The second workshop of the FCP 2017 Series presented by Daniel Waschbusch, Ph.D., was outstanding! Entitled “Empirically Supported Assessment and Treatment of Conduct Problems in Youth,” Dr. Waschbusch quickly showed strong command of this topic, and provided a fast pace, 3 three-hour, focused presentation to a very attentive audience.

I counted only a handful of questions during the workshop, suggesting that the participants were satisfied with his knowledge and his delivery of the topic. Dr. Waschbusch managed to balance a high level of supportive research information to satisfy the experienced professional audience. He also provided a nice review of some basics for both early career and veteran mental health professionals.

Workshop Objectives included:

• Describe research on the causes, correlates, and development course of conduct problems in youth
• Describe empirically based approaches for assessing and treating youth with conduct problems
• Explain current research efforts aimed at better understanding youth with conduct problems

All goals were met.

Dr. Waschbusch stated that conduct problems in youth are a high cost to society. This includes negative impact on families, increased juvenile crime, costing $70,000 per child above and beyond normal expenditure, and a high level of adult criminal activities. The prevalence of conduct problems in American Society is over 5% among children and youth. Typically boys have a higher prevalence than girls, but he noted that, while boys are more aggressive, girls may have a higher rate of social relationship problem behaviors.

Dr. Waschbusch said that the heart of Conduct Problems in youth is antisocial behavior. He defined antisocial behavior as: “Behaviors that inflict physical or mental harm or property loss or damage on others, which may or may not constitute the breaking of criminal laws.”  Early in his presentation, he gave the DSM-V definition of Conduct Disorder as a: “Repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated as manifested by four classes of symptoms.” These include:

• Aggression to people or animals.
• Destruction of Property
• Deceitfulness or Theft
• Serious Violations of Rules.

Dr. Waschbusch listed 15 behavioral symptoms among these for classes, stating that 3 are required to be present in the past 12 months, and 1 in the past 6 months.

Included in his discussion of Conduct Disorder, Dr. Waschbusch, also talked about three characteristics of Oppositional Defiant Disorder (ODD) and Aggression. He said that there were three key characteristics of ODD, including angry, irritable mood, argumentative, defiant behavior or vindictiveness. Dr. Waschbusch stressed that some of these features are common in youth and the symptoms must be persistent and rise to the level of serious distress and impairment before a diagnosis can be made. He mentioned a longitudinal study in New Zealand noting that 94% of teenagers have some antisocial behavior but only 7% have a Conduct Disorder diagnosis.

Research was presented by Dr. Waschbusch showing that many interrelated factors lead to the development of conduct problems. A meta-analysis (Rhee and Waldman, 2002) showed that genetics and environment both played similar roles in development of antisocial behavior. Jaffe et al (2005), and Caspi et al (2002) showed that genetics can moderate environmental influences on the impact of environmental risk with these children and youth with a history of maltreatment and physical abuse.

Dr. Waschbusch also mentioned a study by Moffitt, 1993, which suggested that low verbal IQ, or verbal deficits may cause lower slow development of self-control, less positive reinforcement from adults, less ability to resolve conflicts with peers and increased frustration.  Dr. Waschbusch also presented several substantial studies that showed that high exposure through media, or neighborhood violence can lead to increased aggressive behavior in children and youth, and increased risk for Conduct Disorder.

Dr. Waschbusch talked about the normal development of antisocial/aggressive behavior in children and Youth. He said that Dodge, et al (2007) noted the peak age of aggression occurs around age 2, but subsides with improved verbal communication ability. Parent complaints about behavior peak around age 3. This study also suggested that frequency of aggression declines through adolescence in adulthood but increases in severity.

There were two conceptual approaches presented by Dr. Waschbusch to help understand the development of conduct problems. The Developmental Pathways Model (Loeber et al, 1993, 1997, 2005) suggests that there are three possible pathways for development of Conduct Problems:

1. Overt Pathway (Minor aggression – Physical Fighting – Severe Violence)
2. Covert Pathway (Minor Covert Acts – Property Damage – Moderate/Serious Delinquency)
3. Authority Conflict (Stubborn Behavior – Defiance – Authority Avoidance

The Research by Dr. Loeber et al, suggests that early maladaptive behavior can be predictive of the pathway for an individual child.

Dr. Waschbusch also discussed the Developmental Trajectories Model of Conduct Problems. This model (Loeber and Pardini, 2008, Nagin and Tremblay, 1999, and Moffitt, 1993), was developed through statistical analysis of longitudinal data to identify individuals who share similar traits over time. Research by others as well, showed that two models emerged. A childhood Onset/Life Course Persistent pattern and an Adolescent Onset pattern. According to Dr. Waschbusch, the Childhood Onset pattern may last  throughout life with increasing violence. The Adolescent Onset pattern may resolve through the teenage years.

During his discussion of the etiology and course of Conduct Problems, Dr. Waschbusch stressed that ADHD is a common factor. To put it simply, impulsivity can interfere with social information with information processing and decision making leading to misunderstanding and poor response to a social interaction, leading to higher risk for conduct problems.

Dr. Waschbusch also presented some of his own research on callousness, as a factor in the development of Conduct Problems. He said that Callous-Unemotional traits in youth are characterized by:

• Lack of remorse or guilt after doing wrong
• Lack of empathy or concern for others
• Unconcern about own performance
• Shallow or deficient affect

<< See the New York magazine article, Can You Call a 9-Year-Old a Psychopath,  Dr. Waschbusch mentioned in his presentation >>

He presented several examples of serious aggression reflecting callousness as a factor in violent behavior of youth. Dr. Waschbusch discussed the importance, but also the risks of measuring callousness as a risk factor for aggressive and violent behavior in youth. He said that callousness is present in about 4% of children and youth, and can be a marker for high risk of serious Conduct Problems. Dr. Waschbusch said that there is a risk that measuring callousness will lead to greater stigmatization for the child. This risk can be mitigated through education about development  and individual differences.

Dr. Waschbusch presented several techniques to assess Conduct Problems in children and youth.  He discussed Behavior Ratings, Structured Interviews, and Observations to be used as typical assessment methods. Dr. Waschbusch said that a multi-method assessment is essential, and he warned against relying on child self-reports. Dr. Waschbusch said that he often relies on Behavior Rating Scales because they are objective, usually can be administered to parents and teachers, and are reliable, and valid. He presented names and sources for several scales.

In his discussion of treatment for children and youth with conduct problems, Dr. Waschbusch, discussed several approaches including Parent training in behavior therapy and Cognitive Behavioral strategies for the child. He said that Parent Training is usually the most effective, but should include the child or adolescent more in therapy as they get older. As they get older, the adolescent can learn contracting, and negotiation skills as part of treatment. Dr. Waschbusch said that CBT with the child is often less effective because the child with a Conduct Problem is often oppositional to treatment, and it is difficult to get consistent cooperation.

During the final 30 minutes of his presentation, Dr. Waschbusch presented an excellent overview of parent training. He pointed out that, while parents are often blamed for their child’s misbehavior that is not typically the case. On the other hand, the parent is in the best position to help the child learn the social skills required to overcome Conduct Problem symptoms. Parent training should be the core treatment for these children. In response to a question about parents who were not available for participation in treatment, Dr. Waschbusch stated that the treatment principles are the same, and that others, including teachers can be taught these techniques.

Overall, this workshop was a winner! When I saw 94 pages with 280 slides in the handout, I was worried, but no need. Dr. Waschbusch’s rapid but clear pace in this presentation covered most of the material. He did have to skip some slides toward the end however, there did not appear to be a loss of continuity in his presentation.

A very satisfying workshop! As with all good workshops, during the break, comments were positive and participants appeared eager to return for the second half.

Any other thoughts?