Aggressive behavior in adolescent patients with mental disorders: what we can do

Introduction

The incidence rate of mental disorders among adolescents has emerged as a significant public health concern. Current research and statistical data indicate that approximately one in ten children and adolescents suffer from at least one diagnosable mental disorder (1-3). It has been reported that about one in seven adolescents aged 10 to 19 years are affected by mental disorders, which account for up to 13% of the global disease burden in this age group (4). These mental disorders encompass a range of conditions including depression, anxiety disorders, and behavioral disorders, which are the primary causes of morbidity and disability among adolescents (5). It is particularly noteworthy that the occurrence of mental disorders in adolescents is closely associated with a variety of factors, such as genetic predisposition, family environment, and social context (6,7). Moreover, many symptoms of mental disorders overlap to some extent with the normal behaviors and emotional expressions of children, complicating the diagnostic process and necessitating specialized assessment and diagnostic methods (8-10). Consequently, early identification and intervention are of paramount importance for improving patient prognosis and reducing the overall disease burden, which requires widespread attention and appropriate intervention measures from all sectors of society.

Aggressive behavior is an act of intentionally harming another person’s psychological or physical health, as well as damaging property (11). Such behavior is typically characterized by suddenness, impulsiveness, blindness, and unpredictability (12). Adolescence is a critical phase of individual development, where emotions often exhibit polarization, self-centeredness, and extreme tendencies in behavior (13). Within this demographic, aggressive behavior is a common phenomenon. Patients with mental disorders have varying degrees of impairment in cognition, emotion, will, and behavior (14). The chronic state of illness may lead to significant emotional fluctuations when dealing with issues, making them more prone to aggressive behavior (15). In pediatric and adolescent psychiatric wards, aggressive behavior is especially prevalent. According to surveys (16,17), 41% of psychiatrists and nurses have experienced attacks or threats, severely undermining their work enthusiasm and mental and physical health. Frequent aggressive behavior by patients not only prolongs their hospital stay and reduces satisfaction with hospitalization but may also exacerbate societal prejudice and misunderstanding of patients with mental disorders, which is not conducive to their early integration into society (18). Therefore, this study conducted an in-depth retrospective analysis of the occurrence of aggressive behavior and its influencing factors in hospitalized adolescent patients with mental disorders. The aim of the study is to provide clinicians with theoretical guidance for the early identification of patients’ aggressive behavior, in hopes of reducing the incidence of aggressive behavior among adolescent patients and promoting their recovery and smooth reintegration into society. We present this article in accordance with the STROBE reporting checklist (available at https://tp.amegroups.com/article/view/10.21037/tp-24-330/rc).

Methods

The study employed a retrospective cohort design. The research protocol was meticulously reviewed and granted approval by the ethics committee of Suzhou Guangji Hospital (approval No. 20240314-1). Written informed consent was obtained from the participants or their legal guardians. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The data collected were strictly utilized for the exclusive purpose of this study.

Referring to established methodological guidelines (19), the optimal sample size for a questionnaire-based study is generally recommended to be 10 to 15 times the number of variables being examined. In the context of our investigation, nine distinct variables were collected and analyzed, the required sample size was calculated with precision. Based on these calculations, a minimum sample size of [9×15×(1+10%)=148.5] participants was determined to be necessary. Therefore, the study protocol stipulated the inclusion of at least 149 adolescents with mental disorders to align with methodological standards and to ensure a reliable and valid analysis.

This study selected adolescents with mental disorders admitted to our hospital’s psychiatric department from January 1, 2022, to June 30, 2024, as the population of research. The inclusion criteria were as follows: patients aged between 11 and 18 years, with diagnoses conforming to the mental disorder standards of the International Classification of Diseases, 11^th Edition (ICD-11) (20). The exclusion criteria included patients diagnosed with organic mental disorders or mental retardation, as well as those who, or whose guardians, declined to participate in this study. The premorbid personality was assessed using a dual-method approach: it was either evaluated by the admitting physician during the initial assessment or reported by the patient’s family members.

With formal approval from the hospital’s administrative department, this study was conducted by two experienced researchers who meticulously reviewed medical records from the medical record department to ensure the accuracy and completeness of data collection. Throughout this process, the researchers conducted a rigorous audit of the collected data to ensure it met the study’s standards and requirements. Should any questions or discrepancies have arisen during the review, the researchers would have promptly re-examined the relevant medical records to ensure the data’s accuracy and reliability.

We collected the following personal information from the medical and nursing record, including age, gender, body mass index (BMI), whether the child was the only child of family, diagnostic type of mental disorders, educational level, disease course, pre-morbid personality, family history of mental disorder, history of past aggressive behavior.

The assessment of aggressive incidents during this hospitalization period is based on records documented by nursing staff, which include acts of aggression towards others and objects, excluding verbal assaults such as threats and insults. This delineation ensures the accuracy of the study, focusing on the documentation of physical acts of aggression, thereby providing a more precise evaluation of the actual occurrences of aggressive behavior during hospitalization. We had checked and collected the following information regarding the aggressive behavior: the time when the patient exhibited aggressive behavior, reasons for aggressive behavior, the hospitalization days when the patient exhibited aggressive behavior, target of patient’s aggression.

Statistical analysis

This study utilized SPSS 24.0 software for statistical analysis. Quantitative data were expressed as the mean ± standard deviation, and comparisons between groups were made using the independent samples t-test; qualitative data were presented as counts and percentages, with group comparisons conducted using the Chi-squared test. To explore the correlation between personal characteristics and aggressive behavior in adolescents with mental disorders, we employed Pearson correlation analysis. Furthermore, we investigated the factors influencing aggressive behavior in adolescents with mental disorders through both univariate and multivariate logistic regression analyses. The study considered a P<0.05 as the criterion for statistically significant differences.

Results

There were 395 adolescent patients with mental disorders included in the study, with 42 patients having aggressive behavior, and the incidence of aggressive behavior in adolescent patients with mental disorders was 10.63%. As indicated in Table 1, there were statistically significant differences in the age, only child, education level, pre-morbid personality, and history of past aggressive behavior between aggressive behavior group and control group. No statistically significant differences in gender, BMI, diagnostic type of mental disorders, disease course, family history of mental disorder between aggressive behavior group and control group were found.

As shown in Table 2, the timing of aggressive incidents among patients was predominantly during the nighttime hours (0:00–8:00). The primary cause of these incidents was non-cooperation with treatment and nursing care. The majority of aggressive behaviors occurred on the day of hospital admission, and the primary targets of patient aggression were objects.

As indicated in Table 3, Pearson correlation analysis revealed that age (r=0.459), only child (r=0.583), education level (r=0.497), pre-morbid personality (r=0.520), and history of past aggressive behavior (r=0.516) were related with the aggressive behavior in adolescent patients with mental disorders.

As shown in Table 4, Multivariate logistic regression analysis revealed that age [odds ratio (OR) =1.766; 95% confidence interval (CI): 1.213–1.980], only child (OR =2.642; 95% CI: 2.009–2.858), education level (OR =1.823; 95% CI: 1.104–2.518), pre-morbid personality (OR =2.336; 95% CI: 1.991–2.694) and history of past aggressive behavior (OR =2.708; 95% CI: 2.357–3.102) were the influencing factors for aggressive behavior in adolescent patients with mental disorders.

Discussion

Aggressive behavior among patients with mental disorders manifests as destructive attacks on others, oneself, or the environment, potentially causing serious injury or even endangering life (21). During hospitalization, patients are at risk of exhibiting aggressive behavior, which may not only prolong the duration of hospital stay and increase financial strain but also adversely affect the physical and mental well-being of medical staff and intensify public misconceptions and prejudices about mental illness (22,23). Our study indicates that 10.63% of surveyed patients engaged in aggressive behavior, a rate consistent with previous research data (24). Aggressive acts are more frequent during the day, possibly associated with patients receiving adequate rest at night following the administration of antipsychotic medication (25). The main trigger for aggressive behavior is the patients’ resistance to treatment and care. Many individuals with mental disorders lack insight and do not recognize the need for treatment, thus tending to act impulsively during care (26). Furthermore, the influence of psychiatric symptoms can lead to uncontrollable behavior, increasing the risk of aggression. It is noteworthy that the incidence of aggressive behavior decreases as the duration of hospitalization extends, which may be related to the improvement in the patients’ conditions due to therapeutic effects. Therefore, special vigilance should be exercised regarding the potential for aggressive behavior in adolescent patients immediately after admission.

In our study, we have identified age and educational attainment as significant predictors of aggressive behavior, a finding that corroborates existing literature. Consistent with previous research, we observed that younger patients and those with lower educational levels often demonstrate diminished cognitive capacities and a reduced appreciation for the significance of medication adherence in managing their illness and mental well-being (27). This propensity may result in non-compliance with medication regimens or outright refusal to take prescribed medications, thereby potentially exacerbating their condition. Concurrently, patients with lower educational levels often demonstrate a misunderstanding of health education content, which to some extent, diminishes the therapeutic effect (28). In this study, the term “educational level” denotes the educational attainment of the participants themselves, rather than that of their parents. We acknowledge the potential for multicollinearity between the educational level and age variables, given that educational attainment is frequently correlated with age, particularly in populations where the completion of education is contingent upon age. To address this, we have meticulously evaluated the multicollinearity between educational level and age. Variance inflation factors (VIFs) were employed to measure the degree of multicollinearity and to ascertain that it does not significantly bias our regression models. It is recommended that future research considers the possibility of multicollinearity when incorporating age and educational level as distinct variables in their analyses. Previous study (29) has indicated that the presence of a history of aggressive behavior prior to hospital admission is a crucial factor affecting the likelihood of aggression during the current hospital stay, consistent with our study’s results. Therefore, when assessing the risk of aggressive behavior in adolescent patients with mental disorders, age, educational level, and history of previous aggressive behavior should be considered as important assessment criteria.

The psychological health of only child has always been a focal point of concern for both families and society in China. The manifestation of aggressive behavior in only children may be triggered by a variety of factors, including family background, personality traits, and mental health issues. Particularly, when adolescents with mental disorders are confronted with severe psychological distress or are in a detrimental growth environment over the long term, they are more likely to exhibit aggressive behavior in social interactions (30). During hospitalization, when dealing with issues in the company of peers, they may display irritability and aggression as means to vent personal emotions (31). Research indicates that age, family economic status, the companionship of primary family members, and the father’s level of education are family environmental factors influencing the aggressive behavior of only children (32). Consequently, the incidence of aggressive behavior among adolescent-only children with mental disorders is higher compared to those who are not only children. In light of this, the treatment and intervention for adolescent-only children with mental illnesses should consider a bio-psycho-social medical model comprehensively. It is imperative to intervene in mental symptoms promptly, such as through medication and psychotherapy (33). Additionally, interventions should be based on the psychological and environmental factors of the patients, for instance, by improving the family environment, providing timely psychological support, and correcting cognitive biases (34,35). It must be noted that the mental development of adolescents is significantly influenced by their family environment. The differentiation between single-parent families led by mothers or fathers may provide critical insights into the diverse effects on adolescent mental health. Regrettably, our study was constrained by limitations in data collection, which precluded the inclusion of these variables in our analysis. It is imperative that future research endeavors incorporate these factors to achieve a more nuanced understanding of the family environment’s role. Such understanding is essential for the development of targeted interventions and support systems aimed at enhancing adolescent mental health.

The aggressive behavior of hospitalized adolescent patients with mental disorders is closely related to their pre-onset personality traits. Adolescents with mental disorders who exhibit mild, cheerful, self-effacing, or introverted personalities prior to the onset of their illness are less likely to display aggressive behaviors compared to those with irritable personalities. Adolescents with a high predisposition to anxiety are more prone to emotional and behavioral disorders when faced with stress. If these adolescents with irritable personalities are limited in social interactions or have poor interpersonal relationships, they are more susceptible to the influence of the external environment, and due to their insufficient coping abilities with stressful events, they are more likely to develop emotional and behavioral disorders, potentially leading to aggressive behaviors (36,37). Therefore, it is recommended that healthcare professionals, family members, and school teachers collaborate to correct the undesirable personality traits of adolescents, assisting them in establishing positive interpersonal relationships with peers during hospitalization (38,39). Additionally, they should cultivate a positive and optimistic attitude, reduce negative emotions and cognitions, and prioritize enhancing resilience to setbacks as a key intervention measure to reduce the likelihood of aggressive behavior.

Our study’s results have revealed a significant increase in the frequency of aggressive behavior among patients during the early morning hours, specifically between 0:00 and 8:00 am. This heightened incidence can be linked to the inherent variations in circadian rhythms, which are known to govern the physiological and behavioral cycles within the human body (40). These biological processes, in turn, have a profound impact on the conduct exhibited by patients, particularly during the transitional phases of their day (41). Furthermore, our analysis has demonstrated a correlation between the onset of aggressive behavior and the timing of patient admission. The data suggests that patients are more likely to display such behavior immediately following their admission, particularly if this occurs within the identified early morning window. This correlation implies that the period immediately after admission may be a pivotal juncture for intervention strategies, as it appears to be a time of heightened vulnerability for the manifestation of aggressive acts. The synchronization of aggressive behavior with the commencement of the admission process underscores the importance of considering the timing of admission and the subsequent impact on patient behavior. This insight has significant implications for the development of targeted interventions aimed at mitigating aggressive incidents, potentially improving patient outcomes, and enhancing the safety of the healthcare environment.

While this study offers valuable insights, it is not without limitations that warrant further consideration. Firstly, as a single-center study with a limited sample size, there is a potential for bias in the representativeness of the population and the generalizability of the findings across different regions. Secondly, we recognize that the retrospective design of our study may have limitations in capturing the full spectrum of factors influencing the outcomes, which could potentially impact the precision and comprehensiveness of our conclusions. It is possible that our study did not fully account for the multifaceted nature of factors contributing to aggressive behavior, particularly those pertaining to family dynamics. Specifically, family ecological status, primary caregiver interactions, early parent-child bonding and attachment, and parental violence propensities may exert a more substantial influence on aggressive behavior than what our current analysis has encompassed. We concur that there is a clear imperative for future research to delve into the interplay between these family-related factors and aggressive behavior, as well as to assess their downstream effects. In our analysis, we acknowledge that not all potential confounding factors were accounted for, which may have influenced the results. This limitation was primarily due to constraints in data availability. We recognize that this represents a limitation of our study and could potentially impact the interpretation of our findings. It would be beneficial for subsequent studies to adopt a prospective design and to broaden the sample size to include a more diverse array of regions and populations. Such an approach would bolster the generalizability and reliability of the research findings. Furthermore, by incorporating a more exhaustive array of variables and potential confounding factors, a more nuanced analysis of the treatment and care requirements for individuals with mental health disorders can be achieved. This would not only address the limitations of our current study but also pave the way for a more holistic understanding of the subject matter.

Conclusions

The occurrence of aggressive behavior in adolescent patients with mental disorders is a complex issue with a relatively high incidence rate and correlation with various factors. We have found that factors such as age, being an only child, level of education, premorbid personality traits, and a history of past aggressive behavior may all influence the patient’s aggressive actions. These factors could impact the psychological state and behavioral responses of patients through different mechanisms, thereby increasing the risk of aggressive behavior. Psychiatric medical staff need to pay close attention to this group and take timely and effective intervention and control measures when dealing with them. This includes, but is not limited to, pharmacological treatment, psychotherapy, and environmental adjustments, with the aim of reducing the incidence of aggressive behavior, improving the quality of life for patients, and ensuring the safety of the medical environment. In addition, medical staff should also collaborate with families and schools to provide a supportive therapeutic and rehabilitation environment for patients, helping them to establish positive interpersonal relationships, foster an optimistic attitude, and enhance their resilience to setbacks.

Acknowledgments

Funding: None.

Footnote

Reporting Checklist: The authors have completed the STROBE reporting checklist. Available at https://tp.amegroups.com/article/view/10.21037/tp-24-330/rc

Data Sharing Statement: Available at https://tp.amegroups.com/article/view/10.21037/tp-24-330/dss

Peer Review File: Available at https://tp.amegroups.com/article/view/10.21037/tp-24-330/prf

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://tp.amegroups.com/article/view/10.21037/tp-24-330/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the Declaration of Helsinki (as revised in 2013). The study has been reviewed and approved by the ethics committee of Suzhou Guangji Hospital (approval No. 20240314-1). Written informed consent was obtained from the participants or their legal guardians.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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