Youth Aggression: Economic Impact, Causes, Prevention, and Treatment

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.

Economic impact

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

Recent studies in pharmacotherapy

Diagnosis-specific pharmacotherapy should be the first-line treatment to target aggressive behavior, including²³: stimulantsor atomoxetinefor attention-deficit/hyperactivity disorder (ADHD), antidepressants for depressive disorders, mood stabilizers for bipolar disorders, and antipsychotic agents for psychotic disorders. However, additional pharmacologic interventions are often needed in patients who are seriously aggressive.

Dunn and colleagues²⁴ conducted an open-label study in 24 adolescents with ADHD, oppositional defiant disorder, or conduct disorder who exhibited severe aggressive outbursts, according to the Modified Overt Aggression Scale. The initial treatment consisted of 3 weeks of 54 mg/d of extended-release methylphenidate monotherapy, followed by 9 weeks of a combination of extended-release methylphenidate and quetiapine. Quetiapine was given at dosages up to 600 mg/d. After 12 weeks, verbal aggression and physical aggression toward self, others, and property declined significantly. Both the diagnosis-specific medication and the atypical antipsychotic appeared to contribute to improvement. However, this was an open-label study without placebo or active control. It is unclear how much of a placebo effect, monotherapy with methylphenidate, or the combination treatment contributed to the results.

Connor and associates²⁵ conducted a randomized, placebo-controlled monotherapy study with quetiapine treatment for aggressive conduct disorder. Nineteen adolescents participated in this 7-week study. Dosing was flexible; the average dosage of quetiapine at study end point was 300 mg/d 6 168 mg/d. Eight of 9 patients on medication improved, compared with 1 of 10 on placebo, according to a clinical global impression (CGI) score of 2. Quetiapine appeared to be well tolerated, although data on weight and metabolic parameters were not reported.

Atypical antipsychotics have become the mainstay of pharmacotherapy for aggression, and their use in children and adolescents has increased significantly in the last decade.²⁶ Reasons for this increase may be their effectiveness; their fast onset of action, which makes them useful in acute settings; and their improved neurologic safety profile. Recently, however, significant concern has been raised about their metabolic side effects.

The American Psychiatric Association and the American Diabetes Association have ranked the atypical antipsychotics based on their likelihood to induce metabolic abnormalities. Aripiprazole and ziprasidone were characterized as being least likely to induce weight gain and metabolic side effects. Because of these potential advantages, an open nonrandomized trial of aripiprazole or ziprasidone in a community clinic population of aggressive children and adolescents was performed.²⁷ Forty-six patients (mean age of 11.9 6 2.6) were administered the Mini International Neuropsychiatric Interview and the Child/Adolescent Symptom Inventory. Conduct, bipolar, and depressive disorders were the most common diagnoses. The primary outcome measure was the Overt Aggression Scale. Patients with significant aggressive behaviors were started on aripiprazole (n = 24) or ziprasidone (n = 22). Eighteen patients were taking concomitant anti-ADHD medication.

After 2 months, 34 patients remained in treatment, with an average dosage of aripiprazole of 4.5 mg/d 6 2.3 mg/d and of ziprasidone of 42.9 mg/d 618 mg/d. The average rating on the Overt Aggression Scale improved 63% and the average CGI score was 2.1 (much improved). There were no statistically significant differences between the aripiprazole group and the ziprasidone group in the primary outcome measure at baseline and after 2 months of treatment. However, 3 times more patients on ziprasidone than those on aripiprazole dropped out because of sedation. No other side effects were prominent, although weight change and metabolic indices require further study.

Conclusion

Aggression in youth has an enormous societal impact--economically, clinically, and in terms of human suffering. While primary prevention is clearly desirable, the clinician is more involved with secondary and tertiary prevention and treatment efforts. Controlled studies are needed to sort out which medications or combinations of medications are most effective in controlling aggression in young patients. Treatment that impacts the many biological, psychological, and social factors related to aggression--and is delivered within the patient's environment--may be the most clinically effective and economically sound modality.

Dr Bastiaens is associate clinical professor of psychiatry at the University of Pittsburgh and is associated with Family Services of Western Pennsylvania. He reports that he is on the speakers' bureau and is a consultant for Bristol- Myers Squibb, Eli Lilly, Forest Laboratories, GlaxoSmithKline, Pfizer, and Takeda. He has received research honoraria from Forest Laboratories, McNeil Consumer Healthcare, and Janssen.

Ms Bastiaens is an undergraduate student at Davidson College, Davidson, NC. She reports no conflicts of interest regarding the subject matter of this article.

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