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Concerned About Unconventional Mental Health Interventions?

Concerned About Unconventional Mental Health Interventions?
Alternative Psychotherapies: Evaluating Unconventional Mental Health Treatments

Wednesday, September 14, 2016

If It's Not RAD, What Is It? Disturbing and Aggressive Child Behavior

For some years now, this blog has featured correspondents and me going around in circles about Reactive Attachment Disorder. I comment that symptoms of RAD do not include aggressive or dangerous behavior; correspondents then reply, “Are you saying my child does not behave aggressively? Of course he does! That’s how I know he has RAD.” I then say I am not arguing about the child’s behavior, just saying that this behavior has nothing to do with attachment and can’t be treated with efforts to strengthen attachment, even effective ones--  and around and around we go in our merry disagreement.

Occasionally I’ve pointed out that the behaviors these parents mention actually belong to disorders other than RAD, for example Oppositional Defiant Disorder, and that they may be associated with ADHD too. I haven’t really gone into much detail on this, but today I would like to say more about it, drawing information from an article titled “Narcissism and callous-unemotional traits prospectively predict child conduct problems” (Jezior, McKenzie, & Lee [2016], Journal of Clinical Child and Adolescent Psychology, 45(5), 579-590). Jezior and her colleagues focused on conduct problems (CP), which include oppositional defiant disorder (ODD) and conduct disorder (CD). These problems involve behavior like hostility, defiance, aggression, and property destruction. They are associated with callous-unemotional (CU) personality traits such as low empathy, lack of guilt, and shallow emotions, which also tend to go along with severe and persistent externalizing problems—behavior that expresses anger and resentment. CU traits are highly heritable, a fact that helps to explain how difficult they are to correct—if these problems did not result from experience, a change in experience will not so readily alter them.

Jezior and her colleagues also looked at narcissism in childhood as a factor in conduct problems. This disorder is characterized by bragging, thinking oneself better or more important than other people, and making fun of others, behaviors that are associated with ADHD, ODD, and conduct disorders.
Jezior’s group looked at boys (mostly) between  6 and 10 years of age to see whether their behavior at a first measurement was a good predictor of  conduct problems some years later. In fact, two years after the first measure ,increases in ODD and CD symptoms were related to earlier narcissism and CU traits.

 *** But let me make one note for readers of this blog: these researchers were not looking at preschool children. Younger children are well-known to their parents and teachers for their ready anger and aggression, their selfishness, their inappropriate bragging, their self-importance, and their tendency to ignore or fail to recognize other people’s needs. By age 4 or 5, some children may be more noticeable for their delays in mastering all these undesirable, antisocial characteristics, but the great majority will also still be struggling with their impulsive natures. It is not until school age that we begin to see real individual differences in narcissistic or callous-unemotional traits, so parents should not generalize from Jezior’s study results to thinking about preschool children. It remains to be seen whether preschoolers’ characteristics can predict their later antisocial behavior.

Jezior and her colleagues suggested that early assessment of CU and narcissistic characteristics could be beneficial, in that with early diagnosis, early treatment could begin before adolescence. They noted that detailed assessments might help determine the best form of treatment for conduct disorders. But do existing treatments actually help mitigate conduct disorders and help to decrease further development of problems? Ollendick et al carried out a randomized controlled trial of two treatments, Parent Management Training (PMT) and Collaborative & Proactive Solutions (CPS). Readers should note that each of these interventions works with parents and children together to diminish oppositional behavior--  these are not just attempts to “fix” the child and to give the parent a break. Children aged 7 to 14 were randomly assigned to either PMT or CPS or to a waiting list control group. Both PMT and CPS had better outcomes than the waiting list group, with about 50% judged to be either  much or very much improved, and maintaining their gains six months later. But not only is it notable that about 50% did not improve—in addition, Ollendick et al referred to such weaknesses of the study as the small groups and the number of families who dropped out of treatment. They noted also that younger children responded better to treatment than older ones.
A review by Bakker et al (“Practitioner review: Psychological treatments for children and adolescents with conduct disorder problems—A systematic review and meta-analysis.” Journal of Child Psychology & Psychiatry, 2016; epub Aug. 8) looked at 17 research articles dealing with 19 interventions and reported small effects on reduction of conduct disorder, but pointed out that many of the reports did not provide enough information to assess.

This is all a bit discouraging, of course. It seems that conduct problems can be identified early (although not in the preschool period, when antisocial behavior is to some extent the norm), and that some interventions working with children and parents together can have positive effects. However, the nature of the problems, with their genetic component, means that a “cure” is not likely to emerge. What can be helpful is to realize that these behavioral difficulties are not associated with attachment experiences, are not part of Reactive Attachment Disorder (though they may exist side-by-side with RAD), and are most unlikely to respond to efforts to change or strengthen attachment.  


  1. Hi Jean, I've been successfully using CPS, Ross Greene's approach to parenting kids with "challenging behavior" (in my son's case, aggressive behavior at home, towards me), for a few months now. I had learned about it some years ago, but we've not had therapists who are familiar with it, and I've wanted to try their approaches.

    No longer! CPS works with my son, reliably, where nothing else has. It's no panacea. He has a long list of "lagging skills" and "unsolved problems," as Greene describes them. And we have years of work ahead of us together -- with the help of therapists who agree to be brought on board the "Plan B team" (i.e., no punishments, no rewards, no sticker charts, no logical consequences, no time outs, no earning privileges, no restrictions, no sternness, no rigid scheduling).

    But the CPS (initially, Collaborative Problem Solving; now, Collaborative & Proactive Solutions) approach has nurtured a much more loving and communicative parent-child relationship in our family, which is especially important for my son, who spent the first nearly 7 years in a birth family rife with physical and emotional abuse, directed primarily at him, in part in response to his developmental delays and special needs (another story about the horrible ways in which children who need *MORE* patience, education, and love from their parents too often get less -- and worse).

    Anyway, I'm not much of a True Believer about anything, but let me proselytize a minute here: I highly recommend Ross Greene's books and podcasts (available at his website, Lives in the Balance) for those families dealing with aggression in their children beyond the ages when it is normally expected. Try: THE EXPLOSIVE CHILD; RAISING HUMAN BEINGS; LOST AT SCHOOL; LOST AND FOUND.

    There are also several, very active Facebook groups that help parents refine their technique in using CPS with their children. And, other than the books, all the help is available free of charge.

    The best part about it all? Children receive empathy, understanding, reflective and active listening, and the explicit message that their concerns are central to the resolution of family problems. The technique walks the talk of our family mission: Peace - Respect - Cooperation.

    I couldn't ask for more!

    1. Hi Marianne-- thanks so much for these suggestions and comments. Your son is lucky to have a parent who is able to use CPS-- I really don't think everyone can do it without a good deal of supervision, but for those who can, it does seem to work very well. Active listening does not come easily to everyone, though, and for people who have trouble with it, I think PCIT probably has real advantages (though it works better for younger children).

      I didn't realize there were Facebook
      groups. That sounds like a great help, especially if you need to get other people on board with this approach.

      Thanks again for this suggestion!