Aggression in children and adolescents: A practical approach to assessment and treatment

Aggression is a common and challenging presentation in pediatric practice and may arise from a wide variety of developmental, medical, psychiatric, relational, and environmental factors. Although immediate safety must be addressed when aggressive behavior creates a risk of harm, aggression is a symptom rather than a diagnosis. Effective treatment depends on understanding what is contributing to and maintaining the behavior in an individual child. This review provides a practical approach to the assessment and treatment of aggression in children and adolescents. Assessment begins by characterizing the behavior, evaluating safety, considering the child's developmental capacities, and identifying biological, psychological, and social contributors. These factors can be integrated into a working formulation that considers what predisposed the child to aggression, what precipitated it now, what may be perpetuating it, and what protective factors can support treatment. Treatment should address the factors identified by this assessment, including modifiable environmental and developmental factors, caregiver needs, underlying medical, neurodevelopmental, and psychiatric conditions, and indications for evidence-based behavioral and psychotherapeutic interventions. Medication should likewise target identified conditions whenever possible; medication directed more specifically toward persistent aggression requires careful consideration of expected benefit and potential harm. Treatment intensity should be matched to safety, functional impairment, caregiver capacity, developmental needs, and available supports. The pediatrician can remain central to care by coordinating appropriate consultation, monitoring transitions across levels of care, and revisiting the child's needs as development and circumstances change.