We are the Association for Child and Adolescent Mental Health, or ACAMH for short. And this is ACAMH Learn. Welcome. My name is Dr. Luke Hyde. I'm a professor at the University of Michigan in Psychology at the Institute for Social Research. Today, I'll be sharing an updated review on what we know about early conduct problems, their risk factors, outcomes and aetiology, as well as treatment. Just to start, I don't have any disclosures to report related to this presentation or my work in this area in general. My research is funded by the National Institute of Health in the US. So we know that conduct problems can proceed into serious long-term antisocial behaviour. And when we see antisocial behaviour in the teens-- and by anti-social behaviour, I mean violence, rule breaking, and other costly behaviours. These have major economic and social costs for children that are engaged in them, victims of crime, caregivers, and society more broadly. In later ages, serious anti-social behaviour is diagnosed as cognitive disorder or oppositional defiant disorder in the DSM and the ICD. These disorders are considered to be neurodevelopmental disorders. That is, they start early in life, and they tend to have, at least for a small group of youth, a relatively lifelong trajectory. Though we know that during adolescence, many youth engage in antisocial behaviour, a small group of youth start earlier in life and tend to have a more consistent trajectory of these behaviours over time. So many researchers have studied conduct problems earlier in life, and these are rule breaking, aggression, and defiance. And our outgrowths of common and normative behaviours that most children, most preschoolers show, at least in some form, or briefly. These decline for most youth over time. Unfortunately, for some youth, they do not and can lead to this lifelong course of anti-social behaviour. We think that chronic problems come from common and normative behaviours, and they emerge from a lack of emotion regulation and developing mobility during the toddler and preschool periods, as well as rapid changes in the brain that lead to big emotions. These are also really big challenge for parents and as we'll discuss, can create a conflict within the parent and child relationship. Many parents and clinicians ask when to worry about whether these behaviours are developmentally appropriate or inappropriate. One good way to understand that is using a range of parent report questionnaires that have norms built into them, such as the Child Behaviour Checklist and Eyberg Child Behaviour Inventory. Many researchers have studied conduct problems to help understand how we can prevent and treat these problems early in life before they escalate into more serious behaviours later in life. So what are some of the risk factors for these behaviours? At the child level, one of the most studied risk factors is what's been termed difficult temperament, and this is a combination of negative emotionality and difficulty with self-regulation. Markers of difficult temperament can emerge very early, even during infancy period, with more intense and frequent distress, lower suitability, and higher irritability, which also makes these infants more challenging to parent and can start undermining the parent-child relationship very early in life. A variety of research has also looked at more specific factors called effortful control as well as impulsivity and found that these are robust risk factors for early cognitive problems. In fact, later in life, when antisocial behaviour becomes diagnosed as conduct disorder, some studies show comorbidity with ADHD of up to 90%. Finally, a more recent research has been examining the presence of callous, unemotional traits, or as they're called in the DSM and ICD, low prosocial emotions. These are characterised by low empathy, guilt, and lack of positive prosocial emotions, and the presence of callous, unemotional traits has been linked to a distinct aetiology of conduct problems and a more severe trajectory. Most research in this area has been done on school-aged children or teenagers, but more recent research suggests that you can identify risk factors for these callous, unemotional traits as early as age three. However, this is a risk factor, not necessarily destiny. Emotional traits themselves are downward extension of traits that we see in adults with psychopathy, but I want to emphasise that callous emotional traits and earlier markers of them are risk factors for psychopathy. In one study where psychopathy was diagnosed in adolescents, only one in five adolescents that were diagnosed in adolescents ended up having the diagnosis in adulthood. Almost no children who did not have the diagnosis ended up having psychopathy in adulthood. So it's a great way of identifying who may need treatment, but not a good way of identifying who will have this more severe antisocial behaviour later on. That is, it's like high blood pressure doesn't mean you're going to have a heart attack, but it is an indication that you should get treatment. On the parent side, there's a robust literature linking different qualities of parenting to risk for cognitive problems. In particular, there's a large literature linking harshness, this is physical discipline, verbal aggression, as well as other forms of parenting, including lax parenting, which is parenting without consistent limits. I am concerned that recent trends in the use of gentle parenting may overlap with research on lax parenting. Inconsistent parenting is also a risk factor and often is seen in combination with harshness, in which parents are inconsistent and then occasionally harsh. And then finally, parenting that is low in warmth has also been linked to greater risk for conduct problems, although the effect sizes are the strongest for harsh parenting. I think it's important to note, though, that parenting is shaped by multiple levels of risk. Parents' own stress and stress in the family impacts their ability to parent, as well as exposure to adversity and their relative amount of resources. That is, parenting doesn't happen in a vacuum and is often shaped by the experiences that parenting parents are having inside the home and outside the home. So I like to tell clients, parenting is not the thing that you plan to do, but what happens in the moment. One example of how these external factors trickle down to the child via the parent is the family stress model. This model that was pioneered by Rand Conger decades ago suggests that poverty and exposure to low resources as well as changes in economics creates economic pressure, which in turn impacts parental distress, risk for things like depression and interparental conflict. These, in turn, lead to more conflict in the home and undermine parenting, leading to more harsh parenting and lower parenting warmth, which in turn increased risk for cognitive problems and broader externalising. So to summarise, we think that this parent and child risk factors occur within a broader sphere of influences that start with broad factors structurally, including policies and concentration of disadvantage. These impact the community, including exposures like community violence and the amount of social support, as well as childcare and schools, which in turn shape family factors which in turn impact the parent and later in life, impact the child more directly. At the centre of this is something called the coercive cycle, which was studied first by Jerry Patterson several decades ago. The idea with the coercive cycle is that parent and child get into a cycle in which they're unfortunately reinforcing each other for more harsh parenting and more child noncompliance. The example I like to give to explain this is in a micro example of one that might happen when a parent and child go to the grocery store, potentially with a hungry child. As the parent and child go to checkout, the child demands candy and the parent says no. The child then escalates to a tantrum. As the child's behaviour becomes more intense, the parent may end up feeling embarrassed or otherwise ashamed and want to stop the behaviour, so the parent gives in. This is inadvertently reinforced the child for their behaviour. It's also reinforced the parent through negative reinforcement by helping the parent escape the negative stimulus of the child having this behaviour. What can happen over time is that the parent learns more and more to give in. And even when they do try to stop this behaviour by being firmer, the child will escalate even more, which again punishes the parent for their attempts at being more consistent. These cycles happen to some degree in every family, but when children have more difficult temperaments and trouble with emotion regulation, plus parents who have fewer emotional, financial, and educational resources, these cycles can be magnified and become more intense and escalate over time. And we can see the cycle amplify across development. So we've discussed some risk factors in the environment, but a question is also whether children are bringing risk factors in their genes. Multiple studies have shown that cognitive problems and later antisocial behaviour is about 50% heritable. So that is about 50% of the variance. That explains differences between children across the population can be attributed to genetics. The heritability of cognitive problems and anti-social behaviour is stronger when these behaviours start early, when the behaviours involve aggression, as well as when callous and emotional traits are present. Much of the research in this area has been done during school age and adolescence, but there is some research suggesting that this pattern is likely to be true even during the preschool period. The challenge here is that the fact that there is a heritable component to conduct problems also means that many studies in which we observe parents and children together may not actually do and actually be showing us influences of the parent on the child, but rather the presence of something called gene environment correlation. These can be passive, in which parents and children have the same gene, and this influences similar behaviours. So, for example, parents may have genes that make them harsher and more aggressive, which the child has. And thus when we see an association between harsh parenting and child aggression, we may think that's due to parenting, but it could just be due to the genes that parent and child share. These gene environment correlations can also be evocative, in which the child's genes evoke different parenting. And there's actually a robust literature showing that children with more difficult temperaments do receive parenting that is harsher and less consistent, even when they are being parented temporarily by parents that are not their own. So this is a challenge from a research perspective, but also emphasises the potential interplay between genes and environments over time. So how can we be sure that the associations I talked about earlier with parenting and child are actually due to environments, not just genetics? One way we can do this is by looking at adoptive children. In this case, if we see associations between birth parent behaviours such as their anti-social behaviour and child's behaviours, we can think of this as a genetic main effect, particularly if children were adopted very early after birth. If we see that adoptive parents parenting are associated with their child's behaviours, we know that this is more likely to be environmental because we've eliminated this passive gene environment correlation. We can also look for gene environment interactions, looking at interactions between adoptive parents and birth parents, which can help us understand how the environment is interacting with the child's genetic background. I should also note that though cognitive problems are moderately heritable, multiple genome wide association studies have not found any specific genes or small groups of genes that predict chronic problems. In fact, the largest ones only explain a small variance in conduct problems with many, many large concerts of genes. So going back to our adoption design, in one study, researchers looked at birth mothers reports of their own severe anti-social behaviour across development and found that this predicted early markers for CU traits called CU behaviours here during the preschool period. And they found that there was an association and this is a heritable or genetic pathway, since in this case, most children had been adopted by the time they were two days old. There was also an association between adoptive mothers observed positive reinforcement during a challenging task with their toddler and later, CU behaviours, which again, we think is likely to be a non-heritable parenting pathway. Finally, the researchers found a gene environment interaction in which birth mothers' anti-social behaviour is a marker of genetics interact with the adoptive parents' positive reinforcement. In this case, on the x-axis, we see biological mothers self-reported anti-social behaviour, which is index of genetics and child CU behaviour on the y-axis. In the blue line, we see this positive association, that is children that have birth parents with more antisocial behaviour seem to have higher CU behaviours. But in this case, we see that's only true for kids who have adoptive mothers who are not high on positive reinforcement. In contrast, children that had adoptive mothers who showed high positive reinforcement during a challenging task actually have no association between birth mother's severe antisocial behaviour and their behaviours. In other words, in this case, we see that adoptive mothers positive reinforcement knocks out this genetic risk. We've also seen these kind of interactions using twins with the evidence that positive parenting can mitigate genetic risk in children. Another way to approach the potential that gene environment correlations are undermining our attribution of parenting to child behaviours is to use a twin difference approach. So if we take identical twins and we see that parents parent them differently, and in fact, they do, we find that one of the children receives harsher parenting, in this case is spanked, or receives more harsh parenting. And that child is the one that's more likely to have conduct problems. We know this association has to be environmental since the children have identical DNA. And, in fact, in this paper, researchers found exactly that. So in sum, we have good evidence that parenting does have a true environmental effect, but also that it interacts with child's genetic risk. We know that genetic risk here is not destiny, because we know that positive parenting can help knock out this genetic risk, which gives us hope the interventions that we can help shift parents parenting. We can help impact that genetic risk. Research in adolescence and in school age has also begun to look at neural correlates of antisocial behaviour. A broad model suggests that environmental risk factors like harsh parenting and poverty, exposures to toxicants interact with genetic risk to shaped the development of three specific neural circuits, which in turn impact differences in neurocognition and increased risk for antisocial behaviour. In this case, the three brain circuits that have been focused on are the prefrontal cortex and frontal parietal network, which are associated with inhibitory control and broader executive functioning. The cortical limbic circuit, which includes the amygdala and other areas of the brain that are important for threat detection, as well as emotion and emotion regulation. And the corticostriatal circuit, which involves the ventral striatum and nucleus accumbens, as well as other parts of the prefrontal cortex, and these are important for responses to reward and can lead to reward-dominant decision making in this case, where children focus more on rewards and less on punishments, or continue to choose options that were previously rewarded that are no longer rewarded. These neurocognitive differences, including inhibitory control, emotion dysregulation, reward-dominant decision making form some of the most potent neurocognitive risk factors for antisocial behaviour. Much of this work has been done in adolescence, much less known in early childhood and preschool, because at this age, children are very hard to put in an fMRI scanner and explore these with. But what little research does exist in this area suggests that these circuits are likely important during this period, particularly as they are developing rapidly. So from this model in which environmental risk interacts with genetic risk to shape brain development and neurocognitive risk for antisocial behaviour, we can integrate this with our discussion of the coercive cycle. In this case, we think that infants start with genetic risk and potentially risk from prenatal exposures like lead, which may increase their risk to be more difficult to soothe and have more emotional dysregulation, which undermines the parent-child relationship early on. Parents may also be affected by broader contextual risk, which increases their stress and lowers their emotional resources to be patient and consistent with a more difficult child. This escalates during the toddler period into temper tantrums and intermittent discipline, as well as escalation to harsh parenting, alternating with intermittent discipline. As the coercive cycle continues, children unfortunately learn behaviorally that noncompliance often works to get what they want, and that often they must just escalate their behaviour more. This can leak out and engage teachers in coercive cycles as well as peers early in the school year periods. As we transition into school age and adolescence, this behaviour can lead parents to disengage and not monitor their children's activities as they spend more time outside of the home. These non-compliant behaviours can lead to peer rejection at school and in the neighbourhood, which in turn can encourage association with other deviant peers who are not turned off by this non-compliant behaviour and may in fact reinforce these behaviours. Over time, this can lead to an escalation of problem behaviour and lead from conduct problems to conduct disorder. So what can we do to prevent and treat early conduct problems? In a recent review, authors found that all evidence-based treatments for childhood disruptive behaviour disorders, including conduct problems that met the highest levels of evidence all involved parents. So I think it's important to emphasise that early intervention for conduct problems should involve parents, and parents are usually the major target of the intervention. This is not to say that this is the parents' fault or the parent is responsible, but rather the parent can become like a local therapist to help give more input to the child on a daily basis. The most well established treatments in this area are often termed parent management training under umbrella, and they include similar behavioural constructs that have emerged from research on the coercive cycle. For example, there are group parenting behaviour therapies, including The Incredible Years is one of the branded versions. There is a version of parent management training that's standardised called Generation Parent Management Training Oregon Model, or PMTO. There's also a package called Parent-Child Interaction Therapy, PCIT, which is aimed at children in the younger range three to nine and can include active coaching while parents and children are interacting. PCIT has been extended down to the toddler period through PCITT, and it has been augmented for CU traits through PCITC. These interventions are wonderful in the sense of having used these decades of behavioural research to help inform them and to help us try to end or mitigate this coercive cycle to help parents learn new skills, including positive discipline, positive parenting, along with consistent limits and to use learn new ideas for how to work with a child that might be more challenging than other children. In the prevention sphere, one of the landmark studies in this area is the Fast Track study, which started during the school age years in the US and used multiple components over time to try to prevent and treat cognitive problems and was relatively effective and cost effective. In early childhood, one early preventative intervention that has gained more evidence recently is the family checkup. This is a family-centred intervention that involves a get to know you session and then motivational feedback sessions that then tailors intervention. So it can involve parent management training components, but it can also be tailored to the needs of the parent-child relationship or the family broadly. For example, supporting things like treatment for maternal depression. The family checkup has been combined in various tiered models. So, for example, it's also been combined with a video interaction project to give parents feedback on parenting. Another potentially effective early preventative intervention are Nurse-Family Partnerships. Some of this research dates back decades and was started by Olds. The goal was not to target content problems, but rather have nurses visit during the first years of life. Researchers found that this had downstream effects by helping nurture parent-child relationship early on helped prevent things like child maltreatment. A newer version of this is the Family Connects, which involves Nurse-Family Partnerships, as well as in some versions, other components of treatment later on. The field is likely going to tiered models with various levels of investment and engagement at different ages and trying to meet parents where they are. So, for example, it could start with Nurse-Family Partnerships early in life, a family checkup later in life, as well as options for more structured parent management training and more intensive treatments over time as needed. So starting from primary to secondary to tertiary prevention intervention. One of the keys to these models is the idea that also treatment may need to involve more frequent checkups or yearly check ins, as one round of treatment may not be sufficient to help interfere on these coercive cycles over time. In some context, problems start early and can progress into serious anti-social behaviour that has major public health implications. Conduct problems emerge from parent-child interactions, which are shaped by child and parent traits, as well as the resources and adversities in the broader context. These experiences interact with genetics to shape brain development and increased risk for cognitive problems in antisocial behaviour. We need better public health approaches that target broader socioeconomic and adversity risk and embeds preventative interventions within primary care or other settings that families are likely to engage with regularly. I want to acknowledge co-authors on our annual review and encourage you, if you have questions about this presentation or want to look to more depth of the studies to read our review. I want to acknowledge our co-authors, Chris Trentacosta and Jessica Bezek as well as I'm grateful to the editor, Danny Shaw for helpful feedback and the reviewers on our work. Thank you. [MUSIC PLAYING]