Using Behavioral Treatment To Curb Conduct Problems In Children With Callous-Unemotional Traits

Behavior problems in children take many forms, including verbal defiance towards authority figures, non-compliance, and physical aggression – all of which fall under a broad term known as “conduct problems” (CP). These CP can cause a large degree of impairment in a child’s life, including poor interpersonal relationships and decreased academic performance.

Children that present with chronic and persistent CP are often diagnosed with psychological disorders such as Oppositional Defiant Disorder (e.g., verbal aggression, defiance, vindictiveness) and/or Conduct Disorder (e.g., physical aggression, vandalism, disregard for societal rules). CP are very common in school-aged children and are often the reason that youth are referred to mental health services. Treating childhood CP has been most successful when implementing behavior therapy, which focuses on structure, goal-setting, and consistent use of positive reinforcement and appropriate use of discipline. Behavior therapy is an effective intervention for the majority of children with CP; however, a portion of children with CP seem to be somewhat unresponsive to behavior therapy.

One reason for this reduced response is that a portion of children with CP have callous-unemotional (CU) traits. Children that present with CU traits exhibit a lack of empathy for the well-being of others and have little guilt or remorse for committing wrong-doings – these CU traits have been found to lead to highly aggressive CP, including physical violence/assault, destruction of property, and even cruelty to animals. The literature examining treatment outcomes for this subgroup of aggressive children is inconclusive, especially when considering several limitations that likely contribute to these mixed findings (i.e., treatment type, informant-rater, defining treatment “outcome” vs. treatment “response”).

Our study addressed these limitations in three ways: (a) we delivered treatment directly to children and provided skills to parents – whereas a large portion of past treatment studies have only provided skills to parents; (b) we obtained ratings of child behavior from multiple informants – parents and teachers – whereas a majority of previous studies have only utilized parent report; (c) we analyzed outcomes in two ways, with treatment “response” defined as the change from pre- to post-treatment and treatment “outcome” defined as the rate to which a child’s behavior was normalized at the end of treatment.

Our study included 67 children, 46 of which presented with varying intensity levels of CP and CU traits, while the remaining 21 did not meet any diagnostic criteria and served as controls for research purposes. All children were treated in a summer treatment program, which delivers behavior treatment directly to children while also providing skills to parents. Each child’s behavior before and after treatment was rated by their parents and teachers. The outcome behaviors of interest included: severity of oppositional defiant and conduct disorder behaviors, callous behaviors, and general life impairment from these behaviors. We predicted that CU traits would moderate the association between CP and the effects of behavior therapy (as measured by the above outcomes), as rated by both parents and teachers. We used mixed models to examine the unique association that treatment, CP, CU, and informant-type had on outcomes, as well as the interactions among these variables.

Our first set of analyses focused on treatment response (i.e., amount of change in scores from pre-treatment to post-treatment). We found that children with high levels of both CP and CU traits experienced a significant reduction in their conduct disorder behavior, from pre-treatment to post-treatment, as rated by both parents and teachers. This group of children also experienced a substantial reduction in their callous behaviors, from pre-treatment to post-treatment, as rated by teachers only. Our next set of analyses focused on treatment outcomes (i.e., the degree to which scores were “normalized” at post-treatment). We largely found that children with higher rates of CP (regardless of levels of CU) and children with higher rates CU (regardless of levels of CP) had worse treatment outcomes, whereas children with lower rates of CP and CU had better treatment outcomes.

Overall, results of our study demonstrate that children with high rates of CP and CU traits experienced large treatment response (i.e., larger change from pre-treatment to post-treatment) but experience worse treatment outcomes (i.e., were less likely to have “normalized” scores at post-treatment). Our findings seem to fall in line with much of the research literature: children with CP and CU traits are likely to experience large reductions in treatment due, in part, to their high rates of impairment at pre-treatment. However, these children are also much more likely to remain significantly aggressive and impaired, or less normalized, at post-treatment.

These results highlight the importance of separately evaluating treatment “response” and treatment “outcome,” as well as using data from multiple informants (i.e., parents and teachers). The findings from our study suggest that intensive and continued behavior therapy may be necessary, but likely not sufficient, for children with CP and CU traits.