Chapter 9: Conduct Problems

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All right, so we're diving into something I think a lot of you are curious about, conduct problems in kids and teens.

I've been digging into child psychopathology by Mash, Wolf, and Williams, and let me tell you, this deep dive is already fascinating.

Ready to explore this together?

Absolutely, this is a topic with so many layers.

Right, and we're thrown right into the deep end with this case of 12 -year -old Steve who stabbed his father to protect his mom from an assault.

It really makes you question what bad behavior even means.

Yeah, it highlights how crucial context is.

Sometimes what looks like a conduct problem is actually a reaction to something even worse.

Makes you think, huh?

Totally, and then the book throws out this stab that conduct problems are more common than we think, but serious cases like Steve's are actually rare.

Plus, the gender gap is shrinking.

Apparently, girls are catching up, which is kind of surprising.

Lots to unpack there.

Let's start with the basics.

What exactly are we talking about when we say conduct problems?

Basically, think actions that are totally inappropriate for a kid's age, stuff that violates societal norms or the rights of others.

So we're talking about things like lying, stealing,

aggression, just constantly breaking the rules.

Exactly, and it's not just your typical kid testing boundaries.

For it to be a real problem, it has to be persistent, like a pattern, and it's got to be causing significant impairment in their life.

Right, so like impacting their relationships, their schoolwork, putting them or others in danger, stuff like that.

Exactly, and the costs of these problems are huge, not just emotionally, but also for society as a whole.

The book says conduct disorder can cost over $70 ,000 per child over seven years.

That's a lot of resources.

Whoa, that's a big number.

And the book doesn't just look at this from one angle, right?

We've got legal perspective, psychological, psychiatric, public health.

Yeah, they all bring something unique to the table.

Legally, we're talking about delinquency, kids getting in trouble with the law.

Psychologists tend to see it as part of this spectrum of externalizing behaviors.

And then psychologists get into the official diagnoses, like oppositional defiant disorder, OBD and conduct disorder, CD.

Right, and the book uses these really vivid examples to illustrate the differences.

Like there's Gordon, who was so defiant, he'd refuse to wear socks even when it was pouring rain, classic ODD, right?

Oh, I know that type, always pushing back no matter what.

Yep, then we have CD, which is a whole other level.

They talk about Greg, who was setting fires and even tried to suffocate his little brother.

It's marked by aggression toward people and animals, property destruction, serious rule violations.

That's scary stuff.

And there's this even more disturbing subtype within CD with limited pro -social emotions.

These kids are the ones who show no remorse, zero empathy.

The book describes this 13 year old Jason, who straight up said he enjoyed hurting others and didn't care about consequences.

It's a good reminder that while most kids with conduct problems don't reach that level of severity, it's still really important to recognize these traits early on.

For sure.

Now, one thing that surprised me was how common ODD and CD actually are.

The book says lifetime prevalence is 12 % for ODD and 8 % for CD.

I had no idea it was that high.

Yeah, those numbers are higher than many people expect.

And interestingly, ODD is more common in childhood, while CD rates tend to increase during adolescence.

Oh, so as kids get older, the nature of the conduct problems might change.

Yeah, exactly.

And that old idea that boys are way more prone to these problems, well, that gender gap is shrinking fast, so girls are catching up in a way.

I wonder if that means their behavior is starting to look more similar, or if something else is going on there.

That's a great question.

It's something researchers are still exploring.

But one thing we do know is that there are two main pathways these conduct problems can take.

One is called life course persistent, or LCP.

These are the kids who start showing aggression and antisocial behavior early on.

And unfortunately, those problems often persist into adulthood.

And then there's the adolescent limited pathway, AL, where those behaviors emerge around puberty and usually die down by their twenties, right?

Exactly.

The book tells the story of Marcus, who was a gang member, but managed to turn his life around, which is a classic example of the AL pathway in action.

It reminds us that even when things get tough, change is possible.

That's so important to remember.

But even if those outward behaviors fade,

does the book say anything about the long -term effects?

Like, do those early conduct problems still have an impact on these individuals later in life?

Sadly, yeah.

Even when those outward behaviors fade, adults with a history of conduct problems often face other challenges.

They may struggle with mental health issues, substance abuse, and forming healthy relationships.

So it's not just about addressing the behavior in the moment.

It's about supporting these individuals long -term.

Absolutely.

Now, the million dollar question, what causes these conduct problems in the first place?

It's probably not as simple as finding a single smoking gun, right?

Probably not.

I mean, think about all the factors that shape a person's development.

It's gotta be complicated.

You're so right.

And the book uses this powerful example of two brothers raised in the same family.

One brother end up a successful author while the other is imprisoned for murder.

It really highlights the complexity of this issue.

Wow.

That's a stark contrast.

So what are some of the pieces of this puzzle?

Does the book talk about genetics?

Genetics definitely play a role.

They discuss this variation of the MAOA gene that's been linked to aggression, especially when combined with early maltreatment.

So it's not just nature or nurture.

It's how those two things interact that can make a child more vulnerable.

Exactly.

And then there are prenatal factors, too.

If a mother experiences malnutrition or uses substances during pregnancy, it can increase the risk of conduct problems in her child.

But it's super important to emphasize that these factors aren't destiny.

Right.

There are always other factors at play.

What about the brain itself?

Does the book talk about any neurobiological stuff?

Oh, yeah.

It gets into some fascinating neurobiology.

It focuses on these two systems in the brain, the behavioral activation system or BAS.

Think of it like the gas pedal and the behavioral inhibition system, BIS, which is like the brakes.

So some kids might have their gas pedal stuck, making them super impulsive, while others have weak brakes.

So they struggle to control their reactions.

That's a great way to put it.

And just like we see in ADHD, kids with conduct problems often have trouble with executive functions, which are those higher level thinking skills that help us plan, organize and inhibit those impulsive urges.

I can imagine how challenging that would be for them trying to social situations or make good decisions when those skills are out of whack.

Does that tie into the hostile attributional bias that the book mentions?

Yes.

So social cognitive factors are really important here.

These kids often misinterpret social cues.

And when they're in a challenging situation, they have trouble problem solving effectively.

The hostile attributional bias means they see hostility, even when it's not there, leading to those aggressive responses.

Oh, so they're constantly on guard, expecting the worst from others, which can become a self -fulfilling prophecy.

Sadly, yes.

And we can't forget about the role of family dynamics.

The book points out that two major types of family disturbances are often linked to conduct problems.

I'm guessing those are general disturbances and then more specific issues with parenting practices.

You got it.

General disturbances would be things like parental mental health problems, a family history of antisocial behavior,

constant conflict between parents, lack of resources, instability in home, those kinds of things.

Right.

So a lot of stress and dysfunction in the home environment.

And then those specific parenting practices would be things like harsh or inconsistent discipline, not enough supervision or a lack of emotional support.

Yeah, that makes sense.

It creates a perfect breeding ground for conduct problems to develop.

And I remember the book talking about a theory about how parent -child interactions can spiral out of control.

You're thinking of mom and son arguing over homework.

And it shows how easy it is for everyday interactions to escalate into the cycle of coercion.

It's like those negative patterns get ingrained in the family dynamic.

And what about attachment?

I remember hearing that's a factor too.

Right.

Children with conduct problems often have insecure attachments, especially what's called disorganized attachment, which can really hinder their ability to form healthy relationships and internalize prosocial values.

It's like they're missing that foundation of trust and security that helps them connect with others and develop empathy.

Exactly.

And the influence doesn't stop at the family.

The peer group plays a huge role too.

Right.

The book talked about how kids with conduct problems tend to gravitate toward other antisocial kids.

Unfortunately, they find a sense of belonging and validation in those groups, even if it's for all the wrong reasons.

And guess what often happens in those groups?

More delinquent behavior.

Plus there's the whole issue of bullying.

Right.

It shared that heartbreaking story of 13 -year -old Johnny, who was relentlessly bullied, both physically and emotionally.

It's a reminder that bullying is a serious problem, not just kids being kids.

And with social media, we now have cyber bullying to contend with, which can be even harder to escape because it happens outside of school and can feel relentless.

It's like a whole new battleground for aggression.

And we can't forget about the influence of the school itself and the community a child lives in.

Absolutely.

Conduct problems are way more common in neighborhoods with high crime rates, poverty, and limited resources.

And if the school isn't a functioning well with inconsistent discipline and low expectations, that can make things worse.

It's like a vicious cycle.

These kids are exposed to so much negativity and then they lack the support to break free and thrive.

Right.

And then there's that ongoing debate about the role of the media, especially violent video games.

Does exposure to that kind of content actually contribute to aggression in kids?

Yeah, that's a tough one.

The research seems kind of mixed, but I think we can all agree that we need to be mindful of what our kids are consuming and how it might be affecting them.

Definitely.

And we can't forget about cultural factors either.

Different cultures have totally different norms about aggression and how to deal with it.

It's a good reminder that there's no one -size -fits -all approach to this issue.

So with all these factors at play, is there any hope for these kids?

I mean, could anything be done to help them?

The good news is the earlier we intervene, the better the chances of positive change.

And there are a number of promising treatment approaches out there that have shown to be really effective.

So early intervention is key.

Absolutely.

And we'll dive into those treatment approaches in more detail in the next part of our deep dive.

So we left off talking about the importance of early intervention.

And luckily, there are some really promising treatment approaches that can make a huge difference for these kids.

Yeah.

And you mentioned a few of them last time, parent management training or PMT problem -solving skills training, PSST, and then multistemic therapy or MST.

Going to break those down a bit more.

Starting with PMT, what does that actually look like in practice?

Okay.

So picture this.

You've got a parent who is totally at their wits end struggling with their kid's behavior.

PMT is like giving them a toolkit, you know, a set of strategies to help create a calmer, more structured environment at home.

Okay.

So I'm imagining this toolkit.

What's inside?

What are some of the techniques?

Well, one of the first things we do is help parents understand that cycle of coercion we talked about earlier.

Remember that example of the mom and son arguing about homework?

Oh yeah.

Where the kid learns that if you just push back hard enough, they'll eventually get their way.

And the parent learns that giving in is the fastest way to avoid a complete meltdown.

It's a recipe for disaster.

Exactly.

PMT helps parents break that cycle by teaching them to respond in a more consistent and effective way, you know, setting clear expectations and boundaries.

So no more mixed messages or constantly changing the rules.

Exactly.

Consistency is key.

And then there's positive reinforcement, which is all about catching kids being good and praising them for those positive actions.

I think that's so important.

It's easy to focus on what kids are doing wrong, but we often forget to acknowledge when they're making an effort.

Right.

It can be simple things like, Hey, I noticed you clean up your choice without being asked.

That's awesome.

Or maybe you give them some extra playtime or a special sticker.

The key is to make it specific and immediate so they can connect the dots between their good behavior and the positive consequence.

That makes a lot of sense.

What about when they misbehave?

Are there consequences involved in PMT?

Oh yeah, absolutely.

Setting clear limits and consequences is a crucial part of PMT.

You know, establishing specific rules for behavior and then consistently enforcing those rules.

For example, if the rule is no hitting, then every time the child hits, there needs to be a consequence.

Right.

So it's not about punishment, but about teaching them that actions have consequences.

Exactly.

And the consequences should be something that's meaningful to the child, but also appropriate and fair.

We don't want to resort to, you know, harsh or arbitrary punishments.

It's about teaching them, not breaking them.

Exactly.

And PMT really emphasizes that parents need to stay calm and consistent, even when it's tough.

It takes a lot of patience and practice and they get a lot of support from the therapist throughout the process.

So it's a real partnership between the therapist and the parents.

It is.

And the results can be pretty amazing.

Studies have shown that PMT can significantly reduce disruptive and aggressive behavior in kids, especially younger ones.

That's really encouraging.

And you mentioned earlier these digital -based parent training programs.

Are those a good option for families who maybe can't access traditional therapy?

Oh yeah, definitely.

They can be fantastic.

They're more accessible, often more affordable.

And for some parents, the online format feels less intimidating.

Plus, you know, let's be real, in this day and age, most people are pretty much glued to their devices anyway, so it makes sense to meet them where they are.

I love that.

It's like therapy is involving to meet the needs of modern families.

So we've talked about PMT, which focuses on that parent -child dynamic.

What about problem -solving skills training?

What's the main idea behind that approach?

Think of PSST as like a cognitive bootcamp for kids who struggle to navigate those tricky social situations.

You know how we talked about them misreading social cues, assuming the worst and just defaulting to aggression?

Well, PSST teaches them to slow down, think things through, and come up with better solutions.

Oh, so it's like we're rewiring their brains to respond in a more positive, pro -social way.

Exactly.

It's a very structured approach.

We teach them these specific steps to follow when they encounter a problem.

First, they learn to accurately identify what the problem is.

So instead of jumping to conclusions or making assumptions, they take a moment to really assess the situation.

Exactly.

Then they brainstorm a bunch of possible solutions, not just their usual go -to response, which might be aggression or some other negative behavior.

So they're expanding their repertoire of coping skills.

Yes.

And once they've got a few ideas, we help them evaluate the potential consequences of each option.

So they're thinking about the long -term impact of their actions, not just what will give them immediate gratification.

Right.

They're learning to think more strategically, and then they choose what they think is the best solution, put it into action, and then they reflect on the outcome.

Did it work?

If not, what could they do differently next time?

It's like they're becoming little scientists, experimenting with different approaches and learning from their experiences.

I love that analogy.

And the research backs it up.

PSST has been really effective in reducing aggression and improving social skills in kids with conduct problems.

That's great to hear.

And now what about those teens with really severe conduct problems?

You mentioned multistemic therapy.

Can you tell us more about how that works?

Yeah.

So MST is like going all in when it comes to treating those really complex cases.

It recognizes that conduct problems don't exist in a vacuum.

There are all these interconnected factors in the teenager's life that are contributing to the problem.

So it's about looking at the whole system, not just the individual.

Exactly.

MST therapists become part of the team.

They work closely with the teenager, their family, school, peers, and even the juvenile justice system if that's relevant.

They're like master coordinators, making sure everyone is on the same page and working together to support that team.

It sounds incredibly intensive.

So what are some of the things that the MST therapists focus on?

Well, it really depends on the specific needs of the teenager and their family.

They might work on improving family communication, addressing parenting issues, you know, connecting the teen with mental health or substance abuse treatment if that's needed.

They might advocate for changes at school or work with probation officers to make sure the teen is meeting their court ordered obligations if that's the case.

Wow.

So they really cover all the bases, huh?

Yeah.

It's about addressing all those moving parts that are contributing to the teenager's behavior.

And the results are impressive.

Studies have shown that MST can significantly reduce delinquency, aggression, and out of home placements for these teens.

That's incredible, especially for those kids who haven't responded to other types of treatment.

Right.

It shows that when we take this comprehensive, individualized approach, we can really make a difference, even in the most challenging cases.

Okay.

So I'm noticing a pattern here.

Early intervention, individualized approaches, and looking at the whole system, those seem to be the key ingredients for success.

You're spot on.

And that brings us back to prevention.

Remember Fast Track, that program we talked about earlier?

Yeah, the one that starts in elementary school and follows the kids all the way through high school.

It seemed like a great example of being proactive and intervening early.

It is.

It really embodies that it takes a village approach.

Fast Track involves parents, teachers, and community members all working together to create a supportive environment for these at -risk kids.

They provide parent training, social skills training, academic support.

It's like they're building the safety net.

And it really works.

I remember those studies showing that Fast Track led to a significant reduction in aggression, delinquency, and even substance abuse in the kids who participated.

It's proof that we can make a real difference in these kids' lives.

Absolutely.

And it just underscores how important it is to invest in early prevention programs.

It's not just more effective, it's also more humane, and in the long run, more cost -effective.

It's a win -win all around.

Now, before we move on to our final segment, I want to touch on something we briefly mentioned before.

The impact of these conduct problems on the kids themselves.

You know, it's easy to get caught up in the behaviors and forget that there's a real person behind all of that.

Yes, absolutely.

We can't lose sight of the human element.

These kids are often hurting, and they might not know how to express that pain in healthy ways.

They might be facing rejection from their peers, conflict with their families, struggles in school.

So those behaviors are often a symptom of a deeper struggle.

Exactly.

They need to know that they're not bad kids, that they're worthy of love and support, even when their behavior is challenging.

And they need to know that there's hope, that things can get better, that with the right support, they can learn to manage their emotions, make better choices, build healthier relationships.

You said it perfectly.

Now, before we wrap up this part, I want to go back to those callous, unemotional traits or CU traits that we talked about before, the ones that can make some of these so difficult to treat.

Yeah, those kids who seem to lack empathy, remorse or guilt.

That's always one of the more challenging aspects of this topic.

And I remember you saying that traditional treatment approaches often don't work very well with these kids.

That's right.

Trying to appeal to their sense of empathy or guilt just doesn't work because for them, those emotions aren't really there.

But luckily, there's a lot of research being done specifically on finding effective treatments for these kids.

Well, that's good to hear.

What are some of the strategies that they're exploring?

Well, one approach that's showing a lot of promise is focusing on the benefits of pro -social behavior instead of trying to make them feel bad or guilty.

You know, we teach them how good it feels to be kind, helpful, cooperative.

So it's about appealing to their self -interest, showing them that being pro -social can actually have positive consequences for them too.

Exactly.

We can explain how helping others, cooperating with others can lead to things they want, like having more friends, getting more privileges, having a better reputation.

And then we give them opportunities to practice those behaviors and experience those rewards.

So they're learning that being good can actually be fun and rewarding.

Yes.

It's about building intrinsic motivation where doing the right thing becomes its own reward.

Another promising approach is helping them develop emotional regulation skills.

So teaching them how to recognize and name their own emotions and how to express those emotions in a healthy way.

Exactly.

You see, a lot of kids with QD traits struggle to even understand and manage their own emotions.

They might not even realize how their actions are impacting other people.

It's like they're missing that emotional intelligence piece.

Yes, exactly.

So we teach them how to identify their emotions, how to label them, and then find healthy ways to express them.

We might use things like journaling, role playing, mindfulness exercises.

So it's about helping them develop a greater sense of self -awareness and control.

Exactly.

And of course, we always need to look for and address any other mental health issues that might be contributing to those CU traits, things like anxiety or depression.

Because sometimes those CU traits might be a way of coping with those other emotional struggles.

So by addressing the underlying cause, we might see a reduction in those callous and unemotional behaviors.

Exactly.

Treating kids with CU traits can be challenging, but it's definitely not hopeless.

With these specialized interventions and a genuine commitment to understanding their unique needs, we can help these kids develop the skills they need to live more fulfilling, more pro -social lives.

That's really encouraging to hear.

And even though some cases can be quite severe, it's important to remember that most kids with conduct problems do go on to lead successful and productive lives.

That's absolutely true.

With the right support and interventions, most of these kids are able to overcome those challenges and reach their full potential.

And it's so important for everyone involved, the parents, teachers, therapists, to hold onto that hope, both for themselves and for the kids they're working with.

Hope is so powerful, isn't it?

It fuels our efforts to understand these complex issues and develop effective interventions.

It gives us the strength to keep fighting for these kids, even when it's tough.

Beautifully said.

Now, before we wrap up this part of my deep dive, I'd love to get your take on something.

We talked about that shrinking gender gap in conduct problems earlier, and it feels like a pretty big shift in our understanding of these issues.

What do you think are some of the key takeaways from that research?

You know, what strikes me most is that it really challenges our assumptions.

For so long, we view conduct problems as primarily a boy problem, and I think that really limited our understanding of how these issues might manifest in girls.

Exactly.

By recognizing that girls are just as susceptible to developing conduct problems, we can start to identify those early signs and provide the

And it forces us to consider how social factors and those shifting gender roles might be contributing to these trends.

Right.

It's not just about biology.

We have to look at the social and cultural pressures that girls are facing, the messages they're receiving about what's considered acceptable behavior, and the support systems or lack thereof that are available to them.

And it reminds us that aggression in girls can look different from aggression in boys.

Absolutely.

We need to be aware of those nuances and recognize that relational aggression, like spreading rumors or excluding others, can be just as damaging as physical aggression.

So it's about broadening our understanding of what conduct problems look like and being more sensitive to how these issues might manifest differently in girls.

Exactly.

By doing so, we can create a more inclusive and supportive environment for all kids who are struggling with these challenges.

Okay, that was a great conversation.

We've covered so much ground today exploring the complexities of conduct problems in youth.

Before we move on to our final segment, is there anything else you think our listeners should keep in mind?

You know, I think a really important takeaway from all of this is the need to shift our focus from reacting to conduct problems to actually preventing them.

We've talked about all these treatment strategies, but imagine if we could create a world where those problems don't even develop in the first place.

Okay.

Yeah, I like that idea.

What would that kind of world look like?

Well, I think it starts with building communities that are truly supportive of young people, you know, communities where kids feel safe, connected and empowered.

So it's not just about trying to fix problems after they've already emerged.

It's about creating an environment that fosters healthy development right from the start.

Exactly.

Think about it.

If kids grew up feeling loved, supported and valued, they're much less likely to act out in those destructive ways.

They're more likely to develop those crucial social and emotional skills that help them navigate life's challenges.

That makes so much sense.

So what are some things we can actually do to build these kinds of supportive communities?

Well, I think it starts with awareness.

We need to educate ourselves about the risk factors for conduct problems and the early warning signs.

The more we understand these issues, the better equipped we are to intervene early and effectively.

So parents, teachers, even just neighbors and community members, we all need to be on the lookout for those red flags, those early signs that a child might be struggling.

Exactly.

And we need to create spaces where kids feel safe to talk about their struggles, you know, to express their emotions and to ask for help without feeling judged or ashamed.

It's about fostering open communication and building trust so kids know they can reach out when they're struggling.

Exactly.

And we need to give a kid's opportunities to develop their social and emotional skills.

I'm thinking about things like conflict resolution training, empathy building activities and programs that teach them how to manage their emotions in a healthy way.

You got it.

Those are all great examples.

And we can't forget the importance of positive role bottles.

Kids need to see adults in their lives who are demonstrating pro -social behaviors, kindness, compassion, empathy, respect.

Yeah, they need to see that those qualities are valued and that they could be successful without resorting to aggression or manipulation.

Right.

And we can't ignore those larger societal issues that contribute to conduct problems, poverty, inequality, exposure to violence.

Those are the root causes that we can't just sweep under the rug.

Exactly.

We need to be advocating for policies and programs that create a more just and equitable society.

One where all kids, no matter their background or circumstances, have a real opportunity to thrive.

I love that vision.

So it sounds like it really takes a multi -pronged approach to create real change tackling these issues from every angle.

Absolutely.

It's not about finding this magic bullet solution.

It's about building a web of support that catches those kids who are falling through the cracks and gives them the tools they need to succeed.

And empowers them to make positive choices.

Exactly.

It's about creating a world where kids like 12 year old Steve, you know, those kids facing incredible challenges have a different path, a path that leads to healing and hope.

That's a beautiful way to put it.

So as we wrap up this deep dive into conduct problems in youth, what's the one message you want to leave our listeners with?

Here it is.

Conduct problems are not a life sentence.

With the right support, these kids can overcome their challenges and build a brighter future both for themselves and their communities.

Let's be that support.

That's such a powerful message.

And it's a call to action for all of us, whether we're parents, teachers, community leaders, or simply concerned citizens.

We each have a role to play in creating that brighter future.

Thank you so much for joining us on this deep dive.

We hope you found it informative and empowering.

And remember, understanding is always the first step towards creating a more compassionate and supportive world for all children.