The Hyperaggressive Young Child

Have you ever had a child end up in your office who had been ejected from day care? Or been in a quandary over how worried to be about bruises on a child that were said to be caused by a rough sibling?

You are not alone in facing such disturbing clinical situations. These all-too-common problems are on the rise and require a thorough look and broad differential diagnosis.

It turns out that 25%-40% of boys and 10%-28% of girls aged 2-5 years are rated by their preschool teachers as having moderate to high levels of aggression. (You may be shocked to learn that 40% of adult violent behavior started before the individual was 8 years old.) For a child older than 3 years to be aggressive enough for parents or care providers to call for help is a significant problem which, if left unaddressed, can evolve into a lifetime of dysfunction.

Age 3 is a pivotal age, as aggression is normal and even expected before then. All infants bite once they cut teeth. Kids also experiment with their mouths: You may have had the surprise of cuddling a smiling 9- to 12-month-old just to have him sink his teeth into your shoulder. And both male and female 15- to 18-month-olds will knock over a peer to get a desired toy (instrumental aggression) without a thought.

But aggression that is intended to hurt others (hostile aggression) – not just to get something – should have peaked by age 2½ years and be on the decline by age 3. That means that 3-year-olds who are regarded as aggressive have not progressed as they should have. And before trying to send these young children off to a (difficult-to-access) mental health evaluation, you are in a key position to try to figure out why this is so.

Just as warriors resort to biting only in extremis, preschool children are usually at the end of their ropes when they use aggression repeatedly. It is useful to think about the ways in which the following needs are not being met, rendering these kids so unable to cope.

• Need for assistance in regulating their state of arousal. From the beginning, children need help in managing not only their periods of upset but also their sleeping and waking. The epidemic of inadequate sleep is a great place to look for a simple cause of aggression, or factors aggravating it. In fact, hours of sleep are inversely correlated with behavior problems of all kinds in young children (and probably in older ones, too). Ask parents to keep a sleep diary for their child; it can be a real eye-opener for them as well as a clue for you.

Some environments – for example, those that are noisy (perhaps even blasting TV or videos full of stimulating images) or crowded, or those that lack a clear schedule or routine – make the management of arousal more difficult. On top of this is the direct modeling of aggression that can occur for children as young as 15 months when they watch media violence. Parents may not even realize what their child is experiencing unless they drop in unexpectedly at their child’s day care center, which I strongly recommend they do.

Not all kids are equally likely to react aggressively to overstimulating or chaotic environments, but note any kind of CNS impairment (such as autism spectrum disorders, lead poisoning, prenatal drug exposure, or even irregular temperament). These can set a child up for a less-robust ability to adapt. The most important condition to consider when a child is overly aggressive, however, is ADHD. More than 65% of children who go on to be diagnosed with oppositional defiant disorder (which often presents with early aggression) have ADHD. When symptoms of ADHD are significant, it is never too soon for a full evaluation and consideration of treatments.

• Need for frequent and nutritious meals. Inadequate frequency and perhaps poor-quality food can also set a child on edge. In this age of obesity, we may forget that kids actually need to eat every 3-4 hours, albeit with nutritious, low-sugar foods. I see kids who are shipped to day care after eating a doughnut at 5:45 a.m. who are hitting peers by 10 when they have not yet had a snack.

• Need for mastery. By age 1 year, children have a strong need for mastery which, if thwarted, can make them strike out at others. Ask about a specific incident to sort out what is bringing on the aggressive behavior. A child who lashes out mainly during "art" may be frustrated by his poor fine motor skills and the dent in his self-esteem when he can only scribble and his neighbor has drawn a tree. Kids with lags in expressive language are actually four times as likely to be aggressive and to persist in such behavior, as they do not have the ability to negotiate situations verbally to get what they want – a skill lacking even in some adults!

Some parents and some child care providers don’t let these children exercise the skills they do have – for example, by overprotecting the child, being intrusive, or failing to provide play opportunities – and anger can be the result. Sometimes, the clue is right in front of you during the office visit when a parent won’t let the child explore the room, take toys you hand her, or even answer your questions. So even though a developmental screen is definitely needed when you evaluate aggression, don’t forget to ask about opportunities for the child to try to master things. Of course, the opposite may also be a factor in aggression: A child who has few limits may be wildly out of control, with aggression the ultimate behavioral result.

• Need for positive emotional tone. Positive attention is important for children as they try to acquire self-regulation. Although playfulness may seem like a far reach for stressed families, your suggestions of ways to have fun with the child – even 10 minutes a day of one-on-one special time – can often start to reset the tone of the relationship.

Aggressive behavior sometimes develops when it is the only way children can get the attention they crave from their caregivers. That’s why first attending to the victim of aggression rather than to the perpetrator can be helpful. Teaching parents to put marks on the child’s hand for little demonstrations of positive behavior (aiming for 10 per hour with a reward for "a bunch") can also shift the interaction from reactions that reinforce bad behavior toward those that acknowledge the good.

Sometimes, the source of aggression is no surprise as you enter the exam room to see the parent smacking or screaming at the child for every little thing. Although the cause of the aggression may seem obvious, the solution may not be; such parenting was likely learned when those parents were children themselves, making the behavior extra hard to change. But just because these habits were acquired early does not mean that the parents are actually happy with them. Even among parents who believe in spanking, 85% say that they would rather not spank their children but did not know an alternative.

Rather than reprimand the parent, you can comment, "He sure seems to be a handful," but then follow up with "How is that for you?" This question alone can be an important first step to uncovering a mother who is depressed (35%-50% of mothers of children younger than age 5 years) or who experiences partner violence (3-10 million in the United States), or a father who is stressed by working long hours plus caring for small children. Problem solving with such parents about ways to take a break, to get some help, or to get out of a negative situation may be needed. Although helping them to connect their stresses with the child’s aggression can sometimes be all that is needed to get them to act, efforts to motivate them by focusing on the need to change "for the child’s sake" have been shown to be less effective than first addressing and empathizing with the parents’ own distress.

A good strategy is to first ask permission to discuss the problem of the child’s behavior. This less-judgmental approach will be more likely to get you an opening to explore their situation, consider alternatives, teach "time out," offer advice, or at least schedule a follow-up appointment that will include relevant family members. Parents who are distressed by an aggressive child won’t know that you can help unless you offer.

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Elsevier. E-mail her at pdnews@elsevier.com.

Have you ever had a child end up in your office who had been ejected from day care? Or been in a quandary over how worried to be about bruises on a child that were said to be caused by a rough sibling?

You are not alone in facing such disturbing clinical situations. These all-too-common problems are on the rise and require a thorough look and broad differential diagnosis.

It turns out that 25%-40% of boys and 10%-28% of girls aged 2-5 years are rated by their preschool teachers as having moderate to high levels of aggression. (You may be shocked to learn that 40% of adult violent behavior started before the individual was 8 years old.) For a child older than 3 years to be aggressive enough for parents or care providers to call for help is a significant problem which, if left unaddressed, can evolve into a lifetime of dysfunction.

Age 3 is a pivotal age, as aggression is normal and even expected before then. All infants bite once they cut teeth. Kids also experiment with their mouths: You may have had the surprise of cuddling a smiling 9- to 12-month-old just to have him sink his teeth into your shoulder. And both male and female 15- to 18-month-olds will knock over a peer to get a desired toy (instrumental aggression) without a thought.

But aggression that is intended to hurt others (hostile aggression) – not just to get something – should have peaked by age 2½ years and be on the decline by age 3. That means that 3-year-olds who are regarded as aggressive have not progressed as they should have. And before trying to send these young children off to a (difficult-to-access) mental health evaluation, you are in a key position to try to figure out why this is so.

Just as warriors resort to biting only in extremis, preschool children are usually at the end of their ropes when they use aggression repeatedly. It is useful to think about the ways in which the following needs are not being met, rendering these kids so unable to cope.

• Need for assistance in regulating their state of arousal. From the beginning, children need help in managing not only their periods of upset but also their sleeping and waking. The epidemic of inadequate sleep is a great place to look for a simple cause of aggression, or factors aggravating it. In fact, hours of sleep are inversely correlated with behavior problems of all kinds in young children (and probably in older ones, too). Ask parents to keep a sleep diary for their child; it can be a real eye-opener for them as well as a clue for you.

Some environments – for example, those that are noisy (perhaps even blasting TV or videos full of stimulating images) or crowded, or those that lack a clear schedule or routine – make the management of arousal more difficult. On top of this is the direct modeling of aggression that can occur for children as young as 15 months when they watch media violence. Parents may not even realize what their child is experiencing unless they drop in unexpectedly at their child’s day care center, which I strongly recommend they do.

Not all kids are equally likely to react aggressively to overstimulating or chaotic environments, but note any kind of CNS impairment (such as autism spectrum disorders, lead poisoning, prenatal drug exposure, or even irregular temperament). These can set a child up for a less-robust ability to adapt. The most important condition to consider when a child is overly aggressive, however, is ADHD. More than 65% of children who go on to be diagnosed with oppositional defiant disorder (which often presents with early aggression) have ADHD. When symptoms of ADHD are significant, it is never too soon for a full evaluation and consideration of treatments.

• Need for frequent and nutritious meals. Inadequate frequency and perhaps poor-quality food can also set a child on edge. In this age of obesity, we may forget that kids actually need to eat every 3-4 hours, albeit with nutritious, low-sugar foods. I see kids who are shipped to day care after eating a doughnut at 5:45 a.m. who are hitting peers by 10 when they have not yet had a snack.

• Need for mastery. By age 1 year, children have a strong need for mastery which, if thwarted, can make them strike out at others. Ask about a specific incident to sort out what is bringing on the aggressive behavior. A child who lashes out mainly during "art" may be frustrated by his poor fine motor skills and the dent in his self-esteem when he can only scribble and his neighbor has drawn a tree. Kids with lags in expressive language are actually four times as likely to be aggressive and to persist in such behavior, as they do not have the ability to negotiate situations verbally to get what they want – a skill lacking even in some adults!

Some parents and some child care providers don’t let these children exercise the skills they do have – for example, by overprotecting the child, being intrusive, or failing to provide play opportunities – and anger can be the result. Sometimes, the clue is right in front of you during the office visit when a parent won’t let the child explore the room, take toys you hand her, or even answer your questions. So even though a developmental screen is definitely needed when you evaluate aggression, don’t forget to ask about opportunities for the child to try to master things. Of course, the opposite may also be a factor in aggression: A child who has few limits may be wildly out of control, with aggression the ultimate behavioral result.

• Need for positive emotional tone. Positive attention is important for children as they try to acquire self-regulation. Although playfulness may seem like a far reach for stressed families, your suggestions of ways to have fun with the child – even 10 minutes a day of one-on-one special time – can often start to reset the tone of the relationship.

Aggressive behavior sometimes develops when it is the only way children can get the attention they crave from their caregivers. That’s why first attending to the victim of aggression rather than to the perpetrator can be helpful. Teaching parents to put marks on the child’s hand for little demonstrations of positive behavior (aiming for 10 per hour with a reward for "a bunch") can also shift the interaction from reactions that reinforce bad behavior toward those that acknowledge the good.

Sometimes, the source of aggression is no surprise as you enter the exam room to see the parent smacking or screaming at the child for every little thing. Although the cause of the aggression may seem obvious, the solution may not be; such parenting was likely learned when those parents were children themselves, making the behavior extra hard to change. But just because these habits were acquired early does not mean that the parents are actually happy with them. Even among parents who believe in spanking, 85% say that they would rather not spank their children but did not know an alternative.

Rather than reprimand the parent, you can comment, "He sure seems to be a handful," but then follow up with "How is that for you?" This question alone can be an important first step to uncovering a mother who is depressed (35%-50% of mothers of children younger than age 5 years) or who experiences partner violence (3-10 million in the United States), or a father who is stressed by working long hours plus caring for small children. Problem solving with such parents about ways to take a break, to get some help, or to get out of a negative situation may be needed. Although helping them to connect their stresses with the child’s aggression can sometimes be all that is needed to get them to act, efforts to motivate them by focusing on the need to change "for the child’s sake" have been shown to be less effective than first addressing and empathizing with the parents’ own distress.

A good strategy is to first ask permission to discuss the problem of the child’s behavior. This less-judgmental approach will be more likely to get you an opening to explore their situation, consider alternatives, teach "time out," offer advice, or at least schedule a follow-up appointment that will include relevant family members. Parents who are distressed by an aggressive child won’t know that you can help unless you offer.

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Elsevier. E-mail her at pdnews@elsevier.com.

Have you ever had a child end up in your office who had been ejected from day care? Or been in a quandary over how worried to be about bruises on a child that were said to be caused by a rough sibling?

You are not alone in facing such disturbing clinical situations. These all-too-common problems are on the rise and require a thorough look and broad differential diagnosis.

It turns out that 25%-40% of boys and 10%-28% of girls aged 2-5 years are rated by their preschool teachers as having moderate to high levels of aggression. (You may be shocked to learn that 40% of adult violent behavior started before the individual was 8 years old.) For a child older than 3 years to be aggressive enough for parents or care providers to call for help is a significant problem which, if left unaddressed, can evolve into a lifetime of dysfunction.

Age 3 is a pivotal age, as aggression is normal and even expected before then. All infants bite once they cut teeth. Kids also experiment with their mouths: You may have had the surprise of cuddling a smiling 9- to 12-month-old just to have him sink his teeth into your shoulder. And both male and female 15- to 18-month-olds will knock over a peer to get a desired toy (instrumental aggression) without a thought.

But aggression that is intended to hurt others (hostile aggression) – not just to get something – should have peaked by age 2½ years and be on the decline by age 3. That means that 3-year-olds who are regarded as aggressive have not progressed as they should have. And before trying to send these young children off to a (difficult-to-access) mental health evaluation, you are in a key position to try to figure out why this is so.

Just as warriors resort to biting only in extremis, preschool children are usually at the end of their ropes when they use aggression repeatedly. It is useful to think about the ways in which the following needs are not being met, rendering these kids so unable to cope.

• Need for assistance in regulating their state of arousal. From the beginning, children need help in managing not only their periods of upset but also their sleeping and waking. The epidemic of inadequate sleep is a great place to look for a simple cause of aggression, or factors aggravating it. In fact, hours of sleep are inversely correlated with behavior problems of all kinds in young children (and probably in older ones, too). Ask parents to keep a sleep diary for their child; it can be a real eye-opener for them as well as a clue for you.

Some environments – for example, those that are noisy (perhaps even blasting TV or videos full of stimulating images) or crowded, or those that lack a clear schedule or routine – make the management of arousal more difficult. On top of this is the direct modeling of aggression that can occur for children as young as 15 months when they watch media violence. Parents may not even realize what their child is experiencing unless they drop in unexpectedly at their child’s day care center, which I strongly recommend they do.

Not all kids are equally likely to react aggressively to overstimulating or chaotic environments, but note any kind of CNS impairment (such as autism spectrum disorders, lead poisoning, prenatal drug exposure, or even irregular temperament). These can set a child up for a less-robust ability to adapt. The most important condition to consider when a child is overly aggressive, however, is ADHD. More than 65% of children who go on to be diagnosed with oppositional defiant disorder (which often presents with early aggression) have ADHD. When symptoms of ADHD are significant, it is never too soon for a full evaluation and consideration of treatments.

• Need for frequent and nutritious meals. Inadequate frequency and perhaps poor-quality food can also set a child on edge. In this age of obesity, we may forget that kids actually need to eat every 3-4 hours, albeit with nutritious, low-sugar foods. I see kids who are shipped to day care after eating a doughnut at 5:45 a.m. who are hitting peers by 10 when they have not yet had a snack.

• Need for mastery. By age 1 year, children have a strong need for mastery which, if thwarted, can make them strike out at others. Ask about a specific incident to sort out what is bringing on the aggressive behavior. A child who lashes out mainly during "art" may be frustrated by his poor fine motor skills and the dent in his self-esteem when he can only scribble and his neighbor has drawn a tree. Kids with lags in expressive language are actually four times as likely to be aggressive and to persist in such behavior, as they do not have the ability to negotiate situations verbally to get what they want – a skill lacking even in some adults!

Some parents and some child care providers don’t let these children exercise the skills they do have – for example, by overprotecting the child, being intrusive, or failing to provide play opportunities – and anger can be the result. Sometimes, the clue is right in front of you during the office visit when a parent won’t let the child explore the room, take toys you hand her, or even answer your questions. So even though a developmental screen is definitely needed when you evaluate aggression, don’t forget to ask about opportunities for the child to try to master things. Of course, the opposite may also be a factor in aggression: A child who has few limits may be wildly out of control, with aggression the ultimate behavioral result.

• Need for positive emotional tone. Positive attention is important for children as they try to acquire self-regulation. Although playfulness may seem like a far reach for stressed families, your suggestions of ways to have fun with the child – even 10 minutes a day of one-on-one special time – can often start to reset the tone of the relationship.

Aggressive behavior sometimes develops when it is the only way children can get the attention they crave from their caregivers. That’s why first attending to the victim of aggression rather than to the perpetrator can be helpful. Teaching parents to put marks on the child’s hand for little demonstrations of positive behavior (aiming for 10 per hour with a reward for "a bunch") can also shift the interaction from reactions that reinforce bad behavior toward those that acknowledge the good.

Sometimes, the source of aggression is no surprise as you enter the exam room to see the parent smacking or screaming at the child for every little thing. Although the cause of the aggression may seem obvious, the solution may not be; such parenting was likely learned when those parents were children themselves, making the behavior extra hard to change. But just because these habits were acquired early does not mean that the parents are actually happy with them. Even among parents who believe in spanking, 85% say that they would rather not spank their children but did not know an alternative.

Rather than reprimand the parent, you can comment, "He sure seems to be a handful," but then follow up with "How is that for you?" This question alone can be an important first step to uncovering a mother who is depressed (35%-50% of mothers of children younger than age 5 years) or who experiences partner violence (3-10 million in the United States), or a father who is stressed by working long hours plus caring for small children. Problem solving with such parents about ways to take a break, to get some help, or to get out of a negative situation may be needed. Although helping them to connect their stresses with the child’s aggression can sometimes be all that is needed to get them to act, efforts to motivate them by focusing on the need to change "for the child’s sake" have been shown to be less effective than first addressing and empathizing with the parents’ own distress.

A good strategy is to first ask permission to discuss the problem of the child’s behavior. This less-judgmental approach will be more likely to get you an opening to explore their situation, consider alternatives, teach "time out," offer advice, or at least schedule a follow-up appointment that will include relevant family members. Parents who are distressed by an aggressive child won’t know that you can help unless you offer.

Dr. Howard is assistant professor of pediatrics at the Johns Hopkins University, Baltimore, and creator of CHADIS (www.CHADIS.com). She had no other relevant disclosures. Dr. Howard’s contribution to this publication was as a paid expert to Elsevier. E-mail her at pdnews@elsevier.com.