ReviewAggressive behaviour and violence in children and adolescents with FASD: A synthesizing review
Introduction
It is long standing wisdom that how we interpret and respond to behaviour is predicated on our understanding of it. In fact, researchers have asserted that our ability to provide efficacious interventions for children and adolescents is grounded in understanding all facets that contribute to the presenting behaviour(s), including the biological, environmental, and social domains that drive the behaviour (Fried and Fisher, 2014). Aggressive behaviour among children and adolescents has been referred to as a global health concern (Krug et al., 2002), and internationally is reported to be the leading contributor of youth psychiatric referral (Connor, 2004; Pikard et al., 2018). One disorder that poses a particularly elevated vulnerability for aggressive behaviour is Fetal Alcohol Spectrum Disorder (FASD; Lange et al., 2018). Therefore, it is becoming increasingly important for clinicians and caregivers to truly understand aggressive behaviour and all of the mechanisms that drive it—perhaps especially among children and adolescents with neurodevelopmental differences, such as youth with FASD. According to the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5; American Psychiatric Association, 2013) FASD is classified as a neurodevelopmental disorder (NDD) that is caused by the maternal consumption of alcohol during pregnancy (see also Franklin et al., 2008; Jones and Smith, 1973). Consistent with other NDDs, symptoms associated with FASD become evident during development (i.e., childhood/adolescence) and may include significantly impaired cognition, behaviour and social functioning, (i.e., deficits in learning, language, motor abilities, and neuropsychological functioning; Alabaf et al., 2019). The impairments typically impede daily living (Skorka et al., 2020), and persist across the lifespan (Kelly et al., 2000; Novick Brown et al., 2012; Streissguth et al., 1991).
With an estimated global prevalence of between two and 5% of the general population (May et al., 2018; Popova et al., 2019), FASD is considered a global health concern. In fact, the Centre for Disease Control and Prevention (CDC) recently named FASD as the single leading cause of developmental disability (Centers for Disease Control and Prevention, 2021). FASD also poses significant financial burden through costs associated with social service involvement, foster care, urgent care, mental health referrals/support, and corrections (Popova et al., 2015). Additionally, in the Canadian criminal justice system, youth with FASD are overrepresented in the corrections system, and are at 19-times the risk of incarceration, relative to those without an FASD diagnosis (Popova et al., 2011). What is clear in the present literature, is that aggressive behaviour exhibited by youth with FASD typically leads to risky and criminal behaviour during adolescence and into adulthood (Wyper and Pei, 2016). However, our understanding of all of the mechanisms driving the aggressive behaviour is limited.
In terms of aggressive behaviour for youth with NDDs in general, researchers have identified neurological (Sugden et al., 2006), cognitive (Riccio et al., 2011), genetics (Stoff and Cairns, 2014), emotional (Powell et al., 2010), and environmental (Liu et al., 2013) contributing factors. In elucidating these factors, researchers have sought to describe some of the contributions to aggression, in an effort to highlight the complexity of the behaviour, and unique considerations that may be warranted for groups with brain-based differences. This has been particularly true for individuals with FASD, for whom high rates of aggressive behaviour have been reported (Lange et al., 2018). In review of aggression and violence within this population, researchers have described the lifelong neurocognitive and emotion regulation challenges associated with FASD (e.g., Flannigan et al., 2020; Fuglestad et al., 2015; Novick Brown et al., 2012) and have highlighted the social complexities of FASD and aggressive behaviour (Kelly et al., 2000). Collectively, these reviews have taken important steps in describing and defining aggressive behaviour in ways that are destigmatizing as they suggest there are unique intersections of key factors that warrant consideration when responding to the needs of individuals with FASD. Accordingly, it is our intension to build from this knowledge, and take the next step, by carefully identifying and then integrating the genetic, biological, psychological, and social factors that in combination warrant unique consideration that extends beyond currently accepted models of aggression. We seek to clarify predisposing and perpetuating mechanisms, and to present them in a practically applicable way. To this end, our aim is to bolster our present, integrative understanding of aggressive behaviour and FASD, to help facilitate consistent interpretation and preparation for response to aggressive behaviour in this population. Models are important starting points for establishing shared understanding, identifying key factors to target through intervention, and providing a defined starting point for research that may further delineate understandings and ultimately inform intervention initiatives.
To facilitate shared understanding, interpretations, and consistent responses to aggressive behaviour, an integrated, evidence-informed model of aggressive behaviour is needed. To this end, there are three objectives to the present review: (1) Synthesize the present literature to enhance our understanding of aggressive behaviour, and the mechanisms that drive it, for children and adolescents with NDDs, generally; (2) Identify and integrate information specific to the elevated vulnerability for aggressive behaviour that FASD poses; and (3) Utilize the information derived from the research synthesis to propose frameworks, in the form of two corresponding models, for recognizing and responding to aggressive behaviour via all of the factors that drive it, through a neurodevelopmental lens. The intention for the models is to provide a framework as a first step towards consistent formal intervention and evaluation practices. At present, we introduce these frameworks to be applied more broadly than formal intervention. For example, to help guide an informed and practical, day-to-day understanding of aggressive behaviour among parents, teachers, family support workers, and other mental health professionals (e.g., psychologists, psychiatrists, social workers) currently working with youth with FASD, or other neurodevelopmental disorders. Our perceptions and understanding of aggressive behaviour influence the way that we respond, and consequently also impact the likelihood of future aggressive behaviour (Sukhodolsky et al., 2016). Next steps for these frameworks will include empirical testing to identify impacts on understandings, as well as examination intervention impacts, and ways in which intervention may be optimized within these frameworks.
Section snippets
What is aggressive behaviour?
Definitions of aggressive behaviour are diverse. For instance, some researchers discuss the behaviour in terms of aggression (e.g., Dileo et al., 2017), where aggression is typically defined as a behaviour that is directed outwards with the potential to cause harm (Baron and Richardson, 1994). Other researchers (e.g., Liu et al., 2013) operationalize aggression as aggressive behaviour, or an observable manifestation of the aggression (Zirpoli, 2008). Some specifically focus on violence, a
Cognitive contributors to aggression
Aggression is highly heritable and the genes that govern traits associated with aggression also interact with the environment. Genetic manipulation work, among animals, led to the conclusion that aggression can be selected for, as it is true for coat length, temperament, and sense of smell (Gariepy et al., 1996). Unlike the simple Mendelian single gene transmission, heritability of traits like aggressiveness follows a complex quantitative pattern. Estimating heritability of aggression (30–65%)
Environmental contributors to aggression
Several environmental and/or social contributors to aggressive behaviour have been identified, including: Low income (Mazza et al., 2017), hostile or inconsistent parenting, and family conflict (Campbell et al., 1996; Malone and Koren, 2012), as well as difficulties with peer relationships (Evans et al., 2015) and susceptibility to delinquent peer influence (Maschi and Bradley, 2008). Perhaps most notably, children and adolescents who are exposed to adverse (or traumatic) childhood experiences
Integrating environmental and cognitive factors in youth with FASD
For children and adolescents with FASD, a complex interplay of neuropsychological functioning and environmental conditions exists (Mela et al., 2018). Building on the notion of a “double jeopardy”, used to describe the dual risk factors of biology and environment (Coggins et al., 2007; Olson et al., 2009; Pei et al., 2016), it should also be noted that the highest risk for aggressive behaviour is when both the prenatal and the postnatal environments are unhealthy (Dixon et al., 2008).
Emotional contributors to aggression
In both animals and humans, excessive emotion, or the excessive experience of emotions can lead to aggressive behaviour (Puhalla and McCloskey, 2020; Vitiello and Stoff, 1997). Emotion dysregulation is regarded as the experience of high emotionality that is contextually inappropriate and reflects deficits in the ability to self-regulate in the face of a high emotional state (Lima et al., 2018), exert emotional control (i.e., Pompili et al., 2017), and correctly identify emotions (Cohen and
Emotion dysregulation as a gatekeeper
Thought, affect, and action are interconnected (Abramowitz et al., 2003), and their interconnectedness influences behaviour (Malone and Koren, 2012). Accordingly, not only does emotion dysregulation lead to aggressive behaviour on its own, but also acts as a gatekeeper for the cognitive and environmental factors discussed above. Two of the most studied avenues, in the present literature, where emotion dysregulation acts as a gatekeeper for aggressive behaviour are through misinterpreting social
Recognizing and responding to aggression: two models to facilitate action
Aggressive behaviour is complex and multidimensional with a number of underlying cognitive, environmental, and emotional factors that drive it. The use of models to understand and operationalize aggressive behaviour is not new. In fact, previous researchers have acknowledged the complex interaction of biological and environmental factors that elevate vulnerability towards aggressive behaviour, with well-known and established models. For example, Cairns' (1996) model of aggressive behaviour,
Practically applying the models
Following the description of the models, we refer readers to Appendix A for a detailed case example of a young man named “William” who has an FASD diagnosis and frequently demonstrates aggressive behaviour. The case of William (see Appendix A) will be used in this section to help illustrate the practical application of both the Recognition and Responding Models. The Recognition Model of aggressive behaviour could be used as a mechanism to help identify William's pathways towards his aggressive
Limitations and directions for future research
Although these frameworks include an all-encompassing view of reactive aggressive behaviour that is missing in the present literature, there are limitations to note. First, based on their similarities in terms of presentation and deficits, the present review amalgamated NDDs to provide a generalized overview of reactive aggressive behaviour, with links to FASD specifically. Second, although the intention of this review was to provide generalized frameworks that could be used to understand
Summary and conclusions
Collectively, the intention of the review was to synthesize the current literature regarding the underlying mechanisms driving the aggressive behaviour for youth with NDDs generally, and to highlight the elevated risk for youth with FASD. In doing so, several common themes emerged. First, there are cognitive factors that increase the propensity towards aggressive behaviour for youth with NDDs. More specifically, deficits in executive function (Dileo et al., 2017), as well as heightened
Role of funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
Contributors
Jessica J Joseph, Mansfield Mela, and Jacqueline Pei worked collaboratively to conceptualize this project and develop the study protocol. Jessica J Joseph conducted the literature review, provided summaries of previous research, and wrote the first draft of the manuscript. Jacqueline Pei worked as a supervisor to help facilitate the writing of the first (and subsequent) drafts. Mansfield Mela and Jacqueline Pei both took leadership roles in reviewing and editing the manuscript. Jessica J Joseph
Declaration of Competing Interest
The authors do not have any conflicts of interest to report.
Acknowledgements
No acknowledgements.
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