Case study: Use of propranolol to reduce aggressive behavior in a woman who is mentally retarded

Although neuroleptic medications are frequently used to treat the aggressive behavior of persons with mental retardation, little empirical support exists for their efficacy. In the case study reported here, the beta-blocker propranolol was used to treat the aggressive behavior of a 23-year-old woman with severe mental retardation. Initiation of treatment was correlated with a dramatic decrease in aggression and a less pronounced improvement in self-injurious behavior (SIB). An increase in resting heart-rate was associated with a significant increase in aggression, and progressive increases in propranolol dosage were correlated with reductions in heart rate and in significant behavioral improvement. Consideration of propranolol as a less intrusive, and possibly more effective, pharmacologic treatment for the aggressive behavior of persons with mental retardation is discussed.     

Self-directed and other-directed aggressive behavior in a forensic sample.

Fifty habitually aggressive men were assessed for self-directed aggressive behavior (SDAB) and other-directed aggressive behavior (QDAB). Subjects displaying SDAB were compared with subjects exhibiting exclusively ODAB. The former were found to engage in more frequent acts of verbal aggression, physical aggression against objects, and physical aggression against others, as well as in more severe acts of verbal aggression and physical aggression against others. They were also more likely to receive diagnoses of mental retardation, organic personality disorder, intermittent explosive disorder, or autism. Findings are consistent with the presence of a neurologically based behavioral dyscontrol in the SDAB subjects.     

Impulsive and premeditated subtypes of aggression in conduct disorder: differences in time estimation

Research aimed at identifying and studying subtypes of aggression have historically dichotomized aggressive subtypes, although specific nomenclature has varied; one approach has been to classify aggressive behavior as predominantly impulsive or predominantly premeditated. There are a number of behavioral and cognitive differences between those exhibiting these different forms of aggression. This study was designed to extend understanding of the impulsive/premeditated aggression dichotomy by comparing time estimation among adolescents exhibiting predominantly impulsive or predominantly premeditated forms of physical aggression who have a psychiatric diagnosis of conduct disorder (CD). Time estimation has previously been shown to be disrupted in impulsive and some aggressive individuals. Time estimation was compared between healthy Controls (n = 37) and two groups of adolescents with CD, those with histories of either predominantly impulsive (CD-Impulsive, n = 26) or predominantly premeditated (CD-Premeditated, n = 38) aggressive behaviors. Participants completed five computerized trials during which they estimated when 1 min had passed. Among aggressive adolescents with CD, the misperception of time was specific to those with histories of impulsive aggression, although time estimates improved with repeated testing and performance feedback. This study confirms the importance of considering the role and type of physical aggression when studying heterogeneous diagnostic groups like CD and supports the relevance of time estimation to certain subgroups of adolescents with CD.     

The relationship between impulsive verbal aggression and intermittent explosive disorder

Intermittent explosive disorder (IED) is the sole psychiatric diagnostic category for which aggression is a cardinal symptom. IED focuses on physical aggression, but researchers have argued for the inclusion of verbal aggression (VA) (e.g., arguing, threatening) as a part of the IED criteria set. The utility of VA in identifying clinically relevant aggression, however, is unknown. IED participants were compared to individuals without a marked history of physical aggression, but who report frequent (two or more times a week) VA, and non-aggressive personality-disorder individuals on behavioral and self-report measures of aggression, self-report measures of related constructs (e.g., anger, affective lability), and a clinician assessment of psychosocial impairment. Both the IED and VA groups were more aggressive, angry, and clinically impaired than personality-disorder individuals, while the IED and VA groups did not differ from each other on these measures. These results support the clinical importance of frequent VA for future iterations of the IED criteria set.     

Health-promoting physical activity of adults with mental retardation

This literature review describes the physical activity behavior of adults with mental retardation consistent with the U.S. Surgeon General's recommendation of 30 minutes of moderate intensity physical activity on 5 or more days per week. The proportion of participants achieving this criterion ranges from 17.5 to 33%. These data are likely to be generous estimates of activity as individuals included in physical activity studies to date have been relatively young and healthy volunteers with mild to moderate limitations. Major sources of physical activity were walking and cycling for transport, chores and work, dancing, and Special Olympics. There is a pressing need to conduct studies using appropriately powered representative samples and to validate measures that assess physical activity less directly; including methodologies in which proxy respondents are used. Accurate information about existing patterns of behavior will enhance the development of effective strategies to promote physical activity among persons with mental retardation.     

Brief report: Non-intrusive operant analysis of aggressive behavior in persons with mental retardation

A procedure for operant analysis of aggressive behavior was derived from multi-element assessment methods that have been previously applied to both self-injurious and stereotypic responding. Analog sessions included No Interaction Baseline, Social Disapproval, Demand, Social Reinforcement, and Discriminated Extinction conditions, repeatedly presented within a multi-element design. Three men with differing severity of mental retardation, communicative deficits and aggressive behavior were exposed to multiple brief analog sessions embedded within their normal meal-time routines in group home settings. Mean frequencies of aggressive behavior and concurrent eating indicate that, while aggressive behavior was negatively reinforced in all three participants, both social and non-social contingencies were also prominent. The same contingencies which have been demonstrated to maintain self-injury and stereotypic behavior can therefore also maintain aggression. Results suggest the feasibility of conducting relatively non-intrusive analog assessments in community residences, and support the-extension of functional analysis across differing classes of aberrant behavior.     

Neural correlates of intertemporal choice in aggressive behavior

People often have to make decisions between immediate rewards and more long-term goals. Such intertemporal judgments are often investigated in the context of monetary choice or drug use, yet not in regard to aggressive behavior. We combined a novel intertemporal aggression paradigm with functional neuroimaging to examine the role of temporal delay in aggressive behavior and the neural correlates thereof. Sixty-one participants (aged 18–22 years; 37 females) exhibited substantial variability in the extent to which they selected immediate acts of lesser aggression versus delayed acts of greater aggression against a same-sex opponent. Choosing delayed-yet-more-severe aggression was increased by provocation and associated with greater self-control. Preferences for delayed aggression were associated with greater activity in the ventromedial prefrontal cortex (VMPFC) during such choices, and reduced functional connectivity between the VMPFC and brain regions implicated in motor impulsivity. Preferences for immediate aggression were associated with reduced functional connectivity between the VMPFC and the frontoparietal control network. Dispositionally aggressive participants exhibited reduced VMPFC activity, which partially explained and suppressed their preferences for delayed aggression. Blunted VMPFC activity may thus be a neural mechanism that promotes reactive aggression towards provocateurs among dispositionally aggressive individuals. These findings demonstrate the utility of an intertemporal framework for investigating aggression and provide further evidence for the similar underlying neurobiology between aggression and other rewarding behaviors.     

The aggression-coercion cycle: Use of seclusion and restraint in a child psychiatric hospital

The widespread use of seclusion and restraint in child psychiatric hospitals to manage aggression and noncompliance is based on the assumption that coercive consequences reduce the frequency of undesirable behaviors exhibited by the patients. We report a study of the use of seclusion and restraint in a public child psychiatric hospital during a 3-year period. Twenty-eight percent of the patients had been secluded or restrained a total of 1670 times. About 25% of these patients had been secluded more than five times during their hospitalization, and 32% had been placed in restraints more than once. Behaviors that typically resulted in repeated seclusion included physical aggression toward staff, verbal aggression toward peers, non-compliant or oppositional behavior, and self-harm. Variables that predicted patients most at risk for repeated seclusion included age, gender, and psychiatric diagnosis. The predictor variables for those most at risk for repeated restraint included age, property destruction, and self-harm. The high rates of use of seclusion and restraint suggest that these methods for controlling the behavior of children and adolescents in this child psychiatric hospital may not have been therapeutic. We suggest that staff in such hospitals engage in a pattern of behavior characterized by an aggression-coercion cycle, in which increasingly aggressive and coercive behaviors are exhibited by both patients and staff.     

内隐/外显不同水平攻击者的注意偏向：行为和ERP证据

通过行为实验（点探测）和ERP实验（情绪Stroop）两个实验任务,考察了内隐/外显不同水平攻击者的注意偏向及其脑机制。结果表明：高外显攻击者对愤怒面孔存在注意偏向;高外显攻击者在愤怒面孔上的N100波幅显著低于中性面孔,表明其注意分配和调节能力较弱;高外显攻击者较之低外显攻击者的P300波幅更小表明其存在注意等方面的认知加工缺陷,N400波幅更小表明其对愤怒面孔进行语义编码时加工更为流畅;外显攻击组与内隐攻击组在FCz和Cz电极点上不同。这为内隐/外显攻击二者有着独立结构提供了行为与认知神经科学的证据。     

INTERSPERSED REQUESTS: A NONAVERSIVE PROCEDURE FOR REDUCING AGGRESSION AND SELF-INJURY DURING INSTRUCTION

Interspersed requests are simple commands, with a high likelihood of being followed correctly, that are interspersed among instructional trials to increase the probability that a learner will attempt to perform new or difficult tasks without engaging in aggression or self-injurious behavior. This report presents two assessments of the effect of interspersed requests on aggression and self-injury during instruction. The participants were individuals with severe mental retardation who used aggression and self-injury to avoid difficult instructional situations. Results from both studies indicate that interspersed requests were effective at increasing the responsiveness of the learners to instructions and reducing levels of aggression and self-injury.     

个体攻击性对愤怒表情类别知觉的影响

探讨了个体攻击性对愤怒表情加工中反应偏向和敏感性的影响。使用愤怒、恐惧原型生成表情连续体作为实验材料, 采用类别知觉实验范式考察了高、低攻击个体识别和辨别愤怒-恐惧连续体的类别转折点和斜率。结果发现, 与低攻击个体相比, 高攻击个体识别愤怒-恐惧连续体类别界线处的曲线斜率更大; 高攻击个体具有类别界线向恐惧一端偏移的倾向, 但并没有达到统计显著。这表明, 高攻击个体不存在敌意归因偏向, 而是对愤怒和恐惧表情的转变具有更高的敏感性。     

Association of Normative Beliefs and Anger with Aggression and Antisocial Behavior in Russian Male Juvenile Offenders and High School Students

Examined the association of anger experience and two types of normative beliefs with physical aggression and nonaggressive antisocial behavior in 361 juvenile offenders and 206 high school students in Russia. All participants were male and ranged in age from 14 to 18 years. Higher frequency of aggressive acts was significantly associated with higher levels of anger and stronger beliefs that physical aggression is an appropriate course of action in conflicts. After statistically controlling for nonaggressive antisocial behavior, the relationship between physical aggression and antisocial beliefs was not significant. Similarly, with physical aggression controlled, nonaggressive antisocial behavior was uniquely associated with approval of deviancy, but not with anger or beliefs legitimizing aggression. Juvenile offenders reported higher levels of anger experience and higher frequency of aggression and antisocial behavior compared to high school students. There were no differences in normative beliefs between these two groups. This specificity of association of social-cognitive and emotion-regulation processes to aggressive and nonaggressive forms of antisocial behavior may be relevant to understanding the mechanisms of cognitive-behavioral therapy for conduct disorder and antisocial behavior.     

Prevalence of severe behavior disorders in persons with mental retardation and treatment procedures used in community and institutional settings

A statewide survey of moderate and severe behavior disorders in persons with mental retardation in institutional and community settings was conducted. Information on the treatment procedures used and the adequacy of available resources in both settings was also gathered. Results indicated that community staff had considerably less experience than institutional staff in dealing with serious behavior disorders exhibited by persons with substantial cognitive and physical impairments. The types of aberrant behaviors with the highest prevalence rates showed differences in the institutions and the community. The largest differences in prevalence rates for severe behavior disorders in the two settings occurred for aggressive and self-injurious behaviors. Community staff thus had appreciably less experience than institutional staff in designing interventions for severe aggressive and self-injurious behaviors. About half of the identified individuals in both settings received psychotropic medications. Institutional staff were most likely to use restrictive behavioral procedures than community staff. Findings indicated that the most restrictive procedures were used primarily with only certain severe behavior disorders. Subjective ratings of the overall effectiveness of interventions were lower by community than institutional staff. The usefulness of the obtained data base for statewide planning in the area of behavioral supports is discussed.     

FUNCTIONAL ANALYSIS AND TREATMENT OF ESCAPE-MAINTAINED AGGRESSION CORRELATED WITH SLEEP DEPRIVATION

Functional analysis identified the consequences that maintained aggressive behavior and the relationship between those consequences and sleep deprivation for an individual with severe mental retardation. Results showed that aggression was maintained by negative reinforcement contingencies (escape from demand) and that aggression was more severe when sleep deprivation was present. A multicomponent intervention resulted in reductions of aggression for up to 7 months.     

Suicidal threats and behavior in a person with developmental disabilities: Effective psychiatric monitoring based on a fundamental assessment

A psychiatric monitoring procedure was designed to better manage and treat suicidal behavior and threats in a person with moderate mental retardation, and psychiatric disorders. During the baseline suicidal threats and behavior were managed by assigning the person a counselor available to discuss his problems, keeping him in eyesight at all time, admission to the state school infirmary, counseling from his physician, and admission to a Multiple Disabilities Unit (MDU) located in a state hospital located 2 hr drive away from the state school in which he lived. A functional assessment indicated that these behaviors were not related to depressed mood or a depressive disorder. Rather, they were socially mediated operant behaviors in a person with poor impulse control, in which the attempts to manage the behaviors by the interdisciplinary team might have been counter-habilitative. A psychiatric surveillance procedure was based upon this functional assessment. The procedure consisted of increasing the number of apparently pleasurable activities available on the living area, asking for a no harm agreement following suicide threats or attempts, social isolation for 12–36 hr immediately contingent upon failure to give a no harm agreement, and release from social isolation contingent upon a no harm agreement. Data showed that this procedure was completely successful in reducing admissions to the MDU over a 7 month period. The social isolation was typically used once a week for approximately 25 hours over the 7-month period. It was noted that considerable savings were made by not using admissions to the state hospital over a 7-month period. Functional assessment can form the basis of developing and evaluating a variety of procedures relating to challenging behavior in persons with dual diagnosis including management of suicidal threats and behavior.     

Measuring direct and indirect aggression: behavior of is there a response bias?

Critics of self-report methods suggest that participants are likely to underreport their own negative behaviors given concerns about social desirability. The current study examined the problem of self-report bias by comparing individuals' estimates of their own and others' aggressive behavior. Undergraduate students (95 women, 50 men) completed the Richardson Conflict Response Questionnaire with regard to either their own behavior or that of another person of the same sex. As expected, participants reported significantly less aggression for themselves than for others. However, self and other ratings showed the same pattern of sex differences. These results suggest that, although individuals may underreport their own aggressive behaviors, this tendency may not affect relationships among variables.     

EVidence for dorsolateral and orbital prefrontal cortical involvement in the expression of aggressive behavior

Numerous studies have implicated the role of the prefrontal cortex in the expression of aggressive behavior. However, the nature of this relationship remains poorly understood. As such, the purpose of this article is to review both the animal and human literature pertaining to prefrontal cortical functioning and aggression in an attempt to help clarify this relationship. Particular attention is paid to differentiating the functions of the dorsolateral and the orbital regions of the prefrontal cortex in the expression of aggression. Evidence was garnered from four different types of studies: 1) those examining aggressive behavior in animals following ablations to the prefrontal cortex; 2) those examining aggressive behavior in humans following surgical and accidental lesions to the prefrontal cortex; 3) those examining prefrontal cortical functioning in individuals with psychiatric disorders characterized by aggression; and 4) those relating prefrontal cortical functioning to human aggressive behavior in laboratory situations. The general conclusion of this article is that the dorsolateral region of the prefrontal cortex is more likely to be involved in the expression of physical aggression whereas the orbital region is more likely to be involved in the expression of what is termed herein “disinhibited-nonaggressive” behavior. © 1995 Wiley-Liss, Inc.     

Prevalence of dual diagnosis in an institution for individuals who are developmentally handicapped

The prevalence of dual diagnosis (developmental handicap with accompanying mental illness) was examined in a population of 71 persons who are institutionalized and developmentally handicapped. The Reiss Screen for Maladaptive Behavior (Reiss, 1988) revealed that 69% of the popula- tion had a dual diagnosis. The incidence of dual diagnosis was not related to level of functioning, although the type of psychopathology varied considerably across levels of functioning. In contrast to findings from the Reiss Screen, previous psychiatric diagnosis indicated a much lower rate of dual diagnosis (26.8%), as did current psychiatric assessment. There was little agreement between the two psychiatric assessments, or between the Reiss Screen and the psychiatric assessments. The Reiss Screen appears to provide information of more practical value for community placement decisions than is provided by the psychiatric assessments. Limitations to the concept of ?dual diagnosis’? for characterizing the mental health needs of persons with a developmental handicap are discussed.