W David Lohr, MD

Focusing on prevention may be the initial step for clinicians addressing the problem of aggression. Because most disruptive behaviors begin early in childhood, prevention of risk factors, even during pregnancy involving the mother's environment and social function, may reduce aggression.

Clinicians can advocate for efforts to positively influence moderators such as prenatal care, poverty, crime, nutrition, maternal substance abuse, and early interventions. In addition, pediatricians can promote core competencies for healthy adjustment in adolescence that are thought to be associated with prosocial behavior. These include a positive sense of self, self-control, decision-making skills, a moral system of belief, and prosocial connectedness.

Pediatricians can reinforce basic skills from individual therapies shown to be effective in reducing aggression. Cognitive-behavioral therapies addressing aggression use techniques for arousal management, cognitive restructuring, and social-skills training. 

Problem-solving skills teach children to recognize antecedents, identify their choices, monitor their behaviors, and evaluate the consequences of their behavior. Such therapy can include elements of relaxation breathing, muscle relaxation exercises, and self-talk. 

One such program is the Anger Coping Program, in which children aged 8 to 12 years are taught strategies in small groups to recognize and manage their anger in difficult interpersonal situations.

Parenting behaviors mediate the development of aggressive behaviors; thus, parent management training plays an important part in curtailing aggression.

Components of parent management training include education on causes of defiance, improving the effectiveness of directives, giving large amounts of attention and praise for desired behavior, and ignoring disruptive behavior. 

Parents are taught to make their responses immediate, consistent, and in line with the behavior. Mild punishments such as removing a reward because of negative behavior and time-out procedures are emphasized. Daily school-home report cards and tokens and stickers are used to monitor and reward positive behavior. 

Rewards can include shared enjoyable activities, and it is important to look to promote activities that challenge existing interaction patterns. Evidence supports having families of children with aggression receive parent management training first before medication.

Collaborative problem solving (CPS) emphasizes joint adult-child problem solving. In this perspective, children with aggression have delayed skills (ie, "learning disorders") in managing their emotional regulation, frustration tolerance, and problem-solving and adaptability skills, so parents are taught to recognize their child's limits and support growth.

 When faced with a problem of compliance, parents are taught that there are 3 options: impose adult will; engage in collaborative problem solving; or remove the expectation. The system also focuses on maintenance of the problem-solving relationship to resolve potential conflicts. Collaborative problem solving should reduce hostile or ineffective parenting styles, improve parent-child relationships, and improve externalizing behaviors.

Overall, effective parenting strategies work to improve the parent-child relationship. Motivation is increased when there are positive relationships with the caretaker and collaboration between parent and child. Discipline should be nonpunitive, with the goal of helping the child develop self-control.

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Pediatricians play central roles in coordinating and sustaining collaborative care for all aspects of their patients, including mental health.

Author | W David Lohr, MD

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