Ask An Expert / Behavior Problems

My daughter is so aggressive she isn’t welcome at her grandparents’ house anymore. What should we do?

Getting a thorough diagnostic assessment is critical

Mary Rooney, PhD

I'm the mom of a 7-year-old girl with very strong behaviors. We had an evaluation done at 4-5 years old. The results came back that she was a bright girl with strong behaviors with attachment issues. We began seeing a play therapist on a regular basis to work on the attachment issues and we have her on Lexapro for her anxiety and Tenex to help with her impulsivity. And STILL...we are dealing with pretty aggressive behaviors.It is so bad that she is not welcome at the grandparents' house anymore. Could it be a medical condition, like low blood sugar, or a different type of mental illness that we aren't aware of?

The first step for any family working to address behavioral issues, or anxiety, or mood problems is to have a thorough diagnostic assessment done—not just an assessment of intelligence and achievement. What I see here is that she is a bright girl with strong behaviors and attachment issues, but no diagnosis. So the first step is a full diagnostic assessment based on the DSM, the Diagnostic and Statistical Manual.

I also see that your daughter has been getting play therapy. There is limited evidence supporting this intervention for oppositional or aggressive behaviors, anxiety, or depression and mood problems. So, again, depending on what the diagnosis is, you should pursue evidence-based treatments. (The American Psychological Association (APA) and the Association for Behavioral and Cognitive Therapies (ABCT) maintain a website that details which treatments are supported as evidence-based interventions for particular mental health disorders.)

Depending on the diagnosis, the intervention will be different, but regardless of what the particular treatment is it should always be family-based. So parents should always be heavily involved in treatment. A 7-year-old should never be the only participant in therapy. The parents should receive coaching on how to manage the child’s behavior at home, because therapists only see the child for one hour a week, and the parents are with kids multiple hours every day. Depending on what the underlying issues are, there may also be a component where the therapist works alone with the child.


Depending on the diagnosis medication may be appropriate, and often a combination of medication plus an evidence-based psychosocial intervention is the most effective. But again, any treatment, including medications, depends entirely upon a valid diagnosis. “Diagnosis drives treatment,” we often say.

As far as your concerns about a medical condition, you can work with a pediatrician to rule out any medical problems. It’s not uncommon for kids, if they are hungry or tired or uncomfortable in any way, to become irritable — just like adults. It doesn’t necessarily point to an underlying medical condition, but it doesn’t ever hurt to meet with a pediatrician to see if there is a problem.