Aggression In Adolescents

  • Category: Psychology
  • Words: 1326
  • Grade: 100
Aggression is highly common among patients requested psychiatric treatment.
Among adults the number of physical assault in patients referred for
psychiatric hospitalization has risen 150% for females and 50% for males
over the past 10 years (Tardiff et al., 1997). Among psychiatrically
referred children and adolescents, aggressive behavior patterns have shown a
detectable increase over the past two decades (Achenbach and Howell, 1993)
and are now the most common reason for referral regardless of ambulatory or
institutional setting (Carlson, 1995). The prevalence of aggression
significantly augments the overall cost of child and adolescent mental
health services. It is highly associated with psychosocial, behavioral, and
academic impairment in youth (Vivona et al., 1995); can have an early age of
onset (Moffit, 1993); and demonstrates marked stability over time into
adulthood, especially for males (Farrington, 1991).
The component behaviors subsumed under the domain of aggression are quite
varied. Previous reviews of the development of aggression have repeatedly
emphasized the importance of subtyping aggressive behavior into
theoretically and empirically distinguishable subcategories (Hinshaw and
Anderson, 1996; Parke and Slaby, 1983; Vitiello and Stoff, 1997). Distinct
subtypes may possess differing diagnostic, biological and psychosocial
correlates; novel responses to psychosocial and somatic therapies; and
varying prognoses.
Much previous research on aggression in children and adolescents has focused
on psychiatric diagnoses such as conduct disorder and the disruptive
behavior disorders, nonspecific behavior problems, violence, and crime
(American Psychiatric Association, 1994; Hinshaw and Anderson, 1996; Loeber
et al., 1995; Raine et al., 1994, 1996; Widom, 1989). The use of conduct
disorder for studying aggression in youth has been criticized as inadequate.
This diagnosis offers no guidelines to help clinicians distinguish
pathological from non-pathological aggression, ignores developmental issues,
and ignores the environmental context in which aggressive behavior occurs
(Richters, 1996). Furthermore, disruptive behavior disorder diagnoses,
behavior problems, crime, and violence may confound multiple subcategories
of the aggressive domain and possibly obscure distinctions that may be
useful in treatment planning (Hinshaw and Anderson, 1996).
In the adult psychiatric and psychopharmacological literature, overt
categorical aggression (OCA) has received empiric support as a distinct
subtype of aggression that is prevalent in psychiatrically referred patients
(Kay et al., 1988; Ratey and Gutheil, 1991; Silver and Yudofsky, 1991;
Yudofsky et al., 1986). Overt aggression is defined as openly
confrontational hostile behavior (threats, physical fighting). This is
contrasted with covert aggression, which is hidden (stealing, vandalism,
truancy). In a meta-analysis of childhood antisocial behavior, Loeber and
Schmaling (1985) found empiric support for this subtyping. High overt
aggression is more likely to be impulsive, accompanied by strong affect
(fear, anger), and be poorly controlled in contrast to the instrumental and
over-controlled character of covert aggression. This suggests the
possibility of differing etiologies and neurobiology, the understanding of
which may yield meaningful treatment implications.

Overt aggression encompasses four categories of aggressive behavior
including physical assault on others; verbal threats of violence toward
others; explosive, impulsive property destruction; and self-injurious
behaviors (SIB). Reliable and valid descriptive instruments such as the
Overt Aggression Scale (Yudofsky et al., 1986) and a Modified Overt
Aggression Scale (Kay et al., 1988) are available to measure OCA in both
adults and children.
Research on the OCA subtype in child and adolescent psychiatry has lagged
behind research in adult patients. Studies of psychiatric ambulatory and
inpatient children and adolescents have described several cross-sectional
correlates associated with youth who direct aggression toward others.
Compared with clinically referred nonaggressive children and adolescents,
aggressive youth are more likely to be male (Pfeffer et al., 1983a; Vivona
et al., 1995), to have a history of aggression toward others prior to
psychiatric referral (Gabel and Shindledecker, 1991; Garrison et al., 1990;
Pfeffer et al., 1983a), to possess CNS neurological symptoms (Griffin, 1987;
Lewis et al., 1983), and to experience adverse events in their families such
as physical and sexual abuse (Vivona et al., 1995) and domestic violence
(Pfeffer et al., 1983a). Psychiatric diagnostic correlates have included
developmental disorders such as mental retardation (Pfeffer et al., 1983a),
disruptive behavior disorders (conduct and attention-deficit hyperactivity
disorder) (Griffin, 1987; Pfeffer et al., 1987), and psychotic disorders
(Inamdar et al., 1982). Outcome correlates of aggressive youth include
longer length of stay in psychiatric hospitalization (Gold et al., 1993),
discharge from hospitalization to more restrictive placement (Gabel and
Shindledecker, 1991), use of combined pharmacotherapy (Connor et al., 1997),
and use of neuroleptics (Connor et al., 1997).
However, studies of descriptive correlates of other directed aggression in
psychiatrically referred children and adolescents have not always
demonstrated consistent findings. Gabel and Shindledecker (1991) did not
find child abuse to be significantly associated with aggression in their
sample. Psychotic adolescents were not found to be more externally
aggressive than nonpsychotic adolescents in two studies of inpatient youth
(Delga et al., 1989; Fritsch et al., 1992). Delga et al. (1989) found no
gender differences for assault on others. Differences in findings may
reflect differences in methodology, including definitions of aggression.
Studies have mixed overt and covert, other-directed, and self-directed
aggression in their samples. It is clear that more research with homogeneous
definitions is needed to clarify the cross-sectional correlates of
aggression toward others in clinically referred children and adolescents.
In addition, the relationship between other-directed aggression and
self-directed aggression (SIB, suicidal behavior) is currently unclear for
psychiatrically referred youth. Several studies have been able to identify a
pure self-directed aggression group in populations of referred aggressive
children (Fritsch et al., 1992; Pfeffer et al., 1983b). Other research has
been unable to find a group of only self-directed aggressive children and
has concluded that other-directed aggression and self-directed aggression
are frequently associated with similar correlates (Vivona et al., 1995). It
is not yet clear whether self-directed aggression (SIB and suicidal
behavior) constitutes a distinct subtype of aggression and should be studied
separately from externally directed aggression (physical assault, verbal
threats, explosive property destruction) subcategories within OCA.
The sample consisted of 51 patients admitted to the Devereux Foundation,
Massachusetts, a residential treatment program for seriously emotionally
disturbed children and adolescents. These 51 children and adolescents were a
subset who possessed complete data of 83 consecutive admissions over a
17-month period. These 51 patients did not significantly differ from the 32
patients excluded because of incomplete data on age, gender, Caucasian
ethnicity, Full Scale IQ, Verbal IQ, Performance IQ, family composition,
protective services involvement with child at time of admission, or where
admitted from (ambulatory or institutional referral). This population of 83
children has been previously studied and described (Connor et al., 1997).
They are generally very impaired across multiple domains of functioning.
The study population was 13.3 [+ or -] 2 years old (range 6 to 18 years).
Eighty-eight percent were male; 52.9% were Caucasian. Mean Full Scale IQ was
78.8 [+ or -] 16 (range 40 to 119), mean Verbal IQ was 78.4 [+ or -] 14
(range 45 to 105), and mean Performance IQ was 82.1 [+ or -] 14 (range 46 to
112). State protective services were present for 76.5% of subjects at the
time of admission to residential treatment. In 49% of cases children had at
least one biological parent who remained involved in some parenting
capacity. Children were admitted from ambulatory settings (home or foster
home) (21.5%), institutional settings (inpatient psychiatric hospitalization
or residential treatment) (70.6%), and the juvenile justice system (7.9%).
This study was approved by Devereux's Client Care Monitoring Committee.
Informed consent from legal guardians and assent of children older than 7
years was obtained at the time of admission for all treatments.
A high prevalence of OCA was found in this sample of children and
adolescents admitted to residential treatment. Verbal aggression was present
for 97.1% of subjects, physical assault for 90.2%, property destruction for
60.8% and SIB for 49.0% over an average length of stay of 1,060 [+ or -] 377
days (range: 261 to 1,846 days). A pure self-injury group could not be
identified in this sample. Of the 25 cases with at least one SIB incident,
all displayed externally directed aggression as well.
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