Concerned About Unconventional Mental Health Interventions?

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

Wednesday, November 9, 2016

Conduct Problems and Callous-Unemotional Traits: Something to Think About When You're Worried about RAD

I’ve pointed out again and again that Reactive Attachment Disorder in children is not characterized by aggressive or hostile behavior, by lying, by lack of remorse—and certainly not by an inability to connect cause and effect. But when people ask, “Well, then, what DOES my child have wrong?”, it’s an impossible question for anyone to answer without seeing the child and family in action.

Nevertheless, I want to put forward a possible set of problems that could in fact produce some of the unwanted behaviors that are so often attributed to RAD in Internet material. These are conduct problems and callous-unemotional traits (CPCU). Children who show CPCU are antisocial and oppositional, and often continue to show antisocial behavior later in their lives. These conduct problems, which may occur alone, are in CPCU associated with a number of other concerning traits. For example, they may not show guilt or remorse after misbehaving, they may show no empathy when other people are in distress, and they do not seem to care whether they themselves perform well or poorly.

These CPCU characteristics are not simply disturbing to teachers, parents, and other children; they evoke from the social environment a set of responses that are likely to worsen the child’s behavior problems.  We expect children to be upset if they do poorly at school or in sports, or even when they lose a game with other children, and we are ready to offer comfort or at least “bracing” remarks about how there will be another time or how the child should be a good loser. When a child says, or shows, that he or she does not care what happened, we tend to be at a loss for what to do—we may simply ignore the child, and then or later we may make sarcastic remarks about how we know the child doesn’t care what happens. It’s very difficult for us to model empathy in this unexpected situation, so we model indifference instead. In addition, when we see that a child “doesn’t care” about a person in distress, or “doesn’t care” about what he or she has done wrong, we often feel confused and vaguely hostile, and again model indifference or verbal attack—often, the same sort of behavior that we object to in the child.

Whether these “normal” responses of adults actual worsen CPCU behavior or not is not clear, but it certainly seems unlikely that these responses will help the child develop in a more acceptable direction. There is no evidence that any form of “attachment therapy” is effective in changing CPCU traits, nor would we expect there to be, because the issue is not about attachment-related behavior. However, it’s possible for behavior therapy to bring about changes in CPCU behavior like disruptive behavior, disobedience, tantrums, and inattention. But it may be that children who show CPCU respond differently to rewards and punishments than most other children do, and therefore behavior therapy may need to be fine-tuned to work well with them. They may do well with responding to rewards, but less well than other children when the therapy uses punishments.

An article by Daniel Waschbusch and his colleagues (“A case study examining fixed versus random criteria for treating a child with conduct problems and callous-unemotional traits”, Evidence Based Practice in Child and Adolescent Mental Health, 1(2-3), 73-85) looked at possible ways of fine-tuning behavior therapy for one child with CPCU characteristics. They looked at the results of using one approach with this child, then shifted to another approach, and compared the effects of the two.

The little boy, “Juan”, was  adopted at 17 months and began to show concerning behavior at about age 2 years. (That is, of course, a time of life when typically-developing children often begin to be resistant, to have tantrums, and to react badly to frustration, so it can be difficult to know whether a child’s behavior is or is not problematic with respect to later development.)  Entering school, he was disruptive, aggressive, inattentive, and silly, and his teacher said he did not seem to care about his school performance. His teachers also felt that he lacked warmth and kindness.

Behavior therapists working with Juan focused on managing his behavior with effective commands, positive reinforcement, and immediate consequences for his behavior. They gave or took away points for complying or failing to comply, and he could use the points to buy free time at noon and privileges like screen time at home. In addition, a daily report card helped to determine whether Juan could participate in a “fun field trip” on Fridays. The focus for Juan’s behavior therapy was on his tendency to interrupt other people, to violate classroom rules, and to tease his classmates. Juan’s behavior did change in response to this regimen, and he did best when the behavior change he was asked to perform was clearly stated – not just that he should interrupt less, but how little he had to interrupt in order to be rewarded.

Waschbusch and his co-authors mentioned that there has been less research on the effective use of punishment in behavior therapy than on the effective use of reward. They noted that it seems plausible that effective punishment must be mild, consistent, and predictable, but parents of children with conduct problems often do not manage this. Instead, they ignore bad behavior for some time, then unpredictably use serious punishment, which does not seem effective in changing behavior. Waschbusch and his colleagues also noted how little is known about the use of aversive events as punishments rather than punishment by taking away points or privileges.


Although there is much still to be understood about treatment of children with CPCU, these unwanted behaviors are apparently not related to attachment or any version of RAD. Also, they are treatable with standard treatments and need not destine a child for the school-to-prison pipeline. Treatment both at school and at home seems to be a key to success, and effective treatment requires changes in both teacher and parent behavior.    

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