Understanding and Treating Aggression in Children
Agression is a symptom, not a diagnosis. Aggressive behavior is one of the most common pediatric mental/behavioral health chief complaints. Similar to pain or fever, before trying to treat aggression you have to assess it, generate a differential diagnosis, and figure out where it comes from.
Normal and Problematic Aggression
What does aggression look like?
Aggression may refer to verbal or physical acts which vary widely in their potential to harm others. When a parent presents with a complaint of aggression in their child, you want to know what they mean by that word.
- Using mean words or foul language
- Stomping loudly, slamming doors
- Throwing objects
- Throwing objects at a person
- Pushing, shoving
- Hitting, kicking, biting, pinching, scratching
- Threatening with a weapon
- Harming with a weapon
Is aggression normal? When?
Aggression emerges in infancy around 8 to 12 months of age.
It peaks between age 2 and 4 years and diminishes as children learn alternate strategies to express preferences and achieve goals.
About 5% of boys and very few girls will have persistent or chronic physical aggression.
Aggression is effective.
We can use aggression to get what we want, defend ourselves from others, hunt for food, and drive off competition for mates or resources.
Aggression is a costly use of energy. It puts us at risk for injury or death. Aggression negatively affects social cohesion. Aggressive behavior may exclude us from social roles which are pleasant, protective, and which allow us to access the benefits of complex society.
When is aggression in children a clinical concern?
- When late preschool-age or older children continue to use aggressive behaviors as a routine means of expression
- When a child is causing injury to others or to themselves.
- When a parent or guardian is afraid of their child.
- When a parent or guardian feels unable to keep themselves or other children safe from a child.
- When a child is routinely destroying property.
- When a child's aggression in a school setting impedes learning and/or well-being of peers.
- When a child is actively threatening or planning behavior with intent to harm others (proactive aggression).
What’s the alternative to aggression?
The problem-solving skills which are the alternative to aggression are complex and involve several areas of child development. These skills don't develop evenly in all children.
Here are a few:
Language. Expressive and receptive language help a child identify and state a need and enlist the help of others in getting that need met.
Impulse control. Aggression is often the first impulse. If that impulse can be suppressed, the child has time to think about the next option and how it might work out.
Working memory. In order to problem solve, the child must hold the immediate situation in mind, compare it to similar situations in the past, access other behavioral possibilities from memory, and choose one option to deploy.
Social awareness. The child must observe and copy behaviors they see others use that help them get their needs met. The child must observe the effect of their own behaviors on others.
Why does aggression persist in some children?
Risk factors for persistent aggressive behavior
- Male sex
- Low levels of behavioral inhibition
- Language delay or poor language skills
- Maternal negativity toward child
- Maternal smoking
- Maternal depression
- Low maternal education
- Any parent modeling aggressive behavior
Life and environmental factors
- Exposure to domestic or community violence
- Exposure to abuse
- Exposure to bullying
Aggression shows up in almost any situation when our usual coping strategies or survival tactics fail. Aggressive behavior by itself is not synonymous with a disorder of mental health.
However, aggression shows up commonly in people, including children, with mental health diagnoses, because all mental health disorders limit capacity to calmly and flexibly respond to stress. Here are a few examples.
ADHD. Kids with ADHD act impulsively, and aggression may be the first impulse. Kids with ADHD also get a lot of negative feedback, which may result in cycles of escalating negativity and aggression.
Anxiety. Anxious kids want to avoid the things that make them frightened but they don't always have the means to do so. An anxious child may use aggressive behaviors to avoid having to enter a situation they fear. The simplest example is a child fighting off a vaccination or blood draw in your office.
Trauma-related disorders. Kids who have experienced traumatic events, particularly those who have experienced or witnessed abuse, may exhibit aggressive behaviors themselves.
Oppositional Defiant Disorder. ODD is a pattern of persistent hostile, vindictive, and defiant behavior toward authority figures. Children with ODD are irritable, argumentative, and disobedient. ODD may be diagnosed if this behavior lasts 6 months or longer. ODD commonly co-occurs with ADHD.
Misinterpretation or differing standards of normative behavior. Expectations and consequences of behaviors vary across settings and communities. Sassing, joking, backtalk, and questioning authority may be acceptable in some situations and forbidden in others. Physical displays of frustration, disappointment, shame or anger may be construed as threatening behavior depending on the age, size and appearance of the person.
Studies have shown that minority children, particularly Black children, receive harsher punishments in school settings than do White children. Fadus, et al (2021) found Black children were 3.5 times more likely to be suspended or given detention for oppositional or aggressive behaviors than were White children with the same behaviors. Young Black men are widely stereotyped as violent, dangerous and criminal.
In clinical, school, and juvenile justice settings, "aggression" is a label most commonly applied by adults/authorities to the behavior of children. As with all words in common use that are also symptoms of disorders, the meaning the user attaches to the word must be carefully ascertained.
Determine type of behaviors, frequency, duration, severity, precipitating and alleviating factors, where it tends to happen and with whom.
- Is this normative or problematic aggression?
- Are there immediate safety concerns?
- What’s in my differential diagnosis?
Treatment strategies depend on the underlying cause of the aggressive behavior.
Parent management training or behavioral parent training can help parents manage their children's behavior, reduce conflict and reduce aggression.
Therapeutic strategies for children and adolescents with aggression include teaching emotion recognition and management (e.g., Zones of Regulation), problem-solving skills, and social skills training (e.g, SuperFlex).
Maximizing stimulant treatment for ADHD can reduce aggression associated with ADHD. In children and adolescents with residual aggression symptoms despite maximized ADHD symptom control, valproic acid and risperidone have been found effective.
Impairing Emotional Outbursts: Parents’ Medication Guide (pdf) AACAP
Understanding and assessing aggression in children (Mini-lesson)
Aimé, C., Paquette, D., Déry, M., & Verlaan, P. (2018). Predictors of childhood trajectories of overt and indirect aggression: An interdisciplinary approach. Aggressive Behavior, 44(4), 382–393. https://doi.org/10.1002/ab.21759
Fadus, M. C., Valadez, E. A., Bryant, B. E., Garcia, A. M., Neelon, B., Tomko, R. L., & Squeglia, L. M. (2021). Racial Disparities in Elementary School Disciplinary Actions: Findings From the ABCD Study. Journal of the American Academy of Child and Adolescent Psychiatry, 60(8), 998–1009. https://doi.org/10.1016/j.jaac.2020.11.017
Nærde, A., Ogden, T., Janson, H., & Zachrisson, H. D. (2014). Normative development of physical aggression from 8 to 26 months. Developmental Psychology, 50(6), 1710–1720. https://doi.org/10.1037/a0036324