Roughly every month I receive an e-mail from a parent somewhere in the world asking for help with a child who is violent, angry or aggressive. Some people describe being physically beaten or having their life threatened by their son or daughter. These families may spend thousands of dollars on special schools and treatments. Often they are desperate, afraid 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 assessed using different criteria than those used to diagnose antisocial personality disorder—though 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, all are defined by the fact that affected individuals engage in persistent, severe antisocial or aggressive behaviors. Children diagnosed with conduct disorder or disruptive mood dysregulation disorder, for example, may be physically violent or display bursts of destructive anger. These disorders, which are characterized by patterns of exploitative, hurtful or cruel behavior, place children at risk for 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 antisocial personality disorder is estimated to affect one in 50 people, making it more prevalent than schizophrenia, bipolar disorder or anorexia.
Given the prevalence and severity of these conditions, you might think abundant resources exist to help affected adults and children, but that is not the case. Relative to other common, serious mental disorders, disorders of aggression are underdiagnosed, undertreated and underrecognized. And that is not because these disorders cannot be accurately diagnosed and successfully treated—they can. New research is providing clinicians and scientists more insight than ever before into how these conditions develop and how to intervene. And the earlier in life treatment begins, the more successful it tends to be.
But these disorders are terribly stigmatized, leading well-meaning clinicians 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 added to the intense negative judgment of these conditions. Even some mental health organizations, both private and public, avoid mentioning them.
We now know, however, that these disorders are true illnesses that reflect dysfunctional patterns of brain structure and function that lead to maladaptive 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 previous assumptions, they are not simply the result of “bad parenting”—an idea that has brought harm and shame to families. Varied factors, including birth complications, trauma and exposure to toxins such as lead, may contribute—though for many people, no clear stressor is ever identified. In addition, without treatment, these disorders will likely persist or worsen.
Symptoms often emerge early in life and continue over time. A study conducted by researchers in Cyprus, Belgium and Sweden and published last May tracked more than 2,000 children over the course of 10 years, collecting parent and teacher reports at five different time points between the ages of three and 13. The analysis revealed that an early emerging risk factor for later antisocial behavior was a fearless temperament, which often manifests as insensitivity to risk or harm in preschool-aged children. That trait can make children very difficult to parent because they do not learn to avoid risky, 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-unemotional traits,” such as low empathy and remorse, which can further increase the risk for antisocial behaviors. Fearless temperaments may lead to low empathy in part because children who themselves do not feel fear strongly struggle to empathize with this emotion in others. Over time, “maladaptive fearlessness” can increase the risk of antisocial and criminal behavior in adulthood.
Given these tendencies, punishment does not improve behavior in children and adults with these illnesses. In fact, disorders characterized by aggression are often linked to less responsiveness to punishment, no matter how harsh, making it a futile response to aggression. Last July researchers in Germany, the U.K. and the Netherlands published findings from an experiment that examined how 92 children and adolescents with conduct disorder learned from punishment, compared with 130 of their typically developing peers. The children played a simple game in which they had to learn to select images that would result in a reward (gain of points) versus punishment (loss of points). As the game progressed, most children learned to avoid the images that result in punishment. But those with conduct disorder persisted in choosing these images more often, despite showing normal rates of learning from reward. This suggests that fundamental neurodevelopmental deficits in learning about punishment and risk underlie the emergence of serious antisocial behavior.
Though harsh punishment is ineffective for treating disorders of aggression, there are interventions that do help. In March 2023 another group published an analysis that pooled data from 60 studies that assessed the success of treatment for children with serious disruptive behavior disorders such as conduct disorder. The findings revealed that a range of treatment types were effective in improving children’s symptoms—contrary to the prevalent myth that these disorders are untreatable.
The most effective approaches for severely affected children (those with callous-unemotional traits) were focused on training parents. In such treatments, which include parent management training and parent-child interaction therapy, therapists teach parents to use specific therapeutic techniques to reduce children’s symptoms and improve their social skills and relationships. Consistent with the research on rewards and punishment, the therapeutic approaches that emphasize rewarding desired behaviors—and withholding rewards when children act out—are most effective. In general, these types of treatments should be considered first-line therapy for children with antisocial behavior, although too often they are not offered to families who could benefit from them.
Even the most seriously 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 offences in Dutch high-security 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 more improvement in their symptoms and moved more rapidly through rehabilitation than those who received standard individual or group therapy. This work suggests that rehabilitation is possible and could yield enormous potential savings in costs related to incarceration, as well as significant gains in public health and safety.
Of course, all of these treatments hinge on accurate diagnosis. My colleagues and I have found that children diagnosed with conduct disorder and callous-unemotional traits (which are also called “limited prosocial emotions”) show opposite patterns of brain dysfunction compared with children who have conduct disorder as a result of anxiety or trauma. This finding indicates that these groups of kids would likely benefit from completely different treatments, despite some overlap in their symptoms, which brings us back again to the urgent need to improve the recognition, discussion and accurate diagnosis of these disorders.
Many different steps are needed. For one, all major mental health organizations must give recognized disorders of aggression explicit parity with other mental disorders. Even today, someone who seeks information about conduct disorder, psychopathy or antisocial personality disorder may search the websites of major organizations such as the National Institute of Mental Health or the National Alliance on Mental Illness in vain. This information gap was a major reason 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 bullying, domestic assault and gun violence.
In addition, much more can be done to improve professional training and guidelines. And public and private mental health organizations must devote as many resources to screening tools, interventions and studies of the causes of disorders of aggression as they do to similarly common and serious disorders, such as autism and attention deficit hyperactivity disorder. With more research will come better understanding, better treatments and hope for a full and productive life for affected children and adults. Though these changes wouldn’t yield instantaneous gains, they would represent a more compassionate and—most importantly—more effective approach to helping people, including the many families in need of answers.
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