The Role of Trauma in Conduct Disorder.

Ricky Greenwald, Psy.D.

Citation: Greenwald, R. (2002). The role of trauma in conduct disorder. Journal of Aggression, Maltreatment, and Trauma, 6, 5-23.

Correspondence concerning this article should be addressed to Ricky Greenwald, Psy.D., 483 Belknap Rd., Framingham, MA, USA. Electronic mail is preferred and may be sent via Internet to rickygr@childtrauma.com.

Trauma is proposed as a key to understanding the development and persistence of conduct disorder, in conjunction with other contributing factors. Trauma history is virtually universal in this population, and trauma effects can help to account for many features of the disorder, including lack of empathy, impulsivity, anger, acting out, and resistance to treatment. The current standard of care fails to fully address trauma, which may partially explain the low success rate of extant treatment approaches. Trauma-informed models of conduct disorder are suggested. Research, prevention and treatment implications are discussed.

Conduct disorder represents a fairly common pattern of impulsive and antisocial behavior - including, but not limited to, serious juvenile delinquency - entailing enormous cost to afflicted individuals, their victims, and society (Robins, 1981). We now know a lot about risk factors for the development of conduct disorder, including temperament, gender, low intelligence, ADHD, impulsivity, poor coping skills, social failure, parental psychopathology, inappropriate discipline, affiliation with deviant peers, and socioeconomic disadvantage (see Kazdin, 1995; Moffitt, 1993; Patterson, DeBaryshe, & Ramsey, 1989). We address these factors with a variety of treatment approaches, and do help some youth to be successful in socially acceptable ways. Unfortunately, there is as yet no really good treatment for adolescents with conduct disorder, with even preferred approaches yielding only modest results (Kazdin, 1997b). This may be explained, at least in part, by our failure to address trauma's contribution to conduct disorder.

In this chapter I review child trauma prevalence and outcomes, with an emphasis on the conduct disorder population, and then propose a key role for trauma in the development and persistence of conduct disorder. I will discuss current treatment approaches in that light, and suggest avenues for further research.Child and Adolescent Trauma For present purposes, trauma will be defined as an event in which the child or adolescent experiences intense horror, fear or pain, along with helplessness (Krystal, 1978). Typical examples include auto accident, physical or sexual assault, and witnessing violence. However, there is considerable empirical support for the notion that major loss experiences have a trauma-like impact on children and adolescents (Newcorn & Strain, 1993), except that the hyperarousal response may not be present following a loss. Therefore, although this discussion will focus strictly on trauma, many of the points probably apply to a wider range of adverse life experiences to which these children have been exposed.

Some of the data on the prevalence of traumatic events in childhood are indirect and suggestive, yet persuasive and alarming (Finkelhor & Dziuma-Leatherman, 1994; Pynoos, 1990). Recent research has found astonishingly high incidence rates for prior experience of at least one Criterion A (major trauma) stressor among young adults - most of which presumably occurred during childhood or adolescence. For example, Riise, Corrigan, Uddo, and Sutker (1994) found an 85% incidence among a military population (only a minority of which were combat-related), and Vrana and Lauterbach (1994) found an 84% incidence among college students (for more discussion, see Vrana & Lauterbach, 1994). Trauma during childhood and adolescence is now so common as to be normative (Ford et al, 1996; Greenwald & Rubin, 1999).

Among disadvantaged urban youth, exposure to violence and other potentially traumatic events appears to be a regular occurrence (Campbell & Schwarz, 1996; Jenkins, 1995; Ozer & Weinstein, 1998; Singer, Anglin, Song, & Lunghofer, 1995), a consistent finding despite the under-reporting inherent in many study designs (Wolfer, 1997). With many risk factors for conduct disorder also constituting increased risk for trauma (e.g., exposure to negligent, coercive, pathological, and/or substance-abusing parents; exposure to poverty-related violence and crime), trauma history must be nearly universal in this population. Indeed, many researchers have noted the prevalence of trauma histories in conduct disorder populations (Bowers, 1990; Dembo, La Voie, Schmeidler, & Washburn, 1987; McMackin, Morrissey, Newman, Erwin, & Daley, 1998; Rivera & Widom, 1990; Steiner, Garcia, & Matthews, 1997).

Trauma is experienced as scary, horrible, painful, intolerable. The overwhelming nature of the traumatic experience often leads to a failure to integrate, work through, or "get over" the memory. Then the memory is stuck in a raw, unprocessed state, and the associated imagery, affect, and cognition may intrude unchecked, outside the control or mediation of the normal, verbally encoded memory storage system (van der Kolk, 1987). Indeed, elements of the traumatic memory are likely to intrude, unless and until the memory has gone through the normal processing system. Thematically related stimuli may trigger the intrusion of trauma-related material, leading to over-reactivity in some areas.

Trauma constitutes a violation of the victim's sense of safety and belief in the world as a safe place. This has the profound effect of re-orienting the victim from a complacent to a defensive posture. The post-traumatic survival mode orientation can become self-perpetuating through a dynamic of mutually reinforcing symptoms and responses (Chemtob, Roitblat, Hamada, Carlson, & Twentyman, 1988). In a state of heightened alertness and sensitivity to possible danger, minor or even neutral stimuli are mis-interpreted as threatening, leading to further arousal and defensive action, such as avoidance, withdrawal or aggression. This leads in turn to reinforcement of the perception of the world as a dangerous place, preventing recovery from the trauma. In other words, survival mode is perpetuated by the psychological experience of ongoing retraumatization. Classic examples include the combat veteran diving for cover when a balloon pops, and the physically abused child who perceives an accidental bump by a passing peer to be an assault. Even the intrusive memory itself can be perceived as threatening.

To use an analogy, when someone has eaten a meal and then perceives danger, the sympathetic nervous system will be activated, supporting urgent survival capacity while postponing digestion. Later, when the threat is no longer present, the parasympathetic nervous system will be reactivated and digestion will proceed. In the case of trauma, with the positive feedback cycle of heightened alertness, intrusive symptoms, and hyper-reactivity leading to ongoing reinforcement of the perceived need for survival mode, the "digestion" can never occur. Instead, the trauma victim may learn to live in a psychological war zone and adjusts accordingly, while remaining ever vulnerable to the unprocessed memory elements.

The effects of unintegrated traumatic experiences can thus become permanently established, potentially leading to a variety of post-traumatic symptoms, and forming the basis of much psychopathology (e.g., Brom, 1991; Conaway & Hansen, 1989; Famularo, Kinscherff, & Fenton, 1992; Flisher et al, 1997; Green, 1983; Kendall-Tackett, Williams, & Finkelhor, 1993; Terr, 1991; van der Kolk, 1987). The high rate of conduct disorder-related co-morbidity noted in the literature (Wierson, Forehand, & Frame, 1992) - mainly affective disorders and substance abuse - may partially reflect trauma effects; at least, one does not cause the other, but both arise from common pathways such as adverse living conditions (Fergusson, Lynskey, & Horwood, 1996) which also engender trauma. Note that trauma may also lead to lasting symptoms in lieu of any formal diagnosis (e.g., Cuffe et al, 1998; Fletcher, 1996). This confusing array of responses to traumatization may partially account for the field's general failure to address trauma effects in conduct disorder.

Although trauma effects can manifest in many ways, when combined with the other risk factors noted above, trauma may be integral to the development and persistence of conduct disorder. Certain key features of the disorder can be explained much more completely by considering the trauma contribution. Trauma violates basic trust, disrupts attachment and interferes with empathy (James, 1989), thus removing inhibitions regarding crimes against others. Trauma leaves the victim in a perpetual state of alert; this sensitivity to threat leads to a hostile attribution bias, leading in turn to impaired social competence and increased aggressive behaviors (Chemtob et al, 1988; Hartman & Burgess, 1993). Trauma commonly leads to anger and violent acting out (Chemtob, Novaco, Hamada, Gross, & Smith, 1997). Trauma creates intolerable emotion such as intense fear or sadness, often leading to substance abuse (Clark, Lesnick, & Hegedus, 1997; Steward, 1996) and other high-risk activities (Hernandez, Lodico, & DiClemente, 1993). Trauma diminishes the sense of future (Fletcher, 1996; Terr, 1991), fostering an instant gratification orientation and precluding regard for delayed consequences or investment in the long-term. Trauma's unintegrated imagery and intense emotional reactivity can lead to affect dysregulation along with violent and destructive acting out (van der Kolk et al, 1996). Trauma effects can last indefinitely and can become a primary focus around which personality and behavior are organized (Terr, 1991; van der Kolk et al, 1996).

There is a considerable body of literature documenting the relationship between trauma/maltreatment and subsequent aggressive/criminal acting out (see Malinosky-Rummell & Hansen, 1993; Widom, 1989), including several studies specifically addressing adolescent delinquent behavior (Dembo, Williams, Wothke, Schmeidler, & Brown, 1992; Flisher et al, 1997; Hernandez, Lodico, & DiClemente, 1993; Herrenkohl, Egolf, & Herrenkohl, 1997; Pakiz, Reinherz, & Giaconia, 1997; Rivera & Widom, 1990; see also Paperny & Deisher, 1983). Furthermore, many researchers have noted the prevalence of trauma histories in conduct disorder populations (e.g., Bowers, 1990; Dembo, La Voie, Schmeidler, & Washburn, 1987; McMackin, Morrissey, Newman, Erwin, & Daley, 1998; Rivera & Widom, 1990; Steiner, Garcia, & Matthews, 1997), with some specifically finding post-traumatic symptomatology as well (Burton, Foy, Bwanausi, Johnson, & Moore, 1994; Cauffman, Feldman, Waterman, & Steiner, 1998; Doyle & Bauer, 1989; McMackin et al, 1998; Steiner et al, 1997; Watson, Kucala, Manifold, Juba, & Vassar, 1988; Wood, James, & Foy, 1998).

It is even possible that conduct disorder is a direct expression of post-traumatic symptomatology, perhaps more in some cases than others. Adolescents in residential treatment who are diagnosed with PTSD may be virtually indistinguishable from incarcerated adolescents diagnosed with conduct disorder, in psychological as well as behavioral symptoms (Atlas, DiScipio, Schwartz, & Sessoms, 1991; Cohen et al, 1990; Shamsie, Hamilton, & Sykes, 1996). Furthermore, one study of combat veterans found that combat-related trauma predicted both PTSD symptomatology and antisocial behavior, making an additional contribution to the antisocial behavior beyond pre-morbid predictors (Resnick, Foy, Donahoe & Miller, 1989). However, since there are many possible psychological and behavioral outcomes to trauma, it is certain that other factors are still very important in determining specific outcomes such as conduct disorder.

Recognition of trauma's likely role in the development and persistence of conduct disorder does not necessarily entail discarding prior models; rather, those models are enriched. Trauma can help to account for the dynamic underpinnings of the models, why they work. In this light, two prominent models are briefly reviewed below.

The Reinforcement for Coercive Behavior Model

This model of conduct disorder posits that a pattern of ineffectual combined with intermittently explosive discipline reinforces non-compliant and coercive rather than pro-social behaviors, because the antisocial behaviors lead to positive outcomes such as termination of parental aversive behavior and/or obtaining desired goods or privileges (Patterson, 1986). The child's increasing reliance on non-compliant and coercive behaviors leads to increased parental rejection, peer rejection, school discipline problems, school underachievement, failure to develop empathy (via appropriate family and peer relations), etc. In addition to failing to gain competence in prosocial interpersonal skills, such youth may become socially isolated and depressed. Later exposure to a deviant peer group provides training and reinforcement from peers for more serious antisocial behaviors (Patterson, DeBaryshe, & Ramsey, 1989).

One plausible role for trauma within this model relates to the affect dysregulation and consequent acting out which is characteristic of some traumatized individuals (van der Kolk et al, 1996). Some research suggests that affect dysregulation may be as powerful a predictor of antisocial behavior as parental reinforcement for coercive behavior (Snyder, Schrepferman, & St. Peter, 1997). There may be a synergistic effect of mutual reinforcement between these two factors, in that children who are emotionally over-reactive are more likely to engage in confrontive, coercive, and non-compliant behaviors (Snyder, Schrepferman, & St. Peter, 1997), leading in turn to more parental reactivity and harshness (Lytton, 1990).

Another plausible role for trauma relates to the often unasked question of just what is being reinforced when parents respond to children's non-compliant and coercive behaviors. In fact, many of the child's antisocial behaviors lead to apparently negative consequences such as rejection and loss of privileges. There is some research to support the notion that, at least on some occasions, what is reinforcing is not that the child gets "what he wants" in some material sense, but that by forcing an ostensibly aversive parental response, he has turned a chaotic environment into a predictable one (Wahler & Dumas, 1986). Although many children might find a chaotic environment uncomfortable, it would be particularly disconcerting to a traumatized child, who may view predictable punishment (or predictable "aversive" attention) as preferable to chaos.

The Cumulative Risk Model

The Cumulative Risk model - more accurately, an atheoretical, piecemeal approach to explanation - posits that the greater the presence of risk factors, the greater the risk that conduct disorder will develop. These factors may have interactive and progressive effects. Trauma may play a role in several of the risk factors which have been identified as contributing to conduct disorder. For example, various aspects of temperament have been implicated in predisposition to developing conduct disorder (see Lytton, 1990; Newman & Wallace, 1993; Moffit & Henry, 1989); however, what is identified as temperament in the cited studies may already reflect the pervasive effects of early trauma (Perry, Pollard, Blakley, Baker, & Vigilante, 199*). Attention Deficit/Hyperactive Disorder (ADHD), widely identified as a risk factor for conduct disorder, may sometimes actually represent misdiagnosed PTSD (Cuffe, McCullough, & Pumariega, 1994; Friedman, Harper, Becker, Wilson, & Tinker, 199*). The cognitive processing deficits noted in the literature (e.g., Dodge & Frame, 1982; Dodge & Somberg, 1987) are entirely consistent with the hostile attribution bias" noted among some traumatized individuals who are hypersensitive to potential threat (Chemtob et al, 1988; Hartman & Burgess, 1993).

Despite the prevalence of trauma history and post-traumatic symptoms among adolescents with conduct disorder, treatment programs tend to address it only in a partial manner. Since trauma effects can be so powerful, this gap in treatment may leave the youth relatively impervious to the other elements of the treatment program. Until trauma effects are directly targeted and effectively addressed, success rates with this population may remain at the current low level.

Trauma treatment involves - to oversimplify - two phases: establishing a sense of safety and then working through the traumatic material (James, 1989; Peterson, Prout, & Schwartz, 1991; Pynoos & Eth, 1986). Safety can be effectively addressed in many ways within a milieu treatment program for adolescents with conduct disorder. A range of physical and behavioral controls helps to maintain a sense of bodily safety. Positive relationships with individual staff members, as well as consistent rules and daily routine, help to foster a sense of emotional safety. In outpatient treatment, parent training contributes to environmental stability, predictability, and supportiveness, and indeed has documented effectiveness, particularly with younger children (Kazdin, 1997a). Cognitive-behavioral training also contributes, in that increased self-control allows for increased control over - and predictability of - the environment. For example, in a study of volatile veterans with PTSD, participation in an anger management group led to increased self-control as well as reduction of apparently unrelated trauma symptoms (e.g., intrusive thoughts and images), whereas trauma-focused group therapy did neither (Chemtob, Novaco, Hamada, & Gross, 1997). Although cognitive-behavioral interventions do show modest effectiveness with conduct-disordered youth (Kazdin, 1997b), post-traumatic symptomatology has not been tracked in these studies. Consistent with this trauma-informed perspective, Greenwood (1994) observed that the more effective residential programs for juvenile delinquents do feature cognitive-behavioral treatment as well as small, non-institutional settings in which a relatively secure and supportive environment can be provided.

Unfortunately, current treatment approaches do not address the working through phase very well. In some programs there is at least an attempt to do this, whether individually or in group work, but it's unlikely to be helpful. (In lieu of directly applicable studies, see discussion of treatment difficulties in Solomon, Gerrity, & Muff, 1992). First of all, this population is extremely resistant to even engaging in psychotherapy (Kazdin, Mazurick, & Bass, 1993; Sommers-Flanagan & Sommers-Flanagan, 1995). The trauma effects make them want to avoid close relationships, avoid reminders of the trauma, and avoid even temporary distress for a long-term gain that they don't believe they'll see. Secondly, even those who are willing to address the trauma in treatment typically make only limited progress towards actual resolution and symptom reduction. In fact, many who attempt to face their traumatic memories only get upset, leading to acting out, negative consequences, and then increased resistance to treatment. The treatment methods used are potentially harmful, generally inadequate, and at best, inconsistently effective. However, anecdotal reports of more successful trauma-focused treatment of conduct disordered youth are beginning to emerge (e.g., Doyle & Bauer, 1989; Greenwald, in press).

Further ascertaining the role of trauma in conduct disorder can be accomplished in several ways. Short of longitudinal studies, retrospective interviewing can help to ascertain whether or not trauma history preceded, or even precipitated, conduct problems. Trauma history and symptoms can also be assessed at intake or at other points when youth with conduct disorder are identified and accessible. In this context it would be important not merely to assess for Criterion A events and PTSD, but for the full range of adverse life events and post-traumatic symptomatology, as the issue here is trauma effects regardless of diagnosis. Since conduct disorder itself encompasses subtypes (e.g., Christian, Frick, Hill, Tyler, & Frazer, 1997; Moffitt, 1993; Sorensen & Johnson, 1996), these should also be addressed, as they may prove variably trauma-related.

Trauma-focused treatment approaches can also be tested, preferably systematic trauma treatments (e.g., Doyle & Bauer, 1989; Greenwald, in press) rather than partial approaches such as psycho-education or symptom management training. Since conduct disorder seems to be so complex and multi-determined, a comprehensive approach including trauma treatment is likely to be more consistently effective than a stand-alone trauma treatment. In treatment outcome studies, both trauma symptoms and conduct disorder symptoms should be tracked, to ascertain whether reduction in conduct disorder symptoms is indeed related to the trauma effects.

Existing effective prevention approaches (e.g., Zigler, Taussig, & Black, 1992) can be analyzed for impact on trauma-related issues such as increased environmental stability and reduced risk of trauma exposure, as well as indices of post-traumatic symptomatology. Trauma prevention and treatment components can be added to early intervention/prevention approaches and evaluated for additional yield.

Considering trauma may prove to be key to a more complete understanding of conduct disorder, leading finally to more effective prevention and treatment. Given the ubiquity of trauma in the histories of conduct disordered youth, with potentially profound and lasting effects, trauma may play a central role in the development and persistence of conduct disorder for a large subset - even a majority - of this population. Without negating other important components of prevention and treatment, it may be useful to consider trauma as an organizing principle informing prevention and treatment approaches. Effectively addressing trauma means that other potentially effective components may stand a better chance of success.

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