clinicianshould cover specific areas of information in anorganized fashion using a format similar to the one The questioning can then move on to facts about Cognitive-Behavioral Therapy
the immediate context of the aggression. It is impor- Cognitive-behavioral therapy (CBT) seeks to change tant to obtain collateral information from parents, social cognitive deficits and distortions in aggressive teachers, court records, or security guards, because children and adolescents. It focuses on defining the minimization of responsibility for actions and denial problem, generating alternative solutions, anticipat- are to be expected. It is critical to carefully assess the ing consequences and introducing behavioral moni- patient's attitudes toward carrying a weapon, access toring, and prioritizing responses. Interventions usu- to a weapon, and the risk of using a weapon in a ally involve role-playing, practicing, homework fight. It also is important to identify which adults assignments, and specific skill-building to change support this young patient, including other clini- cognitive distortions and responses. Cognitive-be- havioral problem-solving skills training (PSST), to- Long-term CBT follow-up usually consists of a taling 20 sessions for preadolescent children evalu- 1-year follow-up and frequently does not include ated in inpatient and outpatient support settings, direct observation of the child's behavior or assess- supports the efficacy of the treatment compared with ment of exact skills that may diminish behavior, such therapeutic changes of relationship therapy (RT) and as aggression. Critical indices of treatment efficacy still need to be developed with the caveat that it may effects were demonstrated in a 1-year follow-up be more prudent to conceptualize aggression con- assessment in school and at home with changes in duct disorder as a "chronic disease model." Optimiz- behavior at home and at school A more de- ing treatment of aggression occurs if experienced tailed review of CBT outcome research showed im- clinicians are used, which is not always true outside provements in social competency and lessened ag- of the research setting. Also, it is important to note that incremental gains are achieved with longer research is required to examine child and treatment treatment (up to 50 or 60 sessions) including periodic characteristics that predict outcome and demonstrate Although it is critical to continue the development and evaluation of CBT, several limitations exist. First, Psychopharmacological Interventions
there is the high attrition rate of severely stressed Medications should be considered for violent aggres- families that are hindered by the associated costs, sive children only in the context of a careful diagnos- scheduling difficulties, inconvenience, and reluc- tic assessment that reviews multiple risk factors and tance to participate in a treatment intervention generates a complex formulation. Managing violent This attrition, which can be as high as 50% to 75% of children and adolescents with solely pharmacologi- children referred for treatment, can result in over- cal methods is not recommended. Failure to consider inflated support for using CBT to reduce problem and initiate an active comprehensive treatment plan behavior because the most difficult families don't sets up the treating clinician for dangerous liability.
participate Although the attrition rate may not For a treatment plan to be effective in modifying be the exclusive problem to this modality, it points to aggression, it needs to be comprehensive and ad- the need for further improvements in the implemen- dress family competency, relational capabilities, and Similarly, as in any therapy, children in CBT It is common clinical practice to identify target require motivation to change; obtaining this motiva- symptoms in an aggressive/violent child, such as tion can be challenging when aggressive behavior is irritability, impulsiveness, or affective liability. Only egosyntonic. Garbarino, a psychologist who has then are medication trials conducted that try to worked with extremely violent boys in juvenile de- ameliorate the symptoms. However, this approach is tention systems, cautions: "Some of the boys have tenuous because there is minimal research demon- memorized the list of techniques and concepts but strating its efficacy. Frequently, the research on ag- can do no more than parrot what is in the textbook.
gression in adults is extrapolated to provide pharma- Others say that they can not imagine being able to cotherapy treatment suggestions for adolescents and apply these techniques in the situations that they face children. The concern is that the findings on adults in the world" Another aspect to consider is the are not applicable to adolescents and children. There cognitive development of the child, as it has been are no specific antiaggressive drugs currently avail- demonstrated that preschool and early school-age able; rather there are some drugs, including atypical children who are preoperational in their thinking do antipsychotics, anticonvulsants, mood stabilizers, not respond to CBT as well as older children (ages anxiolytics, beta-blockers, and alpha-agonists that 11-15 years) who are more cognitively sophisticated are used for their capacity to indirectly decrease Another dilemma is that the most vulnerable aggression. There is a growing body of research on aggressive children often have language expressive the indications and efficacy of medication in the deficits, executive functioning difficulties, and im- treatment of aggression in youth. Most of the reports pulse control problems. These limitations make it are of open trials rather than randomized controlled especially difficult for children to put their emotions studies and among all these investigations, the re- into words rather than actions, and they may have ported duration of treatment is seldom longer than 2 difficulty understanding and internalizing the cogni- months One striking example of the impor- tance of rigorous research is a report that found, JOURNAL OF ADOLESCENT HEALTH Vol. 35, No. 4 among youth admitted for inpatient treatment for with selective serotonin reuptake inhibitors may severe aggression, in a double-blind study, almost alleviate symptoms in irritable, depressed children 50% responded to placebo Most of these ran- Nevertheless, the best guideline is to use domized clinical studies use a relatively small sam- the least toxic and safest intervention first.
ple of aggressive adolescents, do not identify comor- Patients with conduct disorder and associated bid disorders, and do not consider the impact of aggressive behavior pose a particular challenge.
They are difficult to build an alliance with because Clinicians need to identify the specific conditions they often oppose adult authority and have concur- that may contribute to the patient's aggressive be- rent substance use. Although there is no medication havior and to use this information as a guide in the with labeling approved by the U.S. Food and Drug selection of potential medications. To determine ef- Administration for conduct disorder, clinicians may ficacy, empirical trials of agents should be suffi- feel pressured to address the explosive impulsive ciently long. Clinicians should rely on studies that aggression with medications. The comorbid condi- use double-blind and placebo design in medication tion of conduct disorder is critical to determine. One trials. Additionally, aggressive and violent behaviors recent study that carefully examined 50 youths (aged should be assessed with standardized ratings 11 to 17 years) in a juvenile detention center found A further complication is that frequently, aggressive that 84% of the sample met criteria for conduct patients may have simultaneous multiple medication disorder (CD) or oppositional defiant disorder trials, making it difficult to determine the pharmaco- (ODD) (60% CD, 24% ODD), 20% had major depres- dynamic effect of the combination of medications sion, and 15% met criteria for ADHD Lithium and the contribution of single agents. Connor and has had equivocal results in trials of patients with conduct disorder Findling et al demonstrated reviewed many of the controlled studies that look at that the use of risperidone was reported as superior each category of psychiatric conditions that may be to a placebo in short-term use with a small number of responsive to medication and may lead to reduction outpatient children and adolescents with conduct in aggressive behavior. The critical clinical recom- disorder, although it is difficult to determine the mendation is that if a comorbid condition exists, then efficacy because of the small sample size Van treating it with indicated medications might reduce Bellinghen and De Troch found that risperdone was significantly more effective than placebo in reducing A guiding principal in the evaluation of violent aggression in a sample of children between the ages and aggressive children is that they often have a of 6 and 14 years at doses ranging from 0.03 to 0.06 wide range of psychopathology, including ADHD, mg/kg/day Risperidone's use is best limited mood disorders learning and communication to cases where the aggressive behavior severely disorders, obsessive-compulsive disorder with asso- affects functioning. Further systematic prospective ciated anxiety, PTSD, substance use and abuse, and treatment trials are needed to fully determine the even rare cases of psychotic disorder with paranoid effective medications for aggression in conduct dis- ideation Puig-Antich studied a subset of de- pressed boys with aggressive behavior and showedthat if their depression improved, the antisocialbehaviors also improved, whether the improvement Psychosocial Treatment
was spontaneous or the result of treatment for de- A careful assessment of the developmental stage of the child or adolescent will define the therapeutic reduced if young patients are treated with stimulants approach. The therapist tries to promote the devel- Some clinicians suggest that clonidine (Catap- opment of new skills and encourage adopting new res) treatment can be useful for ADHD children who ways of coping. Although there are a variety of display overaroused behavior, excessive hyperactiv- techniques that the therapist may employ, adoles- ity, and extreme aggression Furthermore, lith- cents demand an inordinate amount of flexibility.
ium and divalproex (Depakote) have been found The focus usually is on the adolescent's current useful in double-blind, placebo-controlled studies for functioning and his current relationships with an children and adolescents with disruptive disorders emphasis on renegotiating the adolescent-parent re- characterized by explosive temper and mood lability lationship and exploring the role of peers. The ther- or bipolar disorder and comorbid conduct disorder apist usually sees the adolescent alone first, whereas Lastly, some clinicians suggest that a trial with a child, the parent may be interviewed first.
Adolescents often do not recognize their need for these subtypes is needed to develop better screening help and may project their difficulties as derived instruments to identify particular behavior. In turn, from unrealistic responses of teachers or parents. If this information may inform how clinicians prioritize clinicians are making a referral to a therapist they can interventions. Researchers still need to develop and help to anticipate with the adolescent that it is a confirm different models that explain the progres- normal reaction to balk at this type of treatment sion or deterrence of adolescents engaging in these initially. Children are usually more receptive to troubling behaviors. More investigation is warranted building a trusting relationship with a therapist than to discern certain correlates of aggression in both adolescents. Therapists often rely on role playing community populations and clinically referred pa- and engaging game activities with children that help tients so that tailored prevention, early interventions, model how children can control their impulses and evidence-based treatment can be mobilized. As In Parent Management Training (PMT), the focus treatment interventions are more rigorously tested is on parents acquiring concrete skills that concen- and meaningful algorithms are generated, clinicians trate on teaching prosocial behavior Parents may come to see the aggressive teenager as challeng- learn to observe antecedents to their child's behav- ing, and yet also know how to build on the adoles- iors and to modify the consequences. There also is an cents' strengths and help to substantially modify emphasis on active role-playing, practice, and feed- their aggression. The pattern of violence will perpet- back. Outcome studies have shown gains that have uate or not, depending on how clinical understand- been maintained 1 to 3 years after this form of ing deepens regarding the causes of aggression and treatment However, most PMT studies focus how this understanding is turned into prevention, intervention, and treatment. The insight and practi- Multisystemic Treatment (MST), a family-based cal suggestions that are generated will allow our intensive therapeutic approach, has been demon- children and adolescents to make meaningful alter- strated to be effective with adolescent juvenile of- fenders MST is tailored to the needs of eachfamily with the goal of improving the communica- We thank Tony Earls, Mike Jellinek, and Eliot Pittel for theirinsightful comments, and Alexa Geovanos for her research assis- tion skills and management of the family's problem behavior. Borduin also showed that juvenile offend-ers (they averaged 4.2 previous arrests) who receivedthe MST intervention were less likely to be arrestedfor violent crimes than were youths who had re- ceived individual therapy The long-term ef- 1. Fox JA, Zawitz MW. Homicide Trends in the United States.
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