The Neural Basis of Conduct Disorders in Preschool Children

Callous-Unemotional Traits, or ‘Early Disruptive Behavior’

Managing social interactions is one of the most important skills practiced by children in preschool settings—and perhaps the most challenging. Children who navigate the experience successfully show concern about other’s feelings, learn behaviors that make others feel good, and express emotions in a prosocial way.¹⁰ About 3% of children display a severe, relative absence of these skills, and instead behave with cruel insensitivity and an unemotional affect.³⁵ Scientists and behavioral health specialist describe these deficits as callous-unemotional traits, a clinical specifier that was added to the 5^th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM5) in 2013.^{2, 5, 32} The specifier was created to help identify children who lack guilt, empathy, a concern for performance, and the ability to relate well with others. Identifying children early helps to facilitate interventions, as people cannot legally be diagnosed with an antisocial personality disorder (ASPD) until they reach the age of 18.² In 2018, researchers coined a new term, early disruptive behavior, in response to increasing evidence that such behaviors occur well before age 5.⁶ They aim to have this specifier reclassified in the next edition of the DSM. Although the topic can be depressing, the hope this research offers is encouraging for educators as they work to access mental health support for the children in their care.¹⁴

Importance to Preschools

In the context of early childhood education, this is only a relatively recent distinction. In 2009 Paul J. Frick and Essie Viding tried to ascertain if antisocial behavior in children could be classified as a subset of conduct disorders, to make them eligible for treatment. At the time, the clinical term was rather loose: nonspecific deviant behavior. Frick and Viding looked at the causal pathways to behavior problems, and were able to document a link between fearless temperament and poor emotional regulation.¹⁴ They also found that there were underlying neural differences in children with and without CU traits, which called for different treatment options. While they acknowledge that only a minority of antisocial adults have psychopathic traits, those that do have high and stable levels can be especially violent. Even more striking, childhood onset of antisocial behavior was more likely to persist into adulthood than behavior that began in adolescence. Whether this is due to neuroplastic reinforcement from childhood or to different causal relationships (biological or environmental influences) was not a component of this study.

Even more important to early childhood educators, was the speculation that mitigating callous-unemotional traits in young children would be possible by altering psychosocial environmental factors. Over the next several years, the pair engaged in other studies that were among the earliest to encourage treatment for children well before adolescence.^{13, 12, 34,} ⁵ Other researchers focused on communities with family instability and less effective parenting strategies.^10, ^{17, 22, 25, 36, 37, 38, 39, 40} At first, those like Kimonis et. al who studied young children asked if callous-unemotional traits could be measured reliably.²¹ Would parent and teacher reports be internally consistent? Would there be valid associations between the measures of callous-unemotional traits and behaviors such as empathy and aggression? Could the presence of traits such as lack of empathy and remorse in childhood reliably predict antisocial and criminal behavior in adulthood? The answers were, generally, yes—but only relating to aggressive and non-aggressive conduct problems, and not necessarily with impaired emotion. The results, however, were consistent with studies of adolescent children. So, the research supported a predictive quality of the early presence of traits.

The Kimonis study also suggested that parent and teacher ratings of CU traits were associated with low empathy scores, high conduct problem scores, and less accurate recognition of sad and fearful expressions. Ratings that linked the presence of narcissism to psychopathy were not statistically strong, but those that linked impulsivity to psychopathy were better than average. This does not suggest that children who exhibit those traits will become psychopaths, but rather that there may be some valid reasons to take notice.

The major advance that moved this science forward was fMRI technology, and other tools developed in the 1990s, because the biology behind the behavior could now be observed and examined. What had previously been documented only by empirical study (the effect of environment on behavior) could now be tested and quantified on a neural basis. In other words, behavior that was previously observable only in every-day settings could not only be examined in the lab, but had been justified for evidence-based study. The scientists set to work.

Between 2011 and 2019, researchers asked:

How prevalent is callous behavior? About 3% of all children have CU traits, and 25% to 35% of children with diagnosed conduct disorders.³⁵
Can conduct disorders be inherited? Yes, there are statistically significant associations between severe antisocial behavior in biological mothers, and CU traits in young children. These traits can be moderated by positive parenting in adoptive parents. The estimated rate of heritability is 40% to 78%.^18, ³⁵
What are the specific, reliable indicators that can be used to define conduct disorders in the Diagnostic and Statistical Manual? They are currently outlined in the manual.³²^,²
Which traits can be reliably diagnosed in very young children? Some important traits are abnormal fear processing, poor facial recognition of distress, low levels of guilt. ^{6, 5, 10, 23, 35} Interestingly, one study showed that preschool children being treated for conduct disorders were able to discern callous-unemotional traits among their peers.¹⁶
What are the social and environmental influences related to raising very young children? Stable environments free of violence, abuse and discrimination; environments that model accepting and respectful interpersonal communication; freedom from poverty; adult interactions that encourage resilience.^1, ^{14, 33, 37, 39, 40, 24}
What is some of the brain science that contributes to understanding empathy and neuroplasticity? Active peptide systems (oxytocin and vasopressin) that integrate a sense of social safety, coordinated behavioral systems to support facial cues and acoustic signals, and environmental influences that help to develop or “rewire” prosocial neural responses, to name a few.⁷^,¹¹^,⁸^.³⁰
How is interdisciplinary study important to achieving peace in preschools? It brings in the perspectives of psychology and child development, neuroscience, sociology, and cultural anthropology.²⁴^,¹⁵
What interventions are recommended to support healthy development? Help children to reduce violence and to manage their responses in the presence of violence, institute peace education in schools, help to develop skills that support reciprocity between people and cultures, expose children to a diversity of opinions, and increase and maintain equality in education. Successful programs include Toddlers without Tears (home visits); 1-2-3 Magic (positive parenting); the Mother Child Education Program (paternal engagement); Early Head Start and Parental Mediation (strengthening families), among others.⁷^,¹⁹

The risks associated with not intervening at a young age are becoming clear. The research has also documented evidence for the converse principle: individuals who have problems regulating emotional reactions (or having an absence of regulation) are at a higher risk for psychopathology.²⁰, It is important, ethically, to avoid assigning adult labels such as ‘criminal,’ ‘antisocial’ and ‘psychopath’ to children, because they are still developing. Yet, the literature acknowledges that there is a positive association between the onset of antisocial behavior in childhood, and behavior in adolescent and adults.¹⁴^,³⁶^,⁴

If you take the position that young children are not under-developed humans, but individuals on a journey to adulthood, then predicting—and preventing—antisocial adolescent and adult behavior becomes imperative. Professionals who are entrusted with the task of guiding children towards healthy and productive futures see a broad spectrum of personalities and are therefore in an important position to recognize extreme behavior. Setting educator bias aside for the moment (it is a fully developed topic on its own), early childhood professionals can learn the causal pathways to antisocial behavior methodically, critically, and from different perspectives.

Children and Social Pain

Young children can be keenly aware of how they perceive and are perceived. Operating under the theory that empathy for social pain might be different from empathy for physical pain, Carrie L. Masten and her team used functional Magnetic Resonance Imaging (fMRI) to examine the neural responses generated by observing social inclusion and exclusion in adults.²⁷ They hypothesized that there would be activation in the brain regions that are typically linked with social exclusion and physical pain (the dorsal anterior cingulate cortex and the anterior insula) as well as the areas linked with perspective-taking (such as the dorsal medial prefrontal cortex and the posterior superior temporal sulcus).

By the completion of the experiment, they understood that social exclusion increased activation in the cognitive regions, especially the medial prefrontal cortex (MPFC). There was no significant difference between physical and social pain. Yet, when regarded with activation in the left anterior insula (where disgust is processed intuitively) the activation in the medial prefrontal cortex (MPFC) suggested positive associations for later prosocial behavior. In fact, the participants who rated themselves highly for empathy (“trait empathy”) were 68% more likely to act in prosocial ways. This led the researchers to speculate that the MPFC is the more important region when deciding to take another person’s perspective, and to act in prosocial ways. Translated, this means that there is a cognitive element to prosocial behavior, suggesting that it is a skill that can be taught and developed.

Later, in 2014, Ann S. Masten (a different researcher) provided an exploration of resilience in children who had survived violence or war.²⁶ Her research indicates that creating adaptive systems, particularly those provided by communities, provide a promising approach to facilitating an individual’s ability to manage conflict. These systems boost the cognitive and self-regulation skills that are so integral to appropriate emotional responses, and are described as being founded on three practices:

mitigating risk (preventing exposure)
providing resources to nurture peace, and
strategic timing to influence the positive and negative cascades of emotion.

Stepping back and remembering how environmental factors contribute to neuroplastic changes, it becomes apparent that preparing for a future with greater possibilities for peace depends on far more than reminding children to be empathetic. We must also work to understand if, and to what degree can we ethically and responsibly change their brains at a neural level.

Diagnostic Tools

Educators who work with children may wonder why such a high number of children who exhibit early disrupted behaviors are present in preschool classrooms. There is some evidence that although there are many diagnostic tools to evaluate how well a child can regulate emotion, there are no tools to assess the dysregulation (or absence) of emotional regulation strategies.⁹ This could be particularly true if decreased emotional awareness (the ability to recognize and identify emotional experiences) turns out to be one of the main dimensions of emotional dysregulation. If so, it will be important for researchers to consider diagnosis from that perspective.

Neural Conditions That Affect Behavior

Callous-unemotional traits are but one of many neurological factors that influence behavior. A 2014 study by Blair, et. al examined the relative prevalence of different clinical diagnoses that contribute to conduct disorder.⁵ They found that anxiety and attention deficit–hyperactivity disorder (ADHD) represented the largest group, followed by oppositional defiant disorder (ODD), conduct disorder, callous-unemotional traits, and antisocial personality disorder (ASPD). Callous-unemotional traits are a subset of conduct disorders and overlap only a small portion of other diagnoses. This illustrated that some, but not all, children with callous-unemotional (CU) traits will go on to have antisocial personality disorder.

Blair and his team aimed to improve treatment options by identifying and linking important neurocognitive dysfunctions with related behaviors in each clinical entity. They found that standard conduct disorders, and those with callous-unemotional traits (CU) have some important distinctions. When studying children and adolescents, the researchers determined that deficient empathy “occurs relatively selectively in youth” who have callous-unemotional traits. Heightened threat sensitivity did not. That trait was more often found in adolescents with conduct disorder. The adolescents with CU traits also tended to have deficiencies with decision making more often than those without CU traits. In summary, children with conduct disorders tend to react more sensitively than others to threats, and children with callous-unemotional traits tend to be more naturally insensitive to the feelings of others.

In particular, the adolescents who were less likely to recognize facial expressions as being fearful were less likely to respond empathetically to their peers. Increased sensitivity to fearful faces, paired with increased threat sensitivity, and decreased decision-making ability, which are prevalent in children with standard conduct disorders, leads to impulsivity and reactive aggression⁵. These neural differences may eventually point to differences in the way that teachers address behavior management and the development of empathy. The trio of deficient empathy (reduced amygdala function), decreased threat sensitivity, and deficient decision making—makes it difficult for affected children to socialize well with others. Both of these conduct disorders (with or without CU traits) are evident in children at very young ages.³^,⁴^,¹⁴^,²⁹ Waiting to address the behaviors in adolescence only serves to strengthen the neurological pathways that lead there.⁸^,²⁶

Nurturing Empathy When It Seems Absent

There are many ways to nurture empathy in all children: providing a caring environment, exercising mindfulness, and encouraging dialogue and perspective taking. Although some children have impaired empathy, it may still be possible help them, by choosing the right approaches. One way is to encourage a change at the cognitive level.

There are not yet any verified methods to improve behavior by changing neural pathways. However, there are some small signs that it might be possible to make empathy spontaneous where it was previously dysregulated.

In 2013, Meffert et al. compared Blair’s idea of complete emotional dysregulation with Moul et al., who believe there may still be cognitive control.²⁸^,³¹They matched 18 male psychopathic offenders with 26 control subjects, who were all instructed to watch videos of another person’s hands in various situations (including neutrality, loving, painful, and exclusion). They found that the psychopathic offenders were able to regulate their reactions, when instructed to do so. Of course, this assumes there is no underlying physical problem.

As early disruptive behavior continues to be studied as a branch of neuroscience, future scholars may want to track the results to inform socio-emotional education. The experiments described here, and others described in the bibliography, provide a good starting point for additional research about cognition and self-regulation. Perhaps this will lead to interdisciplinary partnerships between neurologists and educators that can help to resolve classroom behavioral challenges affected by mental health.

References