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JOURNAL OF ADOLESCENT HEALTH 2004;35:260–277

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EVIEW ARTICLE

ecent Research Findings on Aggressive and Violentehavior in Youth: Implications for Clinicalssessment and Intervention

ANCY RAPPAPORT, M.D. AND CHRISTOPHER THOMAS, M.D.

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Abstract: Assessing children and adolescents for po-ential violent behavior requires an organized approachhat draws on clinical knowledge, a thorough diagnosticnterview, and familiarity with relevant risk and protec-ive factors. This article reviews empirical evidence onisk factors, the impact of peers, developmental path-ays, physiological markers, subtyping of aggression,

nd differences in patterns of risk behaviors betweenexes. We explore these determinants of violence inhildren and adolescents with attention to the underly-ng motivations and etiology of violence to delineate theomplexity, unanswered questions, and clinical rele-ance of the current research. Interventions, includingognitive behavioral therapy, psychopharmacologicalreatment, and psychosocial treatment, are reviewed withcute recognition of the need to use multiple modalitiesith, and to expand research to define optimal treatment

or, potentially violent children and adolescents. Thenformation considered for this review focuses on vio-ence as defined as physical aggression toward otherndividuals. Other studies are included with wider def-nitions of violence because of their relevance to assess-ng the potential for violent behavior. © Society fordolescent Medicine, 2004

EY WORDS:hildrendolescentsiolenceender differences

From the Harvard Medical School, Cambridge, Massachusetts (N.R.)nd University of Texas Medical Branch, Houston, Texas (C.T.).

Address correspondence to: Nancy Rappaport, M.D.,Cambridgeospital, 1493 Cambridge St., Macht Building, Cambridge, MA 02139.-mail: [email protected]

cManuscript accepted October 6, 2003.

054-139X/04/$–see front matteroi:10.1016/j.jadohealth.2003.10.009

onduct disorderubtypes of aggressionisk factors

lthough arrest rates for serious violent crimes anduvenile homicides have fallen from an all-time highn the mid-1990s, many adolescents and childrenemain involved in aggressive delinquent and vio-ent behaviors such as physical fighting, bullying,sing weapons, verbal threats of harm to others, andhronic impulsive aggression [1]. In 1999, juvenilesccounted for 16% of all violent crime arrests, andomicides committed by youth under 18 accountedor 10.1% of all homicides [1,2]. Although this homi-ide rate is lower than in previous years, the overallrevalence of other violent behaviors among youthemains high. These figures are the culmination of aragic trajectory of violence that has an alarmingmpact on the physical safety and emotional well-eing of our nation’s youth.

Youth violence often emanates from multiple riskactors: biologic vulnerability [3–5]; inconsistent,verly permissive, or harsh discipline [6,7]; commu-ity deprivation [8–10]; easy access to guns [11]; andxposure to violence [12,13]. Violent behavior rarelyppears spontaneously; it typically has a long devel-pmental pathway [14–16]. In certain instances, ag-ression may be a response to stress that occursuring a vulnerable period, and an individual mayot respond in the same volatile way at a different

ime in their life [17]. However, there is usually atrong continuity in violence between childhood,dolescence, and adult life. Aggressive behavior,
onduct problems, and antisocial behaviors generate
© Society for Adolescent Medicine, 2004Published by Elsevier Inc., 360 Park Avenue South, New York, NY 10010

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October 2004 AGGRESSION AND VIOLENCE IN YOUTH 261

ne-third to one-half of all child and adolescentsychiatric clinic referrals, and clinicians are fre-uently asked to provide evaluation and treatmentecommendations for these patients [18]. In the con-ext of disruptive disorders, extensive reviews exam-ne the primary risk factors and developmental path-

ays while also recognizing that there is still a levelf complexity that warrants further research to en-ance our understanding of aggression and to in-orm effective interventions [19].

Even though many clinicians specializing in ado-escent medicine may not have the expertise toonduct this type of psychiatric diagnostic assess-ent and to choose treatment modalities, it is helpful

o be exposed to the relevant research about aggres-ive youth and to appreciate the practical limitationsf our knowledge and possible areas of intervention.he role of the evaluating mental health clinician isritical in providing a diagnostic assessment that isased on a sophisticated clinical formulation. The

nitial steps are to carefully identify and understandhe cumulative effects of risk and protective factorsn the patient; assess acute safety considerations;valuate the onset, severity, and course of the violentehavior; identify comorbidity; and determine theotivation for change and self-reflection. Currently,

o validated screening instruments or protocols existor the prediction of juvenile aggression. Althougheveral assessment instruments appear promising,o single screening instrument has been establishedr generally accepted for predicting youth aggres-ion.

The success in predicting treatment outcomes andiolence for these high-risk patients is variable, and it

s useful for clinicians to continue to assess theseatients and to look for opportunities for preventive

nterventions. Offering the perspective of a commu-ity practitioner rather than that of an individualractitioner is crucial because these aggressive chil-ren usually need coordinated efforts drawing onesources from their family, medical, and mentalealth care providers, educators and other commu-ity members. These assessments may occur in emer-ency rooms, court clinics, schools, outpatient psy-hiatric clinics, or inpatient psychiatric units. In thiseview, we will present the salient information rele-ant to clinicians who may be asked to identifynd/or assess violent children and adolescents, ando determine the capacity for intervention. Becausehere is extensive recent research on youth violence,articular attention is therefore focused on topics

hat have special relevance to clinicians. Most impor-
ant are studies that provide information critical to p
he evaluation of youth violence. These researchindings are grouped into the areas of individualactors (gender, physiological markers, and socialognitive risk factors), social and environmental fac-ors (family, peer and environmental factors), fol-owed by sections addressing conceptual modelscumulative risk factors and aggression subtypes),onsiderations in risk assessment, and prevention/ntervention approaches (cognitive behavioral ther-py, psychopharmacological treatment and psycho-ocial treatment). Special emphasis is devoted toeports from areas that have not received consider-tion in previous general reviews but expand ourlinical awareness and provide a better frameworkor understanding youth violence, such as aggressionn girls and physiological markers.

ethodology of Searchesearch literature on youth aggressive and violentehavior was reviewed after a systematic search ofsycInfo and Medline. Also, manual review of arti-les’ reference lists identified additional pertinenttudies. The review focuses on important findings inouth violence and topics that have not been covered

n previous general reviews, including gender differ-nces, conduct disorder, subtypes of aggression andisk factors, with emphasis on areas of current re-earch.

ndividual Factorsender

ost of the research on youth violence focuses onen and boys with relatively little attention given to

ggressive females, primarily because a much largerercentage of males, as compared with females,ommit violent acts [20]. Typically, gender differ-nces were difficult to discern, as many studiesparticularly those examining conduct disorder) in-luded only male participants [21]. In the past, tonderstand the characteristics, history, and symp-

oms of girls with illegal or aggressive behavior, theost frequently implemented design relied on un-

ontrolled follow-up and cross-sectional studies withredominantly white samples [22–24]. However, in

he last 10 years, researchers have generated morempirical studies of girls’ aggression in several dif-erent disciplines (developmental psychology, childsychiatry, and criminology), with more attention torospective longitudinal studies and more diverse
articipants [25–28]. However, there is still a long

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262 RAPPAPORT AND THOMAS JOURNAL OF ADOLESCENT HEALTH Vol. 35, No. 4

ay to go until the research on female youth violencend aggression provides the same depth of work asn boys, particularly with respect to longitudinaltudies.

Most epidemiological studies have identified con-uct disorder as one of the most severe mentalisorders in adolescent girls, with prevalence ratesarying from 4% to 9% [29,30]. Criminal statisticsnd diagnostic criteria of conduct disorder can beiewed as identifying adolescent females with theame underlying disruptive behaviors of concern.he Office of Juvenile Justice showed in nationaltatistics on adolescent female violent crime arrestsn increase of 23% as compared with an 11% increasen the arrests of male juveniles [31]. It is unclear ifhis marked increase in female arrests is owing toncreased detection of females by the juvenile justiceystem and previous reluctance to arrest girls. Theeverity of adolescent female crime has also in-reased [31].

Girls may have different ways than boys of ex-ressing aggression that are affected by biological,ispositional, and contextual factors. The challenge

s to unravel the interaction of causal factors, theeterogeneity of risk factors, and the identification ofifferent developmental trajectories to determinerecise mechanisms of variable outcomes of femaleggression. There is recognition that girls are oftenxposed to the same biological insults (e.g., prenatalaternal cigarette smoking) as boys, but that this

xposure has a minimal effect on girls’ relative riskRR) of conduct disorder [32]. In contrast, there is anssociation of prenatal smoking with psychiatricorbidity specific to antisocial behavior in males

32]. These outcome measures have some method-logical limitations owing to a reliance on cross-ectional studies and because there is difficulty mea-uring prenatal exposure with precision andeparating risk factors that may have confounded theesults. However, this study highlights the increasedulnerability of males to peri and postnatal stresses32]. It would be clinically useful to delineate whyemales are less vulnerable to prenatal nicotine ex-osure and subsequent associated severe antisocialehavior.

The majority of developmental studies do notifferentiate physical aggression and verbal aggres-ion [33], and the studies tend to examine the exter-alizing observable behaviors that are more consis-

ent with male aggression, such as openlyonfrontational verbal threats and physical assaults34]. Existing classification methods of girls with
onduct disorder may overlook behavior that may d
ubsequently evolve into serious psychopathologyut does not necessarily reflect overt patterns ofggression. In a longitudinal study of 2251 girlsntering kindergarten, who were examined over aeriod of 7 years with a 3-year follow-up, theSM-IV diagnostic criteria of conduct disorder failed

o identify the most impaired, persistently antisocialirls [29]. They suggested that the criteria for girlsight need to be different from those used for boys,hether in reducing the number or type of symp-

oms. Crick expanded the criteria of female aggres-ion from an emphasis on physical and overt aggres-ion to verbal, indirect, and relational aggression35]. Relational aggression refers to gaining controlhrough manipulative behavior that affects peer sta-us and that is recognized by girls as motivated byntent to harm and “meanness.” Later studies dem-nstrated that relational aggression in females pre-icts concurrent psychosocial adjustment problems

36].Separate criteria for identifying conduct disorder

n females and males have not been developed. Thisssue was considered during the development of theSM-IV but was not pursued because there was

nsufficient information available to support gender-pecific criteria for identifying conduct disorder [37].y developing accurate and useful criteria that ex-mines a broad range of behavior for assessingemale aggression, it may be ascertained that there isn unrecognized continuity between persistent trou-ling behavior (not the same type of disruptiveehavior that is seen in males) that increases therobability of developing life-long impairment in

emales [26]. There may be gender-specific levels andypes of behavior that identify girls as disruptive thatre at low risk according to males’ standards butredict subsequent impairment in girls. This identi-

ication may be useful in developing reliable clinicalools to provide early detection and support to thoseoung girls who are at risk of developing late onsetf dysfunction in multiple areas. Several longitudinaltudies show that adolescent girls with conductisorder predictably suffered in multiple adult out-omes after adolescence. Their dysfunction unfoldedver time and included poor physical health [38],

ncreased mortality rates, increased criminality rates,igh rates of psychiatric comorbidity, and participa-

ion in violent relationships [24].Antisocial adolescent females are often more vul-

erable to family dysfunction and have a later onsetf aggressive behavior than males [39]. Some prelim-

nary evidence connects girls’ depression and family
iscord to later antisocial behavior [40]. Expanding

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he analysis of behavior linked to aggression iseflected in one of the first studies of an ethnicallyiverse group of adolescent female offenders thathowed a link between trauma, psychopathology,nd violence [41]. An examination of 96 incarcerateddolescent girls found that they were 50% moreikely to show symptoms of posttraumatic stressisorder (PTSD) than male juvenile delinquents [41].he difficulty with the study was that the sampleas small and the researchers did not consider other

omorbid pathology. Causality was not establishedecause cross-sectional data were collected. The rec-gnition of PTSD and subsequent aggression in

ncarcerated females may lead to focusing on thisften unidentified association between PTSD andggression. Such research also highlights the impor-ance of screening and early intensive intervention

ith traumatized children.Any antisocial behavior (including violence) in

irls should alert clinicians to the possibility ofomorbid psychiatric disorders because girls withntisocial behaviors are at much greater risk thanoys for suffering from a wide range of psychiatric

llnesses [42]. In a recent study examining violencexposure, violent behaviors, psychological trauma,nd suicide risk in a community sample of danger-usly violent adolescents, one in five females was athigh risk for suicide compared with significantly

ower percentages in all other comparison groups43]. The distinctive vulnerabilities of violent femalesnd their pattern of clinical presentation remain to beelineated.

Clinicians must be vigilant about screening forggressive behavior in females, particularly betweenhe female and intimate partners and/or family

embers. Practitioners must also consider that anssaultive adolescent girl may have had some under-ying trauma and may need further counseling. If thelinician sees an aggressive adolescent female for aecent injury or routine examination, it is particularlyelevant to screen for suicide risk, as they are at areater risk [43,44].

hysiological Markers

ecently, researchers have attempted to identify bi-logical markers that may be relevant to the furtherubtyping of aggression. Environmental stressorsan affect hormone production, and experiences canffect physiological states that can, in turn, affectehavior. Aggressive behavior in both children anddults is associated with abnormalities in peripheral
esponses to stress. m
One peripheral measure, salivary cortisol concen-ration, may reflect alterations in the hypothalamic-ituitary-adrenal axis. In a longitudinal study of 38linic-referred school-age boys, low salivary cortisolevels were associated with persistent and earlynset of aggression [45]. Boys with low cortisoloncentrations (measured at Year Two and Four inhe study) had three times the number of aggressiveymptoms than did boys with higher cortisol levels.ontinually restricted (low) cortisol levels may beore relevant to predicting continuous aggression

han an isolated low concentration of cortisol at aingle point in time. This finding was correlated tohe subtype of aggressive children [45].

Boys who bully often have low anxiety and showow cortisol levels [45]. In contrast, affective aggres-ive boys with high arousal show high cortisol levels.his study was limited by a relatively small sampleonsisting only of males and by the failure to controlor time of the day in measuring cortisol, becausealivary cortisol levels show diurnal/circadian vari-bility [45]. The mechanism linking persistent ag-ression and low cortisol concentration is not yetlucidated. Yehuda et al examined the alteration inortisol levels (lowered) in patients with posttrau-atic stress disorder (PTSD) [46]. There may be some

verlap with aggressive patients that have loweredortisol levels. The brain plasticity of the developinghild suggests that prenatal and early developmentaltress (maternal prenatal smoking, abuse, and ne-lect) can change the hypothalamic-pituitary-adrenalxis permanently [47]. Another hypothesis postu-ates that attachment behaviors regulate arousal ac-ivity in the hypothalamic-pituitary-adrenal axis.isorganized attachment relationship in infants is

orrelated with elevated cortisol levels [48]. The laterorrelates of disorganized attachment strategies cananifest in preschool years as disturbed and aggres-

ive interactions with parents and teachers [49,50].owever, clinically, these physiological markers

annot be used as predictors of violence, as manyhildren with disorganized attachment histories andlevated salivary cortisol levels do not become ag-ressive. Some studies have shown that it is noterely the basal level of cortisol that is key to

nderstanding disruptive and aggressive behaviorut rather the hypothalamic axis response to stress-ul stimuli [51]. Consequently, further studies areeeded to fully understand these interactions.

Researchers have postulated that the inhibitoryeurotransmitter serotonin (precursor 5�HT) mayodulate aggressive behavior in youths. Several
ethods of measuring indirect serotonin activity in

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he brain are employed, as serotonin cannot beirectly, economically, or easily quantified: metabo-

ites in the cerebrospinal fluid and platelet receptorsndirectly demonstrate the neuronal functioning aso measurements of whole blood serum [27]. Theypothesized relationship between lowered CSF se-otonin precursors and higher levels of aggression isupported by two longitudinal studies; however,here is not a simple inverse relationship [52,53].hallenge studies use drugs such as dl-fenfluramines a way to indirectly assess the CNS serotoninevels. These challenge studies of prepubertal boysuggest that there may be developmental changes inerotonin function. Prepubertal aggressive boys ini-ially may have increased serotonin functioning asompared with nonaggressive boys [54]. This en-anced serotonin may decrease with the onset ofdolescence [55]. If this hypothesis is substantiated inuture studies, it could have direct clinical implica-ions in terms of avoiding selective serotonin re-ptake inhibitors in aggressive prepubertal boys

55]. It is a more complex picture with youths,ossibly because developmental fluctuations witherotonin confound the results. Further researcheeds to delineate the relationship of the develop-ent of neurobiological systems and specific vulner-

bilities in response to stressful environmentalvents [54].

Gender differences in the rates of aggressive be-aviors have naturally focused on the potential rolef androgens, especially testosterone, in the develop-ent of violence. Numerous studies have found a

orrelation between higher levels of testosterone andhysical aggression in boys [56–58]. Most of thetudies describing this relationship are with boysfter the onset of puberty, suggesting that the acti-ating effect depends on physical maturation [59–2]. There is also some evidence to suggest thatestosterone is specifically related to provoked ag-ression, but not unprovoked aggression, in adoles-ent and young males [58,59].

There are no definitive mechanisms delineated tonderstand the hypothesized association betweenggression in youth and fluctuations in testosterone,ortisol, or neurotransmitters. This is the new fron-ier as researchers attempt to further elucidate howeurobiology and hormones play out differently inggressive versus nonaggressive individuals whiletill acknowledging the impact of environmentaltressful events. Whereas selective serotonin re-ptake inhibitors are used in the adult population toampen aggression by increasing serotonin [63],
reliminary findings in prepubertal boys suggest a
hat treatment for adults cannot be indiscriminatelyransferred to youth [54].

ocial Cognitive Risk Factors

ocial cognitive research has identified differences inhe way that aggressive children process information64–66]. Lochman et al and Dodge examined socialognitive variables in aggressive and nonaggressiveoys at preadolescent and early adolescent develop-ental points [66,67]. They found that aggressive

hildren often misread interpersonal cues and inter-ret ambiguous or prosocial communication as hos-

ile and react aggressively. The children also oftenave heightened sensitivity to rejection derived fromarly experiences of physical abuse or emotionaleglect that then triggers anxiety or angry states68,69]. This tendency to identify affect arousal asnger can also lead to overlooking verbal solutions inavor of frequent and intense aggressive behavior.

Trauma-related emotions can trigger severe ag-ression in response to minor or trivial disappoint-ents. Slaby and Guerra elaborated on the cognitive

rofile of these aggressive adolescents who believehat there are limited consequences for aggression,hat aggression has concrete benefits, and that it is aegitimate response [70]. These findings are exceed-ngly important for clinicians working with aggres-ive children and their parents. Understanding thempact of impaired social communication can assistamilies in understanding violent outbursts anderve as the basis for developing potential interven-ions. This insight can also assist clinicians in recog-izing how distorted social cognition in patients and

heir families impedes their efforts for intervention.

ocial and Environmental Factorsamily Factors

he family environment is the intimate systemherein development is shaped. There is ample

mpirical evidence (longitudinal designs, random-zed controlled clinical trials, and cross-sectionaltudies) demonstrating the pivotal role of consistentarental discipline in preventing early patterns ofggressive behavior [6,7,71,72].

Dishion et al and Patterson et al developed aodel of coercion that starts with family practices

eginning in early childhood [73,74]. In this typicalcenario, when an oppositional child is aggressive,he parents fail to intervene early and to set reason-
ble standards for behavior. Instead, parents may

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espond inconsistently by withdrawing, giving aeutral response, or overreacting with excessivelyarsh punishment or exaggerated negative affect. Aeciprocal escalation of behavior may ensue withncreasingly coercive parent-child interactions. Thehild learns that aggressive reactions to parentalequests often lead to parental abdication and with-rawal. Thus, the child uses aggressive behavior toffectively terminate parental aversive requests, andn turn, the aggressive behavior is reinforced (escapeonditioning). Often, the same parents may overlookr respond inappropriately to the prosocial behaviorheir children may occasionally demonstrate. Thensights on family interaction reinforce the impor-ance of clinician attention to parent-child interac-ions in dealing with aggressive behavior. Parentsre often frustrated in their attempts to manageggressive behavior in their offspring and may benaware of how their responses may unwittinglyustain or even exacerbate behavior. This explana-ion does not mean that responsibility for violent actsy youth should be incorrectly placed on the parents,ut rather points to the need for families to find moreffective means to resolve the issues that contributeo aggressive behavior. In terms of assisting parents,eady information about how parents can use appro-riate discipline methods, attend to positive rein-

orcement, and encourage conflict resolution is use-ul. Consistent parental discipline, increased positivearental involvement, and increased monitoring of

he child’s activities were accompanied by significanteductions in a child’s antisocial behavior.

eers and Gangs

s with the development of other social behaviors,eers have an impact on aggression and violence indolescence. Studies with different age groups indi-ate that the influence of deviant peer behavior onhe development of aggression is most pronounceduring adolescence. Associating with delinquenteers was predictive of self-reported adolescent vio-

ence in several studies [75,76]. In addition, associat-ng with peers who disapprove of antisocial behaviorppears to reduce the likelihood of later violent acts76]. Unfortunately, in mixed groups of children,onaggressive children are more likely to becomeggressive than are aggressive children to becomeonaggressive [77]. Despite the contribution of devi-nt peers to the onset of adolescent aggression, theechanism of the causal influence of peer networks

s not delineated. S

Gangs may be a special case in peer relationshipsnd violence. Numerous studies report an associa-ion between gang involvement and increased vio-ence and delinquency [78–82]. The result of Thorn-erry’s analysis of gang members supports aacilitation model where the norms and group pro-esses of the gang exacerbate the behavior patterns ofhe individual gang members [83]. Interestingly, be-ore and after gang membership, these individualso not have significantly different risk factors orrofiles than nongang members. Also, gang mem-ers are disproportionately responsible for delin-uent crime, particularly serious and violent offenses78,84].

The Seattle Social Development Project also foundhat the influence of gangs was greater than justssociating with deviant peers [79]. Parents can mod-fy the effect of deviant peers, with a positive parent-hild relationship providing protection for adoles-ents [85,86]. Another important peer influence onhe development of aggression may be social ostra-ism, as seen in recent school shootings. In earlyhildhood, both peer group rejection and victimiza-ion are associated with increased risk for aggressiveehavior [87,88]. It is not clear whether this rejectionnd victimization are prompted by early aggressiveehaviors or by some other individual risk factor,uch as impulsivity. Certainly, social ostracism re-ults in youth having fewer opportunities to learnnd practice socially acceptable behaviors throughositive peer relationships. To curtail bullying byggressive children, Olweus designed systemic inter-entions in schools to increase monitoring and estab-

ish consequences for bullying [89]. Twemlow et alxamined how coercive power dynamics in schoolre critical to understanding how bullying can beustained in school settings [90]. By analyzing thechool climate, the power dynamic can be rebalancedo as to decrease the potential for violence [90].

hereas the negative effect of antisocial peers is aisk factor for aggressive behavior in youth, clini-ians should recognize the heightened impact ofangs and their recent spread throughout Americanommunities. It is important to learn not only abouthe patient’s peer group, but also if there is gangresence and involvement.

angs and Females

he finding that male gang involvement is associatedith a disproportionate amount of serious and vio-

ent crime holds true with girl gangs as well [84].
urveys have demonstrated that female gang mem-

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ers are more likely to be violent than non-gang-nvolved boys [91]. Although female gangs representsmall proportion of gang members, the numbers on

emales in gangs vary widely depending on whetherata are drawn from official law enforcementources or self-report surveys. The law enforcementata may underestimate the presence of girls becausef the law enforcement’s limited capacity to getccurate internal information from the gangs andecause of the extensive confusion around how toefine a gang [92]. National surveys of law enforce-ent agencies over two decades, covering 61 police

epartments, show a total of 992 female gang mem-ers comprising approximately 4% of the gang pop-lation [91]. In a multisite, multistate cross-sectionalurvey of a public school sample of eighth gradetudents (not a random sample), 237 girls out of 623ang members in an ethnically diverse group of 6000tudents identified themselves as gang members38%) [93].

The re-examination of the role of female gangembers has redefined the earlier bias by male

esearchers who relied on interviews with male gangembers [91,92]. Female gang members were ini-

ially seen as playing an auxiliary role in the gangnd primarily acting as weapon bearers, sexuallyxploited members, or girlfriends [92,94]. The trajec-ory of female gang involvement may be differentnd more complex than originally posited. Ethno-raphic fieldwork has highlighted that the adoles-ent girls’ participation in gangs may reflect frustra-ion about a harsh, constricted future [84,95].emales were more likely to look to the gang as aefuge than males and they often came from moreroubled families than the male gang members [84].

nvironmental and Situational Factors

tudies of communities and individuals confirm theopular impression that youth violence is moreommon in urban and impoverished neighborhoods96,97]. Certainly the impact of poverty on the familyystem contributes to the risk for violence and ag-ression, but the analysis of neighborhood character-

stics offers a more complex understanding. Collec-ive efficacy (assessed by cross-sectional surveys of782 Chicago adult residents) shows that activengagement by adults to supervise and maintainrder, neighborhood residential stability, and con-entrated affluence decreases the likelihood of vio-ence in a community [8,9]. Additionally, adultsharing relevant information and providing supervi-
ion for informal social control, known as intergen- A
rational support, were more often identified in closeroximity to other stable neighborhoods [10]. An-ther factor that adds to the vulnerability of theeighborhood occurs when youth are exposed toiolence, as this exposure increases the risk forggressive behavior in youth [12].

Access to a potentially lethal weapon, usually airearm, increases the likelihood that a lethal event

ill result from an aggressive or violent altercation98]. The relatively easy access to firearms for youthncreases the risk of youth violence [11]. Weapon-arrying for some adolescents is relatively common,s identified in a 2001 Center for Disease Control andrevention study, Youth Risk Behavior Surveillanceystem [99]. In that national study of high schooltudents, 17.4% of adolescent boys carried a weapona knife, gun, or club) at some point during the

onth before the survey [99]. The rate was higher inome areas (e.g. one survey that was conducted innner-city middle schools found that 25% of maletudents and 11% of female students reported carry-ng a gun with gun-carrying strongly linked toggressive delinquency rather than to self-protec-ion) [100]. Boys most likely to carry handguns werehose with the most aggressive behaviors (i.e., initi-ting fights), who believed that shooting someone is

ustifiable under certain circumstances and who per-eived their peers as accepting violence [101].

Pittel used clinical evaluations to describe some ofhe beliefs of students carrying weapons and catego-ized them as “deniers,” “innocents,” “fearfuls,” anddefenders” [102,103]. For example, deniers claimgnorance of how the weapon came into their pos-ession. They insist that they did not knowinglyarry the weapon into school and claim an unknownulprit planted it in their book bag or locker. Inno-ents admit to possessing a weapon but claim theyere holding it for someone else or found it. It is

mportant to further elucidate the reasons that ado-escents carry weapons, as it will inform clinicalnterventions.

A moderate relationship exists among illicit drugse, alcohol, and violence [104]. Alcohol can stirggression by reducing threat-related inhibition andncreasing arousability. Alcohol also decreases high-r-order cognitive functioning by altering the adoles-ent’s ability to communicate and judge the degree ofhreat in a social situation [104]. A study on youthiolence in schools demonstrated that 40% of thetudents who drank alcohol at school reported car-ying a weapon to school, as compared with 4% ofouth who did not drink alcohol at school [105].
ggression predicts substance use and substance use

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redicts aggression [106]. An extended longitudinaltudy found that aggressive behavior in childhood isredictive of substance use in adolescence [107]. Thisesearch also indicated that the relationship appearso be influenced by the presence of associated symp-oms of depression and impulsivity. Other factorshat may affect the association between aggressionnd substance use in youth include family history oflcoholism and drug abuse and involvement witheers or gangs using drugs [107]. Clinicians must beware of the vicious cycle that exists between sub-tance use and violence in youth, as with adults.

These findings on specific environmental factorsontributing to youth violence enable clinicians tossess the individual patient’s potential risk, as wells current behavior patterns, in greater detail. Suchnderstanding can provide the basis for a more

ailored and individualized approach to developingrevention and intervention plans. Public healthfforts can also be directed to address these definedisks within the broader community to reduce andopefully prevent youth violence.

onceptual Modelsumulative Risk Factors

umerous factors contribute to the relative risk forhe development of violence and no single factor isssociated with all aggression or provides absoluterediction. Studies utilizing multiple factors providetronger prediction of violence and demonstrate thenteraction and increased cumulative risk of thesenfluences [108]. Evidence indicates that the impactf risk factors depends upon their presence duringpecific stages of development [96].

Specific models describing distinct pathways inhe development and progression of aggressive be-avior that incorporate multiple risk factors haveeen proposed based on longitudinal research14,15]. As part of an overall model of the develop-

ent of antisocial behaviors, Loeber et al describe apecific course of development of aggressive andiolent acts. Minor fights and bullying characterizehe early stage, progressing to the later stages of

ore serious assaults, weapon use, rape, and rob-ery [15]. Although many children will exhibit entry

evel behaviors, fewer progress to each successivetage of antisocial acts. The further a youthrogresses in development of aggressive behaviors,

he more likely that other antisocial behaviors willlso appear. Therefore, youth with the most severeehaviors will often exhibit the widest variety of
ntisocial acts [16]. i
The central design of effective preventive efforts iswofold: (a) the examination of risk and protectiveactors at critical developmental periods, and (b) thenderstanding of the mechanisms through which

hese risk factors impair youth behavior. In theontext of assessing violent/aggressive children, therincipal questions are whether children are “hard-ired” and genetically primed to be aggressive,hether the environment is shaping the vulnerable

hild, or both. Raine’s research showed substantialmpirical evidence to support the interaction be-ween biological and environmental variables to spe-ifically explain violent behavior [3,4]. Raine drewomparisons from a large birth cohort (4269 malehildren in Denmark) and classified the childrenccording to two variables. If children had birthomplications or neurological impairment, they hadbout the same chance of becoming criminally vio-ent 18 years later as those children with no riskactors. The group of children with both early child-ood rejection and birth complications (4.5% of pop-lation) accounted for 18% of all violent crimesommitted by the collective sample of 4269 subjects.aine’s study defines early childhood rejection asaternal rejection of the infant (unwanted preg-

ancy and attempt to abort the fetus) and disruptionf the mother-infant bond (public institutional caref the infant). Significantly, the interaction effect wasound to be specific to violent offending and did noteneralize to nonviolent crimes or recidivism, per se.

different example of the critical interaction be-ween genetic risk and environmental influence wasrovided from the Dunedin longitudinal study [5].hysically abused boys with a variant of the mono-mine oxidase A (MAOA) gene were twice as likelyo develop aggressive behaviors and three times asikely to be convicted of a violent offense as an adultn comparison with abused boys without the MAOAariant. In the absence of a history of abuse, boysith the variant MAOA gene were at no greater risk

or later aggressive behaviors than other nonabusedoys.

This research provides specific information aboutome of the very early risk factors for violent behav-or and has major policy implications and clinicalelevance supporting intensive early intervention.ffective early interventions with nurse visitation in

he home environment for high-risk families (aver-ge of 30 visits spanning from prenatal to the child’snd birthday and focusing on maternal functioning)ave shown a significant reduction in adolescentntisocial behavior including arrests and convictions,
n comparison to a control group [109]. This type of

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ntervention can compensate for negative birth com-lications and promote positive parenting, therebyreventing the more serious forms of antisocial be-avior leading to arrests and convictions [109].

ggression Subtypes

rom a clinical perspective, research on subtypes ofggression may be helpful in understanding andreating aggression. Clinical observation, experimen-al paradigms in laboratories, and cluster/factor an-lytic studies show subtypes of aggression that mayave implications for the management and treatmentf aggressive patients [64,110,111]. These qualita-ively distinct forms of aggression in youth mayffect more tailored prevention and interventionpproaches to help predict treatment response.

One subtype of antisocial behavior is classifiedccording to time of onset: childhood-onset (prepu-ertal) or adolescent-onset [1,112–114]. The investi-ations primarily examined longitudinal groups ofales at different intervals utilizing direct observa-

ion, peer nomination (wherein peers identify theost aggressive peers), or teacher/parent ratings of

isruptive behavior. The results are usually pre-ented in terms of variance (percentage) or stabilityoefficient (correlating individuals from one time tonother time with certain behaviors present). Child-ood-onset antisocial behavior is rarer than adoles-ent-onset, typically 5–6% in the general populationf young males, but it is associated with moreeriously persistent violent behavior and worse out-omes [7]. Childhood-onset antisocial behavior isore likely associated with neuropsychological def-

cits (e.g., impaired language and intellectual func-ioning, attention deficit hyperactivity disorderADHD]) and inconsistent discipline by parents

hen the child is young [113].Investigations about aggression and conduct dis-

rder-like behavior demonstrate aggression as a rel-tively stable trait, often compared with intelligence17]. Olweus carefully reviewed 16 longitudinaltudies of subjects 2 to 18 years of age and showedigh stability coefficients (.81 in males). Subsequenttudies, with varying methods of assessment, alsoemonstrated high rates of stability of aggression inlinically referred samples and community samplesith a range from 32% to 81% of children continuedith their disruptive, aggressive behavior in adoles-

ence [17]. Although these studies emphasized hightability of aggression over time, it is critical tonhance the understanding about the significant
roportion of aggressive youth that do not maintain d
ggressive behavior over time, and to recognize thatsmall portion of adult violent offenders had short-

erm escalation of aggression at late onset [115]. It isritical that clinicians not interpret the relative stabil-ty of aggression as equivalent to aggression beingelatively intractable as a fixed and predeterminedehavior. Although there is a consistent finding inhe stability of aggression, this finding has not trans-ated into an understanding of patterns of aggressiveehavior within individuals. Nor has this categoriza-ion generated an understanding about the largendividual differences in the stability of aggression;

hich individuals may replace aggression with bet-er adaptive behavior, which individuals are atreater risk for persistent aggression, and whichouth are intermittently aggressive.

There are several limitations with childhood-onsetnd adolescent-onset subtyping. The problem withhe term “childhood-onset” is that it implies a fixed,etermined behavior, and does not seem to reflect

he ongoing exposure to risk factors and cumulativensults that shape and reinforce persistent aggres-ion. The variability in aggression or antisocial be-avior suggests that different ways of measuringggression may result in different indices of stabilityr discontinuity [116]. This type of measurementoes not capture the periodicity of aggression, andigh correlation does not demonstrate the change ineverity level of aggression with age. The inade-uacy of the categories was further illustrated whenolan and Thomas’ examined early- and late-onsetffenders and showed that both populations lookedurprisingly similar in their cumulative risk factors117]. In creating onset curves in a longitudinalample of 500 males from the Pittsburgh Youthroup Study, the age of onset of aggression gradu-

lly increased for each level of aggression and thereas no bimodal distribution that would support

arly versus late onset [116].The most empirical research analyzing distinct

atterns of aggressive antisocial and delinquent be-aviors relates to the trajectory of overt and covertehaviors [15,111,116]. These underlying dimensionsf aggression were developed almost exclusively onales, and non-Anglos were underrepresented.Despite the limitation, a temporal sequence of

scalating aggressive behaviors was proposed byxamining the Pittsburgh Youth Study of 1500 malesn three cohorts, ranging from ages 7 to 13 years athe first sampling time, with 6-month intervals be-ween assessments followed over 10 years [96]. Theohorts were chosen so as to cover the age-range of
evelopment under investigation (7 years to young

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dulthood), but the three cohorts do not representeparate pathways, just separate age groups. In theovert” pathway, males start by annoying and bul-ying others, followed by physical fighting, then byssaultive behavior and forced sex. The “covert”athway entails sneaky acts such as stealing and

ying, followed by property damage, vandalism, andire setting; culminating in fraud, burglary, and seri-us theft. The third proposed developmental path-ay involved those males with “authority conflict.”his research highlights how identifying commonlusters of aggression and sequences of behaviorsay improve early identification. When this theoret-

cal framework was applied to the National Youthata of a nationally representative sample, a largerroportion of serious and violent youth offenders

ollowed the overt developmental sequence than theeneral population [118]. The initial step of detailinghe developmental patterns of aggression over timend identifying the probable trajectory of serious andiolent offenders may allow a clinician to identifyatients at risk when they have a progression ofehavior and not by the presence of a specific behav-

or. Although the cumulative acts of aggression areetailed, the mechanism of how individuals beginith minor aggressions, progress to more severe

orms of violence, and how individuals with similarehavior will follow these predictable trajectories,emain to be elucidated. Winnicott’s essays on depri-ation and delinquency [119] or Aichhorn’s observa-ions on Wayward Youth still provide insight abouthe inner experience and psychic turmoil [120]. Theseuthors illuminate the meaning of the outward man-festations of behavior through insightful interviewsf individual patients, often overlooked in the pop-lation-based studies.

Another subtype of aggression emanates fromulticultural studies that assessed proactive aggres-

ion and reactive aggression [64,121]. Children initi-te proactive aggression to obtain specific rewardsnd establish social dominance. Proactive aggressionnvolves a minimal level of physiological arousal andelates to predatory aggression. Conversely, reactiveggression or affective aggression involves the de-ensive use of force against a perceived threat orrovocation. This defensive stance is triggered byctivation of the fight-or-flight response, with a highevel of physiologic arousal.

Different neuroanatomical chemical pathways un-erlie these forms of aggression. Affective/reactiveggression is characterized by impulsive/explosivenger and decreased levels of serotonin metabolites
n cerebrospinal fluid [122,123]. The autonomic acti- f
ation is fear-induced and leads to irritability andyperarousability [124]. In animal models, stimula-

ion of the ventromedial hypothalamus reproducessimulates) an affective type of aggression [125].redatory aggression involves minimal levels of au-

onomic activation and the information processing isifferent [124,126].

In a small clinical sample, Vitiello et al providedreliminary evidence of the clinical validity of sub-

ypes of aggression [127]. A scale was constructedith items that demonstrated good internal consis-

ency, reliability, and stability for identifying preda-ory and affective aspects of aggression. The instru-

ent was used to differentiate the types ofggression of 73 aggressive boys and girls aged 10hrough 18 years who were inpatients or enrolled in

partial hospitalization program. Most of the pa-ients had either predominantly affective or mixedredatory-affective scores. Vitiello’s findings suggest

hat those children who are purely proactive/pred-tory aggressors are not as frequently treated ordmitted to psychiatric hospitals. Patients with aigh affective aggression score had a higher inci-ence of psychotic symptoms and a higher likeli-ood of receiving lithium or neuroleptics.

Distinguishing whether adolescents’ aggression isrimarily reactive or proactive may suggest the

herapeutic direction of prevention and treatment, asell as prognosis [128]. If adolescents have reactive

ggression, they most likely have impaired socialognitive processing that misinterprets informationnd can be responsive to cognitive behavioral ther-py that provides an alternative approach to fearfultimuli than reacting aggressively [128–130]. Theseypes of patients may also benefit from medicationshat alter their hyperaroused state. Proactive aggres-ive youth are more likely to progress to externaliz-ng behaviors and subsequent criminal behavior than

ales assessed as having reactive aggression in ad-lescence and followed into adulthood [131]. Proac-ive boys have the expectation of positive outcomesrom aggressive behavior and thus the emphasis isn systematic interventions, increased monitoring,nd consistent consequences [90].

onsiderations in Risk Assessmentssessing children and adolescents for potential vi-lence requires an organized approach that draws onlinical knowledge, a thorough diagnostic interview,nd familiarity with relevant risk and protective
actors. Even with guidelines and checklists for iden-

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ifying risk factors, there is the possibility of errors:alse positives, false negatives, or both. False posi-ives are children and adolescents who may have riskactors but do not act violently, whereas false nega-ives are youth who are overlooked but who subse-uently act violently. In the absence of validated andeliable screening instruments or effective protocols,e propose a rational approach to the clinical inter-

iew, conducted by a mental health practitioner, thatill help in evaluating individual children or ado-

escents for potential violence [132]. Unfortunately,here are practical barriers regarding some adoles-ents that practitioners would ideally like to refer,uch as time lag, financial limitations, and family oratient distrust of practitioners. If the patient makesxplicit verbal threats or appears to have prominentymptoms suggestive of a comorbid state (exacerbat-ng his/her aggression), the treating clinician is ad-ised to make a referral.

The starting point of an evaluation is a generaliagnostic psychiatric interview to determine if theoung patient has a major mental illness, medicalisorder, or substance abuse that could be contribut-

ng to his or her aggressive behavior. A clinicianhould cover specific areas of information in anrganized fashion using a format similar to the one

llustrated in Table 1.The questioning can then move on to facts about

he immediate context of the aggression. It is impor-ant to obtain collateral information from parents,eachers, court records, or security guards, because

inimization of responsibility for actions and denialre to be expected. It is critical to carefully assess theatient’s attitudes toward carrying a weapon, access

o a weapon, and the risk of using a weapon in aight. It also is important to identify which adults

able 1. Assessment Guidelines for Clinicians

. What are the capabilities and skills of the parents?

. Is there any evidence of disorganized attachment to theprimary caregiver?

. Are there any other medical problems that suggestabnormalities with regulation of behavior or affect?

. Does the patient’s aggression fall into predatory aggression oraffective aggression?

. What is the range, severity and frequency of the aggressivebehavior?

. Is there a clear precipitant to the aggression, (predictabletriggers or situations)?

. Has the patient been traumatized, and could that lead tohypervigilance and hostile attributions?

. Is there a past history of violent episodes?

. What are the parents’ attitudes towards violence?

upport this young patient, including other clini- c

ians, and to get details of past treatment attempts.hese clinicians may note what has already beenone for the patient. When a clinician has enough

nformation to make a preliminary formulation, it isseful to explain to the patient the clinician’s currentnderstanding in addition to exploring the patient’s

nsight and motivation.Essential to the diagnostic interview is for the

linician to clarify whether the child or adolescentants to change and is willing to work to change

is/her assumptions, behavior patterns, denial ofesponsibility, and lack of trust. It is important todentify whether the child or adolescent who enjoysitting or hurting the victim has any empathy ornderstanding of the distress inflicted on anothererson.

If the patient expresses no motivation to changend does not have any desire to control aggression oromicidal ideation, the assessment has reached aritical juncture. At this point, it is the clinician’sesponsibility to provide feedback to the adults (e.g.,arents, court personnel, school staff) who have

nitiated the assessment. If the patient poses a veryigh violence risk, preventive action needs to be

nitiated [133].Coercive measures such as hospitalization and the

uestion of warning potential victims also need to beddressed. Although risk factors can indicate theotential for violence, it is still difficult to determinehy some children are on a chronic trajectory of

ggressive behavior and others manage to compen-ate despite exposure to many of the cumulative riskactors that lead to violence. Violence is rarely ran-om, yet the dynamic and situational variables canhange so quickly that an assessment is extremelyime-sensitive. Developing a rational strategy forvaluating adolescents and children at risk for vio-ence leads to the development of a treatment plan/rogram to contain and reduce the risk.

revention/Interventionsognitive-Behavioral Therapy

ognitive-behavioral therapy (CBT) seeks to changeocial cognitive deficits and distortions in aggressivehildren and adolescents. It focuses on defining theroblem, generating alternative solutions, anticipat-

ng consequences and introducing behavioral moni-oring, and prioritizing responses. Interventions usu-lly involve role-playing, practicing, homeworkssignments, and specific skill-building to change
ognitive distortions and responses. Cognitive-be-

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avioral problem-solving skills training (PSST), to-aling 20 sessions for preadolescent children evalu-ted in inpatient and outpatient support settings,upports the efficacy of the treatment compared withherapeutic changes of relationship therapy (RT) andttention placebo control conditions [129,130]. Theffects were demonstrated in a 1-year follow-upssessment in school and at home with changes inehavior at home and at school [134]. A more de-ailed review of CBT outcome research showed im-rovements in social competency and lessened ag-ressive behavior [130]. Nevertheless, furtheresearch is required to examine child and treatmentharacteristics that predict outcome and demonstratelinically meaningful improvement.

Although it is critical to continue the developmentnd evaluation of CBT, several limitations exist. First,here is the high attrition rate of severely stressedamilies that are hindered by the associated costs,cheduling difficulties, inconvenience, and reluc-ance to participate in a treatment intervention [135].his attrition, which can be as high as 50% to 75% ofhildren referred for treatment, can result in over-nflated support for using CBT to reduce problemehavior because the most difficult families don’tarticipate [136]. Although the attrition rate may note the exclusive problem to this modality, it points tohe need for further improvements in the implemen-ation of this approach.

Similarly, as in any therapy, children in CBTequire motivation to change; obtaining this motiva-ion can be challenging when aggressive behavior isgosyntonic. Garbarino, a psychologist who hasorked with extremely violent boys in juvenile de-

ention systems, cautions: “Some of the boys haveemorized the list of techniques and concepts but

an do no more than parrot what is in the textbook.thers say that they can not imagine being able to

pply these techniques in the situations that they facen the world” [137]. Another aspect to consider is theognitive development of the child, as it has beenemonstrated that preschool and early school-agehildren who are preoperational in their thinking doot respond to CBT as well as older children (ages1–15 years) who are more cognitively sophisticated134]. Another dilemma is that the most vulnerableggressive children often have language expressiveeficits, executive functioning difficulties, and im-ulse control problems. These limitations make itspecially difficult for children to put their emotionsnto words rather than actions, and they may haveifficulty understanding and internalizing the cogni-

ive scripts. t

Long-term CBT follow-up usually consists of a-year follow-up and frequently does not includeirect observation of the child’s behavior or assess-ent of exact skills that may diminish behavior, such

s aggression. Critical indices of treatment efficacytill need to be developed with the caveat that it maye more prudent to conceptualize aggression con-uct disorder as a “chronic disease model.” Optimiz-

ng treatment of aggression occurs if experiencedlinicians are used, which is not always true outsidef the research setting. Also, it is important to notehat incremental gains are achieved with longerreatment (up to 50 or 60 sessions) including periodicooster sessions [130].

sychopharmacological Interventions

edications should be considered for violent aggres-ive children only in the context of a careful diagnos-ic assessment that reviews multiple risk factors andenerates a complex formulation. Managing violenthildren and adolescents with solely pharmacologi-al methods is not recommended. Failure to considernd initiate an active comprehensive treatment planets up the treating clinician for dangerous liability.or a treatment plan to be effective in modifyingggression, it needs to be comprehensive and ad-ress family competency, relational capabilities, andducational progress.

It is common clinical practice to identify targetymptoms in an aggressive/violent child, such asrritability, impulsiveness, or affective liability. Onlyhen are medication trials conducted that try tomeliorate the symptoms. However, this approach isenuous because there is minimal research demon-trating its efficacy. Frequently, the research on ag-ression in adults is extrapolated to provide pharma-otherapy treatment suggestions for adolescents andhildren. The concern is that the findings on adultsre not applicable to adolescents and children. Therere no specific antiaggressive drugs currently avail-ble; rather there are some drugs, including atypicalntipsychotics, anticonvulsants, mood stabilizers,nxiolytics, beta-blockers, and alpha-agonists thatre used for their capacity to indirectly decreaseggression. There is a growing body of research onhe indications and efficacy of medication in thereatment of aggression in youth. Most of the reportsre of open trials rather than randomized controlledtudies and among all these investigations, the re-orted duration of treatment is seldom longer than 2onths [138]. One striking example of the impor-

ance of rigorous research is a report that found,

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mong youth admitted for inpatient treatment forevere aggression, in a double-blind study, almost0% responded to placebo [139]. Most of these ran-omized clinical studies use a relatively small sam-le of aggressive adolescents, do not identify comor-id disorders, and do not consider the impact ofther treatment modalities.

Clinicians need to identify the specific conditionshat may contribute to the patient’s aggressive be-avior and to use this information as a guide in theelection of potential medications. To determine ef-icacy, empirical trials of agents should be suffi-iently long. Clinicians should rely on studies thatse double-blind and placebo design in medication

rials. Additionally, aggressive and violent behaviorshould be assessed with standardized ratings [140].

further complication is that frequently, aggressiveatients may have simultaneous multiple medication

rials, making it difficult to determine the pharmaco-ynamic effect of the combination of medicationsnd the contribution of single agents. Connor andteingard [141], and more recently, Frazier [142],eviewed many of the controlled studies that look atach category of psychiatric conditions that may beesponsive to medication and may lead to reductionn aggressive behavior. The critical clinical recom-

endation is that if a comorbid condition exists, thenreating it with indicated medications might reducehe aggressive behavior as well.

A guiding principal in the evaluation of violentnd aggressive children is that they often have aide range of psychopathology, including ADHD,ood disorders [143], learning and communication

isorders, obsessive-compulsive disorder with asso-iated anxiety, PTSD, substance use and abuse, andven rare cases of psychotic disorder with paranoiddeation [142]. Puig-Antich studied a subset of de-ressed boys with aggressive behavior and showed

hat if their depression improved, the antisocialehaviors also improved, whether the improvementas spontaneous or the result of treatment for de-ression [144]. Aggression in ADHD children iseduced if young patients are treated with stimulants145]. Some clinicians suggest that clonidine (Catap-es) treatment can be useful for ADHD children whoisplay overaroused behavior, excessive hyperactiv-

ty, and extreme aggression [146]. Furthermore, lith-um and divalproex (Depakote) have been foundseful in double-blind, placebo-controlled studies forhildren and adolescents with disruptive disordersharacterized by explosive temper and mood labilityr bipolar disorder and comorbid conduct disorder
147–149]. Lastly, some clinicians suggest that a trial w
ith selective serotonin reuptake inhibitors maylleviate symptoms in irritable, depressed children150,151]. Nevertheless, the best guideline is to usehe least toxic and safest intervention first.

Patients with conduct disorder and associatedggressive behavior pose a particular challenge.hey are difficult to build an alliance with because

hey often oppose adult authority and have concur-ent substance use. Although there is no medicationith labeling approved by the U.S. Food and Drugdministration for conduct disorder, clinicians may

eel pressured to address the explosive impulsiveggression with medications. The comorbid condi-ion of conduct disorder is critical to determine. Oneecent study that carefully examined 50 youths (aged1 to 17 years) in a juvenile detention center foundhat 84% of the sample met criteria for conductisorder (CD) or oppositional defiant disorder

ODD) (60% CD, 24% ODD), 20% had major depres-ion, and 15% met criteria for ADHD [152]. Lithiumas had equivocal results in trials of patients withonduct disorder [153]. Findling et al demonstratedhat the use of risperidone was reported as superioro a placebo in short-term use with a small number ofutpatient children and adolescents with conductisorder, although it is difficult to determine thefficacy because of the small sample size [154]. Vanellinghen and De Troch found that risperdone wasignificantly more effective than placebo in reducingggression in a sample of children between the agesf 6 and 14 years at doses ranging from 0.03 to 0.06g/kg/day [155]. Risperidone’s use is best limited

o cases where the aggressive behavior severelyffects functioning. Further systematic prospectivereatment trials are needed to fully determine theffective medications for aggression in conduct dis-rder and comorbid conditions.

sychosocial Treatment

careful assessment of the developmental stage ofhe child or adolescent will define the therapeuticpproach. The therapist tries to promote the devel-pment of new skills and encourage adopting neways of coping. Although there are a variety of

echniques that the therapist may employ, adoles-ents demand an inordinate amount of flexibility.he focus usually is on the adolescent’s current

unctioning and his current relationships with anmphasis on renegotiating the adolescent-parent re-ationship and exploring the role of peers. The ther-pist usually sees the adolescent alone first, whereas
ith a child, the parent may be interviewed first.

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dolescents often do not recognize their need forelp and may project their difficulties as derivedrom unrealistic responses of teachers or parents. Iflinicians are making a referral to a therapist they canelp to anticipate with the adolescent that it is aormal reaction to balk at this type of treatment

nitially. Children are usually more receptive touilding a trusting relationship with a therapist thandolescents. Therapists often rely on role playingnd engaging game activities with children that helpodel how children can control their impulses [156].In Parent Management Training (PMT), the focus

s on parents acquiring concrete skills that concen-rate on teaching prosocial behavior [130]. Parentsearn to observe antecedents to their child’s behav-ors and to modify the consequences. There also is anmphasis on active role-playing, practice, and feed-ack. Outcome studies have shown gains that haveeen maintained 1 to 3 years after this form ofreatment [157]. However, most PMT studies focusn children 3 to 10 years of age [130,158].

Multisystemic Treatment (MST), a family-basedntensive therapeutic approach, has been demon-trated to be effective with adolescent juvenile of-enders [159]. MST is tailored to the needs of eachamily with the goal of improving the communica-ion skills and management of the family’s problemehavior. Borduin also showed that juvenile offend-rs (they averaged 4.2 previous arrests) who receivedhe MST intervention were less likely to be arrestedor violent crimes than were youths who had re-eived individual therapy [159]. The long-term ef-ects of MST have promising outcomes [160].

iscussion and Summaryggression and violence in youth have grave impli-

ations for the progression of psychiatric impair-ent, school difficulties, and legal involvement. As

linicians, it is useful to develop insight about how toonceptualize and organize biopsychosocial infor-ation to better guide patients and incorporate new

nformation about treatment. Clinicians are well po-itioned to identify those individuals that are ex-osed to multiple risk factors, such as poor socialttachments, comorbid psychiatric disorders, coer-ive family discipline, and access to fire arms, andan ideally suggest interventions before the aggres-ive behavior is chronic, frequent, pervasive, andevere. Although there are substantial data definingubtypes of aggression (covert/overt aggression, re-
ctive/proactive aggression), further refinement of
hese subtypes is needed to develop better screeningnstruments to identify particular behavior. In turn,his information may inform how clinicians prioritizenterventions. Researchers still need to develop andonfirm different models that explain the progres-ion or deterrence of adolescents engaging in theseroubling behaviors. More investigation is warrantedo discern certain correlates of aggression in bothommunity populations and clinically referred pa-ients so that tailored prevention, early interventions,nd evidence-based treatment can be mobilized. Asreatment interventions are more rigorously testednd meaningful algorithms are generated, cliniciansay come to see the aggressive teenager as challeng-

ng, and yet also know how to build on the adoles-ents’ strengths and help to substantially modifyheir aggression. The pattern of violence will perpet-ate or not, depending on how clinical understand-

ng deepens regarding the causes of aggression andow this understanding is turned into prevention,

ntervention, and treatment. The insight and practi-al suggestions that are generated will allow ourhildren and adolescents to make meaningful alter-ative choices.

e thank Tony Earls, Mike Jellinek, and Eliot Pittel for theirnsightful comments, and Alexa Geovanos for her research assis-ance.

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