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 ones
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

Irrelevan
t
Ineffectiv
e
Inefficien
t

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