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ADHD: Attention Deficit Hyperactivity Disorder
Childhood Mental Disorders and Illnesses

by Daniel F. Connor
Guilford Press, 2002
Review by Jack R. Anderson, M.D. on May 14th 2004

Aggression and Antisocial Behavior in Children and Adolescents

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 treatments.

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 aggressive behavior.

"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 developmental history.


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 great accuracy." 

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 aggression.


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