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Retrospective Parental Rejection Is Associated With Aggressive Behavior as Well as Cognitive Distortions in Forensic Psychiatric Outpatients

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Objective: Parental rejection in childhood is associated with the increased risk of aggression in adulthood and is thought to contribute to the development of inaccurate beliefs regarding own or others’ behavior (i.e., cognitive distortion) as well. Different forms of aggression are thought to be linked to different types of cognitive distortions. This, however, is unclear in adults. Additionally, it is unknown if parental rejection predicts the presence of aggression and cognitive distortions in adults displaying severe aggression. Method: One hundred twenty-three adult forensic psychiatric outpatients with aggression regulation problems were recruited. Least absolute shrinkage and selection operator (Lasso) regression analysis and path analyses were conducted to investigate distinct patterns of cognitive distortions, as measured by use of the How I Think Questionnaire, and the role of perceived parental rejection, as measured by use of the Parental Rejection and Acceptance Questionnaire. Results: Cognitive distortions related to opposition-defiance (e.g. disrespecting rules) and to physical aggression were most strongly associated with the disposition to act aggressively. Furthermore, a direct association was found between parental rejection and this current disposition. This association was partially mediated by cognitive distortions related to opposition-defiance. Conclusion: The current study supports the notion that parental rejection has profound consequences on adult behavior. Acknowledgement of the impact of cognitive distortions on current aggression might be of importance for treatment. A stronger focus on altering distinct cognitive distortions may be more successful in reducing aggression.
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Running head: PARENTAL REJECTION, AGGRESSION, DISTORTED COGNITION
Retrospective Parental Rejection is Associated with Aggressive Behavior as well as Cognitive
Distortions in Forensic Psychiatric Outpatients
Danique Smeijers1,2, Inti A. Brazil2,3, Erik Bulten3, and Robbert-Jan Verkes1,2,3
¹Department of Psychiatry, Radboud University Medical Center, Nijmegen, The Netherlands
2 Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, The
Netherlands
3Forensic Psychiatric Centre Pompestichting, Nijmegen, The Netherlands
Please direct correspondence to:
Danique Smeijers, MSc.
Email: daniquesmeijers@gmail.com
Smeijers, Brazil, Bulten & Verkes (in press). Retrospective Parental Rejection is Associated
with Aggressive Behavior as well as Cognitive Distortions in Forensic Psychiatric
Outpatients. Psychology of Violence.
© 2017, American Psychological Association. This paper is not the copy of record and may not
exactly replicate the final, authoritative version of the article. Please do not copy or cite without
authors permission. The final article will be available, upon publication, via its DOI:
10.1037/vio0000134
Parental Rejection, Aggression, Distorted Cognition
2
Abstract
Objective: Parental rejection in childhood is associated with the increased risk of aggression
in adulthood and is thought to contribute to the development of inaccurate beliefs regarding
own or others’ behavior (i.e., cognitive distortion) as well. Different forms of aggression are
thought to be linked to different types of cognitive distortions. This, however, is unclear in
adults. Additionally, it is unknown if parental rejection predicts the presence of aggression
and cognitive distortions in adults displaying severe aggression.
Method: One hundred twenty-three adult forensic psychiatric outpatients with aggression
regulation problems were recruited. Least absolute shrinkage and selection operator (Lasso)
regression analysis and path analyses were conducted to investigate distinct patterns of
cognitive distortions, as measured by use of the How I Think Questionnaire, and the role of
perceived parental rejection, as measured by use of the Parental Rejection and Acceptance
Questionnaire.
Results: Cognitive distortions related to opposition-defiance (e.g. disrespecting rules) and to
physical aggression were most strongly associated with the disposition to act aggressively.
Furthermore, a direct association was found between parental rejection and this current
disposition. This association was partially mediated by cognitive distortions related to
opposition-defiance.
Conclusion: The current study supports the notion that parental rejection has profound
consequences on adult behavior. Acknowledgement of the impact of cognitive distortions on
current aggression might be of importance for treatment. A stronger focus on altering distinct
cognitive distortions may be more successful in reducing aggression.
Keywords: aggression, cognitive distortions, parental rejection
Statement: Associations between parental rejection, cognitive distortions and severe
aggressive behavior among adult forensic psychiatric outpatients
Parental Rejection, Aggression, Distorted Cognition
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Aggression is a complex phenomenon with several factors contributing or protecting the
development of this deviant behavior such as empathy, self-control, trauma, impulsivity,
social network and relationships (Klepfisz, Daffern, & Day, 2017). Focusing on relationships,
one of the most important ones, especially during development, is the parent-child
relationship. Healthy parent-child relationships provide a protective factor in development of
aggressive and other deviant behavior. Severe or enduring negative experiences with parents
during childhood, on the other hand, may have long-lasting detrimental effects, such as
disturbed psychological functioning later in life. According to the Parental Acceptance and
Rejection Theory, low parental acceptance and high parental rejection are related to negative
child developmental outcomes (Rohner, 2004). Parental rejection is defined in terms of high
levels of hostility/aggression, undifferentiated rejection, and neglect and low levels of parental
warmth. The opposite is true for parental acceptance. Parental rejection could be a cause of
insecure attachment, as attachment is based on an infant’s information about the caregivers
tendency to be responsive, available, and sensitive to the infant’s needs (Dykas & Cassidy,
2011).
Previous studies have shown that parental rejection is associated with the increased risk
of aggressive behavior, hostility, criminality, violence in childhood, in adolescence and also
in adulthood (Brendgen, Vitaro, Tremblay, & Lavoie, 2001; Eron, Huesmann, & Zelli, 1991;
Khaleque & Rohner, 2012; Leary, Twenge, & Quinlivan, 2006; Rohner, 2016). Furthermore,
there are indications that factors such as parental rejection could have a profound impact on
the development of cognitive abilities that are necessary for appropriate regulation of (social)
behavior (for a review see Dykas & Cassidy, 2011; Shumaker, Deutsch, & Brenninkmeyer,
2009). More specifically, attachment security is thought to facilitate reflective capacities and
social understanding (Fonagy & Target, 1997). Parental rejection on the other hand are
associated with cognitive distortions (Cassidy, Kirsh, Scolton, & Parke, 1996; Dodge, 1993;
Parental Rejection, Aggression, Distorted Cognition
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Dodge, 1996; Rohner, 2016; Shumaker et al., 2009). Cognitive distortions are defined as
inaccurate attitudes, thoughts or beliefs regarding own or others behavior (Barriga & Gibbs,
1996). A possible explanation of the development of cognitive distortions is provided by the
developmental model of hostile attribution style proposed by Dodge (2006). This model holds
that hostile attribution biases are universally acquired in early life and that, usually, children
learn to make benign attributions. However, some children fail to develop the skills to make
benign attributions of non-hostile situations. One of the experiences in early life that might
contribute to this failure is a lack of warmth between caregiver and infant (Dodge, 2006).
Generally, cognitive distortions are thought to lead to problematic functioning, distorted
communications, and negative expectations about others behavior (Cassidy et al., 1996;
Dodge, 1993; Dykas & Cassidy, 2011; Shumaker et al., 2009).
Furthermore, cognitive distortions could lead directly to the disposition to show severe
aggressive behavior (Shumaker et al., 2009). Inappropriate aggressive and antisocial behavior
may be strengthened or maintained by cognitive distortions, that may have a function in
protecting a positive self-image, and neutralizing feelings of blame and guilt (Barriga,
Hawkins, & Camelia, 2008; Barriga, Landau, Stinson, Liau, & Gibbs, 2000). Due to this self-
serving role, cognitive distortions of aggressive or antisocial individuals are often referred to
as self-serving cognitive distortions. Furthermore, it is thought that different forms of
aggression are related to distinct sets of distorted cognitions in youth. Barriga et al. (2008)
reported that a disposition to use physical aggression was associated with self-serving
cognitive distortions particularly related to physical aggression (e.g. “people need to be
roughed up once in a while”, “if people don’t cooperate with me, it’s not my fault if someone
gets hurt”), whereas verbally aggressive behavior was related to self-serving cognitive
distortions related to opposition-defiance (e.g.” rules are mostly meant for other people”, “if I
really want to do something, I don’t care if it’s legal or not”). It was suggested that aggressive
Parental Rejection, Aggression, Distorted Cognition
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behavior is not characterized by generic cognitive distortions. Furthermore, it was proposed
that these different cognitive distortions could contribute to personalized-treatment by
focusing on altering cognitive distortions corresponding to a specific type of aggression.
Taken together, previous studies indicate that parental rejection could increase the risk
of aggressive behavior and could have an influence on the development of cognitive
distortions as well whereas self-serving cognitive distortions are also directly associated with
aggression. In addition, a recent study by de Vries, Hoeve, Stams, and Asscher (2015)
demonstrated that the link between attachment and aggressive behavior is mediated by self-
serving cognitive distortions in adolescents. As parental rejection could also lead to insecure
attachment, a similar negative association may also be found between aggression and parental
rejection. De Vries et al. (2015) focused on adolescents at risk or already involved with
criminal behavior, but who did not commonly engage in excessively aggressive behavior. In
violent adults, this link has not yet been investigated. Importantly, previous studies on
parental rejection and cognitive distortions mainly included community samples that were not
typified by clinical levels of aggressive behavior. It is also unknown whether the association
between parental rejection (retrospectively) and severe aggressive behavior is related to
distinct patterns of self-serving cognitive distortions in aggressive adults. Therefore,
disentangling the association between parental rejection, severe aggressive behavior and self-
serving cognitive distortions will significantly advance our understanding of the
developmental factors promoting aggressive behavior which also may be beneficial for
treatment.
The goals of the present study were two-fold. 1) First, we investigated which self-
serving cognitive distortions were associated with verbal and physical aggression in an adult
sample displaying pathological aggressive behavior, namely in a population of forensic
psychiatric outpatients (FPOs). 2) Second, the association between perceived parental
Parental Rejection, Aggression, Distorted Cognition
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rejection (measured retrospectively) in childhood, verbal and physical aggression, and self-
serving cognitive distortions in this severely aggressive population was explored. Based on
Barriga et al. (2008), it was hypothesized that physical aggressive behavior displayed by
FPOs was associated with cognitive distortions related to physical aggression and verbal
aggression was associated with cognitive distortions related to opposition-defiance. Moreover,
in line with De Vries et al. (2015), a direct link between parental rejection and aggression as
well as a mediating link, via cognitive distortions, was expected. In specific, it was
hypothesized that higher levels of perceived parental rejection were associated with higher
levels of aggressive behavior as well as self-serving cognitive distortions.
Methods
Participants
One hundred twenty-three male forensic psychiatric outpatients (FPOs) with aggression
regulation problems participated in the study (see Table 1 for demographic information). The
FPOs were recruited among patients admitted to “Kairos”, a secondary care and outpatient
unit of Forensic Psychiatric Centre the Pompestichting in Nijmegen, The Netherlands. The
FPOs included in the present study were admitted to Kairos because of aggression regulation
problems. Admission to Kairos occurs on either obligatory (e.g. when sentenced by a judge, N
= 32) or voluntary basis (based on reference by general practitioner N = 91).
The FPOs were screened by trained clinicians with the Structured Clinical Interview for
DSM-IV axis II personality disorders (SCID-II; Weertman, Arntz, & Kerkhofs, 2000) and the
Research Criteria set for Intermittent Explosive Disorder (IED-IR; Coccaro, Kavoussi,
Berman, & Lish, 1998). Inclusion to the study required FPOs to comply with the following
criteria: 1) a diagnosis of an antisocial, borderline and/or narcissistic personality disorder,
Parental Rejection, Aggression, Distorted Cognition
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and/or intermittent explosive disorder (IED), and 2) have a total score of five points or higher
on the Social Dysfunction and Aggression Scale (SDAS; Wistedt et al., 1990). This cut-off
was chosen because healthy, non-aggressive, controls in one of our previous studies had a
mean SDAS score of 2.85 (Smeijers, Bulten, van den Heuvel & Verkes, in press). Five points
or higher suggest severe aggressive behavior. The SDAS measures the severity of current
aggressive behavior based on a 5-point rating scale, and can be completed by an observer or
by the patient. In this study, due to lack of observers, the SDAS was used as a self-report
instrument. Aggressive behavior was rated by each FPO over a period of three months. In
addition, FPOs were excluded if there was a current major depression, current severe
addiction or lifetime bipolar disorder or any psychotic disorder according to the MINI
International Neuropsychiatric Interview (Sheehan et al., 1998; Van Vliet & De Beurs, 2007).
None of the FPOs met the exclusion criteria. The total duration of the assessment was
approximately 45 minutes and the study was approved by the Medical Research Ethics
Committee (CMO region Arnhem-Nijmegen, The Netherlands). All participants signed a
consent form after receiving information about the study and obtained a monetary
compensation.
Materials
The Adult Parental Acceptance and Rejection/control Questionnaire: Short-form
(PARQ; Rohner, 2005) assesses an individuals perceptions, retrospectively, of parental
acceptance and rejection in childhood. It consists of two sets of 29 items, one set for the father
and one for the mother, divided into five subscales: Warmth/affection, hostility/aggression,
indifference/neglect, undifferentiated rejection, and control. The items are rated on a 4-point
Likert scale. The score of the first four subscales were summed to obtain a total score of
perceived parental acceptance/rejection. Higher scores on this variable represent high
perceived parental rejection. A score of 56 or higher is considered to indicate severe levels of
Parental Rejection, Aggression, Distorted Cognition
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perceived rejection. The PARQ has proven to be reliable and valid cross-culturally;
Cronbach’s alpha = .89, test – retest reliability = .62 (Khaleque & Rohner, 2002; Khaleque &
Rohner, 2012). In the current study the internal consistency has also proven to be good
(Father: Cronbach’s Alpha = .95; mother: Cronbach’s Alpha = .93). The total scores of both
questionnaires where summed to obtain a single measure of parental rejection. This procedure
is in line with the study by Senese et al. (2016).
The Aggression Questionnaire (AQ; Buss & Perry, 1992) is a self-report questionnaire
to assess an overall trait of aggression. It consists of 29 items which are divided into four
subscales: Physical aggression, verbal aggression, anger and hostility. The items are scored on
a 5-point Likert scale (1=extremely unlike me to 5= extremely like me). The Dutch translation
has adequate psychometric properties; Cronbach’s alpha ranged from .50 to 84 (Morren &
Meesters, 2002). In the current study the internal consistency has also proven to be good
(Cronbach’s Alpha ranged from .67 to .85).
The How I think questionnaire (HIT; Barriga & Gibbs, 1996) is a 54-item self-report
questionnaire to assess self-serving cognitive distortions. The items are divided into four
cognitive distortion subscales; self-centered, blaming others, minimizing/labeling, assuming
the worst, and four behavioral referent categories; physical aggression, opposition-defiance,
lying, stealing. The behavioral referent categories refer to cognitive distortions related to
specific forms of antisocial behavior. Items have to be answered on a 6-point Likert scale. The
Dutch translation was found to be reliable and valid; Cronbach’s alpha ranged from .66 to .92
(Nas, Brugman, & Koops, 2008). In the current study the internal consistency has also proven
to be good (Cronbach’s Alpha ranged from .77 to .85).
Parental Rejection, Aggression, Distorted Cognition
9
Statistical analyses
A three-step procedure was applied. First, an initial non-parametric correlation analysis
was performed on all subscales of the AQ, PARQ and HIT, to explore the association between
these questionnaires (see Table 1 for descriptive statistics for the PARQ, AQ and HIT). A
bootstrapping (1000 samples) procedure was used to determine 95% confidence intervals and
to test the significance of the correlations. By using bootstrapping, one is able to simulate the
population distribution of the correlation and to provide confidence intervals for the
correlation coefficients (Sideridis & Simos, 2010). Moreover, when using this approach a
more accurate estimate of the associations is provided as compared to estimates produced by a
single sample, as would be the case in traditional parametric correlation analysis (Hesterberg,
Monaghan, Moore, Clipson, & Epstein, 2003).
In step 2, the Least absolute shrinkage and selection operator (Lasso, available in SPSS
as an option of Categorical linear regression (CATREG), SPSS version 20) was used as a
data-driven variable selection method, to reduce the amount of subscales of the HIT by
identifying the parameters with the most stable contribution in the explained variance of the
AQ physical and verbal subscale score, as all subscales of the HIT were highly correlated
with the AQ subscales and because of the high inter-correlation between the subscales of the
AQ (van der Kooij, 2007). This procedure was, furthermore, conducted in order to reduce the
amount of variables for the subsequent path analysis due to the relative small sample size. The
Lasso approach successively shrinks the model coefficients to zero by adding a penalty term
to the sum of the absolute values of the coefficients in each iteration. Applying this penalty
term provides a solution when there is high inter-correlation between predictors (Tibshirani,
1996). For the regularization, the minimum penalty was set at 0.0 and the maximum at 1.0
with a 0.02 increment in shrinkage in each iteration. This procedure yields a model that is
Parental Rejection, Aggression, Distorted Cognition
10
biased towards obtaining higher accuracy with the least amount of variables possible and with
the smallest predicted margin of error. The expected prediction error was estimated by using
the .632 bootstrap procedure (50 samples) (Efron & Tibshirani, 1997). The use of Lasso as a
variable selection technique for the identification of variables with high explanatory power
was the main purpose of this step. Therefore, the statistical significance of the coefficients
was of no interest (see also Brazil et al., 2013). All variables were defined on a numeric scale
and discretized by transforming the variables into z-scores and then multiplying them by ten
(van der Kooij, Meulman, & Heiser, 2006). The results of this procedure are displayed as
Lasso paths in which each position on the horizontal axis represents a model (Hartmann, Van
Der Kooij, & Zeeck, 2009). The original model is represented at the most right side of the
figure. The maximum standardized sum of coefficients (SSC, horizontal axis) was set at 1.0,
representing 100% of the contribution of the HIT scales to the corresponding γ parameter. The
Lasso path should be read from right to left. Towards the left, the penalty value increase and
the standardized sum of coefficients are gradually shrunken to zero at different rates
(Hartmann et al., 2009). The variable coefficients (y-axis) are displayed for different stages of
shrinkage of the SSC. The vertical line indicates the optimal model.
Finally, to investigate distinct patterns of cognitive distortions and the role of perceived
parental rejection on aggressive behavior as well as cognitive distortions, Bayesian path
analyses were conducted using Mplus version 7 (Muthén & Muthén, 1998). Based on the
results of the variable selection step, the HIT scales opposition-defiance and physical
aggression were entered as predictors in addition to Parental rejection, while AQ verbal and
physical aggression served as dependent variables. In order to be able to compare the
estimates, these variables were standardized by computing z-scores. Furthermore, to explore
the indirect effects, parental rejection was also entered as predictor of HIT opposition-
defiance and physical aggression. With model constraints, four indirect effects were defined:
Parental Rejection, Aggression, Distorted Cognition
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PARQ * HIT opposition-defiance * AQ verbal; PARQ * HIT opposition-defiance * AQ
physical; PARQ * HIT physical aggression * AQ verbal; PARQ * HIT physical aggression *
AQ physical. All variables were treated as continuous, observed, variables. Path analyses was
conducted with a Bayesian estimator (using the default Gibbs sampler PX1), 4 Markov Chain
Monte Carlo (MCMC) chains and 100.000 iterations (of which the first 50.000 were used as
burn-in trials) (see also de Vries, Brazil, Tonkin, and Bulten (2016). A Bayesian estimator
was favored because it is data driven and, furthermore, it avoids statistical assumptions about
the distribution of the test statistics. When the number of observations is relatively small, a
Bayesian approach is expected to perform better than traditional Maximum Likelihood
estimators because these estimators based on the large-sample theory do not provide good
approximations (Muthén, 2010), while Bayesian estimators provide reliable results even in
relatively small samples (Scheines, Hoijtink, & Boomsma, 1999).
In this study, a model was considered to show good fit if convergence was achieved
with a Proportional Scale Reduction (PSR) ≤ 1.05 (B. Muthén, 2010). Furthermore, the
posterior predictive p-value (PPP), a measure of similarity between observed and simulated
data generated by the model being examined, should ideally be close to 0.5, which means that
the model’s predictions are consistent with the observed data (Gelman, 2013). Finally, the
Chi-Square test to conduct Posterior Predictive Checking (with a 95% credibility interval;
95% CI) should include the value 0 (B. Muthén, 2010). Significance of the regression weights
were determined based on the 95% CIs of the Bayesian posterior distribution. The 95% CIs of
the regression weights that did not contain the value 0 were considered significant.
Parental Rejection, Aggression, Distorted Cognition
12
Results
Step 1: Correlation analyses
The association between the AQ and PARQ was explored using correlation analyses.
All traits of the disposition to act aggressively were significantly correlated with parental
rejection. Subsequently, to explore the associations between the AQ and the HIT, another
correlation analysis was performed in which all subscales of the HIT were correlated with all
subscales of the AQ. All subscales of the AQ were significantly correlated with all types of
cognitive distortions. Correlations are displayed in Table 2. Furthermore, a high inter-
correlation between the subscales of the HIT was found with r ranging from .56 to .85. (all p’s
< .001) as well as a high inter-correlation between the subscales of the AQ with r ranging
from .45 to .84 (all p’s < .001).
Step 2: Lasso
Because of the high inter-correlation between the AQ and HIT, Lasso procedure was
used, in an explorative way, to identify the parameters with the greatest prediction accuracy in
the explained variance of the AQ physical and verbal subscale score, in order to further
explore the association between cognitive distortions and the disposition to act aggressively in
general. Therefore, all subscales of the HIT were included. The results are displayed as Lasso
paths in Figure 1.1 and 1.2. Based on these results, the following subscales of the HIT were
selected representing an optimal model for physical aggression: opposition-defiance and
physical aggression whereas for verbal aggression only opposition-defiance was selected as
optimal model. Therefore, only these two subscales were included in subsequent path
analyses.
Parental Rejection, Aggression, Distorted Cognition
13
Step 3: Path analyses
Parental rejection, AQ physical and verbal aggression, HIT opposition-defiance, and
physical aggression were included in the model. The model as a result of the Bayesian path
analysis is displayed in Figure 2, only significant results were displayed. The results revealed
that parental rejection had a direct effect on AQ physical aggression and an indirect effect on
AQ physical as well as verbal aggression via opposition-defiance, see Table 3. No indirect
effect via HIT physical aggression emerged. Additionally, both HIT opposition-defiance and
physical aggression had direct effect on AQ physical and verbal aggression. The 95%
credibility interval for the difference between the observed and the replicated Chi-Square
values is -16.62 to 18.14. Posterior predictive p-value = .47, indicating an excellent model fit
1
.
Discussion
Perceived parental rejection, measured retrospectively, appeared to be associated with
the disposition to act aggressively in male adult FPOs. Furthermore, significant correlations
emerged between aggressive behavior and cognitive distortions. The findings of the path
analyses, however, indicated that cognitive distortions related to opposition-defiance (OD)
and physical aggression (PA) were most strongly associated with self-reported aggressive
behavior (see Figure 2). The current results are in agreement with previous findings indicating
that distinct types of cognitive distortions were differentially related to verbal and physical
aggressive behavior (Barriga et al., 2008). Additionally, our findings provide evidence for a
1
The path analysis was conducted again without FPOs without a diagnosis of IED. Results were comparable: the 95%
credibility interval for the difference between the observed and the replicated Chi-Square values is -16.63 to 18.32. Posterior
predictive p-value = .46.
As a single measure of parental rejection was used, the path analysis was conducted again for paternal and maternal parental
rejection separately. Results were comparable: for father the 95% credibility interval for the difference between the observed
and the replicated Chi-Square values is -16.82 to 18.15. Posterior predictive p-value = .47. For mother the 95% credibility
interval for the difference between the observed and the replicated Chi-Square values is -16.71 to 17.69. Posterior predictive
p-value = .47.
Parental Rejection, Aggression, Distorted Cognition
14
stronger association between cognitive distortions related to OD and PA and aggressive
behavior as compared to the other types of distorted cognitions, in a sample of FPOs
displaying pathological levels of aggression. This suggests that underlying cognitive
distortions have a different impact on severe aggressive behavior, which is of special interest
with respect to the treatment of aggressive behavior in forensic mental health settings.
In addition, an association was found between perceived parental rejection and
aggressive behavior. The present results are in line with previous literature suggesting that
parental rejection is related to aggressive behavior in childhood, adolescence, and adulthood
(Brendgen et al., 2001; Eron et al., 1991; Gallarin & Alonso-Arbiol, 2012; Khaleque &
Rohner, 2012; Rohner, 2016; Leary et al., 2006; Savage, 2014). Additionally, our study is one
of the first to point out that (retrospectively) perceived parental rejection is linked to self-
reported aggression in FPOs. The results may underline the notion that an individual’s
experiences and views on parental behavior during maturation are associated with current
aggressive behavior in adult FPOs. Our findings suggest that it is important to take into
account that aggression might have its origin in environmental factors such as parental
rejection that have a profound impact on an individuals cognitive processing style.
Furthermore, a mediating link with cognitive distortions was found in addition to the
direct link between parental rejection and aggressive behavior (see also de Vries et al.,
2015).The current findings complement the study by de Vries et al. (2015) by showing that
this link is measurable retrospectively in adult FPOs. In addition, the mediating link only
emerged regarding cognitive distortions related to OD. The items belonging to this subscale
are associated with disrespecting rules, laws, and authority and external reasons for deviant
behavior. Parental rejection seems to contribute to the development of these more general
deviant cognitions, which in turn may lead to the development of more specific cognitive
Parental Rejection, Aggression, Distorted Cognition
15
distortions, for instance related to physical aggression, as all the subscales of the HIT emerged
to be highly correlated.
The direct link between parental rejection and aggressive behavior may be explained in
terms of observational learning. Through observation and social modelling children may copy
or learn aggressive like behavior (Bandura, 1978). Another explanation might be that children
display aggressive behavior as coping mechanism. The Interpersonal Acceptance-Rejection
Theory (Rohner, 2016) suggests that the negative consequences of parental rejection, such as
high tendency towards aggression, occur either because of the intense psychological pain that
is produced by perceived rejection or by a phenomenon that rejected individuals protect
themselves from further rejection by closing off themselves emotionally. The mediating link,
on the other hand, may be explained in term of impaired social information processing
according to the Social Information Processing model (SIP; Crick & Dodge, 1994). The SIP
model consists of six steps that describe different stages of cognitive processing of social
information and behavior, ranging from the encoding of social cues to the selection and
evaluation of social responses. Moreover, the model assumes the existence of latent mental
structures, such as one’s beliefs or schemas generated based on previous experiences, that
guide the processing of social stimuli by integration into long term memory (Crick & Dodge,
1994). Latent mental structures can be formed based on interactions with primary caregivers
during maturation, but these mental structures can be distorted depending on the amount of
security a child experiences through the relationship with the parents (for review see Dykas &
Cassidy, 2011; Shumaker, Deutsch, & Brenninkmeyer, 2009).
Clinical implications
In forensic mental health settings, successful treatment requires exploration of the
parental bonding and the cognitive processing style of the patient. Cognitive therapeutic
Parental Rejection, Aggression, Distorted Cognition
16
interventions should be more concentrated on the aforementioned specific cognitions that are
distorted instead of more general cognitive therapy. In the end, this will result in more
targeted treatments which are further aimed at, and probably also more successful in, reducing
aggressive behavior. Moreover, it might be of interest to explore involving family systems in
interventions to reduce aggressive behavior. Several studies have shown that this is effective
in reducing conduct problems in adolescents (e.g. Farrington & Welsh, 2003; van der Stouwe,
Asscher, Stams, Deković, & van der Laan, 2014). As parental rejection was reported
retrospectively, it might be of importance to discuss these experiences with ones parents (if
possible). One might speculate that by elucidating these experiences, this also may have a
positive effect on the current relationship between an adult and his parents which,
subsequently, might have positive effects on the reduction of aggressive behavior.
Moreover, it is important to note that the current results do not reveal the whole
developmental link of aggressive behavior. Many more risk factors of adult aggression, such
as genetic predisposition, low socio-economic status and adverse life events, should be
considered when investigating and treating severe aggressive behavior (for review see e.g.
Raine, 2002).
Limitations
The present study and results have a number of limitations which merit further
comment. First of all, it could be argued that the fact that all measurements consisted of self-
report scores could be a limitation of this study, as participants could have answered the
question in a socially desirable way (Colet, Pamies, Carrasco, & Seva, 2012). However, a
recent meta-analysis on this issue found that social desirability in responding is limited in the
measurement of self-reported psychopathy, a condition typified by excessive use of
Parental Rejection, Aggression, Distorted Cognition
17
aggression and elevated prevalence of childhood maltreatment (Ray et al., 2013). This
suggests that the use to self-report in aggressive populations, such as the one used in the
current study, can be considered to be a valid approach. Another consideration is that forensic
psychiatric patients may not be fully capable of reflecting on their own behavior and that the
cognitive distortions displayed by FPOs affect the way they filled out questionnaires
(Schmidt, Banse, & Imhoff, 2015). One way of remediating this issue would be to try to
replicate the current findings using more implicit measures in order to rule out this possibility.
Thirdly, the cognitive distortions assessed in the current study are just a subset of the possible
distortions associated with aggressive behavior. Prospective research is needed to replicate the
current findings among other forms of cognitive distortions. Furthermore, to further clarify
the relation between parental rejection and the development of adult aggressive behavior
future research should include a control group consisting of non-violent individuals.
Additionally, previous research suggests that there are two pathways to adult aggression: late
and early starters. It is thought that the role of parenting in developing aggressive behavior is
larger among early starters then among late starters (Simons, WU, Conger, & Lorenz, 1994).
In the current study no information about the onset of aggression was available. This would
be an important avenue for future research. Lastly, the questionnaire regarding parental
rejection was filled out retrospectively and the information was not verified with parents. As
retrospective measures of childhood experiences are assumed to be sensitive to distortions, it
might be possible that there was a memory bias or that the patients’ current views on their
prior caregivers are affected by recent events or current mood (Brewin, Andrews, & Gotlib,
1993). Note, however, that a review suggested that retrospective measures still tend to be
reliable (Brewin et al., 1993).
Parental Rejection, Aggression, Distorted Cognition
18
Conclusions
The present results revealed that perceived parental rejection contributes directly to the
development of physical aggressive behavior in adult FPOs with severe aggression problems
and also indirectly via the emergence of cognitive distortions. The findings seem to stress the
notion that the consequences of parental rejection during childhood are profound and result in
impairments which remain present during adulthood. Regarding prospective research, it
would be of great interest to investigate the development of cognitive distortions and to
explore whether cognitive distortions are associated with aggression change over time in, e.g.,
a longitudinal design. The cognitive distortions related to OD and PA, found to be strongly
associated with aggressive behavior, need to be elucidated in further detail in order to take
further steps towards personalized treatment. This form of intervention may enhance
treatment adherence and improve the effectiveness. In the long run, this might result in a more
successful reduction of aggressive behavior in FPOs.
Conflict of interest
On behalf of all authors, the corresponding author states that there is no conflict of interest.
Acknowledgments
This research was funded by Netherlands Organization for Scientific Research (NWO),
National Initiative Brain & Cognition (NIHC, grant NWO-056-24-011). I.A. Brazil was
supported by a NWO VENI grant (451-15-014).The authors would like to thank the staff in
the outpatient clinics of Kairos, Pompestichting at Nijmegen, The Netherlands, for their
Parental Rejection, Aggression, Distorted Cognition
19
support in recruiting participants.
Parental Rejection, Aggression, Distorted Cognition
20
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Table 1.
Demographic information and means for the PARQ and the subscales of the HIT and AQ. Sample size
and means, with standard deviations (SD) between brackets
Mean / N
Total sample size
Age
IQ*
Antisocial personality disorder
Borderline personality disorder
Narcissistic personality disorder
Intermittent explosive disorder
Questionnaires
Parental Rejection (PARQ)
Aggression Questionnaire (AQ)
Physical
Verbal
Anger
Hostile
Total
How I Think Questionnaire (HIT)
Self-centered
Blaming others
Minimizing/labeling
Assuming the worst
Opposition-defiance
Physical aggression
Lying
Stealing
Total
N = 123
M = 36.50 (SD = 10.89)
M = 88.94 (SD = 12.29)
N = 45
N = 23
N = 4
N = 100
M = 93.47 (SD = 31.13)
M = 28.97 (SD = 7.83)
M = 16.70 (SD = 3.66)
M = 23.54 (SD = 5.09)
M = 22.85 (SD = 6.01)
M = 92.05 (SD = 18.18)
M = 2.51 (SD = .98)
M = 2.34 (SD = .75)
M = 2.39 (SD = .84)
M = 2.66 (SD = .79)
M = 2.69 (SD = .85)
M = 2.68 (SD = 1.02)
M = 2.62 (SD = .88)
M = 2.01 (SD = .76)
M = 2.49 (SD = .75)
*measured with the Dutch Adult Reading Test (Schmand, Bakker, Saan, & Louman, 1991).
AQ
Physical
AQ
Verbal
AQ
Anger
AQ
Hostile
AQ
Total
PARQ
HIT, Self-centered
HIT, Blaming others
HIT, Minimizing/labeling
HIT, Assuming the worst
HIT, Opposition-defiance
HIT, Physical aggression
HIT, Lying
HIT, Stealing
HIT, Total
r = .276, CI = .099 - .424,
p = .002
r = .592, CI = .461 - .694,
p < .001
r = .519, CI = .405 - .632,
p < .001
r = .583, CI = .445 - .698,
p < .001
r = .559, CI = .412 - .690,
p < .001
r = .656, CI = .405 - .632,
p < .001
r = .667, CI = .560 - .747,
p < .001
r = .387, CI = .211 - .561,
p < .001
r = .403, CI = .245 - .536,
p < .001
r = .628, CI = .501 - .727,
p < .001
r = .233, CI = .072 - .384,
p = .009
r = .348, CI = .188 - .481,
p < .001
r = .329, CI = .182 - .471,
p < .001
r = .231, CI = .080 - .379,
p = .010
r = .400, CI = .259 - .516,
p < .001
r = .478, CI = .345 - 591,
p < .001
r = .338, CI = .173 - .485,
p < .001
r = .224, CI = .062 - .368,
p = .013
r = .210, CI = .078- .348,
p = .020
r = .366, CI = .226 - .491,
p < .001
r = .300, CI = .135 - .460,
p = .005
r = .477, CI = .312 - .604,
p < .001
r = .444, CI = .286 - .566,
p < .001
r = .335, CI = .162 - .484,
p < .001
r = .411, CI = .218 - .577,
p < .001
r = .508, CI = .352 - .629,
p < .001
r = .516, CI = .362 - .631,
p < .001
r = .218, CI = .012 - .420,
p = .015
r = .310, CI = .128 - .456,
p < .001
r = .463, CI = .281 - .593,
p < .001
r = .349, CI = .205 - .479,
p < .001
r = .419, CI = .249 - .561,
p < .001
r = .507, CI = .367 - .626,
p < .001
r = .348, CI = .179 - .503,
p < .001
r = .515, CI = .355 - .658,
p < .001
r = .544, CI = .393 - .665,
p < .001
r = .469, CI = .300 - .604,
p < .001
r = .286, CI = .090 - .485,
p < .001
r = .390, CI = .229 - .518,
p < .001
r = .494, CI = .334 - .619,
p < .001
r = .366, CI = .224 - .497,
p < .001
r = .598, CI = .457 - .707,
p < .001
r = .582, CI = .466 - .676,
p < .001
r = .507, CI = .356 - .628,
p < .001
r = .607, CI = .446 - .735,
p < .001
r = .701, CI = .591 - .782,
p < .001
r = .655, CI = .541 - .744,
p < .001
r = .367, CI = .180 - .544,
p < .001
r = .432, CI = .268 - .567,
p < .001
r = .638, CI = .512 - .732,
p < .001
Figure 1.1. Results of the (Lasso) variable selection procedure for physical aggression.
Each position on the horizontal axis represents a model. The original model is represented at
the most right side of the figure. The maximum standardized sum of coefficients (SSC,
horizontal axis) was set at 1.0, representing 100% of the contribution of the HIT scales to the
corresponding γ parameter. The Lasso path should be read from right to left. Towards the left,
the penalty value increase and the standardized sum of coefficients are gradually shrunken to
zero at different rates. The variable coefficients (y-axis) are displayed for different stages of
shrinkage of the SSC. The vertical line indicates the optimal model.
Parental Rejection, Aggression, Distorted Cognition
26
Figure 1.2. Results of the (Lasso) variable selection procedure for verbal aggression.
Each position on the horizontal axis represents a model. The original model is represented at
the most right side of the figure. The maximum standardized sum of coefficients (SSC,
horizontal axis) was set at 1.0, representing 100% of the contribution of the HIT scales to the
corresponding γ parameter. The Lasso path should be read from right to left. Towards the left,
the penalty value increase and the standardized sum of coefficients are gradually shrunken to
zero at different rates. The variable coefficients (y-axis) are displayed for different stages of
shrinkage of the SSC. The vertical line indicates the optimal model.
Parental
Rejection
Verbal
Aggression
HIT
Opposition-
Defiance
HIT
Physical
Aggression
= Direct effect
= Indirect effect
= Correlation
.262
.451
.823
.536
Physical
Aggression
.236
1.40
.054
.248
.188
Dependent
variable
Parameter
Estimate
(β)
95% C.I.
Lower 2.5% - Upper 2.5%
Direct effect
Indirect effect 1
Indirect effect 2
Indirect effect 3
Indirect effect 4
AQ physical aggression
AQ verbal aggression
HIT opposition-defiance
HIT physical aggression
AQ physical aggression
AQ physical aggression
AQ verbal aggression
AQ verbal aggression
Parental rejection
HIT opposition-defiance
HIT physical aggression
Parental rejection
HIT opposition-defiance
HIT physical aggression
Parental rejection
Parental rejection
Parental rejection +
HT opposition-defiance
Parental rejection +
HIT physical aggression
Parental rejection +
HT opposition-defiance
Parental rejection +
HIT physical aggression
.188
.248
.451
.124
.536
-.109
.236
.090
.054
.038
.121
-.005
.053 - .323*
.019 - .478*
.227 - .675*
-.045 - .292
.250 - .821*
-.389 - .169
.059 - .414*
-.091 - .272
.001 - .144*
-.041 - .136
.025 - .262*
-.062 - .025
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