The increase in youth violence and aggression in the past 50 years has been called an "epidemic."1 This epidemic has had a tremendous impact on society. From an economic and public health perspective, primary prevention of youth violence is obviously desirable. From a clinical perspective, evaluation and treatment of aggression is a primary concern. In this review, we discuss the economic impact of youth aggression, with an emphasis on the rationale for primary prevention; the use of current knowledge to guide evaluation and treatment of aggression in the clinical setting; and recent reports on pharmacotherapy in aggressive youths.
Before taking into account the costs of juvenile justice programs and institutions, youth violence alone costs the United States more than $158 billion each year.2 Violent crime peaks in the late teenage years, despite spending nearly 15% of the gross domestic product on the upbringing and education of children.3 Obviously, juvenile violence remains a serious societal issue with a significant financial burden. Perhaps it is necessary to both reallocate resources and readjust attitudes to combat, prevent, and treat youth violence and delinquency in a sustainable and efficient manner.
In 1998, Donohue and Siegelman4 investigated the trade-off between imprisonment funding and potential social spending. They explained that if they could "identify and treat the worst 6% of delinquents and reduce their crime rate by 20%, [their] thought experiment of shifting resources from imprisonment to social programs would likely reduce crime or maintain it at the same level."4
It is important to note that the 20% was derived from an adjustment made to the hypothetical result of a preschool intervention program that modeled the Perry Preschool Program (which generated a 40% reduction in crime among its participants).5 The social spending in Donohue and Siegelman's investigation4 could hypothetically be applied to large-scale programs modeled on current small but successful organizations that reduce juvenile crime and improve socialization, self-esteem, and school and family functioning. Today, all smaller, successful programs contain the following components: starting at a young age; involving the family in teaching discipline and care skills; and being "small scale, high quality, and high cost."4 However, replicating these programs on a macro-level creates high cost curves that could rise exponentially with size. Also, providing the same quality of care on a large scale will be challenging.
Youth violence is not only a criminal justice concern, but also a public health issue. Welsh2 explained the role of prevention in public health, including classes dealing with aggression; public information campaigns; emergency department treatment and intervention; and early recognition of at-risk warning signs by families, physicians, school administrators, nurses, and teachers.
US cities lose nearly $50 billion a year because of crime and violence.2 Such large, negative externalities demand government attention and societal action. Reallocation of resources, new social spending initiatives, programs with a higher quality of care, and a better public health perspective would change the lives of our youths and cut the social cost of juvenile crime in the United States.
Current knowledge about aggression
While primary prevention falls in the public health domain, the treatment of aggressive youth is a concern for every health practitioner involved in the provision of care to children and adolescents.
Aggression is a complex behavior with several subtypes. Childhood-onset violent behavior appears more persistent than adolescent-onset aggression and may be associated with more neuropsychiatric problems.6Overt aggression (eg, bullying and fighting) may come to clinical attention more often than covert antisocial behavior (eg, stealing and vandalism).
Another subtyping supported by animal research divides aggression into reactive, irritable, and defensive behaviors versus planned, purposeful, and premeditated acts.7 Psychiatrists are most often called on to evaluate and treat childhood-onset, overt, and reactive aggression because of the link to identifiable biopsychosocial disturbances and their responsiveness to treatment.
Knowledge of the research findings on the causes and pathogenesis of aggressive behavior in youth should guide the assessment of the individual patient (Figure). Many children and adolescents with aggressive behaviors suffer from psychiatric disorders. A study evaluating juvenile delinquents in a detention center reported that over 60% had a diagnosed psychiatric disorder, excluding conduct disorder.8 Disruptive behavior disorders, substance use disorders, and mood disorders were particularly common.
Cutting across psychiatric diagnoses are maladaptive traits that appear to play a major role in overt and reactive aggression, such as impulsivity and the tendency to interpret benign social cues as hostile.9
There is a significant amount of evidence that suggests aggressive behavior is the result of an interaction between individual and environmental factors. Thus, parental practices are important. Environmental issues, such as abuse and discipline, are paramount in understanding the individual with aggressive behavior.10 In addition, parental psychiatric disorders, including substance use disorders, are important in the assessment of a violent child or adolescent.
Because children spend a lot of time in school, this environment can substantially influence--either negatively or positively--aggressive tendencies.11 Association with a deviant peer group is also important to recognize, but on the other hand, being ostracized by peers has been related to the increased likelihood of aggressive behavior.12 Other environmental factors, such as excessive exposure to violence in the media and living in an impoverished neighborhood, clearly play a role.13
Taking into account the numerous variables (many of which are external to the individual) that play a role in shaping aggressive behavior, some form of "outreach" into the home and community appears to be necessary to deliver effective treatment. Many of the factors involved in aggression are not readily observed in a clinical setting and may not be known or discussed by the parent or child. In-home visits can help clinicians more readily identify hostile interactions between family members, inconsistent discipline, evidence of abuse, evidence of substance use, excessive involvement with television and video games, and inappropriate involvement or noninvolvement with peers. Therapists who are able to visit the school and take the patient into the community, can continue their observations and treatment. It appears, then, that some form of in-home/family-based therapy is the best way to impact the psychosocial environment of the young patient who is aggressive.
Evidence shows that this type of outreach treatment is effective. An 18-month follow-up in young people involved in the juvenile justice system who were treated with multisystemic therapy showed improvement in arrest rates and level of functioning, compared with a treatment-as-usual cohort.14 Since this type of in-home therapy may not always be available, other models that try to impact many aggression-related factors are being developed.15
Such a treatment plan can address known and observed factors of aggressive behavior. A psychiatric disorder can be treated with pharmacotherapy or psychotherapy depending on the nature and severity of the disorder. Maladaptive traits can be treated with cognitive behavioral techniques such as problem-solving steps, social skills training, and anger management.16 Parental factors can be addressed through parent management training, psychiatric treatment, referral to child protective services, or parenting classes.17 School personnel can be involved in the generalization of skills learned in therapy and in providing a more prosocial environment for the patient.18 Peer factors can be targeted through social skills training and academic counseling to promote success. Parent management training and education could reduce the amount of exposure to the desensitizing effects of mechanistic violence in the media.
While there is significant evidence available for intensive psychosocial programs to reduce aggressive behavior in youth, the psychiatrist is most commonly involved in the pharmacologic part of treatment.19 However, evidence in randomized controlled trials for drug treatment of aggression in youth is sparse.19 Traditional mood stabilizers, such as lithium, divalproex, and atypical antipsychotics, are often used to treat violent behavior in adults, regardless of a diagnosis of bipolar disorder or psychosis. At this time, there is insufficient evidence of the effectiveness of one type of medication over another to treat violence in children and adolescents. While some recent controlled data are available for divalproex therapy to treat aggression in conduct disorder,20 most studies have focused on atypical antipsychotics.21,22
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