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by Daniel F. Connor
Guilford Press, 2002
Review by Jack R. Anderson, M.D. on May 14th 2004
In the 480 pages of this book, Connor has assembled, organized and discussed an
immense treasure-trove of information about a problem that poses an
ever-increasing threat to the very foundations of civilization—the problem of
violence, aggression and antisocial behavior. Connor addresses this problem at
its inception during the developmental periods of childhood and adolescence.
The possibility is raised that early identification of at-risk children and
adolescents, followed by appropriate and persistent intervention, might reverse
the current trends of increasing adult violence, overwhelmed police forces and
over-crowded correctional facilities. Unfortunately, the author notes, a study
of health insurance coverage found that more than four million youngsters, aged
10-18 years, had no coverage at all in the United
States for the year 1995. "In
short, the caveat is that the very youth who need comprehensive, readily
available and long-duration mental health care for CD may not have enough (or
any) mental health insurance coverage—and that mental health treatment without
adequate funding is never satisfactory or effective."
Chapter 1, "Definitions and Subtyping of Aggressive Behavior,"
differentiates between aggressive behaviors that are adaptive—e.g. for self-preservation
or defense of the family or community, and those that are
maladaptive—antisocial and criminal behaviors.
Terms currently used to describe maladaptive aggression vary according to their
social contexts. For example, the same terms may have different meanings in
medical settings than they do in criminal justice studies. It is recommended
that common terminology be adopted for all settings so that research can allow
for more explicit distinction of various types and sub-types. Such distinction
is necessary because of differences in risk factors, etiologies, prognoses and
Chapter 2, "Prevalence of Aggression, Antisocial Behaviors and Suicide,"
gives evidence that the current rates of maladaptive aggression in children and
adolescents, with resultant injuries and deaths, present a serious public
health problem for the United States. Identification and treatment of affected individuals
are among the greatest challenges for professionals in juvenile justice,
educational, psychiatric and mental health treatment settings.
Chapter 3, "Stability, Impairment and Desistance," discusses the
importance of early differentiation of sub-types so that those who will have
lifelong antisocial behavior patterns are identified and treated early.
Chapter 4, "Categorical Psychiatric Diagnoses and Aggression," points
out that aggression in the context of these diagnoses has "multidimensional,
diverse and complex etiologies." There is no simple way to explain or
understand such aggression.
These first four chapters taken together may be considered as a section
intended to acquaint us with the nature and scope of the aggression problem.
The next four chapters, chapters 5 through 8, consider the various social and
biological factors that are found to be associated with increased maladaptive
"Chapter 5, "Risk and Protective Factors in Aggression and Related
Behaviors," defines risk factors as "conditions and influences that
predispose children and adolescents to the maladaptive expression of aggressive
behavior," and protective factors as "contingencies that shield
youngsters from the influence of risk factors."
Individual risk factors discussed are: heritable factors; temperament;
infant-caregiver attachment; exposure to neurotoxins (prenatal alcohol, fetal
cocaine, prenatal and childhood lead); academic underachievement and academic
failure; and body size and build.
Family risk factors include: ineffective
parenting practices; family functioning; family structure; parental
psychopathology; and child abuse and neglect.
Extrafamilial risk factors considered are: peer
factors; social deprivation, community factors (collective efficacy,
neighborhood violence, availability of firearms and media violence).
Protective factors are presented in tabular form. They include: easy
temperament; higher IQ; internal locus of control; high self-esteem; academic
competence; social competence; competence in activities; good parent-child
relations; external supports; friendships and availability of opportunities.
Chapter 6 discusses psychobiological factors, and chapter 7
neurobiological factors associated with aggressive behaviors. Chapter 8
presents the results of research that attempts to identify and test "multivariable
models of the development of early-onset aggression and related behaviors in
children and adolescents."
Throughout this four-chapter section the author expresses
disclaimers of any sort of deterministic orientation toward aggressive
behaviors. Risk factors are frequently described as "correlative, not
causal. In chapter 5 summary, Connor writes: "Most of the associations
between these factors and behavioral outcomes are correlational and not causal;"
and in chapter 8 summary we find this sentence: "It is important to
highlight the idea that this research does not find biological processes to be
deterministic for antisocial outcomes (McCord, 1996); rather, the degree to
which biological factors determine outcomes varies in relation to environmental
conditions, as well as the variability in biological risk factors."
Despite the author's denials, this reviewer finds the orientation
of the book to be generally deterministic. There is little said about the child's
or adolescent's ability to choose pro-social rather than antisocial behaviors,
despite the accumulation of risk factors and lack of protective factors in his
Chapter 8, "Issues in Female Aggression and Related
Behaviors," discusses gender differences in the quality and quantity of
aggression and related behaviors. Research is quoted to confirm that "the
individual, family and environmental correlates of aggression and antisocial
behaviors are generally similar in males and females." The findings of
some laboratory studies suggest that testosterone is related to aggression,
anger, and violence in adult females, as it is in adult males. However, in
adolescent females, studies found no such relationship. In the chapter summary,
the author concludes: "Although males tend to be more aggressive than
females at all developmental ages throughout the lifespan, female aggression is
neither uncommon, trivial, nor unimportant."
The last three chapters, 10 through 12, are concerned with
planning and carrying out treatment plans for children and adolescents with
aggressive and antisocial behaviors.
Chapter 10, "Clinical Assessment, Case Formulation and
Treatment Planning," contains a detailed table of goals and specific
content areas for the assessment of children and adolescents with conduct
disorder. This table considers appropriate goals and content areas for the
child; the family; larger systems in the environment; and treatment resources
and expertise available in the clinical setting. Some specific assessment
techniques discussed are: structured diagnostic interviews, behavior rating
scales, and direct behavioral observation. The last section in the chapter
presents a plan for conducting a forensic assessment—assessing the risk of harm
to others. Although there are risk factors known empirically to be related to
future violence, the author warns that "None of these risk factors are
powerful enough alone or in combination to produce individual predictions with
Chapter 11, "Psychosocial Interventions," discusses
family interventions, cognitive-behavioral skills training, and prevention
programs. In a summary of prevention programs, Connor writes: "The
characteristics of successful programs include (1) multimodal interventions that
target family supports and early childhood education (interventions with only a
single focus are much less effective); (2) interventions of sufficient
intensity delivered on a daily to weekly basis; (3) sufficient duration of
intervention (at least 2 years and often longer); (4) use of interventions
shown to be effective in ameliorating known psychosocial mechanisms that
increase risk for CD; (5) interventions that begin early in a child's life
(between ages 0 and 6 years); and (6) collaboration among community, school,
and mental health professionals. Prevention programs that have these
characteristics appear to reduce CD during a child's development."
Under the heading "Treatments That Appear Not To Work,"
the author includes psychoanalysis and group therapy.
In the final chapter, "Psychopharmacological Treatments,"
the author warns that "there is a very real risk that nonmethodically
conducted medication trials may result in the exposure of aggressive youth to
multiple ineffective medications, each with the potential for adverse side
effects or drug-drug pharmacological interactions that may impair the
youngsters' quality of life." With this caveat, however, he reports
studies that demonstrate the effective use of neuroleptics, antipsychotics,
mood stabilizers and stimulants in selected cases of childhood and adolescent
Connor writes very clearly. The only suggestion this reviewer can
think of to increase the book's readability is to add a glossary of
abbreviations. For example, here are some I came across in a few pages: AACAP,
ADHD, ADHD-PHI, ANS, ASPD, BAS, BD, BIS, CD, CDC, CPS, CSF, CNS, DA, DSH, DSM,
EDA, ECF, ERP, HRL, HRR, MDD, MDI, NE, OCD, ODD, PCL, PCL-R, PFC, PTSD, SC,
SCL, SES, SF's, and SUD. A glossary in the form of a bookmark could save the
readers—who represent so many different disciplines—a lot of time.
Some idea of the amount and the breadth of material Connor has accumulated,
organized and discussed in this book, can be gained by considering the 78-page
list of references. There are 17 or 18 references per page, alphabetized by
authors, making a total of over 1300 if my arithmetic is correct. If and when
the book is re-published, this reviewer would recommend adding a few more. On
page 134, there is a section "Body Size and Build," and the terms "endomorphic",
"mesomorphic" and "ectomorphic" are used. I believe this
section would justify the inclusion of W. Sheldon,'s "Varieties of
Delinquent Youth" New York 1949, as well as his two previous volumes, "Varieties
of Human Physique" and "Varieties of Human Temperament"; E. Kretschmer's
"Physique and Character" Berlin 1948; and P. Schilder's "The
Image and Appearance of the Human Body" London 1935.
Hopefully, Connor's explanations of the root causes for the
constantly increasing violence in our society will come to the attention of
politicians, insurance providers, and the health-care industry, so that funding
will be provided for the remedial treatment Connor recommends.
© 2004 Jack R. Anderson
Jack R. Anderson, M.D. is a retired psychiatrist living in Lincoln, Nebraska.