Dr. Connor, you have spent many years working with and studying aggressive children. Why don’t you give us a little background on your interest in these kids?Dr. Connor: About 50 to 80 percent of all children and adolescents who are referred to child psychiatry clinics or inpatient sites have problems with disruptive behavior disorders, conduct disorder, oppositional behavior and aggression. When I was first running a child psychiatry clinic, I became interested in trying to make more sense of this because I was very dissatisfied with the way DSM handled the problem of externalizing behavior disorders.
And what did you learn?Dr. Connor: What I found were several things. One is that aggression per se is not associated with specific DSM diagnoses; instead, aggression is a good measure of overall symptom severity. Tom McLaughlin and I published a study of aggressiveness in children and we found that the highest aggression ratings actually occurred in kids with anxiety disorders. And aggression did not identify a specific diagnostic category such as bipolar disorder (Connor DF et al., Child Psychiatry and Human Development 2006;37:1–14). It appears that like pain in surgery or a fever in medicine, aggression in psychiatry is a marker of illness severity, not specificity
So if we have a patient come into the office with a complaint of aggression, what approach should we take?Dr. Connor: First, you should explore the history of the aggression. Chronic disruptive behavior with an onset before 10 years old is more difficult to treat than new onset or acute disruptive behavior. The earlier the disruptive behavior begins, the worse the prognosis.
What else do you look at?Dr. Connor: You have to assess the child’s contextual relationships—what are the antecedents and what are the consequences of aggressive behavior? It’s important to find out if child has learned to use aggression “contingently”—that is, to get out of something that he or she doesn’t want to do or to obtain something desired.
So you should be thinking about what purpose the aggression serves?Dr. Connor: Yes, and that leads to looking at parenting practices. Things like failure to monitor the child’s whereabouts and who he or she is hanging around with after school, and harsh or inconsistent discipline, meaning that the child’s antisocial aggressive behavior is ignored at some times and then is responded to harshly at others.
What does this evaluation teach you about a child’s aggressive behavior?Dr. Connor: There are two types of aggression: First, there is reactive aggression, which is highly emotional, defensive, and impulsive, and is generally a response to some sort of threat or frustration. Second, there is predatory or proactive aggression, which is generally planned and premeditated. We can help in many ways with reactive aggression, but we are less successful with proactive aggression. Fortunately, most kids fall into the first group.
What is the role of trauma in aggression?Dr. Connor: Physical abuse is highly associated with reactive forms of aggression. Sexual abuse appears to be more associated with internalizing symptoms such as anxiety and depression.
What’s the best treatment for aggression?Dr. Connor: Well, treatment rests on a careful evaluation, and I think this is where the way we pay for mental health care seriously impacts the clinician’s ability to do a thorough evaluation. These kids are time-consuming to treat with methods such as behavioral therapy, family therapy, etc., and those things have a lower reimbursement rate than prescribing meds. That said, there are some medications that are quite effective at treating aggressive behavior.
Such as?Dr. Connor: When aggression occurs in the context of ADHD, stimulants and adrenergic agents, such as atomoxetine and guanfacine appear to have a large anti-aggressive effect. This is true even for kids who have comorbid oppositional defiant disorder, in that the defiant behavior often responds to ADHD treatment.
And what about other types of aggression?Dr. Connor: For other kids, atypical antipsychotics and the first generation neuroleptics also have anti-aggression properties that seem independent of sedation. There is also some evidence from Steve Donovan at Columbia and Hans Steiner at Stanford that mood stabilizers such as Depakote are helpful for conduct disorder (Donovan SJ et al., Am J Psychiatry 2000;157:818–820; Steiner A et al., J ClinPsychiatry 2003:64:1183–1191). Interestingly, SSRIs have not been shown to be helpful for aggression in children, whereas they are effective for adults. But that may be a function of the fact that few studies have been done in children.
I assume you would use an SSRI for an anxiety disorder?Dr. Connor: Actually, I think first about skill-building treatments such as cognitive behavioral therapies and relaxation training. Furthermore, in my experience, when you have an anxious child you usually have an anxious parent, and I look carefully to see if the child is being reinforced for his or her anxiety by an anxious parent. So first I try cognitive behavioral therapy with a family component and then, if needed, I would add an SSRI targeting the anxiety. But you are treating anxiety here; you are not treating aggression.
Do you think that antipsychotics are overused in children?Dr. Connor: Yes. There are rising rates of antipsychotic use in the pediatric population over the past decade, including in very young children—three, four and five-year-old kids. And we know that the younger the children, the more dependent they are on the family environment for emotional homeostasis, so they require an extensive family and parenting evaluation before being medicated. But the reimbursement rates are higher for prescribing medications, and so this tends to be what happens.