Every month or so I receive an email from a parent somewhere in the world asking for help with a violent, angry or aggressive child. Some people describe being physically beaten or receiving death threats from their son or daughter. These families can spend thousands of dollars on schools and special treatments. They are often desperate, scared and looking for guidance.
Psychologists recognize several conditions that are characterized by violence and aggression. They include conduct disorder and disruptive mood dysregulation disorder in children, as well as antisocial personality disorder in adults. To this list I would add psychopathy, which is evaluated using different criteria than those used to diagnose antisocial personality disorder, although it is not an official diagnosis in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.
Although each of these conditions differs from the others in important ways, they are all defined by the fact that affected individuals engage in persistent and severe antisocial or aggressive behavior. Children diagnosed with conduct disorder or disruptive mood dysregulation disorder, for example, may be physically violent or display outbursts of destructive anger. These disorders, which are characterized by patterns of exploitative, hurtful, or cruel behavior, put children at risk of developing antisocial personality disorder or psychopathy when they grow up..
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These disorders are not rare. Conduct disorder affects up to 9 percent of girls and up to 16 percent of boys. Its symptoms, such as stealing and deliberately harming people or animals, are among the most common reasons for referring children for mental health treatment. And it is estimated that antisocial personality disorder affects one in 50 people, making it more common than schizophrenia, bipolar disorder or anorexia.
Given the prevalence and severity of these conditions, you might think that there are abundant resources to help affected adults and children, but that is not the case. Compared to other serious and common mental disorders, aggression disorders are underdiagnosed, undertreated, and underrecognized. And that’s not because these disorders can’t be accurately diagnosed and successfully treated: they can. New research is giving doctors and scientists more information than ever about how these conditions develop and how to intervene. And the earlier treatment begins, the more successful it tends to be.
But these disorders are terribly stigmatized, leading well-intentioned doctors to avoid diagnosing them and many patients and parents to refuse to accept them. The fact that generations of psychologists have invoked unhelpful moralistic frameworks (essentially condemning people with these disorders as “bad” or even “evil”) has only increased the intense negative judgment about these illnesses. Even some mental health organizations, both public and private, avoid mentioning them.
However, we now know that these disorders are true diseases that reflect dysfunctional patterns of brain structure and function that lead to maladaptive processes. thoughts and emotions and, ultimately, aggressive or violent behavior. These problems result from the combined influence of genetic risk factors and environmental stressors. Contrary to what was previously assumed, they are not simply the result of “bad parenting,” an idea that has brought harm and shame to families. Various factors, including birth complications, trauma, and exposure to toxins such as lead, may contribute, although for many people no clear stressor is ever identified. Furthermore, without treatment, these disorders are likely to persist or worsen.
Symptoms usually appear early in life and continue over time. A study Conducted by researchers in Cyprus, Belgium and Sweden and published last May, it followed more than 2,000 children over 10 years, collecting reports from parents and teachers at five different times between the ages of three and 13. The risk factor for later antisocial behavior was a fearless temperament, which often manifests as insensitivity to risk or harm in preschool children. That trait can make children very difficult to raise because they don’t learn to avoid risky and dangerous behaviors or behaviors that could result in punishment.
Perhaps unsurprisingly, the study also found that children with this temperament tended to experience harsher parenting and more conflict with their parents over time. They also developed “callous and unemotional traits,” such as low empathy and remorse, which can further increase the risk of antisocial behavior. Fearless temperaments can lead to low empathy in part because children who do not feel fear have difficulty empathizing with this emotion in others. Over time, “maladaptive fearlessness” can increase the risk of antisocial and criminal behavior in adulthood.
Given these trends, punishment does not improve the behavior of children and adults with these diseases. In fact, disorders characterized by aggression are often related to less responsive to punishment, no matter how harsh, making it a useless response to aggression. Last July, researchers from Germany, the United Kingdom and the Netherlands published the results of an experiment that examined how 92 children and adolescents with conduct disorders learned from punishment, compared to 130 of their typically developing peers. Children played a simple game in which they had to learn to select images that would result in a reward (point gain) versus a punishment (point loss). As the game progressed, most children learned to avoid images that result in punishment. But those with conduct disorder persisted in choosing these images more frequently, despite showing normal rates of learning from the reward. This suggests that fundamental neurodevelopmental deficits in learning about punishment and risk underlie the emergence of severe antisocial behavior.
Although harsh punishments are ineffective in treating aggression disorders, there are interventions that do help. In March 2023, another group published an analysis that pooled data from 60 studies that evaluated treatment success for children with severe disruptive behavior disorders, such as conduct disorder. The findings revealed that a variety of treatment types were effective in improving children’s symptoms, contrary to the prevailing myth that these disorders are not treatable.
The most effective approaches for severely affected children (those with callous and callous traits) focused on training parents. In such treatments, which include parent management training and parent-child interaction therapy, therapists teach parents how to use specific therapeutic techniques to reduce children’s symptoms and improve their social skills and relationships. According to research on rewards and punishments, therapeutic approaches that emphasize rewarding desired behaviors (and not rewarding when children misbehave) are the most effective. In general, these types of treatments should be considered first-line therapy for children with antisocial behavior, although they are too often not offered to families who could benefit from them.
Even the most severely affected adults can improve with evidence-based treatment. A study published last year examined the effects of a treatment called schema therapy on more than 100 people convicted of violent crimes in high-security Dutch forensic hospitals. All of these people had diagnoses of personality disorders, such as antisocial personality disorder or narcissistic personality disorder. Schema therapy involves identifying and replacing maladaptive patterns of thinking, feeling, and relating to others. Patients treated with this therapy showed greater improvement in their symptoms and progressed more quickly through rehabilitation than those who received standard individual or group therapy.. This work suggests that rehabilitation is possible and could generate enormous potential savings in costs related to incarceration, as well as significant gains in public health and safety.
Of course, all of these treatments depend on an accurate diagnosis. My colleagues and I have found that children diagnosed with conduct disorder and callous-calling traits (also called “limited prosocial emotions”) show opposite patterns of brain dysfunction compared to children who have a conduct disorder as a result of anxiety or trauma. This finding indicates that these groups of children would likely benefit from completely different treatments, despite some overlap in their symptoms, which brings us back to the urgent need to improve recognition, discussion, and accurate diagnosis of these disorders.
Many different steps are needed. On the one hand, all major mental health organizations must give recognized aggression disorders explicit parity with other mental disorders. Even today, someone seeking information about conduct disorders, psychopathy, or antisocial personality disorder may search in vain on the websites of major organizations such as the National Institute of Mental Health or the National Alliance on Mental Illness. This information gap was one of the main reasons my colleagues and I came together to found Psychopathy Is, an organization dedicated to providing information and resources about psychopathy, a major contributor to many forms of antisociality in both children and adults. , including stalking, domestic assault, and firearms. violence.
Furthermore, much more can be done to improve training and professional guidelines. And public and private mental health organizations should devote as many resources to screening tools, interventions, and studies of the causes of aggression disorders as they do to equally common and serious disorders, such as autism and attention deficit disorder. hyperactivity. More research will lead to better understanding, better treatments, and hope for a full, productive life for affected children and adults. Although these changes would not produce instant benefits, they would represent a more compassionate and, most importantly, more effective approach to helping people, including the many families who need answers.
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