Elsevier

Psychiatry Research

Volume 151, Issue 3, 30 June 2007, Pages 231-242
Psychiatry Research

Characterizing aggressive behavior with the Impulsive/Premeditated Aggression Scale among adolescents with conduct disorder

https://doi.org/10.1016/j.psychres.2006.11.001Get rights and content

Abstract

This study extends the use of the Impulsive/Premeditated Aggression Scale for subtyping aggressive behavior among adolescents with Conduct Disorder. Of the Conduct Disorder symptoms, aggression has the strongest prognostic and treatment implications. While aggression is a complex construct, convergent evidence supports a dichotomy of impulsive and premeditated aggressive subtypes that are qualitatively different from one another in terms of phenomenology and neurobiology. Previous attempts at measuring subtypes of aggression in children and adults are not clearly generalizable to adolescents. Sixty-six adolescents completed a questionnaire for characterizing aggression (Impulsive/Premeditated Aggression Scale), along with standard measures of personality and general functioning. Principal components analysis demonstrated two stable factors of aggression with good internal consistency and construct validity. Compared to the premeditated aggression factor, the impulsive aggression factor was associated with a broader range of personality, thought, emotional, and social problems. As in the adult and child literature, characterization of aggressive behavior into two subtypes appears to be relevant to understanding individual differences among adolescents with Conduct Disorder.

Introduction

Despite the importance of aggression to the prognosis of Conduct Disorder, psychiatrists do not have self-report instruments to characterize this behavior in adolescents. Aggressive behavior is a primary symptom of Conduct Disorder (CD), which is a disturbance emerging during childhood or adolescence that is defined as a pervasive pattern of behavior involving violation of others' basic rights and/or major age-appropriate societal norms (American Psychiatric Association, 2000). Within the CD diagnosis there are four types of characteristic behaviors: serious violation of rules, deceitfulness or theft, destruction of property, and aggression toward people or animals. While multiple factors appear to contribute to the expression of conduct problems and aggressive behaviors (e.g., cognitive ability, parent characteristics, peer relationships, early environmental stress, and demographics), there is little consensus as to what factor, or combination of factors, function as predictors or mediators of treatment outcome (Conduct Problems Prevention Research Group, 2002; for reviews, see Yoshikawa, 1994, Hinshaw, 2002).

On the other hand, it is the expression of the aggressive behavior itself that has been shown to be an important predictor of behavioral health outcomes among those with CD. For example, aggressive behavior (along with Oppositional Defiant Disorder) is a significant predictor for development of CD (Patterson, 1993, Loeber et al., 1998), of treatment outcome (Loeber et al., 1992, Loeber et al., 1993), and of impaired functioning (Loeber et al., 2000) and antisocial behaviors (Lynam, 1996, Huesmann et al., 2002) extending into adulthood. In fact, findings from a 22-year longitudinal study revealed that, while many childhood variables (e.g., low IQ, poor housing, lower parent education) were individually related to criminality in adulthood, these variables “did not add to predicting criminality once early aggression was considered” (Huesmann et al., 2002, p.204). Collectively, these studies indicate that when antisocial behaviors (e.g., destruction of property, physical fighting, and physical cruelty) are present in childhood there is an increased risk for continued psychosocial problems well into adulthood (for reviews, see Olweus, 1979, Yoshikawa, 1994, Frick and Loney, 1999).

While identifying and targeting specific antecedents to antisocial behaviors is undoubtedly important to treatment outcomes, defining and characterizing subtypes of aggressive behavior has a clear influence on research outcomes (Barratt et al., 2000) and implications for determining etiology of, and treatment strategies for, aggressive disorders (Coccaro et al., 1991, Yoshikawa, 1994, Crick and Dodge, 1996, Barratt et al., 1997a, Brown and Partsons, 1998, Vitaro et al., 2002). For these reasons, identifying a valid method for classification of aggression has important clinical as well as research relevance, particularly in light of the growing movement to target pharmacological and non-pharmacological interventions for aggressive behaviors (e.g., Steiner et al., 2003, National Institutes of Health, 2004). The current study was designed to validate the Impulsive/Premeditated Aggression Scale (Stanford et al., 2003a) for characterization of aggressive subtypes among adolescents with Conduct Disorder.

Aggressive behavior is a widely heterogeneous construct, which is one barrier to understanding adolescent aggression. Within the animal literature, at least seven subtypes of aggression have been identified and the behavior among humans is dimensional as well (Vitiello and Stoff, 1997). Important distinctions among aggressive subtypes include: level of planning, appreciation for consequences, and affective intensity associated with the aggressive acts. Based on these distinctions, researchers investigating aggressive subtypes in human adults and young children have commonly concluded that there is a dichotomy of aggressive subtypes that have variously been described as: [a] impulsive, reactive, affective, or non-planned; and [b] premeditated, proactive, instrumental, predatory, or controlled (e.g., Heilbrun et al., 1978, Coccaro, 1989, Atkins et al., 1993, Barratt et al., 1997a, Vitaro et al., 2002, McEllistrem, 2004). For the purpose of this investigation, the terms impulsive aggression and premeditated aggression are used to facilitate comparison to similar adult literature (Stanford et al., 2003a, Kockler et al., 2006). We use the term impulsive aggression to refer to spontaneous aggressive outbursts that are out of proportion to the provoking event, while premeditated aggression describes aggressive behaviors that are planned, controlled, and/or goal-oriented (Barratt et al., 2000).

Individuals classified as expressing either impulsive or premeditated aggressive behaviors differ from one another across a variety of domains, including: social adjustment, emotional function, cognitive ability, biological function, physiological reactivity, and treatment response. For instance, impulsive aggressive adults have diminished language ability (Barratt et al., 1997b) and lower cerebrospinal fluid 5-hydroxyindoleacetic acid concentrations (Linnoila et al., 1983), relative to premeditated aggressors. Compared to non-aggressive adults, impulsive aggressors have reduced executive functioning (Villemarette-Pittman et al., 2002) and decreased cortical activation (Mathias and Stanford, 1999, Houston and Stanford, 2001), as well as central serotonergic dysregulation (Coccaro, 1989, Coccaro et al., 1991, Coccaro and Kavoussi, 1997). Further, impulsive aggression is associated with self-reported impulsivity, neuroticism, physical aggression, and anger (Stanford et al., 2003a). While the adult literature has largely focused on cognitive and biological mechanisms involved in impulsive aggression, the research on childhood aggression tends to focus on social information processing, peer relations, and emotional dysregulation (Dodge et al., 1997, Waschbusch et al., 1998). Specifically, impulsive aggression in children is associated with high levels of hostile behaviors (Atkins and Stoff, 1993, Atkins et al., 1993) and hostile attribution bias (Schwartz et al., 1998). Compared to children with premeditated forms of aggression, impulsive aggressive children have higher ratings on measures of neuroticism, including numerous somatic and anxious/depressive symptoms (Dodge et al., 1997). Socially, impulsive aggression in children is related to rejection and early childhood physical abuse from parents (Dodge et al., 1995) and victimization by peers (Dodge and Coie, 1987, Schwartz et al., 1998). Despite the wide range of cognitive, emotional, social, physiological, and biological disturbances associated with impulsive aggression, individuals expressing this aggressive subtype tend to respond well to pharmacological treatment (Coccaro and Kavoussi, 1997, Barratt et al., 1997a, Stanford et al., 2001, Stanford et al., 2005). Taken together, children and adults who emit predominantly impulsive types of aggression would also be expected to show increased levels of general impulsivity, hostility, and difficulties with cognition, socialization, and mood.

Results from research with individuals who exhibit predominantly premeditated aggression suggests that their overall functioning tends to be better than their impulsive aggressive counterparts. For instance, adults with premeditated aggression have relatively normal performance on tests of executive function (Stanford et al., 2003b), and they emit an appropriate level of cortical activation on physiological measures (Raine et al., 1998, Stanford et al., 2003b). However, relative to impulsive aggressors, adults with premeditated aggression score high on measures of psychopathic traits (e.g., callousness and unemotionality; Cornell et al., 1996), and their aggressive behavior is largely unresponsive to pharmacological intervention (Barratt et al., 1997a). Self-reported premeditated aggression is inversely associated with measures of extraversion, but positively associated with psychoticism, neuroticism, impulsivity, verbal aggression, and physical aggression. Premeditated aggressive adults score high on measures of anger and hostility questionnaires (Stanford et al., 2003a), although children with premeditated forms of aggression do not have elevated hostility/frustration ratings (Little et al., 2003). Children with premeditated aggression tend to expect positive outcomes from aggressive actions and lack remorse or empathy regarding the use of force (Smithmyer et al., 2000), which may lead to the tendency to use aggression as a tool to achieve a desired outcome. Additionally, children who are rated as more premeditated in their use of aggression have relatively normal parent interactions, peer relations, and ratings of self-worth (Dodge et al., 1997) and are less impaired overall in comparison to their impulsive aggressive counterparts (Waschbusch et al., 1998). The child and adult aggression literature together supports the conclusion that premeditated aggression may be best characterized by a disturbance of personality rather than the cognitive or cortico-physiological disturbances observed with the impulsive aggressive subtype.

While there is growing support for the characterization of aggression, classifications of aggressive subtypes from studies of adults and young children provide limited generalizability to adolescents with CD. Studies on classification of aggression have tended to sample either adults (e.g. Barratt et al., 1997a) or young children (e.g., kindergarten through 3rd grade; Dodge et al., 1997) and, as a result, understanding of impulsive or premeditated aggression in the developmentally distinct period of adolescence is limited, despite the long history of interest in adolescent aggression (e.g., Dollard et al., 1939). Further, many of the adult studies examining subtypes of aggression have excluded participants with DSM Axis I and II disorders (e.g., Mathias and Stanford, 1999, Villemarette-Pittman et al., 2002, Stanford et al., 2003a), even though studies with children suggest psychiatric condition is relevant to dichotomizing aggressive subtypes (e.g., Dodge et al., 1997). The current study extends this previous research by examining aggressive subtypes among adolescents with a psychiatric diagnosis of CD.

Valid self-report measures of characterizing subtypes of aggression would be an important adjunct to current methodologies for assessment of aggressive subtypes in adolescents. Many studies that have attempted to characterize aggression in children have relied on clinical judgement (e.g., Blanchard, 1984) or observations from parents, teachers, peers, or hospital staff (e.g., Dodge and Coie, 1987, Vitiello et al., 1990). The predictive precision of externalizing behavioral patterns has been shown to be less accurate largely because of observer reports from adult informants (Bennett et al., 1998, Hinshaw, 2002). Relying solely on observer-ratings of adolescent behavior may be problematic because: (1) there tends to be a low level of agreement between informants regarding adolescents' aggressive behavior (Loeber et al., 2000, Little et al., 2003); (2) the validity and reliability of adolescent self-reports of health or psychopathology increases with age, while the validity of parent and/or teacher reports decreases with age (Guyatt et al., 1997, Kamphaus and Frick, 2002); and (3) answering questions regarding the motivating influence behind an aggressive act requires personal insight that may not be evident to an observer (Little et al., 2003). Taken together, there is general support for the use of self-report measures of aggression in adolescent samples. However, the validity of self-reported subtypes of aggression has not been satisfactorily investigated among adolescents in general, or specifically among those most at risk for aggressive behaviors like Conduct Disorder.

The current study was designed to extend the use of the Impulsive/Premeditated Aggression Scale to an adolescent-aged sample with Conduct Disorder. Based on the volume of work outlined above that indicates a dichotomy of aggressive subtypes, and based on the most recent adult study using the IPAS (Kockler et al., 2006), our primary hypothesis was that the IPAS would yield two factors (Impulsive and Premeditated) that demonstrate internal consistency, and construct validity. Furthermore, based on correlations of the previous IPAS study of a community-recruited sample of aggressive adults (Stanford et al., 2003a), we predicted that both the Impulsive and Premeditated Aggression scales would be positively correlated with the Barratt Impulsiveness Scale Total Score (BIS-11, Patton et al., 1995), the Eysenck Personality Questionnaire — Junior (EPQ—J; Eysenck and Eysenck, 1975) Neuroticism subscale, and the Buss–Perry Aggression Questionnaire (BPAQ; Buss and Perry, 1992) Physical Aggression subscale. We also predicted that the IPAS Impulsive Aggression scale would correlate positively with the BPAQ Anger subscale, while the Premeditated Aggression scale would correlate positively with the EPQ—J Psychoticism subscale and the BPAQ Verbal Aggression and Hostility subscales, and negatively with the EPQ—J Extroversion subscale.

Section snippets

Participants

Participants were recruited from the inner-city area of Houston, TX. Parents of potential participants responded to newspaper advertisements for adolescents with disruptive behaviors. For all respondents, an initial telephone screening was conducted to determine the suitability of their adolescent for the study (e.g., age 13–17 and physically healthy with symptoms of Conduct Disorder and physical aggression). Based on the results of this telephone survey, potential participants and their

Demographics

A sample of 66 adolescents (24 girls and 42 boys) with Conduct Disorder were recruited and included in all analyses. The median severity of Conduct Disorder symptoms was Moderate (Mild, n = 11; Moderate n = 33, Severe n = 22), the average number of current Conduct Disorder symptoms was 5.3 (S.D. = 2.2), and average age of CD onset was 8.4 years (S.D. = 3.4). Comorbidity with Attention Deficit Hyperactivity Disorder was present in 37% (n = 25) of the total sample. The sample was racially diverse: 51%

Discussion

This study supports the interpretation of subtypes of aggression among adolescents with Conduct Disorder (CD). Our analyses identified two distinct factors (Impulsive Aggression and Premeditated Aggression) with strong psychometric properties including: (a) interpretability (i.e., factor saturation and stability), (b) internal consistency, and (c) construct validity. Of the two factors, the Impulsive Aggression scale was associated with the broadest range of personality disturbance and

Acknowledgements

This research was sponsored by a grant from the National Institutes of Health (R01-MH63908).

During the collection of data for this project, Charles Mathias, Donald Dougherty, and Dawn Marsh were affiliated with the Department of Psychiatry and Behavioral Sciences of the University of Texas Health Science Center at Houston. These authors are now affiliated with the Department of Psychiatry and Behavioral Medicine at Wake Forest University Health Sciences in Winston-Salem, NC.

We thank Melissa L.

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