From Victim to Aggressor:

By Dwain C. Fehon, PsyD | June 1, 2007

Dr Fehon is assistant professor in the department of psychiatry at Yale University School of Medicine and director of psychology, and coservice manager of adolescent services at Yale-New Haven Psychiatric Hospital. He reports that he has no conflicts of interest concerning the subject matter of this article.

Approaches to decrease risk of violence

Despite the strong association between violence victimization and later violence perpetration, not all children exposed to violence become aggressive and perpetuate the cycle of violence. Some withstand the negative effects of violence and show a pattern of resilient development. Many of the protective factors associated with decreased impact of violence exposure make intuitive sense.

Youths exposed to high levels of community violence but who live within families with high cohesion, high structure, effective parenting practices, and strong beliefs about the family are less likely to engage in violent behaviors than are youth in less well-functioning families.^49,50 Supportive parent-child relationships characterized by communication, concern, and parent-connectedness have been linked to reductions in internalizing and externalizing behavior, including PTSD and aggression.^51,52 Programs that build school safety also enhance adaptive functioning at school under conditions of high violence exposure.⁵² Thus, while supportive families, peers, and schools may not prevent an individual from being exposed to violence, they can indeed protect against the risk of subsequent emotional maladjustment, including the risk of violence.

Along these lines, community-based intervention programs in which mental health clinicians work side-by-side with police departments to rapidly respond to incidents of community violence have been shown to be especially helpful in addressing the emotional impact of traumatic violence.⁵³ Therefore, interventions that involve an integrated approach that includes available family, school, and community supports would seem to be most likely to reduce the risk of violence among traumatized/violence-exposed youth.^54,55

Once an adolescent is referred for mental health treatment because of impulsive aggressive behavior, a range of therapeutic options are available. Individual cognitive-behavioral therapy can be an effective method of improving problem-solving skills and social skill deficits.⁵⁶ Dialectical behavior therapy may decrease internalizing and externalizing symptoms such as anger and depression in adolescents.⁵⁷ Group therapy offers peer support and validation for one's reaction to traumatic events. Family therapy offers an emotionally neutral forum to discuss the antecedents and consequences of aggressive behavior in the home, and it is a link to the intergenerational transmission of violence.

Psychopharmacological therapies may also reduce symptoms of hyperarousal and impulsivity associated with PTSD, yet knowledge of medication treatments targeting aggression for children and adolescents is limited by a lack of reliable, well-controlled clinical trials. The FDA has yet to approve medication for pediatric use targeting PTSD or aggression. However, in 2 separate reviews of pharmacological treatment approaches for adults with PTSD,^58,59 a number of options were recommended. Namely, SSRI antidepressants were suggested for targeting anxiety, mood, or re-experiencing symptoms. Sertraline(Drug information on sertraline)⁶⁰ and paroxetine(Drug information on paroxetine)⁶¹ are FDA-approved for adults with PTSD. Adrenergic agents, such as clonidine(Drug information on clonidine) (an FDA-approved agent for the treatment of ADHD in pediatric patients) used either alone or in combination with an SSRI were viewed as useful for treating symptoms of hyperarousal and impulsivity.⁶² Supplementing with a mood stabilizer may be indicated for cases with severe affective dyscontrol, impulsivity, and anger.

Open label trials of carbamazepine(Drug information on carbamazepine),⁶³ valproic acid,⁶⁴ and topiramate⁶⁵ have shown positive results for adults with PTSD comorbid with bipolar disorder. Atypical antipsychotic agents (risperidone and quetiapine(Drug information on quetiapine)) have the potential to reduce dissociation, self-injurious behavior, and aggression in adults.^66,67

Conclusion

Given the rate at which America's youth are exposed to violence, mental health providers are encouraged to develop effective treatments that decrease the victim-to-perpetrator cycle of violence. Adolescents who exhibit symptoms of impulsive aggression are likely to lack prerequisite affect regulation skills to modulate aggressive impulses and will require integrated psychopharmacological and behavioral strategies to improve affect regulation and behavioral control. Approaches that integrate individual, family, community-based, and psychopharmacological interventions are required to address the pervasive and deleterious effects of violence exposure and childhood abuse.

Pages: 1 2 3

Borowsky IW, Mozayeny S, Stuenkel K, Ireland M. Effects of a primary care–based intervention on violent behavior and injury in children. Pediatrics. 2004;114: e392-e399.
Wolfe DA,Wekerle C, Scott K, et al. Dating violence prevention with at-risk youth: a controlled outcome evaluation. J Consult Clin Psychol. 2003;71:279-291.

References
1. Centers for Disease Control and Prevention. Youth Violence: Overview. Available at: http://www.cdc.gov/ncipc/factsheets/yvoverview.htm. Accessed April 24, 2007.
2. Edleson JL. Children's witnessing of adult domestic violence. J Interpers Violence. 1999;14:839.
3. Straus MA. Children as witnesses to marital violence: a risk factor for lifelong problems among a nationally representative sample of American men and women. Report of the 23rd Ross Roundtable. Columbus, Ohio: Ross Laboratories; 1992.
4. McKibben L, DeVos E, Newberger E. Victimization of mothers of abused children: a controlled study. Pediatrics. 1989;84:531-535.
5. Ludwig S. Child abuse. In: Fleisher GR, Ludwig S, Henretig FM, eds. Textbook of Pediatric Emergency Medicine. 5th ed. Philadelphia: Lippincott Williams and Wilkins; 2006:1761.
6. Kocher MS, Kasser JR. Orthopaedic aspects of child abuse. J Am Acad Orthop Surg. 2000;8:10.
7. Kolbo JR, Strong E. Multidisciplinary team approaches to the investigation and resolution of child abuse and neglect: a national survey. Child Maltreatment. 1997; 2:61.
8. Bell CC, Jenkins EJ. Community violence and children on the southside of Chicago. Psychiatry. 1993:56:46-54.
9. Gorman-Smith D, Tolan P. The role of exposure to community violence and developmental problems among inner-city youth. Dev Psychopathol. 1998;10: 101-116.
10. Sheehan K, DiCara JA, LeBally S, Christoffel KK. Children's exposure to violence in an urban setting. Arch Pediatr Adolesc Med. 1997;151:502-504.
11. Campbell C, Schwartz DF. Prevalence and impact of exposure to interpersonal violence among suburban and urban middle school students. Pediatrics. 1997;98: 396-402.
12. Centers for Disease Control and Prevention. Web-based Injury Statistics Query and Reporting System (WISQARS). Available at: http://www.cdc.gov/ncipc/wisqars/default.htm. Accessed April 25, 2007.
13. US Surgeon General's Office. Youth Violence: A Report of the Surgeon General. Washington, DC: US Dept of Health and Human Services; 2001.
14. Garbarino J, Gilliam G. Understanding Abusive Families. Lexington, Mass: Lexington Books; 1980.
15. Widom CS. Does violence beget violence? A critical examination of the literature. Psychol Bull. 1989;106: 3-28.
16. Resnick MD, Bearman PS, Blum RW, et al. Protecting adolescents from harm: findings from the National Longitudinal Study on Adolescent Health. JAMA. 1998; 278:823-832.
17. Brookoff D, O'Brian KK, Cook CS, et al. Characteristcs of participants in domestic violence: assessment at the science of domestic assault. JAMA. 1997;277: 1369-1373.
18. Wissow LS. Child abuse and neglect. N Engl J Med. 1995;332:1425-1431.
19. Ehrensaft MK, Cohen P, Brown J, et al. Intergen- erational transmission of partner violence: a 20-year prospective study. J Cons Clin Psychol. 2003;71: 741-753.
20. Chapin MG. A comparison of violence exposure and perpetration in recruits and high school students. Mil Med. 1999;164:264-268.
21. Lai DW. Violence exposure and mental health of adolescents in small towns: an exploratory study. Can J Public Health. 1999;90:181-185.
22. Malik S, Sorenson SB, Aneshensel CS. Community and dating violence among adolescents: perpetration and victimization. J Adolesc Health. 1999;21:291-302.
23. Moses A. Exposure to violence, depression and hostility in a sample of inner city high school youth. J Adolesc. 1999;22:21-32.
24. Song LY, Singer MI, Anglin TM. Violence exposure and emotional trauma as contributors to adolescents' vio- lent behaviors. Arch Pediatr Adolesc Med. 1998;152: 531-536.
25. McGee RA, Wolfe DA, Wilson SK. Multiple maltreatment experiences and adolescent behavior problems: adolescent perspectives. Dev Psychopathol. 1997;9: 131-149.
26. Werkerle C, Wolfe DA. The role of child maltreatment and attachment style in adolescent relationship violence. Dev Psychopathol. 1998;10:571-586.
27. Lewis DO. From abuse to violence: psychophysiological consequences of maltreatment. J Am Acad Child Adolesc Psychiatry. 1992;31:383-391.
28. Maxfield MG, Widom CS. The cycle of violence: revisited six years later. Arch Pediatr Adolesc Med. 1996; 150:390-395.
29. Bandura A. Social cognitive theory. In: Vasta R, ed. Annals of Child Development, Vol. 6. Six Theories of Child Development. Greenwich, Conn: JAI Press; 1989:1-60.
30. Cicchetti D, Lynch M. Toward an ecological/transactional model of community violence and maltreatment: consequences for children's development. Psychiatry. 1993;56:96-118.
31. Nofziger S, Kurtz D. Violent lives: a lifestyle model linking exposure to violence to juvenile violent offending. J Res Crime Delinq. 2005;42:3-26.
32. Stewart EA, Schreck CJ, Simons RL. "I ain't gonna let no one disrespect me." Does the code of the street reduce or increase violent victimization among African American adolescents? J Res Crime Delinq. 2005;43: 427-458.
33. Freeman L, Mokros H, Pozanski E. Violent events reported by normal urban school-aged children: characteristics and depression correlates. J Am Acad Child Adolesc Psychiatry. 1993;32:419-423.
34. Horowitz K, Weine S, Jekel J. PTSD symptoms in urban adolescent girls: compounded community trauma. J Am Acad Child Adolesc Psychiatry. 1995;34: 1353-1361.
35. Caetano R, Field CA, Nelson S. Association between childhood physical abuse, exposure to parental violence, and alcohol problems in adulthood. J Interpers Viol. 2003;18:240-257.
36. Cooley-Quille M, Turner S, Beidel D. Emotional impact of children's exposure to community violence: a preliminary study. J Am Acad Child Adolesc Psychiatry. 1995; 34:1362-1368.
37. Berenson AB, Wieman CM, McCombs S. Exposure to violence and associated health-risk behaviors among adolescent girls. Arch Pediatr Adolesc Med. 2001; 155:1238-1242.
38. Vermeiren R, Ruchkin V, Leckman PE, et al. Exposure to violence and suicide risk in adolescents: a community study. J Abnorm Child Psychol. 2002;30:529-537.
39. Schwartz D, Gorman AH. Community violence exposure and children's academic functioning. J Educ Psychol. 2003;95:163-173.
40. Berenson AB, Wiemann CM, McCombs S. Exposure to violence and associated health-risk behaviors among adolescent girls. Arch Pediatr Adolesc Med. 2001;155: 1238-1242.
41. Children's Safety Network & Data Analysis Resource Center. State costs of violence perpetrated by youth.
42. Bremner D. Long-term effects of childhood abuse on brain and neurobiology. Child Adolesc Psychiatr Clinics. 2003;12:271-291.
43. Southwick SM, Paige S, Morgan CA, et al. Neurotransmitter alterations in PTSD: catecholamines and serotonin. Semin Clin Neuropsychiatry. 1999;4:242-248.
44. Sapolsky RM. Glucocorticoids and hippocampal atrophy in neuropsychiatric disorders. Arch Gen Psychiatry. 2000;57:925-935.
45. Yehuda R. Post-traumatic stress disorder. N Engl J Med. 2002;346:108-114.
46. Bremner D, Vythilingam M, Vermetten E, et al. MRI and PET study deficits in hippocampal structure and function in women with childhood sexual abuse and posttraumatic stress disorder. Am J Psychiatry. 2003; 160:924-932.
47. Sapolsky R. Why stress is bad for your brain. Science. 1996;273:749-750.
48. Gollan JK, Lee R, Coccaro EF. Developmental psychopathology and neurobiology of aggression. Dev Psychopathol. 2005;17:1151-1171.
49. Gorman-Smith D, Henry DB, Tolan PH. Exposure to community violence and violence perpetration: the protective effects of family functioning. J Clin Child Adolesc Psychol. 2004;33:416-449.
50. Brookmeyer KA, Henrich CC, Schwab-Stone M. Adolescents who witness community violence: can parent support and prosocial cognitions protect them from committing violence? Child Dev. 2005;76:917-929.
51. Blum J, Ireland M, Blum RW; Adolescent Health. Gender differences in juvenile violence: a report from Add Health. J Adolesc Health. 2003;32:234-240.
52. Ozer EJ, Weinstein RS. Urban adolescents' exposure to community violence: the role of support, school safety, and social constraints in a school-based sample of boys and girls. J Clin Child Adolesc Psychol. 2004; 33:463-476.
53. Berkowitz SJ, Marans SM. The Child Development-Community Policing Program: a partnership to address the impact of violence. Isr J Psychiatry Relat Sci. 2000;37:103-14.
54. Borowsky IW, Mozayeny S, Stuenkel K, Ireland M. Effects of a primary care-based intervention on violent behavior and injury in children. Pediatrics. 2004;114: e392-e399.
55. Wolfe DA, Wekerle C, Scott K, et al. Dating violence prevention with at-risk youth: a controlled outcome evaluation. J Consult Clin Psychol. 2003;71:279-291.
56. Kazdin AE, Siegel T, Bass D. Cognitive problem-solving skills training and parent management training in the treatment of antisocial behavior in children. J Consul Clin Psychol. 1992;60:733-747.
57. Nelson-Gray RO, Keane SP, Hurst RM, et al. A modified DBT skills training program for oppositional defiant adolescents: promising preliminary findings. Behav Res Ther. 2006;44:1811-1820.
58. Donnely CL. Pharmacologic treatment approaches for children and adolescents with posttraumatic stress disorder. Child Adolesc Clin N Am. 2003;12:251-269.
59. Asnis GM, Kohn SR, Henderson M, Brown NL. SSRIs versus non-SSRIs in post-traumatic stress disorder: an update with recommendations. Drugs. 2004;64: 383-404.
60. Davidson JR, Rothbaum BO, van der Kolk BA, et al. Multicenter, double-blind comparison of sertraline and placebo in the treatment of post-traumatic stress disorder. Arch Gen Psychiatry. 2001;58:485-492.
61. Marshall RD, Schneider FR, Fallon BA, et al. An open trial of paroxetine in patients with noncombat-related, chronic posttraumatic stress disorder. J Clin Psychopharmacol. 1998;18:10-18.
62. Marmar CR, Foy D, Kagan B, Pynoos RS. An integrated approach for treating post-traumatic stress. In: Pynoos RS, ed. Post-Traumatic Stress Disorder: A Clinical Review. Lutherville, Md: Sidran Press; 1993:65-98.
63. Looff D, Grimley P, Kuller F, et al. Carbamazepine for PTSD. J Am Acad Child Adolesc Psychiatry. 1995;34: 703-704.
64. Fessler FA. Valproate in combat-related post- traumatic stress disorder. J Clin Psychiatry. 1991;52: 361-364.
65. Berlant J, van Kammen DP. Open-label topiramate as primary or adjunctive therapy in chronic civilian posttraumatic stress disorder: a preliminary report. J Clin Psychiatry. 2002;63:15-20.
66. Horrigan JP, Barnhill LJ. Risperidone and PTSD in boys. J Neuropsychiatry Clin Neurosci. 1999;11: 126-127.
67. Hamner MB, Deitsch SE, Brodrick PS, et al. Quetiapine treatment in patients with posttraumatic stress disorder: an open trial of adjunctive therapy. J Clin Psychopharmacol. 2003;23:15-20.

FROM PHYSICIANS PRACTICE

Primary Care Can't Thrive Without Nurse Practitioners
Courtney H. Lyder, ND, May 17, 2013
With a projected shortfall of primary-care physicians, it's time for alternate solutions to patient care. Nurse practitioners are one logical remedy.

VWhat Physicians Can Learn from the Allscripts EHR Lawsuit
Marisa Torrieri, May 16, 2013
Lawsuit prompts question: What should physicians do to ensure they end up with a great EHR instead of buyer’s remorse?

Eight Ways ICD-9 Will Still Matter to Medical Practices
Brenda Edwards, CPC, May 15, 2013
What should your medical practice do with your ICD-9-CM book after October 1, 2014? Keep it.

Seven Ways Technology Can Speed Up Patient Collections
Cheyenne Brinson, May 15, 2013
Failing to adopt widely available billing and collections technology can cost medical practices big. Here's how to do it right.

Four Reasons Private Medical Practice is Becoming Extinct
Carol Stryker, May 15, 2013
It’s becoming increasingly difficult for private medical practices to thrive. Here’s what’s driving the trend toward consolidation.

From Victim to Aggressor:

Join the Conversation