BAL HARBOUR, FLA. — Aggression is an increasing and troubling problem among young children, but there are things physicians can do to help parents address the matter, Barbara J. Howard, M.D., said at the annual Masters of Pediatrics conference sponsored by the University of Miami.
Teachers and day care workers report that up to 40% of boys and 28% of girls aged 2-5 years exhibit moderate to high levels of aggression. The problem is of concern—particularly before age 3, when aggression peaks in children—because early aggression was associated with later behavior disorders (correlation coefficient 0.68), including conduct disorder, said Dr. Howard, of Johns Hopkins University, Baltimore, Md.
About 40% of severe aggression in adults—the kind associated with criminal behaviors—begins before age 8, she noted.
A number of factors can contribute to aggression, but a particularly important point is that aggression can be stimulated by the thwarting of any major developmental need, she said.
Dr. Howard addressed key developmental needs, including:
▸ State regulation. State regulation requires consistency in routines (such as eating and sleeping) and parental responsiveness. Routines stabilize mood and reduce resistance among children and are especially important for temperamentally irregular, unadaptable children, she said.
Try to educate parents about the impact of environment on emotional state. Encourage routines, including regular snacks and meals, and suggest parents talk softly to their children, decrease television time, and increase sleep time.
Make parents aware of the association between aggression and sexual exposures, bullying (by siblings or peers), and inadequate child care (see box), and advise them to watch for these things. For some parents, keeping a diary of stresses and their effects can be helpful in identifying problems.
▸ Mastery. Experiences of mastery involve balance between respecting the child's need for autonomy and providing the protection the child needs to avoid being overwhelmed by that autonomy. Teach parents to give the autonomy but not beyond what the child can handle.
Mastery also involves avoiding overprotection and over-strictness and providing adequate limits. Inadequate limits can evoke aggression, Dr. Howard said.
Parents with a hyperaggressive child should be counseled about proper discipline—such as instructions about small consequences and the use of time-outs.
For children with gaps in skills such as fine-motor and expressive language skills, placement with younger children should be considered, as should treatment for the deficits to help in the management of problems with mastery that lead to aggression.
▸ Positive emotional tone. Positive tone and stable attachment reduce suspiciousness and enhance resilience under stress that might otherwise evoke aggression in children. Hostility in the family environment increases tension in the child and provides a model for aggression.
Parents should be advised to address their hostility problems, and nonphysical discipline measures should be encouraged.
Eliciting information about parental history of discipline can be helpful for prompting such discussions.
Consider referring families with a lack of positive emotional tone for family therapy, Dr. Howard said.
▸ Assistance in regulating negative affect. Parents can help in the regulation of a child's negative affect through “jollying,” distraction, modeling, acknowledgment, verbalization, and compromise. Lack of a tolerance for negative feelings can lead to excessive negative affect, and this can be a source of aggression, she noted.
Encourage parents to help the aggressive child express negative emotions by echoing their feelings or allowing the child to use alternative outlets for the emotions—such as a punching bag.
Consider referring those families trapped in a “coercive cycle” in which the aggression leads to the parents' backing down; such cycles are highly associated with poor outcomes with regard to childhood aggression, she said.
▸ Learning pro-social behavior and empathy. Children must learn such behaviors, including trading, taking turns, waiting, asking for things, using good manners (such as saying “thank you”), considering other points of view, considering the effects of one's actions, and recognizing the feelings of others. Methods for teaching such behaviors include modeling within the family and providing selective attention to and rewards for positive behaviors.
Providing more individual attention (not linked with aggressive behavior) to an aggressive child also can be helpful, as can providing sympathy to the victims of the aggression, Dr. Howard said
Signs of Problematic Child Care Settings
An important question when a young child is aggressive is “Who is taking care of the child?” Dr. Howard said.
Aggressive children who spend a great deal of time in day care could be exhibiting behaviors associated with problems there. She advised encouraging parents of aggressive children to look for the following warning signs of problematic child care settings: