Aggressive behaviour in adolescent psychiatric settings: what are risk factors, possible interventions and implications for nursing practice? A literature review.

This study was aimed to identify the risk factors of aggressive behaviour in adolescents (1318 years), and to describe available intervention strategies. The findings are evaluated on the basis of their implications for nursing practice. Aggressive behaviour in adolescent psychiatric settings is a neglected research area. The consequences of aggressive behaviour on nurses, other patients and the therapeutic environment can be profound. For the development and implementation of innovative intervention strategies aimed at preventing aggressive behaviour in adolescent psychiatric patients, knowledge of risk factors and evidence-based interventions for aggressive behaviour are of the utmost importance. A systematic search of PubMed, Cinahl, PsychINFO and Cochrane Systematic Reviews (19912007) was employed. The risk factors for aggressive behaviour comprise personal and environmental risk factors. Some risk factors can be influenced by nursing intervention strategies. Available intervention programmes range from interpersonal skills training to massage therapy, parent management training, functional family therapy and multi-systemic therapy. The most effective programmes combine interpersonal skills training with parent management training. No specific nursing intervention programmes were found for dealing with aggressive behaviour in adolescent patients. Nursing staff can assist in achieving a systematic improvement in the treatment outcomes of existing intervention programmes for the prevention of aggression. There is a need for specific nursing intervention programmes to deal with aggressive behaviour in adolescent psychiatric settings.

Pathways of problem behaviors from childhood to adolescence.

OBJECTIVE: the purpose of this study was to determine the 6-year longitudinal course of psychiatric disorders in children from the general population commencing at age 4 to 11 years. METHOD: three groups of children were selected on the basis of Child Behavior Checklist ratings obtained at 2-year intervals: "persisters," "decreasers," and "increasers." Selected subjects and their parents were clinically interviewed, and DSM-III-R diagnoses were derived. RESULTS: the majority of children whose overall level of psychopathology persisted over time obtained lifetime DSM-III-R diagnoses classified as externalizing: attention-deficit hyperactivity disorder, oppositional disorder, or conduct disorder. The majority of children whose overall level of psychopathology decreased obtained lifetime DSM-III-R diagnoses classified as internalizing: anxiety disorders, major depression, or dysthymic disorder. Children with initial Child Behavior Checklist scores in the normal range whose problem scores increased received lifetime diagnoses that were neither predominantly externalizing or internalizing. CONCLUSIONS: this study showed that the majority of initially disordered children with the poorest outcome showed aggressive or antisocial behaviors, whereas disordered children whose functioning improved had problems reflecting fearful, inhibited, or depressive behavior. The findings also showed that retrospective information on the course of children's problem behaviors should be regarded with caution.

Major life events and changes in the behavioural functioning of children.

The relationship between major life events and changes, across a 2-yr period, in the level of parent-reported behavioural/emotional problems in 1397 children from a general population sample was investigated using a highly modified version of the Coddington Life Events Record and the Achenbach Child Behavior Checklist. The life event questionnaire used in the present study proved to have a satisfactory reliability. The number of life events increased significantly with increasing age of the child, and a higher incidence of such events was found for families with lower socio-economic status. A significant relationship was found between the total score of negative life events across the 2-yr period and changes in the level of behavioural/emotional problems of the children.

Problem behavior in international adoptees: III. Diagnosis of child psychiatric disorders.

This study is a clinical extension of two previous epidemiological studies on problem behavior in international adoptees. In depth pictures were obtained by clinical interviews of 132 14-year-old international adoptees and their parents. Children were selected on the basis of previously obtained Child Behavior Checklist (CBCL) scores. Clinical severity ratings and DSM-III-R diagnoses were obtained. The correlations of r = 0.63 and r = 0.45 between clinical severity ratings and CBCL problem and competence scores, respectively, indicated that the results from the authors' extensive epidemiological survey and the clinical evaluation, which took place more than 10 months later, converged. The results showed that the CBCL may be used in epidemiological studies to obtain an estimate of the prevalence of psychiatric disorders in children. The 28% prevalence rate of psychiatric disorders in this sample of 14-year-old international adoptees (22% rate for girls, 36% for boys) was somewhat higher than for general population samples reported in comparable studies. Conduct disorders were elevated in the sample. The behavior of disordered adopted children was characterized by antisocial behaviors, poor relationships, and problems of affect.

Four-year follow-up of an epidemiological sample.

In this 4-year follow-up of behavioral/emotional problems in an epidemiological sample of 1,200 children originally aged 4 to 12 years assessed with the Achenbach Child Behavior Checklist (CBCL), high stability in the level of CBCL total problem scores was found. Stability of problem behavior was equally substantial for ages 4 to 12 and both sexes. Aggressive and other externalizing behaviors showed the highest stability. Even in children as young as 4 to 5 years, aggressive and attentional problems showed considerable stability. The results of the present study were informative with respect to methodology in indicating clearly that employing a mailing survey for obtaining parent reports on behavioral/emotional problems resulted in the selective exclusion of a group of especially problematic children who were recovered when parents were interviewed at home.

The Child Assessment Schedule: parent-child agreement and validity measures.

Parents' and children's reports of behavioural-emotional problems in 116 children assessed by the Child Assessment Schedule developed by Hodges et al. (Journal of the American Academy of Child Psychiatry, 21, 468-473, 1982) and the Graham & Rutter Parent Interview (British Journal of Psychiatry, 114, 581-592, 1968), both semi-structured interviews, revealed relatively high agreement compared with studies using highly structured assessment procedures. The majority of disagreements could be attributed to higher parents' scores. Only fears were reported more often by children, especially by the better-functioning children, suggesting that children's reports of fears may be related to a higher level of adaptive functioning rather than a higher level of psychopathology. Although the child interview may be crucial to obtain information often not reported by parents such as fears and anxiety, it was found that information from the child contributed only little to overall clinical judgement based on information already available from the parents.

Mental health in Dutch children: (II). The prevalence of psychiatric disorder and relationship between measures.

This study concerns the second, more clinically oriented, part of our epidemiological project. The prevalence of child psychiatric disorders in random samples of 8- and 11-year-old children is assessed by using standardized parent- and child-interviews. The relationships between different measures of child psychopathology are determined. Furthermore, additional validity measures of the Child Behavior Checklist (CBCL) and Teacher Report Form (TRF) developed by Achenbach, are provided. Of the 153 8- and 11-year-old children selected through a two-stage sampling procedure, 116 (76%) children and their parents were intensively clinically assessed. The correlation between CBCL and direct child assessment is .42, whereas the correlation between the TRF and direct child assessment is .28. The correlation between TRF and CBCL is .26. The implications of the low correlation between raters who saw children is different situations are emphasized. The weight given to reports from different sources varies with the kind of problem the child exhibits. It is concluded that more research is needed to investigate the relative value of different types of data for different conditions. Seven percent of the 8- and 11-year-olds were judged severely disordered, whereas for 26% the clinicians judged the child to be moderately or severely disordered. The high prevalence rates found in our study compared with others is partly attributed to the arbitrary nature of clinical judgement. ANOVAs and discriminant function analysis were performed to obtain those CBCL items that showed the best discrimination between children who were clinically judged disordered and children from the normative comparison group. Many items found to be good discriminators of clinical status in this study were among the best discriminators of referral status in the earlier reported part of the study. A number of family and social factors were found to be associated with psychiatric disorder. These findings support those in other studies.