Tuesday, March 01, 2005

Aggression and antisocial behavior in youth

Daniel F. Connor, M.D

Aggression and antisocial behavior in children and adolescents are central issues in our time. In the media everyday are stories of public school shootings, young children killing other young children, rising rates of youth crime and delinquency in the community and the growing trend of adjudicating youth charged with violent crimes as adults. This raises questions about the relationship between unrecognized and untreated mental illness and violence in youth.Because school personnel and mental health clinicians may be faced with the task of evaluating and intervening with a potentially aggressive child, the purpose of this article is to highlight some important points about aggression and antisocial behaviors in children and adolescents.Aggression and antisocial behaviors in youngsters are complex, heterogeneous conditions with multiple diverse psychosocial and neurobiological etiologies and consequences extending across the individual, family, and community environments.

Because of this complexity, established antisocial behavior is not easily altered. However, recent research has documented some important findings that may help to guide efforts to diminish serious antisocial behavior in youths.At-risk childrenWhile most aggressive children do not grow up to be aggressive adults, it is now clear that a small percentage of aggressive children are at high risk to continue their aggressive behaviors into adolescence and adulthood. These children are called early starters. They demonstrate an onset of diverse aggressive behaviors (stealing, threats, physical fighting, lying, cheating, vandalism, fire setting, rule defiance) across multiple settings (home, school, community) beginning before age 10 years.

In early starter children, these behaviors are persistent across time and development and do not appear to be transient problems. These children are at risk to follow a trajectory of ever increasing severity and diversity of antisocial behaviors as they develop into adolescents and adults.It is important to recognize that interpersonal conflicts and aggressive behavior are normative for infants, preschoolers, and children. Healthy aspects of aggression facilitate competence in social assertiveness, competition in games, and success in meeting daily life challenges. Observational studies indicate that approximately 50 percent of the social interchanges between children 12 to 18 months of age in a nursery school setting could be viewed as disruptive or conflictual, but by age 2 and 1/2 years the proportion of conflicted social interchanges drops to 20 percent. As children enter school physical aggression decreases and verbal forms of aggression increase. So, if inter-personal conflict is normal for young children how can we recognize the at-risk infant, preschooler, or child?

The preschool child who largely directs aggression towards adults in out-of-home environments such as nursery school does not fit what is presently known about the normative aspects of aggression.
The school-age child, who frequently and repetitively initiates physical attacks on others, rather than beginning to modulate overt aggression with words, may also be deviating from a normative developmental trajectory.
The school-aged child who consistently uses physical aggression to obtain possessions from others may also be at-risk.

The persistently hyperactive/impulsive child is at risk for antisocial behaviors since there is a significant overlap between hyperactivity/ impulsivity and aggression/conduct problems in children, especially in unstructured, unsupervised environments.

At-risk parentingOver the past 50 years research in behavioral science has documented qualities of parenting and parent-child interactions that contribute to risk for continued aggression and antisocial behaviors in offspring. Early recognition and intervention to establish more effective parenting practices is important in interrupting the aggressive trajectory of the at-risk child. These include recognizing:

Coercive parent-child interaction patterns: These occur when a parent sets a limit or asks the child to do something and the child resists or is oppositional and defiant. As the parent persists the child escalates eventually causing the parent to back down. The child then learns that escalating behavior allows them to escape aversive requests or demands (negative reinforcement). At the next parent-child encounter the child will once again use this strategy, and if successful, will be further reinforced. Eventually the child may generalize this oppositional strategy outside of the home into school and the community.

Harsh and inconsistent parental discipline practices: Closely coupled with the above parent-child interaction pattern is the parental use of harsh and inconsistent discipline practices. Occasionally the parent will retaliate on the oppositional child. The child then becomes transiently compliant in the face of harsh punishment. The parent is negatively reinforced for aggressive behavior. The parent-child dyad becomes locked in a spiral of ever-escalating conflicted behavior. The harshness and inconsistency of the parental response further serves to reinforce maladaptive parent-child interactions that contribute to child aggressive behavior by modeling aggression as a means of solving interpersonal conflict.

Failure to monitor and supervise children after school: Children whose parents do not know where they are after school and children whose parents are unaware of their friends and peer group, are at risk for engaging in more antisocial behaviors than closely monitored children.

Early interventionIt is becoming clear that effect sizes for interventions diminish as the at-risk child grows older. Family, educational and community treatments appear to be stronger for younger aggressive children and their families, rather than older aggressive children and teenagers. To the extent that an early starter antisocial trajectory can be modified, the earlier the intervention, the better. Transition points Critical periods of development for diminishing aggressive behavior may be concentrated in the transitions from preschool to elementary school and during the transitions from late adolescence to the young adult years. At each of these points in development, research shows a proportion of antisocial and aggressive individuals desisting from further maladaptive behaviors.Although the effect sizes of interventions diminishes as the antisocial child grows older, these "windows of opportunity" may represent times when concentrated treatment efforts might further interrupt a lifetime anti-social trajectory.Verbal competencyGroups of persistently aggressive and antisocial children and adolescents consistently demonstrate diminished verbal competency relative to non-aggressive control samples. This diminished competency is reflected in overall poorer reading skills, increased incidence of learning disabilities, and poor expressive and receptive language skills in aggressive youngsters.If a child is unable to articulate their moods, feelings, and frustrations verbally, they may be more at-risk to act them out behaviorally. Efforts to decrease antisocial and aggressive behaviors in youngsters need to emphasize early verbal and language skill acquisition as an anti-aggression primary prevention strategy.Community interventionsAlthough the importance of safe neighborhoods, antipoverty efforts and educational access in the prevention of youth violence and antisocial behaviors cannot be under stressed, two other community interventions need emphasis.

The role of violent media: American children are awash in violent images from television, magazines, movies, music and the Internet. While exposure to violent media does not cause violence or aggression de novo, it contributes through three mechanisms. Constant exposure to media violence may engender desensitization and a numbing of emotional response to real violence. Being submerged in a sea of media violence may contribute to a feeling that all people are more violent than they actually are and that the world is a very threatening place.

Finally, violent media glamorize conflict resolution strategies emphasizing aggression - strategies that are easily adopted by impressionable youngsters. Communities might facilitate regulation of highly violent media as a primary youth violence prevention strategy.
The role of handguns: At last estimate 60 million American homes contained at least one handgun. Having easy access to a gun at the point of interpersonal conflict increases risk for violent outcomes. Communities might facilitate handgun regulation as a primary youth violence prevention strategy.

Effectively intervening in the epidemic of youth antisocial behavior and aggression will require public health strategies coordinating evaluation and interventions across multiple educational, mental health, community, public policy, public safety and juvenile justice institutions.The individual professional can help by supporting early recognition of at-risk children and families and supporting effective psychoeducational and parenting interventions delivered early in the at-risk child's development.Dr. Connor is Associate Professor of Psychiatry, Director of Ambulatory Child and Adolescent Psychiatry, and Co-Director of Research in the Division of Child and Adolescent Psychiatry, University of Massachusetts Medical School, Worcester, MA. Connor DF: Aggression & Antisocial Behavior in Children and Adolescents: Research and Treatment. New York, NY: The Guilford Press, 2002, 480 pages. To order, call 1-800- 365-7006; or e-mail: info@guilford.com

The Brown University Child and Adolescent Behavior Letter
September 2002
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