5. Possible Early Preventive and Treatment Interventions
There are a number of well-established models for parent training and family treatment, and several of these have been proved effective for children and adolescents with behavioural problems
[33][34]. In general, these programs are aimed at improving the child’s context as a developmentally supportive environment. For younger children, this takes place by teaching the parents new parenting strategies such as positive involvement, praise, and encouragement, as well as effective and non-conflictual setting of boundaries. In the treatment of adolescents, weight is still given to improving parenting practices, but the involvement of the young person in the treatment process is emphasised, and additional focus is put on important areas outside the family, such as relations with friends, school, and leisure activities. Detailed descriptions of the various effective programs are presented by various public clearing houses, such as the Blueprints website (
https://www.blueprintsprograms.org/program-search/ (accessed on 6 November 2021)). It is important to ascertain whether these family-oriented treatments are appropriate to disrupt the development of CU and/or reduce the antisocial behaviour of children and youth with CU traits. Frick et al.
[5] conclude that children who score high for CU traits have a poorer treatment prognosis. Out of the 20 studies reviewed, 18—i.e., almost 90%—reported that persons with a high level of CU traits showed poorer treatment outcomes than those who only had behavioural problems. Many of these studies were conducted in residential or correctional settings and some lacked a clear description of the treatment provided.
Parent training programs aimed at children with behavioural difficulties are intended to help parents meet the child with positive involvement, encouragement, and praise as the main means of ensuring improved cooperation with the child on day-to-day activities and chores. In these programs, parents also learn how to set boundaries for and respond to negative behaviour through age-appropriate and conflict-reducing strategies. As children with CU traits might be less influenced by negative consequences and more “indifferent” to whether they perform tasks in the right way, it is of interest to examine if the various elements of parent training have differential effects for these children. Hawes and Dadds
[35] showed that children with high CU traits achieved just as much positive change as children with low CU traits when their parents learned ways to encourage prosocial behaviour. This was not the case when parents learned to discourage deviant behaviour through appropriate and contingent use of mild sanctions. Here, children with stable high CU traits showed a far less reduction of their problematic behaviour than children with low CU traits
[36].
Families in which a child shows CU traits may need additional treatment components than those included in the regular parent training programs. “Family Check Up” (FCU) is a family intervention with a flexible approach to which topics are addressed, based on the family’s needs
[37]. A study of the program showed that although early behaviour related to CU (at the age of 3) predicted negative development, the treatment outcome from the program was no lower for those with a high CU
[38]. This indicates that even though children with CU traits score higher for behavioural problems both before and after treatment, participation in this program tailored to the family’s specific needs provided same level of reduction in problematic behaviour as for the children without CU traits.
This shows that in general, well-founded parent training interventions can contribute to reducing behavioural problems, also in children with CU traits. It does appear, however, that some elements of these programs do not have the expected effect, and more individualised and intensified treatments are needed to address the specific limitations related to CU traits. As previously stated, children and adolescents with CU traits are less sensitive to negative sanctions from others and to negative consequences of their actions. This means that, to an even greater extent, parent training measures for these children should emphasise warmth, cooperation, and encouragement based on the child’s positive interests, as a way to help the child reduce their problematic behaviour. Research has also shown that a structured empathy exercise that the child performs together with the parents improves the treatment outcome for children with CU traits
[39]. The inclusion of such exercises could thus be a relevant element in the treatment of children with CU traits.
Another example of treatment advancements for younger children with CU traits is a tailored CU specific version of Parent Child Interaction Therapy (PCIT-CU). This program specifically emphasizes reward-based strategies over punishments, coaches’ parents to respond in a warm emotional manner, and aims to support the child’s development of emotional skills. A pilot study showed significant reductions in behaviour problems and increases in empathy among 23 children with conduct problems and elevated CU traits
[40]. The fact that reductions in CU traits were observed in an effectiveness trial of another adaptation of PCIT directed at internalizing problems, suggests that the treatment components related to moral behaviour and emotion understanding might be sufficient to reduce CU traits
[41]. Further research on the effect of various treatment components of parenting programs will advance the level of specificity of interventions appropriate for children with CU traits.
The treatment malleability of CU traits in children has also been observed in other studies. Research by Hawes and Dadds
[35][36] showed a reduction in CU traits from before to after participation in the parent training. This change was maintained in follow-up six months later. In a randomised controlled study (RCT) in which parent training intervention in the home was compared with ordinary services (the sample was 66 families with children aged between four and nine), the experimental group had a reduction of psychopathy scores from before the start of treatment to after treatment, with a large effect size (d = 0.95). The reduction was maintained after 20 months, with an equivalently large outcome size (d = 0.89). More in-depth analyses showed that reductions in maternal harsh and inconsistent discipline were linked to a reduction in CU traits
[42].
Similar reductions in CU traits were seen in a randomised control study (RCT) of an intensive parent training program for children between the ages of three and five years. The program focused on both parents’ and children’s self-regulation skills, and showed reductions in CU score of d = 0.85 from before until after treatment, with these changes being maintained one year later
[43]. This demonstrates that sustainable reductions in CU traits are achievable through specific and tailored psychosocial interventions.
An attempt to identify specific treatment components related to reductions in CU traits for school-aged children was made in a study compiling pooled data from three randomized controlled effectiveness trials evaluating different treatment options within a municipality-based prevention program
[44]. One treatment program was a shorter group-based course on parenting, namely Brief Parent Training. The second treatment option was the more extensive PMTO program. The third treatment program was individual social skills training (ISST), where school or kindergarten staff work individually with children identified to have behavioural problems. The participants were 550 families that included children (aged 3–12 years) with exhibited conduct problems (e.g., aggression or delinquency) at home, kindergarten, or school. Measurements were made both before and after treatment, as well as through a follow-up investigation six months after the completion of treatment (for more details on the RCT’s, see
[45][46][47]).
The results from this study showed a positive change in CU traits across treatment for both parent training programs, but not for the social skills training. This points to the central role played by parents in creating change for children with CU traits. Moreover, it seems that individual social skills training given alone is probably not sufficient to stop the development of CU traits. With respect to sustained effects, only the comprehensive parent training model (PMTO) had a significant and direct impact on the children’s CU traits at the six-month follow-up. This indicates the need for extensive specialised parent training to achieve a permanent reduction of CU traits. Supplementary analyses showed that improved positive parenting skills (such as positive involvement, warmth, and praise/reward) were the change mechanism that led to a change in CU traits, while the reduction of negative parenting skills (such as harsh discipline) did not, similar to the results with the aforementioned studies. Improved parenting skills that are practised through PMTO can thus lead to a change in the child’s CU traits in a more positive direction. The PMTO program puts fundamental emphasis on positive involvement, praise, and encouragement as the most important parenting competence, which is in line with the knowledge of these children’s needs. A change in negative parenting impacts the level of behavioural problems in children without co-occurring CU, but showed no significant correlation with changes in CU traits in this study.
Overall, these studies give grounds for optimism, as they show that CU traits in children can be influenced through parent-oriented treatment programs. The relationship between parental warmth, positive involvement, and CU traits may in part explain this. For most parents, it seems natural and appropriate to be able to set protective limits for their child and to impose fair sanctions/consequences for repeated negative behaviour. If a child has clear CU traits, however, the research indicates that these parenting strategies might contribute little to the child’s positive development and acquisition of social interaction skills. In such situations, parents may need extra support to be reminded that their child might not benefit from boundaries and consequences in the same way as other children, and that attempting to maintain this can make it difficult to maintain the positive involvement that could provide better opportunities to teach their child more positive forms of interaction.
7. Conclusions
Children and adolescents who show signs of violating the general social expectations of acting empathetically and showing consideration for others are a source of concern. The ability to regulate one’s own behaviour in relation to the needs and feelings of others is such a fundamental aspect of human interaction that any violation of this leads to unrest, irritation, and sometimes aggression. As an element of normal upbringing, it is natural to set boundaries for this type of behaviour and to make the child aware that behaviours that are detrimental to other people will have negative consequences. Most children will learn from this feedback, develop empathy, and increasingly use this to regulate their behavior.
Some children and adolescents repeatedly show a lack of this ability, which, in a severe and persistent form, is referred to as CU traits. It is interesting that research has shown that the most natural reactions to these children’s behaviour (e.g. reprimands, boundary setting, and negative consequences) appear to have the least effect on their behaviour. On the contrary, research indicate that the path to positive regulation of these children’s behaviour lies in positive and warm relationships. They seem less affected by negative consequences (e.g., time-out), but respond well to positive encouragement (e.g., rewards). As these children are primarily motivated by self-interest, the best way to influence them appears to be making sure that they like the people around them and therefore choose to show (self-) consideration for them as someone they like.
Given that what these children might need is quite different from the reactions they typically receive, it is important to have specialised and professionally updated treatment programs for this group. On a general basis, it is important to emphasise that several of the existing research-based treatment programs for children and adolescents with behavioural difficulties seem to have a positive effect on this group. In particular, a prevention perspective can be important, as those who receive treatment early appear to achieve a noticeable and sustainable reduction in CU. There are promising results from applying strategies to reward good behaviour—notably by giving the reward immediately. In parent training aimed at children with CU traits, it seems to be important to support and motivate parents to maintain a warm relationship with a focus on positive encouragement. Special adaptations of parenting programs are also showing encouraging results. When it comes to slightly older children and adolescents (from 11 to 17 years old), it seems that both FFT and MST can work relatively well for this group. Both methods are based on in-depth analyses and individual adaptation of the treatment, as well as a focus on creating positive family relationships and a developmentally supportive environment. In the FFT model, there is also focus on ensuring effective collaboration strategies in which the adolescent can be included as an equal party, and this may be of importance to this target group. Interventions developed specifically to target CU trait reduction are also of great interest in order to diminish the risk that CU traits can develop into adult psychopathy and life-course persistent anti-social behaviour.
Even though already established programs may claim treatment effects for young people with CU traits, there may be a need for the further development of these programs. It may also be important to gain more knowledge of how to forge a good alliance with adolescents with CU traits, so that the treatment can take greater account of the unique challenges faced by adolescents with CU traits. There is ongoing research aiming to identify which treatment elements seem to be particularly effective for children and adolescents with CU traits. This research might contribute to greater customization of existing treatment programs, and to developing completely new treatment programs for the CU group. When directed at children with CU traits, parenting programs should emphasize boundary setting as a last-resort strategy and should focus even more on affection, praise, and reward as a means to influence the child’s or adolescent’s behaviour
[61]. Possible additions to existing programs might be different forms of empathy training, either via the parents or directly with the child. In any attempts to train children and adolescents with CU traits, such as in empathy and the ability to form a perspective, it is probably most effective to focus on an understanding of empathy, rather than the feeling of empathy. At noted previously, such developments have been made with the PCIT-CU program for children. Socializing children and adolescents with CU traits to (1) understand empathy for others, (2) be able to choose to act empathetically based on this understanding, and (3) themselves experience positive and beneficial effects, can be a means to promote prosocial behaviour. This form of empathy training has been proven to have good treatment effects for children with CU traits
[39]. In this study, the researchers reflected that it might have been significant that the exercises took place through interactions between the child and the parents. The study that showed the importance of a therapeutic alliance for adolescents with CU traits also pointed to how it is the positive relational aspects of human interaction that seem to have a positive effect on children and adolescents with CU traits.
A promising development made for the treatment for adolescents with CU traits is the PSYCHOPATHY.COMP program, based on motivational interviewing strategies and Compassionate Focused Therapy (CFT)
[62][63]. The program focuses on helping youth to reconcile with the notion that although much is determined by a range of external influences that have no control over (e.g., evolutionary, genetic, epigenetic, and environmental factors), everybody has a responsibility to act in prosocial ways. During sessions, the adolescent is introduced to CFT practices that diminish threat responses, increase emotion regulation, and instil soothing and compassionate feelings and actions. A pilot study of the program has shown promising results in reducing psychopathic traits
[63]. Furthermore, it seems that the inclusion of the youth in treatment, although challenging, might be a key element in providing effective care
[64]. The studies of the treatment of children and adolescents with CU traits have not looked at potential effects stemming from parental psychopathy. Given that CU traits are highly heritable and, to some extent, could be influenced by genetics, one should assume that parents of children with CU traits would have some degree of CU traits themselves. It is likely that parental CU traits might lower their motivation for and compliance with parent training and family therapy aimed to help their child, but empirical data on this has been lacked of. Moreover, few studies of interventions for preventing the development of psychopathic traits among children and adolescents have follow-up data beyond a year. Future research is therefore needed to examine whether treatment gains persists into adulthood.