ARTICLE IN PRESS

International Journal of Nursing Studies 42 (2005) 229–241

www.elsevier.com/locate/ijnursto

Biosocial bases of aggressive and violent

behavior—implications for nursing studies
Jianghong Liua,, Anne Wuerkerb
a
Social Science Research Institute, University of Southern California, Los Angeles, CA 90089-0375, USA
b
School of Nursing, University of California, Los Angeles, USA
Received 18 February 2004; received in revised form 13 May 2004; accepted 8 June 2004

Abstract

Although aggression and violence have been increasingly viewed as a major public health problem with a biological
and health basis, it has been under-researched in the nursing and health context. This paper reviews early biological risk
factors for violence. These factors include pregnancy/birth complications, fetal exposure to nicotine, alcohol, and drugs,
low cholesterol, malnutrition, lead and manganese exposure, head injuries and brain dysfunction, low arousal, low
serotonin, low cortisol, and high testosterone. A biopsychosocial violence mode is proposed. Finally, the paper argues
that nursing is ideally placed to develop a new body of knowledge based on a biosocial perspective that can lead to more
effective prevention programs for violence.
r 2004 Elsevier Ltd. All rights reserved.

Keywords: Aggression; Aggressive behavior; Antisocial behavior; Biological risk factors; Biosocial interaction; Delinquency;
Prevention; Violence; Crime

1. Introduction aggression and violence) over two century ago. Inspired

1.1. The significance of aggression and violence
Aggressive and violent behavior are being increasingly
viewed as a public health problem (Comerci, 1996;
Gerbert et al., 2003) and violence prevention has become
one of the most pressing issues facing our society today
(Hann, 2002). While reducing aggressive and violent
behavior and violence prevention are increasingly
receiving international attention (Ahmad, 2004), the
nursing profession has not fully acknowledged the
potential role it may play in helping to reduce this
major problem in society. Ironically, the nursing
profession had its origins in warfare (a form of
Corresponding author. Tel.: +1-213-740-6956.
E-mail address: jianghol@usc.edu (J. Liu).
by Florence Nightingale, nursing education and science
evolved out of care for the victims of warfare, yet since
then the profession has largely lost its links to violence
and has not made major efforts to prevent violence.
While we are living in a relatively peaceful world, the
significance of violence for nursing professionals cannot
be overemphasized.
This is not to say that nursing has completely ignored
the victims of violence. Significant progress has been
made by the nursing in the areas of domestic violence
(Frost, 1999; Limandri and Tilden, 1996) and child
abuse (McFarlane et al., 2000; Paavilainen et al., 2001,
2002). While these area are mainly related to psychoso-
cial aspect, yet within the last two decades, there
has been a rapidly growing and increasingly signifi-
cant body of knowledge built up on the biological
bases of antisocial, aggressive, and violent behavior

0020-7489/$ - see front matter r 2004 Elsevier Ltd. All rights reserved.
doi:10.1016/j.ijnurstu.2004.06.007
 ARTICLE IN PRESS
230 J. Liu, A. Wuerker / International Journal of Nursing Studies 42 (2005) 229–241
(Brennan et al., 1999; Caspi et al., 2002; Mednick et al.,
1984; Raine 2002a; Virkkunen et al., 1995). Such
research includes, among other areas, genetic studies,
biochemical approaches, and brain-imaging research, a
literature that has to date been little recognized in
nursing science.
1.2. Why biological basis of violence research
Why should one presume that there is a biological
basis to violence that can give important clues for
intervention and prevention research? Both twin and
adoption studies have clearly shown that there is a
genetic basis to antisocial, aggressive, and violent
behavior (Mednick et al., 1984), as such, the biological
context must be incorporated into any comprehensive
account of violence. In addition, despite decades of
attempts at psychosocial intervention for violence, there
have been very few studies that show success in the long
term, possibly because such studies have ignored
biosocial complexities. Also, there is a growing
body of empirical evidence that convincingly demon-
strates some role for biological processes in shaping
antisocial and violent behavior (Brennan et al., 1999;
Moffitt et al., 1998).
The purpose of this paper is to emphasize one area in
which nursing research/practice can make a critical
societal contribution. First, recent studies on biological
factors and aggressive/violent behavior will be reviewed.
Second, a biopsychosocial model of aggressive and
violent behavior of relevance to nursing will be outlined
which integrates biological with social research. Third,
implications for nursing research and practice will be
briefly discussed. In addition, the following review will
not extensively cover all biological factors, but will
instead focus on the health risk factors that are directly
relevant to nursing science. Furthermore, this review
covers antisocial, aggressive, delinquent, and criminal
behavior as well as violence. These constructs are not
synonymous, but because antisocial and delinquent
behavior are major risk factors for later aggression
and violence (Farrington, 1989), they also are included
in this review.
2. Biological risk factors for aggressive and violent
behavior
2.1. Prenatal factors
Prenatal risk factors for antisocial and violent
behavior are especially relevant for maternal-child
health nursing and midwifery because if these factors
do indeed raise the risk for aggressive and violent
behavior, there would be implications for prevention
programs focused on nursing concepts. To date, studies
have examined prenatal risk factors which include
maternal exposure to alcohol, tobacco and drugs,
pregnancy/birth complications, and malnutrition. Most
of these studies are limited to childhood behavior
disorder, but because childhood behavior problems are
a major predisposition to adult violence (Farrington,
1989), they are also of relevance to later adult violence.
2.1.1. Smoking, alcohol, and drug exposure during
pregnancy
Both animal and human studies have established links
between nicotine exposure in utero and altered brain
development (Ajarem and Ahmad, 1998; Stoff et al.,
1997). At least a dozen studies recently have revealed a
significant effect of maternal cigarette smoking on
antisocial behavior problems in childhood (e.g. Fergus-
son et al., 1993; Orlebeke et al., 1997), and adulthood
(Brennan et al., 1999). The effect still exists even when
other biopsychosocial risk factors such as demographic,
parental, and perinatal risk confounds were controlled
(Brennan et al., 1999). These studies suggest that
maternal smoking is a robust risk factor that predisposes
to violence.
How exactly smoking during pregnancy results in
later behavior problems is not clear. Animal studies
suggest both functional and structural routes. First, the
noradrenergic system is thought to be impaired by
carbon monoxide and nicotine, two key components of
cigarette smoking. Additionally, dopamine and 5-HT
are decreased in the forebrains of rat offspring following
prenatal nicotine exposure (Muneoka et al., 1997), while
reductions in brain glucose content in chick embryos has
also been reported (Eckstein et al., 1997). Second, at a
structural level, animal studies have shown that prenatal
smoking exposure impairs the basal ganglia, cerebral
cortex, and cerebellar cortex (Raine, 2002b; Olds, 1997),
brain deficits that have also been found in violent
offenders.
Fetal alcohol exposure has long been known to cause
IQ deficits and physical abnormalities, including struc-
tural deficits to the corpus callosum, an area that brain-
imaging studies have implicated in violence. One recent
study indicates that mothers who drink heavily and
continuously during pregnancy put their children at high
risk for psychiatric and behavior problems (Roebuck et
al., 1999). Similarly, prenatal cocaine exposure is
associated with increased delinquency (Delaney-Black
et al., 2000). Animal studies have repeatedly found that
prenatal cocaine exposure has direct effects on the
offspring’s brain and results in abnormal, aggressive
behavior (Spear et al., 1998). On the other hand, findings
are not consistent, and null results for outcome at
age 6 years have been reported for cocaine exposure
(Richardson et al., 1996).
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J. Liu, A. Wuerker / International Journal of Nursing Studies 42 (2005) 229–241
2.1.2. Pregnancy and birth complications
Nearly half century ago, Pasamanick et al. (1956)
were one of the first to establish a link between birth
complications and behavior disorders in children,
findings that were confirmed by Cocchi et al. (1984).
An important question concerns whether there are long-
term effects of birth complications that extend into
adulthood. One study of a large sample of 4269 males
has shown that birth complications, when combined
with early maternal rejection of the child, are associated
with violent behavior in adulthood (Raine et al., 1994),
findings which have been replicated by Piquero and
Tibbetts (1999) in a prospective longitudinal study of
867 babies showing that both obstetric complications
and a disadvantaged familial environment increase the
risk for adult violent crime.
Disturbances to fetal development in pregnancy may
also be associated with violence. Minor physical
anomalies (MPAs) reflect fetal neural maldevelopment
at the end of the first/beginning of the second trimester
of pregnancy, and in the newborn consist of subtle
abnormalities such as a curved fifth finger, furrowed
tongue, single palmer crease, and low-seated ears (Pine
et al., 1997). A few longitudinal studies have found an
association between MPAs in children and later
delinquency and violent behavior (Arseneault et al.,
2000; Laucht et al., 2000). Arseneault et al. (2000) found
that children with MPAs are more at risk for violent
delinquency in adolescence, an association that was
independent of childhood aggression and family adver-
sity.
2.1.3. The mechanism
An important question concerns the process whereby
prenatal risk factors lead to violence. It is assumed that
prenatal factors directly and indirectly alter brain
structure and function in the developing fetal CNS,
and brain dysfunction has been linked to later aggres-
sion and delinquency (Mednick et al., 1987; Moffitt,
1990; Raine and Liu, 1998). More specifically, the fetus
may experience brain growth retardation as a result of
maternal smoking or alcohol consumption, and may
suffer hypoxia or anoxia through pregnancy and birth
complications. It is known that hypoxia selectively
damages the hippocampus; one component of the limbic
system that brain-imaging research indicates is involved
in aggression regulation (Liu, 2004a).
Nevertheless, not all studies find a relationship
between prenatal risk factors and offspring behavior
problems. McNeil and Wiegerink (1971) found no
relationship between pregnancy/birth complications
and behavioral disorders, suggesting that birth
complications alone may not predispose to aggression
in the offspring, but may instead require the presence of
other factors interacting with birth complications in
231
predisposing to aggression. This is a potentially im-
portant point that will be returned to later.
2.2. Nutrition deficits and metal toxicity
Nutritional risk factors are of particular relevance to
nursing because they reflect processes that can be
affected by nursing interventions. There is growing
evidence that nutritional factors and metal toxicity are
related to antisocial and violent behavior (Fishbein,
2001; Rutter et al., 1998; Masters and Coplan, 1999).
This section briefly outlines evidence to support this
view from the areas of cholesterol, protein and amino
acid deficiency, iron/zinc deficiency, and excessive lead/
manganese, and discusses possible mechanisms.
2.2.1. Cholesterol
Research suggests that reduced serum cholesterol
levels may increase the risk of violent behavior. At least
20 studies derived from epidemiological human investi-
gations, animal studies, and clinical research during the
past 10 years has examined this relationship (e.g.
Alvarez et al., 2000; Kaplan et al., 1997; Santiago and
Dalen, 1994). Low levels of cholesterol have been
repeatedly associated with violence in psychiatric
patients (Engelberg, 1992; Mufti et al., 1998), criminal
offenders (Gray et al., 1993), and community samples
(Muldoon et al., 1990). These findings in humans receive
added weight from monkey research which has observed
the same relationship (Kaplan et al., 1994). Importantly,
experimentally lowering cholesterol in animals’ diets
results in increased aggressive behavior (Kaplan et al.,
1994). Intriguingly, meta-analyses of clinical rando-
mized trials have shown that men without heart disease
who were placed on diets low in cholesterol show an
excess rate of violent death (Golomb, 1998).
The mechanisms linking cholesterol and antisocial/
violent behavior are unknown, but it has been suggested
that low cholesterol influences 5-HT (serotonin) func-
tion. Monkeys fed a low-cholesterol diet have lower
CSF serotonin than monkeys fed a high-cholesterol diet
(Kaplan et al., 1997). This is of potential significance
because low serotonin has in turn been linked to
violence.
It must be recognized that a minority of studies fail to
replicate the cholesterol–violence relationship (e.g.
Steinert et al., 1999). On the other hand, it must also
be recognized that several different lines of evidence
(human correlational studies, animal correlational stu-
dies, animal experimental studies, human clinical inter-
vention studies) make the case of the relationship
particularly compelling, and most studies do find a
significant relationship. However, practical implications
must be treated with caution.
 ARTICLE IN PRESS
232 J. Liu, A. Wuerker / International Journal of Nursing Studies 42 (2005) 229–241
2.2.2. Protein and amino acid deficiency
In animals, male rats fed a low-protein diet in early
postnatal life have been reported to show increased
aggressive behavior in pair interactions (Tikal et al.,
1976). Recent studies of humans support these findings.
The male offspring of pregnant women starved
during the German blockade of food to Holland at
the end of World War II had 2.5 times the rates of
antisocial personality disorder in adulthood compared
to controls. Effects were found for severe malnutrition
during the first and second trimesters of pregnancy, but
not the third trimester (Neugebauer et al., 1999),
suggesting that good nutrition is particularly crucial
when the fetal brain is developing rapidly in the second
trimester.
Amino acids have been also implicated in aggressive
and violent behavior. Both monkeys and rats fed diets
depleted in the amino acid tryptophan become more
aggressive than control, while high-tryptophan food
reduces aggressive behavior (Bjork et al., 1999). Because
tryptophan is the dietary building block of serotonin,
diets low in tryptophan could contribute to the low
levels of serotonin found in impulsive violent offenders
(Virkkunen et al., 1995; Werbach, 1995).
2.2.3. Iron and zinc deficiency
In addition to protein deficiency, research is beginning
to implicate iron deficiency in cognitive and behavior
problems (Rosen et al., 1985; Tu, 1994; Sever et al.,
1997). Several studies reported iron deficiency
in aggressive and conduct disordered children (Rosen
et al., 1985; Werbach, 1995). Rosen et al. (1985) found
iron deficiency in a third of juvenile delinquents.
Furthermore, in a clinical trail, Sever et al. (1997) found
that non-iron deficient children with attention deficit
hyperactivity disorder showed both cognitive and
behavioral improvement after iron supplementation
treatment.
Researches also have implicated zinc deficiency in
aggression and violence (Watts, 1990). In animals, the
offspring of rats zinc-deprived during pregnancy
have been found to be significantly more aggressive
than controls (Halas et al., 1977). In humans, zinc
deficiency in pregnancy was found to be associated with
hyperactivity in the offspring (Brophy, 1986). It is
believed that zinc is an key co-factor for metabolism
related to neurotransmitters, which indirectly affect
dopamine metabolism and affect behavior (Arnold
et al., 2000).
Importantly, studies indicate that mineral deficits
alone may not produce behavior problems, but that
instead low mineral levels exacerbate the effects of toxic
metals (Walsh et al., 1997). For example, adding calcium
to the diet can decrease the toxic effects produced by
lead exposure (Bogden et al., 1997). Similarly, Masters
et al. (1998) have reported that animals fed a diet high
in manganese do not have high levels of blood
manganese when diets contained normal levels of
calcium. In contrast, manganese uptake was high when
the diet was deficient in calcium.
2.2.4. Neurotoxins
Research on effects of metal toxicity on behavior has
gained increasing attention in recent years. In humans,
individuals prone to aggression and violence have been
found to show abnormal trace metal concentrations
both in blood and hair (in particular elevated serum
copper and depressed plasma zinc), while hair analysis
also has revealed an elevated copper-to-sodium ratio
(Walsh et al., 1997). In addition, research on rats has
found that microinjections of manganese chloride
(McCl2) can cause neurodegenerative processes that
further alter the animal’s emotional behavior (Ponzoni
et al., 2000). Furthermore, several studies of prison
inmates have all found that hair levels of manganese,
lead, or cadmium were significantly higher in violent
offenders than in non-violent offenders or controls
(Gottschalk et al., 1991; Masters et al., 1998; Masters
and Coplan, 1999).
Lead exposure has long been known for negatively
impacting cognitive functions (Needleman et al., 1996).
More recently, both animal studies (Delville, 1999) and
human studies (Burns et al., 1999; Needleman et al.,
1996) have found that higher lead exposure measured in
bone and blood is significantly related to aggressive and
delinquent behavior. Burns et al. (1999) found that
school children from a lead smelting community had
increased externalizing behavior problems. This effect
remained after controlling for a number of confounding
variables, including the quality of the child’s home
environment, maternal psychopathology, and the child’s
IQ. Nevertheless, studies are to date few and limited to
childhood antisocial behavior.
Interestingly, research has found that the individual
effects of some mineral abnormalities and neurotoxins
do not directly cause behavior problems, but instead
require the presence of other deficits such as calcium
deficiency. Masters et al. (1998) have reported that
feeding animals a diet high in manganese does not lead
to high levels of blood manganese when diets contained
normal levels of calcium. In contrast, manganese uptake
became significantly higher when the diet was deficient
in calcium. Several studies of prison inmates have all
found that hair levels of either manganese, lead, or
cadmium were significantly higher in violent offenders
than in non-violent offenders or controls (Gottschalk et
al., 1991; Masters and Coplan, 1999). Nevertheless,
despite these findings, the research literature on mineral
deficiency and externalizing behavior problems remains
both limited and controversial (Rutter et al., 1998;
McGee et al., 1990).
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2.2.5. The mechanism of malnutrition/metal toxicity and
violence
The nature of how nutrition deficits or metal toxicity
contribute to aggressive and violent behavior is not well
understood. There is speculation that proteins and
minerals play a role in either regulating neurotransmit-
ters or hormones, or else exacerbate neurotoxins, and in
doing so predispose to aggressive and violent behavior
(Coccaro, 1996). Excessive copper in the neonatal brain
is associated with abnormal development of the
hippocampus, a brain structure that plays a critical role
in learning and which functions abnormally in mur-
derers (Masters et al., 1999; Raine et al., 1997b). Animal
studies indicate that iron deficiency may alter behavior
by reducing dopamine transmission (Werbach, 1995).
In terms of neurotoxins, Murphy et al. (1991) found
that levels of dopamine, norepinephrine, and serotonin
were lowered in manganese-intoxicated animals. Thus,
excessive manganese is thought to reduce brain levels of
neurotransmitters such as serotonin while increasing
serotonin concentrations elsewhere in the body (Masters
et al., 1999). Interestingly, Moffitt et al. (1998) found
antisocial individuals in a community sample had higher
blood serotonin levels, a view opposite to the usual
findings for CSF serotonin, but consistent with the
notion that manganese exposure produces low CSF
serotonin but high blood serotonin. As outlines earlier,
the effects of manganese may be potentiated by low
calcium. Just as manganese inhibits neurotransmitters, a
recent molecular study on lead-exposed rats indicates
that lead inhibits the NMDA receptor, which in turn
plays a critical role in learning and conditioning (Nihei
et al., 2000).
Despite the potential importance of nutritional
deficits/metal toxicity in predisposing to violence, this
research area has four important limitations. First, there
are simply very few studies of this potential relationship.
Second, little research has investigated prospectively the
effect of early nutrition/metal toxicity on later violent
behavior. Third, findings have not always been consis-
tent. Fourth, few if any studies have tested for
interactions with other risk factors.
2.3. Brain damage
Brain damage and dysfunction is a robust finding in
the field of the biosocial bases to antisocial and violent
behavior (Raine, 1993, 2002b). Evidence for this
position converges together from studies of head injury,
neuropsychological testing, and brain imaging.
2.3.1. Head injury
Studies have shown a surprisingly consistent associa-
tion between even minor injuries and violence (Leon-
Carrion and Ramos, 2003). In children, Andrews et al.
(1998) and Max et al. (1998) found that after traumatic
233
brain injuries (TBIs), children displayed increased
emotional and behavior problems including aggressive
behavior. Grafman et al. (1996) found that Vietnam
veterans with frontal ventromedial lesions from pene-
trating head injuries had higher aggression than both
controls and patients with lesions in other brain areas.
Violent criminals have also been found to have poor
brain functioning as indicated by neuropsychological
tests. Specifically, poor ‘‘executive functions’’ (e.g.
planning, attention, decision-making) are a well-repli-
cated finding of antisocial and violent behavior in
juveniles (Moffitt, 1990a, 1990b; Henry and Moffitt,
1997) and adults (Morgan and Lilienfeld, 2000). In
addition, EEG studies have also shown that aggressive
prisoners are more likely to show EEG abnormalities
(Raine, 1993; Volavka, 1999).
2.3.2. Brian imaging studies
Brian image research represents a relative new
approach to violence, and recent studies have confirmed
and extended findings from neuropsychological, EEG,
and head-injury studies (Raine et al., 1998, 2000, 2002b).
Studies show that violent offenders display reduced
glucose metabolism in the prefrontal region of the brain
even after controlling for handedness, sex, ethnicity, and
the presence and absence of head injury (Raine et al.,
1997b; Soderstrom et al., 2000). More recently, one
study has shown that even slight, visually imperceptible
reductions in prefrontal gray matter are significantly
associated with antisocial personality disorder (Raine et
al., 2000). Consequently, brain-imaging research is
confirming that there are both structural and functional
brain deficits in relation to violence. One limitation of all
brain-imaging studies is that they are not able to isolate
the cause of the structural and functional brain deficits
that are observed, while a second criticism is that there
have been few if any studies on children.
2.3.3. Mechanism of brain damage
Why should brain dysfunction predispose to violence?
One explanation is that the prefrontal region of the
brain normally acts to control and regulate the
emotional feelings and reactions generated by deeper,
limbic brain mechanisms such as the amygdala. If the
prefrontal region of the brain is dysfunctional, it will be
less able to keep in check these aggressive impulses,
resulting in an increased likelihood of disinhibited,
impulsive violent acts.
2.4. Neurotransmitters, hormones, and arousal
As outlined earlier, several risk factors (e.g. nicotine
exposure, malnutrition) are thought to act through
alterations in neurochemical functioning. This section
briefly summarizes key findings from this area.
 ARTICLE IN PRESS
234 J. Liu, A. Wuerker / International Journal of Nursing Studies 42 (2005) 229–241
2.4.1. Neurotransmitters
Aggressive offenders have repeatedly been found to
have lower levels of the neurotransmitter serotonin
(Virkkunen et al., 1995; Halperin et al., 1994). Similarly,
aggressive monkeys have also been found to have low
levels of serotonin (Kyes et al., 1995). Drug research also
suggests that the relationship may be causal. Prozac,
which increases serotonin, has been found to reduce
aggression in humans (Coccaro et al., 1997). However,
the mechanism of action is still not well understood.
2.4.2. Hormones
Numerous studies have demonstrated that high levels
of testosterone are related to aggression (Book et al.,
2001; Chance et al., 2000; Harris, 1999). High levels of
testosterone are associated with withdrawal and aggres-
sion among 9–11-year-old boys (Chance et al., 2000).
Female criminals have also been found to be much more
likely to commit crimes around the menstrual phase of
their cycle when progesterone is low, while aggression is
reduced around the time of ovulation when estrogens
and progesterone levels are high (Carlson, 1998). More
recently, however, others have argued that elevated
testosterone alone does not account for aggressive
behavior (Bernhardt, 1997). Rather, it is suggested that
aggressive behavior may be influenced by high testoster-
one levels combined with low levels of brain chemical
serotonin. In addition, it is clear that environmental
factors influence the level of testosterone. Other
hormones such as cortisol have also been found as a
correlate of severe and persistent aggression in male
children and adolescents (McBurnett et al., 2000;
Susman and Ponirakis 1997).
2.4.3. Low physiological arousal
Physiological arousal is traditionally assessed by
taking psychophysiological measures of skin conduc-
tance, heart rate, and EEG. Relatively low physiological
arousal (i.e. lower heart rate, lower skin conductance
activity, more slow-wave EEG) has been found to be a
correlate of aggressive behavior (Maliphant et al., 1990).
Furthermore, it is predictive (though imperfectly) of
which children grow up to become criminal offenders
(Farrington, 1997). Autonomic nervous system (ANS)
arousal is measured in at least two ways. Skin
conductance activity reflects sweat rate, and indexes
sympathetic nervous system activity. Heart rate reflects
both sympathetic and parasympathetic branches of the
ANS.
It has been argued that low autonomic arousal as
measured by low resting heart rate is the best-replicated
biological correlate of childhood antisocial aggressive
behavior (Farrington, 1997; Raine et al., 1990, 1996).
Studies in over six different countries have replicated the
finding, which applies to females as well as males, and is
not accounted by confounds such as body size, smoking,
poverty, and teen pregnancy. Furthermore, prospective
longitudinal research also demonstrates a link between
low heart rate and later antisocial and criminal behavior
(Farrington, 1997; Raine et al., 1997a). Importantly,
prospective longitudinal studies have also shown that
other indicators of low arousal such as low skin
conductance activity and more slow-wave EEG are also
predictive of later antisocial and criminal behavior
(Raine et al., 1990, 1993). Low arousal as early as 3
years predisposes to aggressive behavior at age 11
(Raine et al., 1997a). Regarding the mechanism of
action, it is conceivable that children with low levels of
arousal seek out stimulation in order to increase arousal
levels back to normal, with antisocial behavior being one
form of stimulation-seeking (Raine et al., 1998).
3. Biosocial approach to study aggressive and violent
behavior
3.1. The significance of biosocial research
While the emphasis of this review lies with biological
processes, the psychosocial context should not be
forgotten. Farrington (1989) in a longitudinal survey
of 411 London males from ages 8 to 32 years of age
found that the best predictors of aggression and violence
were poverty, family criminality, poor child-rearing,
school failure, hyperactivity-impulsivity-attention defi-
cit, and child antisocial behavior. Similarly, other
authors have emphasized the importance of parenting
(Webster-Stratton, 1998), child abuse (Widom, 1989),
marital conflict (Margolin et al., 1988), teenage preg-
nancy (Coley and Chase-Lansdale, 1998), and domestic
violence (Campbell, 1998; Parker et al., 1999; McFar-
lane et al., 2000). Furthermore, research on the causes of
aggressive and violent behavior also includes work on
social learning, imitation, the media, school violence,
and TV violence (Ferris and Grisso, 1996; Feshbach and
Feshbach, 1998; Huesmann et al., 2003).
More specifically, studies have shown that high stress
in parents and single-parent status are important factors
in the development of antisocial behavior and conduct
disorder (Webster-Stratton, 1995). Child maltreatment
has been found to be related to low family functioning,
including the parent’s low educational background,
many children in the family, unemployment of a parent,
and poor stability and security within the family
(Paavilainen et al., 2001).
Psychosocial risk factors for aggressive and violent
behavior also include teenage pregnancy. A review by
Coley and Chase-Lansdale (1998) indicates that there
are many negative outcomes of teenage pregnancy which
are debilitating to both the mother as well as the
offspring. A few small-scale studies have examined the
cognitive and behavioral functioning of children of
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J. Liu, A. Wuerker / International Journal of Nursing Studies 42 (2005) 229–241 235

teenage mothers and shown that the preschool offspring
of teenage mothers tend to show behavior problems,
including higher levels of aggression and low impulse
control relative to their peers who are born to adult
mothers (Coley and Chase-Lansdale, 1998).
Another example of psychosocial risk factors for
aggressive behavior involves imitation and learning.
Through television, motion pictures, and the Internet,
children as well as adult are being exposed to brutal acts
of aggression at historically high rates (Grana et al.,
2004; Huesmann et al., 2003; Haridakis, 2002). The
research literature on the long-term effects of media such
as TV violence on aggression has demonstrated that for
both boys and girls, early exposure to media violence
increases the risk for later aggressive behavior (Hues-
mann et al., 2003). Studies have also suggested that this
relationship is exacerbated by children identifying with
aggressive television characters and fantasizing about
aggression.
So far risk factors for aggressive and violent behavior
have been discussed with respect to their main effects,
and with respect to biological risk factors. This
approach is, in all likelihood, overly simplistic. A recent
development in the field has been the biosocial
conceptual approach to violence (Fishbein, 2001; Raine,
2002a). Importantly for a nursing perspective, it is likely
that the causes of violence do not reside in single
biological (e.g. birth complications/nutritional deficits)
or single social factors (poor parenting, child abuse), but
instead involve interactions between multiple biological
and psychosocial predispositions (Steiner et al., 1997;
Stoff et al., 1997).
3.2. Biopsychosocial model of aggressive and violent
behavior
In this context, based on the original biosocial model
of violence (Raine et al., 1997c), a modification model of

PREDICTORS INTERACTION/MEDIACTORS OUTCOME

Biological
Factors
Aggressive/
Interaction Mediation Violent
Behavior

Psychosocial
Factors

(a)

Predictors Interaction Mediators Outcome

Biological Risk Factors

Pregnancy / birth complication
fetal exposure to nicotine/
alcohol /drugs
low cholesterol
malnutrition
lead and manganese exposure
head injuries
brain dysfunction
low arousal
low serotonin, low cortisol x Aggressive/
e.g Poor Violent
high testosterone Behavior
Cognitive ability

Psychosocial Risk Factors

Child abuse
Domestic Violence
Teenage pregnancy
Poor Parenting
Social learning, imitation
School aggression
TV violence
(b)

Fig. 1. Biopsychosocial bases of aggressive and violent behavior model: (a) Model A, conceptual model; (b) Model B,
operationalization model.
 ARTICLE IN PRESS
236 J. Liu, A. Wuerker / International Journal of Nursing Studies 42 (2005) 229–241
biopsychosocial model of aggressive and violent beha-
vior is proposed to further understand of the relation-
ship between predictors—moderator/mediator—
outcome. Model A (Fig. 1a) outlines the conceptual
model for nursing research and practice in the area of
aggressive and violent behavior. Model B (Fig. 2b)
represents the operationalization of the above model
using the specific biosocial risk factors summarized in
this review paper.
Psychosocial and biological risk factors during the
pre/perinatal period are viewed in this model as
predictors of the outcome, aggressive and violent
behavior. Such behavior can be directly produced by
biological risk factors. Similarly, aggressive and violent
behavior can be also developed from biological risk
factors. Additionally, there is a reciprocal relationship
between biological risk factors and psychological risk
factors, which suggests that some risk factors could be
influenced both by biological risk factors and psycho-
social risk factors (Liu, 2004b). For example, alcohol
and drug exposure during pregnancy often is viewed as a
psychosocial risk factor, but it could be that genetic/
biological traits may predispose some individual
to vulnerable to addict substance abuse. The model
also includes mediating processes that account for
the relationship between predictors and the outcome
variable. As one example, Liu et al. (2004c) recently
found that malnutrition at age 3 years is associated
with increase scores on externalizing behavior
problems of children at ages 8, 11, and 17, and
that the malnutrition-externalizing relationship
was mediated by cognitive ability. The results suggested
that malnutrition predisposes to lower IQ which in
turn predisposes to externalizing behavior problems.
The model also includes moderating processes that
may disrupt or enhance the interaction relationship. As
one example, Hodgins et al. (2001) found that the
interaction of pregnancy complications and inadequate
parenting increased the risk of violent and non-violent
offending.
4. Implications for nursing studies
Despite its historical links to the nursing profession
which embraces biological perspectives, nursing science
has not yet recognized the full implications that this new
body of biological research has for violence prevention.
The significance of understanding the etiology of
aggression and violence for nursing science is broad.
As indicated by this review, rather than having limited
relevance to psychiatric nursing, violence etiology also
bears on the nursing areas of maternal-child health
nursing, community health nursing, and occupation
nursing. While the social context of aggression and
violence must not be ignored, it is argued that a broader
and more complex biosocial context represents an
important prerequisite for new advances in etiology
and prevention research on violence. An important issue
is how nursing can make a contribution in helping to
reduce aggression and violence, a major problem in
society (Raine and Liu, 1998; Liu and Raine, 2000). The
recent landmark study of Olds et al. (1998) which
demonstrated the effectiveness of pre- and postnatal
home visitations by nurses in significantly reducing
juvenile delinquency 15 years later provides a new vista
for nursing studies and sets an excellent example for
future nursing studies. Early health preventions for
violence show effective and promising results when they
target the development of risk factors and promote
protective factors.
Liu and Raine (2000) proposed three prevention
strategies for aggressive and violent behavior: (1)
primary prevention programs focused on the prenatal
and perinatal periods, such as instructing pregnant
women to take folate to prevent birth complications.
Nurses can instruct mothers in the prenatal and
postnatal care of their child, the process of infant
growth and development, the importance of proper
nutrition, and the benefits of avoiding smoking and
drinking during pregnancy. For example, since brain
damage is associated with increased aggressive behavior,
early prevention of head injury is important in the
prevention of brain damage and consequently aggressive
behavior. Nurses can develop patient educational plans
for the prevention of head injury and implement such
plans in the caring of patients in clinics and hospital
wards. Such plans includes educating parents, caregivers
and children about the risks and consequences of head
injury, the importance of selecting safe, age-appropriate
toys, including a comfortable, well-fitting helmet for all
wheel-related sports. (2) Secondary prevention focused
on the early identification of risk factors especially in
vulnerable populations such as pregnant teenagers and
substance abusers. For example, nurses can provide
information for pregnant women about the negative
consequences of smoking during pregnancy (including
pregnancy-induced hypertension, preterm birth, and low
birth weight of infant) which may predispose offspring
to develop aggressive behavior. In addition, Paavilainen
et al. (2002) emphasized that nurses can collaborate with
other health care staff in identifying child maltreatment
while caring for them in hospital settings. Such
identification includes assessing for fractures, multiple
bruises, frequent injuries, and the child’s or parent’s odd
or unusual behavior. Once the maltreatment is identi-
fied, early intervention can be implemented to reduce
further injury. (3) Tertiary preventions for those
children already showing conduct disorders and hyper-
activity could include treatments such as medication,
cognitive-behavior therapy, and education remediation
programs.
 ARTICLE IN PRESS
J. Liu, A. Wuerker / International Journal of Nursing Studies 42 (2005) 229–241
In conclusion, it is argued here that the nursing
profession can play a much greater role than hitherto in
making innovative and effective contributions to pre-
venting the next generation of violent children and
adults. By recognizing the complexity of violence
etiology, by a more thorough development of the
biosocial context in which violence develops, and better
integrating biological with social risk factors, nursing
profession can help develop the next generation of new,
innovative knowledge on the causes of violence, while at
the same time developing more effective prevention
programs based on early health factors.
Acknowledgements
This work was supported in part by a NRSA award (1
F32 NR008661-01) from the National Institute of
Nursing Research, USA to Jianghong Liu.
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