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. Sertraline60 and paroxetine61 are FDA-approved for adults with PTSD. Adrenergic agents, such as 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,63 valproic acid,64 and topiramate65 have shown positive results for adults with PTSD comorbid with bipolar disorder. Atypical antipsychotic agents (risperidone and 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.
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