Self- and other-directed aggression in child and adolescent psychiatric inpatients.

OBJECTIVE: To examine self- and other-directed aggression in 89 children and adolescents on a psychiatric inpatient unit to determine ways in which aggressive and nonaggressive patients differ and to discover those factors associated with self-directed versus other-directed aggression. METHOD: Three types of data were collected: ongoing observations of aggressive behavior during hospitalization, Child Behavior Checklists completed by a parent or guardian at admission, and patient and family history data gathered from a retrospective chart review. RESULTS: Compared with nonaggressive patients, aggressive patients were more likely to have a history of antisocial behavior, to be victims of abuse or neglect, to have lived in a foster home, and to have had several primary caretakers. Both groups of aggressive patients engaged in three types of aggressive behavior with equal frequency and were strikingly similar on a host of other variables. Only the number of primary caretakers with whom a patient had lived discriminated self- from other-directed aggressive patients; patients who experienced frequent disruptions in caretaking were likely to engage in acts of self-injury during hospitalization. CONCLUSIONS: Whether a particular patient will engage in aggressive behavior during hospitalization can be accurately predicted from preadmission characteristics; however, the manner in which a patient is likely to aggress, i.e., toward others or self, is difficult to predict because of striking similarities between types of aggressive patients. Further investigations are needed to determine how self- and other-directed aggressive patients differ and to elucidate relationships between disrupted, unstable, or inadequate caretaking and aggression, particularly self-injury, in children and adolescents.

Interactions between parents and pediatric primary care physicians about children's mental health.

Interaction patterns between parents and pediatricians were examined during 1,378 well-child visits to four public and private pediatric clinics. During 327 visits, parents listed at least one psychosocial concern related to their child's mental health. At 37 percent of these visits, parents said they did not wish to discuss the concern with the physician. Physicians failed to address concerns during approximately 35 percent of visits at which parents were willing to discuss them. Successful parent-physician interactions were three times more frequent in private practices than in a public clinic; they were more likely when fewer concerns were stated and less likely when behavior problems were the concern. Parents concerned about the parent-infant relationship were four times more likely to be referred to outside mental health services, although these cases were relatively rare. Older children and families receiving Medicaid were also more likely to be referred to such services.

Temperament characteristics and clinical outcomes in young children with diabetes mellitus.

Thirty-four children with diabetes and their mothers were studied to investigate the relationship between individual differences, as measured via the temperament construct, and disease-related indices. Analysis of variance revealed that child characteristics such as age, sex, duration of disease, higher activity level, and shorter attention-span were related to behavioral compliance. Multivariate discriminant analyses revealed that combinations of certain child and maternal characteristics were highly efficient in distinguishing between children in adequate vs poor glycemic control and behavioral compliance. The optimum model for classification of regimen adherence used a combination of child characteristics. The optimum model for glycemic control used both child and parent temperament characteristics.

Young children's subjective reports about their diabetes mellitus: a validation of the Diabetes Pictorial Scale.

The authors report on a validation study using the Diabetes Pictorial Scale (DPS), a measure of disease-related attitudes, behaviors, and knowledge specifically designed for use with younger children with insulin-dependent diabetes mellitus (IDDM). Results of this study, based on the responses of 39 children ages 4 to 10, suggest that the DPS demonstrates sufficient variation between and within patients to merit further field-testing of the technique. Preselected DPS items hypothesized to affect metabolic control in IDDM were examined in this study and compared with glycosylated hemoglobin (HbA1) values collected concurrently. Children's reports concerning adherence to their dietary plan, the regularity of insulin injections, and the regularity of meals/snacks were related to glycemic control. Broader issues pertinent to the utility, reliability, and validity of children's subjective reports are briefly discussed within the context of demand characteristics in the IDDM provider-patient interaction.

Aggression and counteraggression during child psychiatric hospitalization.

The article reports on a 1-year descriptive study of aggressive incidents and staff counteraggressive strategies within a child psychiatry inpatient unit. Ninety-nine child/adolescent patients produced a total of 887 reportable aggressive incidents during the 12-month study period. Seclusion, activity restriction, physical restraint, and administration of p.r.n. medication were studied in relation to patient aggression. Results of the study confirm the hypotheses that (1) much patient aggression within defined clinical contexts conforms to patterns of prediction directly related to person and environmental variables, and (2) the primary value of counteraggression strategies such as seclusion and restraint resides in the acute management of aggressive children and not in long-term therapeutic functions. The article offers some recommendations for new research in this general area as well as suggestions for clinical applications of these methods.

Predicting violent behavior in psychiatrically hospitalized boys.

A naturalistic study of violent behavior in a sample of 100 boys residing within an inpatient psychiatric facility is reported. Over 1000 recorded incidents of interpersonal aggression were used to explore patterns of male violence in a contextually defined setting. Findings include a proportionately greater incidence of violence in younger boys. Staff members, particularly males, were more likely to be the victims of interpersonal violence, but peers and staff were equally likely to be the target of aggressive behavior in general. Observable provocation in the social context, the age of the child, and choice of victim (staff vs. peer) were found to be important predictors within a logistic regression model of violence. An estimate of the predictive utility of a logistic model for the occurrence of violence was found to be too low for clinical purposes. An application of a descriptive statistical method to collections of incidents for five highly aggressive boys yielded idiopathic models of violent behavior. Predictive accuracy estimates from these models suggest that multivariate description of behavioral data can be a clinically useful tool in understanding and possibly preventing violence within defined contexts such as residential psychiatric facilities.