Journal of Child and Family Studies

, Volume 27, Issue 10, pp 3385–3394 | Cite as

Theory of Mind Deficits and Reactive Aggression in Child Psychiatric Inpatients: Indirect Effects Through Emotion Dysregulation

  • Kurt K. StellwagenEmail author
  • Patricia K. Kerig
Original Paper


Nationwide, there is a pressing need to develop more efficacious treatment regimens for reactively aggressive youth receiving inpatient psychiatric services. Identifying the relevant clinical characteristics of youth with reactive aggression is an important first step in this process. Past research findings and theoretical formulations have suggested that deficits in both social skills and emotional regulation abilities are significantly associated with the development of reactive aggression in children. Utilizing a highly aggressive child inpatient sample (65 males and 36 females) receiving crisis-stabilization services, we tested the hypothesis that emotion dysregulation statistically mediated the relationship between theory of mind deficits and reactive aggression. As hypothesized, results of bootstrapped mediational analyses indicated that theory of mind deficits were associated with higher levels of reactive aggression via the indirect influence of dysregulated affect. These findings suggest that intervention programs for reactively aggressive children should promote both theory of mind skills and emotion regulation abilities. Children that develop more thoughtful styles of perspective taking coupled with an enhanced ability to modulate their emotions may develop a greater ability to employ the rational conflict resolution skills that underlie peaceful social relationships.


Reactive aggression Emotion dysregulation Theory of mind Child behavior problems Child psychiatry 


Author Contributions

K.K.S. designed and executed the study, conducted the data analysis, and wrote the paper. P.K.K. collaborated with all aspects of the study.

Compliance with ethical standards

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

All procedures involving human participants were in accordance with the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

Informed Consent

Informed consent of legal guardians and voluntary assent of children were obtained prior to children’s involvement in the study and the protocol was approved by the IRBs of the University of North Carolina at Chapel Hill and John Ulmstead State Hospital. Children’s attending psychiatrists gave informed consent, as did teachers.


  1. Arsenio, W. F., & Lemerise, E. A. (2001). Varieties of childhood bullying: Values, emotion processes, and social competence. Social Development, 10, 59–73. Scholar
  2. Baeza, I., Correll, C. U., Saito, E., Ramani, M., Kapoor, S., Chekuri, R., et al. (2013). Frequency, characteristics and management of adolescent inpatient aggression. Journal of Child and Adolescent Psychopharmacology, 23, 271–281. Scholar
  3. Barker, E. D., Vitaro, F., Lacourse, E., Fontaine, N. M., Carbonneau, R., & Tremblay, R. E. (2010). Testing the developmental distinctiveness of male proactive and reactive aggression with a nested longitudinal experimental intervention. Aggressive Behavior, 36, 127–140. Scholar
  4. Balkin, R. S. (2006). A reexamination of trends in acute care psychiatric hospitalization: Ethnicity, payment, and length of stay. Journal of Professional Counseling, 34, 49–59.CrossRefGoogle Scholar
  5. Barzman, D. H., Brackenbury, L., Sonnier, L., Schnell, B., Cassedy, & Salisbury, S. A., et al. (2011). Brief Rating of Aggression by Children and Adolescents (BRACHA): Development of a tool for assessing risk of inpatients’ aggressive behavior. Journal of the American Academy of Psychiatry and the Law, 39, 170–179.PubMedPubMedCentralGoogle Scholar
  6. Berkowitz, L. (1963). Anger and aggression: An essay on emotion. New York, NY: Springer-Verlag.Google Scholar
  7. Blader, J. C., Abikoff, H., Foley, C., & Koplewicz, H. S. (1994). Children’s behavioral adaptation early in psychiatric hospitalization. Journal of Child Psychology and Psychiatry and Allied Disciplines, 35, 709–721. Scholar
  8. Capage, L., & Watson, A. C. (2001). Individual differences in theory of mind, aggressive behavior, and social skills in young children. Early Education and Development, 12, 613–628. Scholar
  9. Caravita, S., Di Blasio, P., & Salmivalli, C. (2009). Unique and interactive effects of empathy and social status on involvement in bullying. Social Development, 18, 140–163. Scholar
  10. Card, N. A., & Little, T. D. (2007). Differential relations of instrumental and reactive aggression with maladjustment: Does adaptivity depend on function? In P. H. Hawley, T. D. Little & P. C. Rodkin (Eds.), Aggression and adaptation: The bright side to bad behavior (pp. 107–134). Mahwah, NJ: Lawrence Erlbaum Associates Publishers.Google Scholar
  11. Crick, N. A., & Dodge, K. A. (1996). Social information-processing mechanisms in reactive and proactive aggression. Child Development, 67, 993–1002. Scholar
  12. Crocker, L. D., Heller, W., Warren, S. L., O’Hare, A. J., Infantolino, Z. P., & Miller, G. A. (2013). Relationships among cognition, emotion, and motivation: Implications for intervention and neuroplasticity in psychopathology. Frontiers in Human Neurosceince, 7, 1–19. Scholar
  13. Crosland, K. A., Cigales, M., Dunlap, G., Neff, B., Clark, H. B., & Giddings, T., et al. (2008). Using staff training to decrease the use of restrictive procedures at two facilities for foster care children. Research on Social Work Practice, 18, 401–409. Scholar
  14. Dodge, K. A. (2000). Conduct Disorder. In A. J. Sameroff, M. Lewis & S. M. Miller (Eds.), Handbook of developmental psychopathology: Second edition (pp. 447–463). New York, NY: Kluwer Academic/Plenum Publishers.CrossRefGoogle Scholar
  15. Dodge, K. A. (2006). Translational science in action: Hostile attributional style and the development of aggressive behavior problems. Development and Psychopathology, 18, 791–814. Scholar
  16. Dodge, K. A., & Coie, J. D. (1987). Social-information-processing factors in reactive and proactive aggression in children’s peer groups. Journal of Personality and Social Psychology, 53, 1146–1158. Scholar
  17. Dollard, J., Doob, C. W., Miller, N. E., Mowrer, O. H., & Sears, R. R. (1939). Frustration and aggression. New Haven, CT: Yale University Press.CrossRefGoogle Scholar
  18. Eisenberg, N., Fabes, R. A., Shepard, S. A., Murphy, B. C., Guthrie, I. K., Jones, S., et al. (1997). Contemporaneous and longitudinal prediction of children’s social functioning from regulation and emotionality. Child Development, 68, 642–664. Scholar
  19. Eisenberg, N., Fabes, R. A., Shepard, S. A., Murphy, B. C., Jones, S., & Guthrie, I. K. (1998). Contemporaneous and longitudinal prediction of children’s sympathy from dispositional regulation and emotionality. Developmental Psychology, 34, 910–924. Scholar
  20. Ellis, M. L., Weiss, B., & Lochman, J. E. (2009). Executive functions in children: Associations with aggressive behavior and appraisal processing. Journal of Abnormal Child Psychology, 37, 945–956. Scholar
  21. Feindler, E. l. (2006). Anger-related disorders: A practitioner’s guide to comparative treatments. New York, NY: Springer Publishing Company.Google Scholar
  22. Fite, P. J., Stoppelbein, L., & Greening, L. (2009). Proactive and reactive aggression in a child psychiatric inpatient population. Journal of Clinical Child and Adolescent Psychology, 38, 199–205. Scholar
  23. Fonagy, P., & Luyton, P. (2009). A developmental, mentalization-based, approach to the understanding and treatment of borderline personality disorder. Development and Psychopathology, 21, 1355–1381. Scholar
  24. Frick, P. J., Cornell, A. H., Barry, C. T., Bodin, S. D., & Dane, H. E. (2003). Callous-unemotional traits and conduct problems in the prediction of conduct problem severity, aggression, and self-report of delinquency. Journal of Abnormal Child Psychology, 31, 457–470. 1023899703866.CrossRefGoogle Scholar
  25. Frick, P. J., & Hare, R. D. (2001). The Antisocial Process Screening Device (APSD). Toronto, Canada: Multi-Health Systems.Google Scholar
  26. Glick, B., & Gibbs, J. C. (2010). Aggression replacement training: a comprehensive intervention for aggressive youth 3rd edn Champaign, IL: Research Press.Google Scholar
  27. Greene, R. W., Ablon, J. S., & Martin, A. (2006). Use of collaborative problem solving to reduce seclusion and restraint in child and adolescent inpatient units. Psychiatric Services, 57, 610–612. Scholar
  28. Happé, F. (1994). An advanced test of theory of mind: Understanding of story characters’ thoughts and feelings by able autistic, mentally handicapped, and normal children and adults. Journal of Autism and Developmental Disorders, 14, 385–389. Scholar
  29. Happé, F., & Frith, U. (1996). Theory of mind and social impairment in children with conduct disorder. British Journal of Developmental Psychology, 14, 385–398. Scholar
  30. Happé, F., Winner, E., & Brownell, H. (1998). The getting of wisdom: Theory of mind in old age. Developmental Psychology, 34, 358–362. Scholar
  31. Haimowitz, S., & Urff, J. (2006). Legal consequences of seclusion and restraint. Psychiatric Services, 57, 1516 Scholar
  32. Hayes, A. F. (2013). Introduction to mediation, moderation, and conditional process analysis. New York, NY: Guilford Press.Google Scholar
  33. Kerig, P. K., & Stellwagen, K. K. (2010). Roles of callous-unemotional traits, narcissism, and Machiavellianism in childhood aggression. Journal of Psychopathology and Behavioral Assessment, 32, 343–352. Scholar
  34. Kennedy, S. S., & Mohr, W. K. (2001). A prolegomenon on restraint of children: Implicating constitutional rights. American Journal of Orthopsychiatry, 71, 26–37. Scholar
  35. Kloo, D., & Perner, J. (2008). Training theory of mind and executive control: A tool for improving school achievement? Mind, Brain, and Education, 2, 122–127. Scholar
  36. Kraemer, H. C., Stice, E., Kazdin, A., Offord, D., & Kupfer, D. (2001). How do risk factors work together? Mediators, moderators, and independent, overlapping, and proxy risk factors. The American Journal of Psychiatry, 158, 848–856. Scholar
  37. Larson, J., & Lochman, J. E. (2010). Helping schoolchildren cope with anger: A cognitive-behavioral intervention. 2nd edn New York, NY: The Guilford Press.Google Scholar
  38. LeBel, J., Stromberg, N., Duckworth, K., Kerzner, J., Goldstein, R., & Weeks, M., et al. (2004). Child and adolescent inpatient restraint reduction: A state initiative to promote strength-based care. Journal of the American Academy of Child and Adolescent Psychiatry, 43, 37–43. Scholar
  39. Lecce, S., Bianco, F., Devine, R. T., Hughes, C., & Banerjee, R. (2014). Promoting theory of mind during middle childhood: A training program. Journal of Experimental Child Psychology, 126, 52–67. Scholar
  40. Lochman, J. E., & Wells, K. C. (2004). The coping power program for preadolescent boys and their parents: Outcome effects at the 1-year follow-up. Journal of Consulting and Clinical Psychology, 72, 571–577. Scholar
  41. Marsee, M. A., Weems, C. F., & Taylor (2008). Exploring the association between aggression and anxiety in youth: A look at aggressive subtypes, gender, and social cognition. Journal of Child and Family Studies, 17, 154–168. Scholar
  42. Miller, P. A., & Eisenberg, N. (1988). The relation of empathy to aggressive and externalizing/antisocial behavior. Psychological Bulletin, 103, 324–344. Scholar
  43. Murphy, B. C., Shepard, S. A., Eisenberg, N., Fabes, R. A., & Guthrie, I. K. (1999). Contemporaneous and longitudinal relations of dispositional sympathy to emotionality, regulation, and social functioning. Journal of Early Adolescence, 19, 66–97. Scholar
  44. Painter, K. (2009). Multisystemic therapy as community-based treatment for youth with severe emotional disturbance. Research on Social Work Practice, 19, 314–324. Scholar
  45. Poulin, F., & Boivin, M. (2000). Reactive and proactive aggression: Evidence of a two-factor model. Psychological Assessment, 12, 115–122. Scholar
  46. Raine, A., Dodge, K., Loeber, R., Gatzke-Kopp, L., Lynam, D., & Reynolds, C., et al. (2006). The reactive-proactive aggression questionnaire: Differential correlates of reactive and proactive aggression in adolescent boys. Aggressive Behavior, 32, 159–171. Scholar
  47. Repacholi, B., Slaughter, V., Pritchard, M., & Gibbs, V. (2003). Theory of mind, Machiavellianism, and social functioning in childhood. In B. Repacholi & V. Slaughter (Eds.), Individual differences in theory of mind: Implications for typical and atypical development (pp. 67–97). New York., NY: Psychology Press.Google Scholar
  48. Ronouf, A., Brendgen, B., Séguin, J. R., Vitaro, F., Boivin, M., & Dionne, J. R., et al. (2010). Links between theory of mind, peer victimization, and reactive and proactive aggression. Journal of Abnormal Child Psychology, 38, 1109–1123. Scholar
  49. Ryan, E. P., Hart, V. S., Messick, D. L., Aaron, J., & Burnette, M. (2004). A prospective study of assault against staff by youths in a state psychiatric hospital. Psychiatric Services, 55, 665–670. Scholar
  50. Scarpa, A., & Raine, A. (1997). Psychophysiology of anger and violent behavior. The Psychiatric Clinics of North America, 20, 375–393. Scholar
  51. Schwartz, D., Dodge, K. A., Coie, J. D., Hubbard, J. A., Cillessen, A. H., & Bateman, H. (1998). Social-cognitive and behavioral correlates of aggression and victimization in boy’s play groups. Journal of Abnormal Child Psychology, 26, 431–440. 1022695601088.CrossRefGoogle Scholar
  52. Sharfstein, S. S. (2008). Reducing restraint and seclusion: A view from the trenches. Psychiatric Services, 59, 197 Scholar
  53. Sharp, C., Pane, H., Ha, C., Venta, A., Patel, A. B., Sturek, J., & Fonagy, P. (2011). Theory of mind and emotion regulation difficulties in adolescents with borderline traits. Journal of the American Academy of Child and Adolescent Psychiatry, 50, 563–573. Scholar
  54. Shields, A. & Cicchetti, D. (1995). The development of an emotion regulation assessment battery: Reliability and validity among at-risk grade-school children. Poster presented at the Society for Research in Child Development. Indianapolis, IN.Google Scholar
  55. Shields, A., & Cicchetti, D. (1997). Emotion regulation in school-age children: The development of a new criteria Q-sort scale. Developmental Psychology, 33, 906–916. Scholar
  56. Shields, A., & Cicchetti, D. (1998). Reactive aggression among maltreated children: The contributions of attention and emotion dysregulation. Journal of Clinical Child Psychology, 27, 381–395. Scholar
  57. Skripkauskate, S., Hawk, S. T., Branje, S. J., Koot, H. M., van Lier, P. A., & Meeus, W. (2015). Reactive and proactive aggression: Differential links with emotion regulation difficulties, maternal criticism in adolescence. Aggressive Behavior, 41, 214–226. Scholar
  58. Sourander, A., Ellilae, H., Vaelimaeki, M., & Piha, J. (2002). Use of holding, restraints, seclusion and time-out in child and adolescent psychiatric in-patient treatment. European Child and Adolescent Psychiatry, 11, 162–167. Scholar
  59. Sprung, M. (2010). Clinically relevant measures of children’s theory of mind and knowledge about thinking: Non-standard and advanced measures. Child and Adolescent Mental Health, 15, 204–206. Scholar
  60. Stegge, H., & Terwogt, M. M. (2007). Awareness and regulation of emotion in typical and atypical development. In J. J. Gross (Ed.), Handbook of emotion regulation (pp. 269–286). New York: Guilford Press.Google Scholar
  61. Stellwagen, K. K., & Kerig, P. K. (2010). Relating callous-unemotional traits to physically restrictive treatment measures among child psychiatric inpatients. Journal of Child and Family Studies, 19, 588–595. Scholar
  62. Stellwagen, K. K., & Kerig, P. K. (2013). Ringleader bullying: Association with psychopathic narcissism and theory of mind among child psychiatric inpatients. Child Psychiatry and Human Development, 44, 612–620. Scholar
  63. Sutton, J., Smith, P. K., & Swettenham, J. (1999). Social cognition and bullying: Social inadequacy or skilled manipulation? British Journal of Developmental Psychology, 17, 435–450. Scholar
  64. Vitaro, F., & Brendgen, M. (2005). Proactive and reactive aggression: A developmental perspective. In R. E. Tremblay, W. M. Hartup & J. Archer (Eds.), Developmental origins of aggression (pp. 377–385). NY: Guilford Press.Google Scholar
  65. Vőllm, B. A., Taylor, A. N., Richardson, P., Corcoran, R., Stirling, J., & McKie, S., et al. (2006). Neuronal correlates of theory of mind and empathy: A functional magnetic resonance imaging study in a nonverbal task. Neuroimage, 29, 90–98. Scholar
  66. Wynam, P. A., Cross, W., Hendricks Brown, C., Yu, Q., Tu, Q., & Eberly, S. (2010). Intervention to strengthen emotional self-regulation in children with emerging mental health problems: Proximal impact on school behavior. The Journal of Abnormal Child Psychology, 38, 707–720. Scholar

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Authors and Affiliations

  1. 1.Department of PsychologyEastern Washington UniversityCheneyUSA
  2. 2.Department of PsychologyUniversity of UtahSalt Lake CityUSA

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