Hi XXXXXXX

Just wanted to clarify what diagnistic entity is being referred to as "aggressive behaviour disorder" in the question... Actually, there is no DSM or ICD diagnostic entity by this name currently. So, is this term referring to a common group of disorders like conduct disorder, cppositional defiant disorder, etc. where aggression is a predominant symptom or a proposed new diagnostic category which encompasses aggressive behaviours in children?

- Dr. Jonas Sundarakumar
Consultant Psychiatrist

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Hi XXXXXXX

Aggressive behaviour in children and adolescents is a common symptom of a variety of psychiatric disorders like:

- conduct disorder
- oppositional defiant disorder
- attention deficit hyperactivity disorder
- mood disorders (including bipolar disorder)
- substance-related disorders, alcohol-related disorders
- mental retardation
- pervasive developmental disorders
- intermittent explosive disorder
- Tourette's disorderpersonality disorders (particularly Aggression is common in some epileptic patients and some endocrinological diseases (e.g., diabetes and hyperthyroidism) may be associated with aggressive behavior.

Secondly, all young children can be naughty, defiant and impulsive from time to time, which is perfectly normal. So, behavioural problems such as agressive behaviour (to a certain limit) can also be considered as part of the normal developmental process.

With this background, let us examine the pros and cons of diagnostic entity of "aggressive behaviour disorders in children...

The first issue is whether it is appropriate to use the term "aggressive behaviour disorder" to describe children with significant levels of aggression, especially very young children. The following are the concerns:

1) One of the basic components of aggression is "intentionality", Now, "intentionality" is difficult to infer and clearly establish among very young children. So, labelling behavioural problems in childhood as a "disorder" is questionable.

2) Most children do not have the cognitive capacity to comprehend aggression fully until their 3rd or 4th year.

3) Aggression is well known to occur in transient periods at certain ages. For example, the ages of 2 to 4 yrs. and 14 to 16 yrs. are the times where children are found to exhibit increased agression and defiant behaviours.

So, whether the diagnostic category of "aggressive behaviour disorder" itself is appropriate and necessary is a big question mark?

The "cons" of this diagnostic category are as follows:

1) Firstly, this may not be a stable diagnostic entity. Studies have shown that early aggressive behaviour or aggression-like behaviour is not strongly predictive of a sustained pattern of aggression in later life. Moreover, the fact that there is a higher incidence of aggressiove behaviours cerain age groups (which are often transient), also may point to the fact that this is not a stable diagnostic entity.

2) Secondly, like mentioned earlier, aggressive behaviour can just be a "symptom or "manifestation" of many other underlying psychiatric conditions. For example, a child with an intellectual or learning disability may display aggression-like behaviour out of his frustration and inability to cope with his academic demands. Similarly, a child with a mood disorder may present with aggressive behaviors as an indirect manifestation of his mood symptoms. So, labelling such kind of children as having "aggressive behaviour disorders" will only result in missing out the real underlying pathology causing the aggressive behaviour. In other words, in these case such a diagnosis is akin to "missing the woods for the trees".

3) Thirdly, it is not necessary or correct to "pathologize" behavioural deviations, which are ever so common in this age group. This will only add on to social stigma, social ostracization and have an adverse impact on the child's emotional development..

4) Fourthly, but very importantly are the cultural and ethnic issues. Now, the way a child's behaviour is interpreted is largely dependent on the social environment where the child lives. So, a particular behaviour which is considered socially appropriate in one particular culture may be interpreted as abnormal, inappropriate or as aggressive behaviour in a different culture. For example, a child who has been brought up in a risky or XXXXXXX enviorment may exhibit certain aggressive behaviours, which could have been adapted out of necessity or to safeguard himself. But without taking into account this cultural context, if these behaviours are looked into in isolation, it may appear to be pathological, abnormal or socially inappropriate.

On the other hand the "pros" of having this diagnostic category are:

1) It is a known fact that early intervention for agressive behaiours in childhood can prevent the development into severe personality problems, like anti-social personality disorder and criminality. So, treatment interventions will be effective only if these disorders are diagnosed in childhood itself, when it is easier to correct behavioural problems through behavioural techniques, proper parenting and by providing a structured environment.

2) A common diagnostic entity like "aggressive behaviour disorders" may help clinicians easily identify agressive behaviours which are out of the norm for their age.

3) Provided clearly defined, age-appropriate criteria are established, then the validity and stability of this category would improve and thus diagnosis would become more specific and effective.


Considering these pros and cons, it is clear that a state-of-the-art diagnostic assessment needs to be formulated in order to make the correct diagnosis and not over- or under-diagnose children with agressive beahviours. Such assessment tools should have the following features:

1) Age-appropriate behaviour check lists
2) standardised questionnaires for administering to the child, parents or techers, so that the child's behaviour can be comprehensively assessed
3) Diagnosic assessments should be done by a specialist service, which may include a child psychiatrist or a child psychologist.
4) Often, multiple sittings and in-depth interviews with the parents, child and teachers may be required to clearly understand the child's problems
5) The assessments should be culturally appropriate and also culturally sensitive
6) Since the etiology of aggressive behaviours is multifactorial, the assessment tools shold also adopt a MULTI-DIMENSIONAL approach, taking into account the complex issues like diverse etiological factors, social factors as well as cultural factors.

- Dr. Jonas Sundarakumar
Consultant Psychiatrist

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