# 33 – CONDUCT DISORDER(S)

Note:  Just as a forewarning, this is a particularly long post with a considerable amount of practical practice content concerning a complicated topic, so please take your time.

In a paper summarizing research psychologist Stanton Samenow’s work on conduct disorder, my colleague and a psychologist himself, Dr. Steven Taylor, wrote that the diagnostic term ‘Conduct Disorder’ was dimensional rather than categorical. The term encompasses an area of human functioning that spreads beyond the historical field view that a conduct disorder was the youth equivalent of the adult Antisocial Personality. ‘Conduct disorder” is more a syndrome than a distinct diagnosis, which, among other things, makes appropriate treatment choice a multiplicity rather than something singular. The one consistency is that conduct problems in all their various forms can be among the most difficult problems that outpatient mental health addresses.

As per the DSM V, the diagnosis of a conduct disorder for a child or adolescent requires three or more of  the following symptoms

Relatedness traits that often appear in conduct disorder presentations include:

Prevalence Data

The DSMs III – V all cite the range of conduct disorder prevalence studies  to be 2% to 10%. They establish the rate at 4%. Another study source (Understanding The Demographic Predictors… of Conduct Disorder; Patel, et.al; Behavioral Sciences; 9/12/18) indicates that 9.5% of youth in this country have a period of conduct disorder before adulthood, including 12% for boys. At any given time, they state that 4% – 9% of youth are in the midst of a conduct disorder, averaging out to 6% (presumably 7+% for boys). In essence, that study is saying roughly one out of eight boys have a conduct disorder at some time from childhood through eighteen years of age, and one out of fourteen boys do at any given time. 

One article that was researched also stated that conduct disorder occurs at 3% across “many countries”. At the same time, 6% of American black youth black youth have a CD diagnosis at any given time, almost double that of other races. Assuming that African countries were included in the cited international rates, is the higher rate among African American youth in this country a function of diagnostic bias or from the overall experience of racism, or to what degree both. Unfortunately, the notation of the article was not transcribed, and the article now could not be re-located, so take that summary with a grain of salt…or two.

If the rate of mental health disorders among youth in this year 2020 is between 20% and 24% and assuming this 4% prevalence of CD, close to one out of five youth who are experiencing mental health disorders have a conduct disorder. Understanding the DSM and Behavioral Sciences deserve and have  all due respect as the major source of reliable professional information in regards to diagnosis, these figures do seem inordinately high and difficult to believe. 

Only one case (2%)in this study fitting the Conduct Disorder diagnostic criteria seems statistically low. Translated in an epidemiologically loose sense to my practice and based on the DSM the prevalence rate of 4% conduct disorder, the number of Conduct Disorder cases within this group of 56 would be somewhere around10 – 12,  or certainly something much higher than one. 

4% just doesn’t correlate to my experience working with youth and families, and makes me wonder exactly what criteria is being used in the field on an ongoing basis. Look again at the diagnostic criteria, keeping in mind that one has to have three or more of those symptoms at the same time to warrant the diagnosis. In hindsight, I recognize now that my seeing a client as having a ‘conduct disorder’ was based more globally on the severity of misbehavior rather than an exact application of the diagnostic criteria. Do difficult youth get tagged with a conduct disorder when the actual problem may well be something else, including problems less intransigent and socially toxic?

When first doing the statistical breakdowns of these sub-groups, and this was before looking at the diagnostic criteria myself, I labeled four as being conduct disordered sub-group. Subjectively at the time, an average of two severe or serious conduct problems in any given year subjectively sounded about right.  I now doubt that I saw as many as 20 true conduct disorders, that being out of 1000. Perhaps this is standard for an outpatient, masters-level mental health practice. Likely no data exists against which these numbers could be compared. Still, something just seems to be off with the formally estimated prevalence numbers cited in the DSM.

One other odd set of study results is worth considering. One international study quoted found that nations around the world had 3% of their youth having conduct disorders. Another found that 6% of African American youth had conduct disorders. One assumes that the international study included sub-Saharan African nations. Concerning this result that doubles the incidence rates of black children in the U.S.A., is that a result of the experience of racism, or do black children get more easily tagged with the diagnosis, or some combination of the two.

As our consult group was gathering one evening in the early 90’s for a monthly session at Steven’s place, he was sharing an anecdote from a Seattle workshop given by a national figure on child and adolescent behavior disorders. As with all seven members of this particular group, Steven is committed, discerning, and responsible. And from that perspective, he was grinning incredulity at an over-the-top proclamation by the expert. 

“Being empathetic with and antisocial is like pouring delectable sauce over bad meat.”

Our 70 year old, gold standard child psychiatrist Alan Leider, who sat in on these meetings as a peer, was not amused. He could be intolerant of blanket disregard, so he wasn’t letting the matter just drop. Alan was notoriously stubborn. In a socratic-like style, he pushed the six of us to examine our own experiences, conceptions, and conclusions about conduct disorder. I’m certain his intent was for us to appreciate the variations within our group’s thoughts, and the inchoate nature of the diagnosis itself. Conduct disorder was more a range of issues than a distinct behavioral system. The ’delectable sauce’ could still be of some substantive help with some of the kids involved, but some were also clearly beyond that kind of help. Identifiability was hard.

Study Group “Conduct Disorder” Cases 

Data Summary

The identification of sub-groups within the study occurred about a year after the initial data collection. Conduct disorder was one of several specific sub-group of interest. I simply went through the list of cases and selected those that seemed to fit. The judgement was based on having established a client’s patterns of posing a threat to others, over a period of time, and in multiple settings. Identifying conduct disorders within the 56 case study group was based on experience rather than using the DSM V’s symptom list – that came as the post itself was being organized a couple of months ago. The data collection process certainly presents validity issues, let alone reliability. Once again, though, certain statistical results of the relatedness sub-group as whole do correlate with other findings, lending a soft support to validity. Please do take these cautions into account as you read on.  

Four boys, aged 9, 11, 15, and 18, presented with problems that included multiple elements of the seven relatedness traits listed above. They represent 7% of the study group. None were among the four (of seventeen) relatedness cases that had their presenting problems resolved by treatment’s end. 

Only one of the 56 study cases qualified for a diagnosis of Conduct Disorder using the DSM symptom list. Not coincidently, that was the only case with eight overall relatedness traits. in order of their age, youngest to oldest, the four clients had 4, 1, 1, and 0 DSM CD traits. The older client was involved in an illegal activity – dealing – that could be seen as a threat to the community but which did not fit the DSM CD criteria. Not all illegal behaviors are conduct disorder symptoms. Both of the younger two conduct problem clients posed a threat to fellow students, one in the form of verbal and physical aggression, disruptiveness, and theft of personal items, and the other in the form of “conning”. None of the four engaged in any of the last three symptoms of the DSM conduct disorder list, which do seem categorically different than the first twelve.

Using the above list of relatedness traits found in conduct problems, the four cases had 5, 3, 3, and 2, youngest to oldest. The total relatedness traits for each were 8, 5, 6, and 6. Roughly half their traits contributed to the conduct problems. All four were involved in lying, etc., and three had remorse/empathy problems. Additionally, two of the biological parents among the four cases were APD and four others appeared to have had immature-group personality problems. 

The DSM symptom list was insufficiently elastic to include some of the presenting patterns of behavior that were illegal. By the same token, a list of relatedness traits can lack specificity. If one were to use the level of threat that the client posed toward family, school, social relationships, and the broader community as the baseline of concern, the number of relatedness traits deemed relative to conduct problem may well be a more definitive assessment tool than the DSM CD criteria.

Their average initial CGAS score was 40.5, and their termination average was 48. Their average number of sessions was 25, and the average length of treatment 1.1 years. Compared to the overall data results, The 7.5 point average gain is low for the number of services used. 

None of the four cases left treatment wholly resolved, although two did show some to modest  improvement.  The youngest was referred to an individual therapist following a short psychiatric hospitalization I had recommended. The next went through phases of family and individual therapies and terminated, ostensibly due to financial problems but a certain degree of chaotic parental circumstance was a determining factor. The next was also in family therapy followed by individual therapy; ceased the risky behavior and had some other noticeable improvements; elevated his functioning from a low serious level to a low moderate level disturbance; the parents were comfortable with stopping, albeit at his request, and would have been comfortable returning upon need. The fourth went to inpatient drug and alcohol treatment without much in the way of clinical gain; six months after leaving inpatient he remained abstinent, a follow-up indicated his continuing outpatient CCDC counseling and doing better in other areas; the initial therapy improved his compliance and self-awareness, and contributed to his cooperation in being sent to inpatient treatment, according to his custodial grandmother.

Categorizing conduct problems

Premeditative Behavior

Journalist Jennifer Kahn published an article (New Yorker Magazine, 5/11/12) that discussed the nature of    conduct disorders, particularly in children. She followed the family of a life-long troubled youngster. In doing so, she also sought information and explanations from the psychologist working with the boy. Dan Waschbusch is a researcher at Florida International University who specializes in child and adolescent conduct problems, including conduct disorders, ADHD, oppositional defiance, and pediatric bipolar disorder.

Waschbusch splits the conduct disordered youth into two sub-types, the callous-unemotional (CU), and the “hot-blooded”. Citing several research findings and quotes from other researchers, the typical CU youth is manipulative, deceitful, and untruthful. Rather than being reactively assaultive or otherwise physically threatening, the CU is manipulative, observant, scheming, impulsive, often charming, emotionally flat, lacking in the capacity for remorse and empathy, aggressive, and defiant. States Waschbusch, “you have a person who may be hostile when provoked, but who also has this ability to be very cold. The attitude is ‘so let’s see how I can use this situation to my advantage, regardless of who gets hurt.” The anger that “goes way beyond” refers a style of the smoldering, plotting, and carrying out  revenge. Manipulativeness is often the most defining element of the callous-disordered . The CU afflicted child can be seen as a “fledgling psychopath”.

Waschbusch estimates that the CU-sub-type constitutes 1% of the population. A substantial plurality of prison populations are Antisocial Personality Disordered, the frequent adult outcome of childhood Conduct Disorder. Assuming the DSM estimate that 3% of the youth population are conduct disorders is accurate, the CU would represent around 1/3 of them. One study concluded that heritability brings about 80% of callous-unemotional personalities.

At the time of Kahn’s article, an emerging belief was that psychopathy was like autism in the sense of being a distinct neurological condition that can be identified. Low levels of cortisol and amygdala activity have been noted. Another neurological scanning finding indicates the brain portion that processes negative feedback is less active. Child psychopathy scales appear to identify psychological markers of CU as early as the age of three. 

In terms of the fifteen Conduct Disorder symptoms in the DSM, the CU youth could be engaged in any one of these. The last three can either be manifestations of Conduct disorder or ODD. The difference is that ODD youth generally do not engage in any of the first twelve DSM CD symptoms, at least in my experience. Of the seven relatedness traits listed above, the CU can be identified with six out of seven, reactive rages being the one exception. 

Reactive Rage

Rage can be seen as categorically different from the CU type, posing threats to physical and emotional safety, and to damage or theft of property.  Rage and ODD are similar in the sense that both are reactive to frustration, as opposed to the CU’s heedless plotting, manipulativeness, and scheming. One major distinction is that ODD youth experience anxiety, and though they may be loath to admit it during their rages, they feel empathy and remorse. 

 According to Waschbusch, one theory is that the ‘hot-blooded’ conduct disorder has a hyper-active threat detection system. Functional impairments have been identified in neurological research of rage. Pre-frontal cortex functioning and brain lesions similar to those of PTSD have been identified as precipitants. Low levels of cortisol and amygdala activity have also been noted. Another neurological scanning finding indicates the brain portion that processes negative feedback is less active. However, identifying rage propensities at young ages like the psychopathy scales that can help detect CU at early ages. Perhaps hot-blooded, as per Waschbusch’s description, could be akin to autism as well.

With the possible exceptions of cruelty to animals and conning, the youth with rage-type conduct disorder would seem capable to do any of the fifteen DSM Conduct Disorder Symptoms. Rage-troubled youth could fit any of the relatedness traits common to conduct disorder listed above, with the exception of premeditated exploitation.

Other Conduct Problems

Waschbusch pointed out the difficult problem of differentiating the natures of the callous-unemotional type  conduct disorder from the hot-blooded conduct disorder type from ODD from Pediatric Bi-polar Disorder from ADHD. Is the defiance, vengeance, spite, and disruptiveness that a client presents ODD or CD? Are the up-and-down behavioral patterns and the aggressive nature of irritability – particularly with boys – Pediatric Bipolar or CD? Is the impulsivity ADHD or CD? With increasing frequency, the diagnoses become dual and the client gets treatment for both. My own experience is that two concurring treatments for the same problem can create as many problems as it solves, if not more. Dual conduct diagnoses run the risk of over-diagnosis, the issue of ‘two diagnoses for one problem’ issue,  possibly complicating an already complicated situation.

ODD in particular had been seen as a co-diagnosis with conduct disorder, hence another precursor to adult Antisocial Personality Disorder. After the pediatric bi-polar diagnosis was popularized in the early 90’s and quickly became over-diagnosed (read Your Child Does Not Have Bipolar Disorder, Stuart Kaplan, MD, Penn State Univ. 2011), clinicians and other counselors increasingly grouped bi-polar, oppositional defiant, and conduct disorders as contiguous in some way. Understandably wanting to cover the bases and meet what were becoming informal community standards of treatment, particularly using dual diagnoses, assessments generated treatment plans for two and occasionally three diagnoses, i.e. ODD, Bi-polar, and ADHD. The treatment plan often became a complicated combination of psychotherapy and some admixture psychotropics, sometimes numbering up to five different medications. (For an interesting perspective on this, read a front-page investigative article on pediatric bipolar appearing in the New York Times on May 12, 2007).

Multiple mental health diagnoses for youth, particularly adolescents in the midst of identity formation, can create the sense of not only having a problem, but being defective, and that self-perception be carried into adulthood. Determining the “best” management approach can be difficult with difficult kids amidst pressures both internal and external to the case itself. But, best embrace the challenge given the opportunity…for them and for you. 

Treatment Considerations

Please be reminded that all writing here is from the perspective of the line practitioner, often in private practice, often solo. The treatment suggestions are the result of experience and a continued education that consists of trainings, consulting, collegial talk, reading, listening, and otherwise absorbing over time. Pick through here and take what seems helpful. This can also serve as a picture of child, adolescent, and family practice out there, challenged by new problems to be understood, never having quite enough information, having to rely on your developing process (they are always developing), your ingenuity and commitment, and priding yourself when things work out, and they usually do, and you don’t even think about that very much in the aftermath because some new case has already come along.

Depression

The improvement rate for depression within the seventeen relatedness cases group was lower than that of the other three diagnostic categories, including anxiety, behavior, and relatedness itself, and was substantially lower than that of the thirty-nine non-relatedness cases. Depression appears to be an issue for these conduct disorders.

Based on that finding, the depression part of the evaluation for a client who appears to have relatedness difficulties, including conduct disorders, may warrant greater scrutiny. For example, in going through the ten depression symptoms during the initial evaluation, spending more time fleshing out the picture of the endorsed or postulated symptoms could sensitize others in the client’s orbit to his or hers dilemmas. That may reduce negative feedback that had little chance of external impact on the client’s behavior. The same approach might be used if the evaluation entails some depression inventory rather than question-and-answer, i.e. go through each endorsed area more closely.  

Empathy and Remorse 

76% of the relatedness group had empathy and remorse problems. Usually, all of the conduct disordered have this problem, although one of the four who were deemed to be conduct disorders by this study’s criteria did demonstrate that problem. 

The experience here is that the format of choice is conjoint family, best including siblings, unless the problem set mandates some other clinical process. Regardless of what particular problem the family brings into the session for discussion, socio-cognitive work can be inserted into the hour. In part, this entails the client and another family member, usually the mother when the technique is first being used, and having the client identify what the mother or other was thinking and feeling in regards to something that happened involving the client. The process then progresses to an informative back and forth, with guidance as needed by the therapist.This is an exercise which is usually approached with an intent interest and often a certain enthusiasm by youth. Part of the clinical work is helping the conduct disordered client identify and differentiate their feelings of anxiety, anger, and particularly guilt.

The work can also be done in individual therapy with the clinician using hypotheticals. On a limited basis, the therapist can be the ‘other’ in the dyadic exchange.. The work is less rich compared to the family format, and probably not effective until a firm trust of the clinician is developed. 

Improvements and resolutions can occur during therapy. If they don’t, they can still occur later as the client matures, and I have heard that in follow-ups. The family process lends new communication techniques, a way for the parents to more impartially judge the growth of their child, and a way to be easier on themselves. Sometimes the delectable sauce works, less so than with other kinds of clients, but sometimes. In those cases, members of the family can at least be better prepared to deal with problems in the future that the conduct disordered youth may present.

Callous – Unemotional Conduct Disorder Type

If the callous-unemotional conduct disorder type is a distinct neurological disorder and in that regard a cousin to autism, the future of C.U. treatment may be vastly different than what we have at present. Life now for autistic youth is incomparable to that of years before, to wit:

What’s Up With Lukie 

Following undergrad studies at UW, I was hired by Russ Roepcke to be a counselor guiding a group of eight Everett adolescents as part of a city summer youth work project. This would become my first venture into something resembling social work. I liked the experience, began to understand the intentions and nuances of job, and probably could have found something similar to do up there and explore the field further. For a host of reasons, though, among them being done with college and just needing to get out again, I took off with a backpack for East Coast roots.

After being dropped off at an I – 90 eastbound entrance in Bellevue one late August dawn, I stuck out my  right thumb. Six days and nine rides later I walked into Hyannis, Massachusetts, noted for the Kennedy estate, but more germane for me, near the area of the Truro beach summer vacations as a kid. It being the early seventies, I had a place to crash for a few days within an hour. Two days later I applied for a job posted on a bulletin board as a child care worker at a residential school for autistic children in nearby Chatham. By the end of the week, I had the job, rented a cheap, month-by-month motel room in South Dennis, bought a used bike, and started cycling the fifteen miles back and forth to work. The salt air was good.

In a traditional New England-style clapboard house, the May School housed about 20 autistic kids ranging from five to eighteen years old, mostly boys. Included were the May’s twin sons, who were both autistic. They were about 25 and had grown up there, occupying a large bedroom on the third floor. Their father, who was a United Nations official working out of NYC, and mother built the school for them. The school blended in to the surrounding residential area amidst the small town. I was responsible for shepherding a half dozen of the school’s younger boys through the week-days, from 8AM to 5PM with time out for lunch, an afternoon break, and an after-work dinner. I was invigorated, as I guess was the intent behind the move.

Chatham is at the point of Cape Cod’s elbow. The school was off a two lane road and up a shady residential street, somewhat hidden by trees and shrubs. The only nearby commerce was a tiny, quaint tourist stop with a cluster of four or five small cabin-like shops down a tree-lined lane across the road. One was a candy store. Within a minute after one of the May boys escaped out the front door, the unhappy owner was letting the school know the boy was raiding her jars. He couldn’t be stopped.  All staffers were implored to make sure the front door was always locked. Other than that, the School was welcomed by what seemed to be an iconic sort of quiet, old-style New England.

The only contact I’d ever had before with autistic kids was during sixth grade. Because the wave of baby boomers were overwhelming the capacity of public schools in Ridgewood, NJ, the sixth grade classes were moved out of George Washington Elementary into the annex building of the Westside First Presbyterian Church across Monroe Avenue, traditional places labeled by traditional names. For good weather morning recess, our class was usually marched in two lines back to the recreation area behind the school proper. On the way out, off to the right and more or less out of public sight, was a fenced-in area maybe fifteen feet wide in front. Often times, a group of maybe ten kids, our age and younger, would stand on the other side, faces pressing the fence, fingers grasping the mesh, expressionlessly watching us except those of us in line knew they were at least curious and must have wanted to be out? I’d look at them, then look down, feeling uneasy. 

Most of them had features that we now readily recognize as Down’s. One couldn’t help but feel sorry. The others standing there, as I came to realize at the May School, must have been autistic. The memory of those kids behind the fence stays with me, still haunting.

After a couple of weeks at the School, I spent several afternoon breaks going through the charts of each resident. I wanted to understand things like early history, what was done, did anything really work. The stories were interesting, but didn’t really help.  

For some now forgotten reason, one 11 year old seemed somehow reachable to me, at least less remote than the other five with whom I usually worked. During an afternoon break and with permission, I took Thomas on a walk over to the nearby Atlantic beach. He seemed comfortable, if expressionless, looking over little interesting things I picked up off the sand, or looking at sightings of mine as I chattered. He didn’t really engage. He was calm during the hour-long the trip, but I didn’t notice anything different about him for the rest of the afternoon.

I took him on the same walk a twice more, these times asking him a small few questions about his own experience. That did not get. Sometimes I walked along side him then moved away as we went, moved closer, moved away, sometimes quietly, sometimes talking. He moved slowly but steadfastly ahead. I worked on him holding stuff I picked up, talk about it, ask about it, and he’d quietly look and hand it back. The third time I gave him a long, perfect gull feather to take back to the school. He dropped that, too, but I took it back and showed a couple of staffers with him by my side. I’m just experimenting. Nothing yet.

Toward the end of that fourth walk, we came across a horseshoe crab shell that had washed up overnight. My brother and I would find an occasional shell on the beach in Truro, carry them back to our cabin only to have Mom declare “not in here!”. Picking up the piece, I explained its details, mentioning finding them years ago as a kid myself. Tom silently looked, as was his bent, but he did seem interested. I handed the shell over to him, and he turned it over a couple of times to look himself. I suggested he carry it back and show the others. He seemed to understand. We walked another few yards, and just as wordlessly he dropped the find back on to the beach and kept walking. Nothing had really happened. I didn’t take him the next week, or the next, and nothing in the way of recognition or reaction to not going, maybe no memory at all. I didn’t know. The experience changed neither how I related to him nor how he did with me. A bit of a let down. Who were these kids?

As seen by a novice, they didn’t really relate, could use a few words, some with a kind of intent, some difficult to decipher, some quite silent; they could get preoccupied with minutia or routine from which they could be difficult to detach, but once in line, easy to lead from one class to meal to an activity to the playground, but nothing interactive along the way like we always did as kids ourselves; learning was problematic but once a routine was set, they went along; infrequently, they could individually get riled up, sometimes understandably from circumstance and sometimes bewildering, thankfully more infrequently; as a group they could act distressed, albeit in twenty  different ways.

They also could enjoy and smile, some could laugh. Working with them did involve joy,  both theirs and ours. They could come out occasionally with adept comment or observation. They could be touching. Having no real idea about their fundamental capacities, we relied on articles of faith and keeping them safe. They were comfortable with us, but attached? Impossible to tell. For sure, we’d get attached to them.

The fall on Cape Cod that year was warm, with those wild arboreal yellows, oranges, and reds lasting through October. People were out and traveling. During one Friday though, more than the common citizenry got out.

The May twins, young men at this point, were active. They were about 5’ 7”, maybe 5’ 8” because both tended toward sloped shoulders, and surprisingly muscular. As I recall, they were groomed every couple of days, making me think they may not have been so cooperative. So they’d be unshaven for a day or two, monosyllabic, hair occasionally unkempt. Particularly with one of the two’s quickness and intent when wanting something, for all the world he could look a bit pongidae-ous. The both of them could create mayhem, and when they did, not surprisingly, tension could radiate through the building. They could be like loose fire alarms.

On this particular Friday morning, the more aggressive one – I can’t recall their names – escaped out the front door and loped a beeline to the candy store, went right to to the salt water taffy container and began grabbing, all in front of three terrorized elderly shoppers who had dropped by the shops on their casual way to a day in Provincetown. As the irate shop owner was calling the school, having long memorized the number, a staffer had raced through the front door and pulled the spiky, resistant resident out. No one had a heart attack. 

The day got worse. One of the other older boys – maybe the one of the twins but I never asked and no one wanted to know about it let alone ask about it because of its vile implications – did a smear job on an upper bedroom wall. This was truly the worst of the job. The boy’s staffer had to clean it off, and he was probably gagging fury. The rest of us were pale…there but for the grace of God… an unsettled state crept through the house. Early in the afternoon, a younger girl somehow hurt herself during a game of log-rolling down the back yard slope. It’s hard to get injured that way, but she was led crying into the small nursing room. Then later in the afternoon one of my boys twisted an ankle jumping off the small jungle gym, and he was upset, and the mood permeated yet more. This was not a happy-camp day. 

Normally the work is constant, without being an overload. The administrator was adept at staffing and scheduling, getting the reasonable most out of his workers. Put the events of this day into the mix, and the work becomes truly taxing. I was heads down walking after work into the staff dining area for dinner, having briefed the night staffer on the day’s events. The older woman muttered something about Jesus but I wasn’t paying attention. I was done and done in.

I ate alone at the small four-person table in a nook by the kitchen. When finished, Lukie appeared at my side. His job was to clean off dishes and take them into the kitchen to be washed.

Within the school population, Lukie stood out. About fifteen years old, he’d been at the School for ten years, I think from Roxbury. His family seemed to be around a bit more than others during weekends, at least as I understood. He was a bit more verbal than the others, but not conversant nor curious. I was told he could recognize and remember the names of his school caretakers going back to his first years. He was probably the only resident who could reliably manage the task of clearing a table. He was also the only African-American kid in the facility, which made him being the busboy a little weird, but he was the only one who could consistently manage the task and he wouldn’t begin to understand the irony. Lukie was usually happy.

I found out from another staffer that Lukie had been taught this trick. If he is asked “Lukie, how’re things lookin’?”, he’d look straight up at the sky and reply “Things’re lookin’ up!” and then look at you with a smile, and then clear the table. He clearly liked the interchange, and when Lukie looked right into your eyes, he had a  smile that could melt clear down to absolute zero. For us day workers who ate dinner there, that the last person with whom we’d interact each day being Lukie made the trip home all that much better.

So, on this day of days, Lukie comes up to clear off the table. I was so tired, so with simply a glance and return to gaze at the plate, wearily I do my part of then skit. “Lukie, how’re things lookin’?”

“Things’re lookin’ sideways!”, followed by that same grin.

I whipped my head to the right with brows creased poised doubt ”What??? “, but Lukie’s just standing there smiling like nothing new and waiting for me to laugh. I forced a chuckle and he seemed pleased as always, cleared the table as always, and turned around to disappear into the kitchen, as always. I don’t know how long I just sat there, but eventually left peddled hard toward the west because the sun had just set and riding in the dark could be a problem, Lukie on my mind.

Somebody must have taught him that line, recently, maybe that day, or the previous night. On Monday, I checked around. No one had heard it before, no one gave a hint of holding back about being the source. I checked with the night staff when they came in. Same thing. Somebody taught him. But why did he know to use it that day? And I never heard him say it again – thereafter, always ‘things’re are lookin’ up’ , just as before.  And I did the routine with him every day, and every day he smiled the same way.

I puzzled more about autism. There was more to these kids.

I never got much further with the thinking. A few weeks later, I got a call from Russ. He’d been hired as the director of a community crisis and youth counseling center, and he wanted me as the assistant director.

There was something in that kid that went beyond what we imagined.

Arguably, the greatest advancement in psychology over the past few decades has been the development of intensive early intervention techniques for the autistic. With autistic kids being mainstreamed into regular classrooms increasingly over the past twenty years, referrals to private practitioners by school counselors for help with family and social difficulties started arriving. My first one was a sixth grader running the risk of being transferred out of his regular elementary classroom and into a behavior class.  A combination of problem relationships within the family coupled with urges toward inappropriate touching that were difficult for him to control led the parents to choose the option of family therapy.  

Given my experience in the early 70’s and a lack of contact with the autistic population since then, the difference between Lukie and my new client was shocking. Using conjoint family therapy that included the boy’s younger sister as an important source of information, feedback, and reinforcement, the boy’s social problems resolved nicely over many months. He related, he participated, he worked like a normal client would, developed social relationships in school, controlled the urges. The process did take 2 1/2 years. Stepping back, though, the change in autistic functioning seemed almost other-worldly. 

After doing all the pre and post CGAS scoring for the 56 cases in this study, reminiscing back to this case raised the question about whether an autistic youngster could score above 80, The answer seems to be ‘yes’ . At the end of the last appointment, he made certain that a small construction-paper story booklet he wrote and illustrated, intended for other kids coming into  waiting-room play area to read, was securely fastened to the wall. 

If half the youngsters currently scoring high on psychopathy scales are predicted to resolve their issues by adulthood, do those that do not resolve lack the capacity to love another person?  Just a question….

That the callous-unemotional profile may be identifiable in the toddler stage may add credence to the theory that CU is more closely related to autism than to other forms of conduct problems. Some core element(s) of relatedness is missing. The theoretical hope would be that targeted, intensive early interventions could be developed to work on re-programming an afflicted child’s cognitive impairments and social deficits. Again theoretically, the treatment could aid in the development of trust, attachment, empathy, remorse, and operating with a functional set of values. The person gains a life of acceptance. Society could eventually be spared a good portion of the estimated half-billion dollars annual cost that antisocial personality behaviors generate, the figure quoted in the Kahn article. The incentives are there to fill the vacuum.

In the meantime, though, the psychotherapeutic world deals with the dilemma of the “delectable sauce”. Kahn quoted John Dadds, a psychology professor at the University of New South Wales, who said that “the nuns used to say ‘Get them young enough, and they can change.”  Kahn reported also one early study indicating that warm and loving parenting can reduce callousness, even for those kids that resist the close warmth.Yet another expert was quoted  “to take the attitude that psychopathy is not treatable because it’s genetic, that is not accurate”. The resolution rate may be small, but an effort can also be life-saving.

Via Taylor’s summary, Samenow suggested that mental health work is “typically amoralistic”. Normally, the function of psychotherapy is to facilitate change through any through any number of techniques in the context of a clinical relationship, relying upon the client’s trust toward the therapist to inculcate feedback and suggestions that the client thought to be meaningful, given who they were. The existence of a client’s functional value system is presumed. 

On the other hand, when dealing with anti-socials, including conduct disorders, who do not trust, are blind to their drives, and and bereft of considered choices, taking the approach that emphasizes values and self-respect rather than self-esteem and social regard may prove more effective. The National Association of Social Workers issues a frequent on-line ‘SmartBrief’ shares information on various clinical and social concerns. A recent SmartBrief discussed a number of values that have applicability in the clinical setting. Those plus a couple more form the following list:

With this particular list, the first five involve the socio-cognitive awareness of how the client perceives others perceiving them. The second five underscore giving where nothing is expected in return. In turn, discussions about manipulativeness, first in the abstract, and then moving into an examination of self can occur when the client becomes more comfortable talking about issues from a values perspective. 

Clinical patience is a necessity here. The last message that the clinician wants to convey is disappointment or any other negative judgement that the client can detect by the merest of grimaces or movement of the eyes upward. The CU probably has a geiger counter for rejection as much as they have one for an opportunity to manipulate.

Working one at a time from a list of chosen values that might number eight to ten, the clinician can shape whatever situation the clients brings to discuss toward examining one of values. Exploration of the client’s thoughts and feelings about the value itself, its application to the particular situation, how the client might employ the value itself to someone else’s benefit, and how that might ultimately be of help to the client themselves would be the general clinical process. Perhaps assume they may not “feel it”, but they can ‘think’ in lieu of ‘feel’ as they try to apply. 

Values work can also shapes the language used in future sessions.They become points of reference that both client and clinician understand in similar terms. That opens an avenue for spontaneous and random positive reinforcements the clinician can offer the client as the clients changes are carefully observed. Hence, the reinforcement is deserved. The reinforcements may need to be almost understated, lest the client’s inherent suspiciousness interprets the praise as a euphemism, something that disguises less flattering the therapist is thought to think. 

Other ideas based on Samenow’s advice for callous-unemotional conduct disorder work can be implemented in either family or individual work, and include:

Elicit disclosure, follow the path 

Randomly reinforce insight improvements 

Focus on self-respect rather than self-esteem – the values work outlined above is a good example

Use open-ended questions about lessons from experience, 

Don’t try to “build” rapport – be yourself

Teach rather than confront

Use praise judiciously

Work on the ability to recognize worry

Detach from power struggles that begin to emerge in treatment*

Help build an acceptance that “Life can be unfair” 

Develop humility, reinforce its evidences appearing in treatment

*My Wyoming-bred practicum supervisor and future department head at Children’s Hospital Dept. of Social Work once advised in regard to power struggles  “Don’t get into a pissing match with a skunk – you’ll lose.”

“Hot-blooded”-type Conduct Disorder

The prototype would be the older child or adolescent who flies into rages and retaliates by acting upon several DSM conduct disorder symptoms, including physical aggression, bullying, intimidating, use of a weapon, stealing, damaging property, and/or setting fires. The episodes would occur randomly in multiple settings with virtually no sincere remorse in the aftermath. As such, they pose a threat to the welfare of individuals and safety within the community.

Two clients who resorted to fits, aggressions, and destruction come to mind, one in this study and one from the calendar year before. The clinical formulation at the time of service for case in the study assumed a genetic load for conduct disorder based on his biological parents’ profiles, but he was also manifesting PTSD. His parents were deprived of parenting rights dues primarily to serious neglect. The aggressions decreased some, but most concerns persisted.The case before the study could have been seen as conduct disordered at treatment’s outset, but turned out also to be PTSD. Once the trauma was revealed during a session, the conduct problem quickly dissipated. The boy returned to high 80’s – low 90’s CGAS functioning.

Based entirely on recollective impression, maybe 20 – 25 of these ‘hot-blooded” rage cases appeared in the practice over time, or roughly 2% of the practice’s population. Most these cases are probably funneled into psychiatry, community mental health programs, state custody, or other mandated treatment programs .

Anger management programs are becoming the community standard of treatment. If the clinician wants to remain involved but has concern about the client being a continued danger to the community, a referral to an anger management program or to a child psychiatrist would seem requisite. Still, the clinician can remain clinically involved and be of a difference-making service. The problem is segregating the anger management treatment that is occurring elsewhere from the work being done in the psychotherapy office. The family or individual treatment would focus on other problems and symptom areas that would do not include anger management, per se, unless necessary and coordinated with the specialist.

Other Conduct Problems

Both ODD and Pediatric Bi-polar Disorder are distinct from Conduct Disorder, and will be discussed in what is planned to be a Diagnostics Section within the overall Therapy Process segment of this blog project.

Process Management Considerations for C.U. disorders

High risk traits like major breaches of laws, norms, etc, lying, intimidating, physical and verbal aggression, and rages probably need to be on the explicit problem list. Included in major breaches would be most all of the fifteen DSM conduct disorder symptoms. Other traits may be best left on the clinician’s baseline list. 

As stated earlier, avoid trying to “build” a clinical relationship. In the same vein, avoid enthusiastic praise, at least until a certainty about clinical trust is present. The praise may be reinforcing the perceived personal change, or reinforcing the client’s manipulativeness. With these clients, a full basic trust is hard to achieve, and hyperbole may not help. 

The basic footing of clinical trust is always honesty, acting in the best interests of the client(s), maintaining the boundaries of confidentiality and other ethical considerations, and the ability to answer whatever

questions that may arise from the client regarding process and communications.

Supporting the basic mother – father – child triangle (substitute other gender arrangements as needed),  inasmuch as possible in keeping all three sides viable. Avoid “taking sides”.

Maintaining an awareness of parental Axis II ramifications, and adjust as seems required to protect the process. The next post addresses some of those concerns.

Lastly, avoid leaving a floridly CU child alone in the waiting room while meeting with the parent(s) unless demonstrable progress is being made. Waiting rooms have been known to get vandalized under those specific circumstances – not likely to enhance the therapy process.

Administrative Considerations

Particularly if the setting is private practice and the work involves behaviorally high-risk clients, the clinician may want to have certain resources available upon need, however uncommon that need might arise. They include:

Consultant or consult group – the most important resource for difficult cases.

Child psychiatrist – available for second opinions and medication evaluations. Most of the cases referred for psychiatric evaluations involved more serious instances of suicidal thinking rather than antisocial behaviors, but having that psychiatric expertise and sets of skills and tools available will prove helpful.

Neuropsychologist – if available within a reasonable distance, for evaluations of questionable cognitive- behavioral processes and educational recommendations. Not commonly used by mental health practitioners, but as neurology becomes more involved in mental health, neuropsychologists are likely to take a more prominent role.

Certified Chemical Dependency Counselor (CCDC) – for evaluations and recommendations on need.

PTSD expert or clinic – Certified PTSD specialists are becoming a community standard of treatment beyond some level of severity, as per CCDCs for alcohol and drug problem,  so having one as a referral and consulting source will become of increasing benefit.

Lawyer – For advice. This may seem like overreach, but I used one with a mental health special throughout my practice, contacting him for advice four times, all phone calls, a couple of which he charged and the other two he didn’t, all worthwhile. Like child psychiatry, having that expertise identified and available upon need is a comfort.

Therapy tends to the person, about whom the diagnosis is but a fraction, and occasionally incorrect. 



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