References

the present review of functional neuroimaging studies suggests that some psychological functions targeted in CBT may need more attention: anger recognition, the ability to generate situation appropriate solutions to social problems, reinforcement-based decision making, response inhibition, and affective empathy.

Conclusion

family-based psychotherapy

parents may not start treatment because they think that their parenting skills are of a sufficient level and their child has to deal with his or her problems.

Thus, children and adolescents first become familiar with the cognitive and behavioral skills during group psychoeducational sessions on anger management (one module) and social problem solving (another module)

For example, a balanced eating diet, sufficient amount of sleep, and physical activity (e.g., sports) may improve learning and executive functioning which, in turn, enhance psychological functions associated with anger regulation and social prob-lem solving

Discussion

lower correlations between the amygdala and ventromedial prefrontal cortex in youth with conduct problems and CU traits as compared to healthy controls and youth with ADHD

less likely to learn to avoid harming other individuals, because the distress of other individuals is less aversive for them.

iagnostic specifier for individuals who meet full criteria for Conduct Disorder.

In particular, this emotional response is appropriate to or congruent with another’s situation than to one’s own

benefits of improving executive functions will be greater if children’s and adolescents’ emotional, social, and physical needs are also addressed

When children and adolescents know which social situation is problematic for them, this awareness can help them to engage in the thinking process and ask themselves questions on how to solve the problem

We, therefore, suggest that CBT therapists instruct parents, foster parents, child care workers, and teachers to assist the child or adolescent in withstanding his or her impulsive urges by engaging into the thinking process of social problem solv-ing that children and adolescents learn in CBT during daily life (in vivo practice)

Accord-ing to teachers, children with low levels of inhibitory control appeared to profit more from individual delivery of Coping Power than children with high levels of inhibitory control, suggesting that individual delivery offers opportunities for tailoring CBT to children’s individual needs (Lochman et al., 2015).

As a complement, collaborative discussions with parents may teach children how to generate mutually satisfactory solutions.

In sum, response inhibition may be impaired in children and adolescents with conduct problems either due to the association with ADHD (symptoms) or to motivational demands (reward and punishment) included

In our opinion

A study that did not control for the presence of ADHD showed reduced anterior insular activity on a cognitive interference (Stroop) task. The extent of impairment did not particularly relate to severity of conduct problems but did positively correlate to ADHD symptom severity (Hwang et al., 2016)

seem to be clearly associated with conduct problems

much repetition is needed to improve the child’s or adoles-cent’s decision making

Whether just discussing these topics in CBT is sufficient to change chil-dren’s and adolescent’s decision-making process remains an open question

dorsome-dial frontal cortex, and caudate nucleus of the striatum

reduced neural responsive-ness to reward puts an individual at risk of poor decision making because response choices are less guided by expecta-tions that an action will result in reward relative to punish-ment

It is interesting to note that children and adolescents with conduct problems even after an extensive assessment of the social information pro-cess in which examples of appropriate responses are shown and numerous questions about the various responses asked, are still inclined to select an aggressive response

If these appropriate behaviors produce a rewarding effect on the child, these behaviors are more likely to re-occur in comparable situations and consequently have a higher likelihood that they become part of the child’s behav-ioral repertoire for dealing with social situations effectively

reducing hostile-attribution biases, increasing the genera-tion of socially competent responses to social problems, and devaluing aggression

romotion of children’s social-cognitive skills, children’s social skills, and parenting skills, among others, resulted in a decrease of antisocial behavior.

help seeking, verbal assertion, com-promise, verbal aggression, and physical aggression

Children and adolescents with conduct problems have been found to show reduced responses in the orbitofrontal cortex, ventromedial prefrontal cortex, and striatum during both anticipation and response to rewards

amygdala

When individuals demonstrate problems with the pro-cessing of reward cues, they are less able to make accurate predictions about which kind of behaviors is beneficial for them

aggressive children have been shown to offer fewer verbal assertive solutions than their peers

defining the problem or interpreting the situation, generating possible solutions, and deciding which solution will be implemented

when the child is teased by peers or when a peer outperforms in a game (Dodge et al., 1985). These are all problematic social situations that will be addressed in the next section

The school is an ideal environment for children and adolescents with conduct problems to improve their anger management and social problem-solving skills given the amount of time they spend in school in a wide variety of social contexts.

coping self-statements, distraction techniques, and brief deep-breathing relaxation method

In our view,

parents can observe their child and therapist working on anger recognition, including the recognition of physiological cues which signal that the child is becoming angry

studies have been overlooked by researchers involved in CBT but results are in line with the previously discussed neuroim-aging studies.

adolescents with conduct problems did not show differences between these adolescents and controls in their anger after viewing videos depicting problem situations in which youths were disadvan-taged by accident, while these adolescents generated more aggressive responses and selected more often an aggressive response among various responses shown

boys and girls with disruptive behavior referred into a crime prevention program were impaired in anger recogni-tion

But in their motivation the authors do not seem to consider anger recognition problematic for children and adolescents with conduct problems as no ref-erence is made to psychological studies showing that anger recognition may be problematic for children and adolescents with conduct problems.

In Coping Power trials, the effect sizes for proactive aggression have been as much as three times larger than the effect sizes for reactive aggression (Miller et al., 2020).

have difficulty in rec-ognizing anger in others and their own feelings of anger

Also, female adolescents with conduct problems demon-strated decreased medial orbitofrontal cortex functioning while viewing facial expressions among which anger rela-tive to controls

to learn managing their anger is to become aware and recognize their own anger

have difficulties recognizing anger in others and their own anger. These difficulties have been associated with hyporeactivity of the orbitofrontal and anterior cin-gulate cortex involved in the processing of angry expres-sions

is of utmost importance, especially given the range of short- and long-term negative outcomes of con-duct problems in adulthood, including crime, substance use disorders, suicide attempts, low educational achievement, anxiety disorders, depressive disorders, manic episode, schizophreniform disorder, eating disorders (Fergusson et al., 2005; Kim-Cohen et al., 2003), as well as high costs in terms of service utilization across all three domains of criminal justice, health, and social welfare (Rivenbark et al., 2018).

Oppositional Defiant Disorder (ODD) or Conduct Disorder (CD) according to the Diagnostic and Statistical Manual of Mental Disorders (fifth edition; DSM-5, American Psychiatric Association, 2013), Oppo-sitional Defiant Disorder or Conduct-Dissocial Disorder according to the International Classification of Diseases

we will focus on conduct problems in the clinical range, e

In behavioral parent training, children and adolescents acquire appropriate behaviors and learn to refrain from inappropriate behaviors as a result of parents’ or caregivers’ giving posi-tive instructions, praising appropriate behaviors, ignoring minor inappropriate behaviors, and using time-out for severe inappropriate behaviors

Problem-Solving Skills Training was offered in cases when working with parents was not a viable option due to severe family dysfunction or parent psychopathology

Cognitive Behavioral Therapy

conclusion as a theoretical statement and work-ing hypothesis about the potential role of the psychological function in the maintenance of conduct problems and finally discuss possible implications for CBT

We will cur-rently review functional magnetic resonance imaging (fMRI) studies examining psychological functions that are targeted in CBT for conduct problems

learn better ways to manage their anger and solve social problems by increasing emotion-regulation and problem-solving abilities

(Lochman et al., 2019; Matthys & Loch-man, 2017)

One way might be to examine neuroimaging studies that investigate biological correlates of psychological func-tions targeted in CBT.

Clearly, attempts at increasing effectiveness of CBT as a psychologi-cal treatment for conduct problems in middle childhood and adolescence are appropriate.

According to a more recent meta-analysis of behavioral parent training, the ES for children aged 2–9 years is even larger: d = 0.69 (Leijten et al., 2019)

(Weisz et al., 2017)

In the meta-analysis by McCart et al. (2006)

Clinical Child and Family Psychology Review

Cognitive behavioral therapy (CBT)

Introduction

Lochman et al., 2019; Matthys & Lochman, 2017

Walter Matthys1,2 · Dennis J. L. G. Schutter3

CBT provides these children and adolescents with anger regulation and social problem-solving skills that enable them to behave in more independent and situation appropriate ways. Typically, CBT is combined with another psychological treatment such as behavioral parent training in childhood or an intervention targeting multiple systems in adolescence.

Accepted: 21 February 2021 / Published online: 8 March 2021

Increasing Effectiveness of Cognitive Behavioral Therapy for Conduct Problems in Children and Adolescents: What Can We Learn from Neuroimaging Studies?

Abstract

The aim of this review is to describe how the effectiveness of CBT may be improved by paying more attention to a series of psychological functions that have been shown to be impaired in neuroimaging studies: (1) anger recognition, (2) the ability to generate situation appropriate solu-tions to social problems, (3) reinforcement-based decision making, (4) response inhibition, and (5) affective empathy