Likewise, a review of evidence-based psychosocial treatments for adolescents with disruptive behavior shows that improving moral thinking in CBT is typically not part of conventional CBT (McCart & Sheidow,
2016). Yet there are some treatment programs that include sessions aimed at improving moral reasoning such as EQUIP (Gibbs et al.,
1995). Based on the positive findings from the initial randomized controlled trial (Leeman et al.,
1993), EQUIP meets criteria as a probably efficacious treatment for disruptive adolescents detained in correctional facilities (McCart & Sheidow,
2016). The sessions in EQUIP (Gibbs et al.,
1995) aimed at improving moral reasoning are guided by Aggression Replacement Training (Glick & Gibbs,
2011). However, with regard to Aggression Replacement Training, results from a systematic review indicate that there is insufficient evidence to substantiate the hypothesis that Aggression Replacement Training has a positive impact on recidivism, self-control, social skills or moral development in adolescents and adults (Brännström et al.,
2016). Finally, Moral Reconation Therapy, developed for the treatment of adult and adolescent offenders, also includes sessions aimed at improving moral reasoning (Little & Robinson,
1988). In a meta-analysis of Moral Reconation Therapy criminal offending subsequent to treatment was the outcome variable (Ferguson & Wormith,
2012). The overall effect size (
r = 0.16) of 33 studies indicated that Moral Reconation Therapy had a small positive effect on recidivism. Youth, however, benefited from Moral Reconation Therapy less than adults (Ferguson & Wormith,
2012). Importantly, in comparison to the theoretical approaches of moral reasoning underlying the treatment programs, alternative theories of morality have been developed over the last decades (see section on Developmental Psychology).
From here on we use the term children for both children and adolescents, except in studies of adolescents and when making statements about adolescence specifically.
Moral Thinking and Empathy in CBT
To examine the possible implications of moral thinking and empathy for CBT we further developed the social problem-solving model by Matthys and Schutter (
2022) and present an overview of this adapted model in Table
1. Analogous to the Crick and Dodge model (
1994), the model consists of nine steps. The first four steps are crucial in view of starting up the social problem-solving process and preventing the disruption of this process; these steps are only briefly discussed here (for more details see Matthys & Schutter,
2022). Empathy, however, is an important theme in Step 3. From Step 5 on we extensively describe the role of moral thinking and empathy in the interpretation step (Step 5), clarification of goals (Step 6), generation of solutions (Step 7), evaluation of solutions (Step 8), and decision-making (Step 9).
Conduct problems are heterogeneous in nature. Children with conduct problems not only differ in typical symptoms (e.g., defiant behavior, irritability, aggressive behavior, antisocial behavior, limited prosocial emotions), but also in symptoms of associated conditions (e.g., attention problems, impulsivity, depressive mood, anxiety, deficits in intellectual functioning). Related to this, when CBT is offered to a group of children with conduct problems then this group will most likely consist of children with weakly developed but also with well-developed psychological functions or skills. For this reason, CBT needs to be tailored to the child’ characteristics of psychological skills; this also applies when CBT is offered individually. This variety in psychological skills can be used for therapeutic purposes. For example, in a session on a specific psychological skill, a child with a reasonably well developed psychological skill can act as a model for others whose psychological skill is less well developed. Likewise, the variety of normative beliefs about the acceptability of oppositional, antisocial and aggressive behaviors is used to elicit discussions in view of changing these beliefs. Importantly, parents and other adults including teachers, and child care workers in day treatment, inpatient treatment, and residential treatment are also involved in CBT to elicit, support, and reinforce children’s use of the psychological skills in everyday life (in vivo practice).
In
step 1, children learn which particular situations are challenging for them, such as being provoked by a peer or being expected to comfort a peer who is troubled, worried or upset (Dodge et al.,
1985; Matthys et al.,
2001; Van der Helm et al.,
2013). Importantly, how children with conduct problems solve social problems depends on the types of social problems (Matthys et al.,
1999; Van Rest et al.,
2020). In addition, knowing which particular situation is problematic is important for the child in view of starting social problem-solving activity. After all, social problem-solving in a step-by-step manner is anything but ordinary for children. Issue of morality may be introduced here in terms of finding solutions which are beneficial both for the child and the peer or adult involved in the problematic social situation. For this step and all subsequent steps, psychotherapists can use written scenarios of problem situations, videos depicting a range of problem situations, and children’s own experiences in problem situations.
Step 2 is about face recognition. Facial expressions of others have a communicatory function as they signal relevant information, such as feelings and intentions, to the observer (Blair,
2003). We suggest that recognition of other’s facial expressions sets in motion the social problem-solving process. Meta-analyses have shown impaired emotion recognition in children with antisocial behavior (Marsh & Blair,
2008) or with psychopathic (callous-unemotional) traits (Dawel et al.,
2012). If displays of fear, sadness or anger are not recognized then there is a risk that a potential social problem is ignored and social problem-solving activity is not started. Improving facial emotion recognition is therefore crucial. There is some evidence that facial emotion recognition can be changed. Children with disruptive behavior referred to a program to prevent antisocial outcomes and who showed impairments in facial emotion recognition completed a computerized intervention designed to improve the identification of facial expressions. Children improved significantly in recognition of sadness, fear, anger and neutral facial expressions (Hunnikin et al.,
2022).
Step 3 involves becoming aware of one’s own emotions elicited by the social problem and regulation of one’s own emotions. Becoming aware of one’s own emotions is also relevant for empathy, as the capacity to become affectively aroused by others’ emotions is the first component of empathy (Decety & Cowell,
2014; Decety & Jackson,
2004). Low emotional awareness (i.e., difficulty identifying and labeling one’s emotions) has been shown to be associated with psychopathology, including aggression and rule-breaking in children (Weissman et al.,
2020). Following emotion awareness, emotions may need to be regulated. Female adolescents with conduct problems have been found to be less successful than typically developing adolescents in emotion regulation by cognitive reappraisal (Raschle et al.,
2019). In CBT children first learn to identify physiological cues of anger (e.g., hot flushes, faster heart rate, tightened muscles) as well as find words for various levels of anger (e.g., irritated, mad, furious) with the use of an anger thermometer (Lochman et al.,
2008). They then learn to use coping self-statements (i.e., cognitive reappraisal), distraction techniques, and brief deep-breathing relaxation methods to handle the arousal associated with anger (Lochman et al.,
2008). Learning to handle the arousal aspect of emotions is also relevant for empathic responding as empathy can lead to personal distress resulting in an orientation towards the self which interferes with attending to others’ needs (Spinrad et al.,
2023).
In
step 4, CBT therapists work with children on behavioral inhibition and working memory problems. Impairments in the ability to inhibit impulses can prevent children with conduct problems from starting the thinking process before acting, especially those with symptoms (or full diagnosis) of attention-deficit/hyperactivity disorder (see Matthys & Schutter,
2022). Children learn not to act right away in a problem situation, but think first and concentrate on the nature of the problem. In addition, working memory may be relevant for social problem-solving in children with conduct problems, especially those with attention-deficit/hyperactivity disorder diagnosis or symptoms (see Matthys & Schutter,
2022). Working memory arguably affects interpretation (step 5) as interpretation involves assembling multiple pieces of potentially contradictory information. Results of recent studies showing positive effects of central executive training targeting working memory on response inhibition and hyperactivity are promising (Kofler et al.,
2018,
2020). Thus, for some children with severe executive function deficits executive training may be useful.
Step 5 involves the interpretation of the social problem, including empathy. Hostile attribution biases or the tendency to attribute hostile intent to peers in social situations with a negative outcome have been demonstrated in aggressive children (De Castro et al.,
2002; Verhoef et al.,
2019). Therefore, in CBT therapists work on children’s perspective taking abilities to correctly infer the other’s intentions and thoughts. There is also evidence that adolescents with conduct problems are less inclined to take the perspective of the other person (Klapwijk et al.,
2016; Van den Bos et al.,
2014). Thus, in addition to improving perspective taking abilities, attentional focus is also needed to the propensity to think from another’s perspective, for example, using role-playing.
In addition, normative beliefs as cognitive standards about the acceptability or unacceptability of aggression and antisocial behavior are important as well, as they may affect the way children perceive (or interpret) the behaviors of others. In particular, the more children approve of aggression, the more likely they may be to perceive hostility in others, even if no hostility is present (Huesman & Guerra,
1997; Zelli et al.,
1999). In other words, when they have been treated unfairly, they shouldn’t by default think that this was done on purpose. They should come to understand that this is because they think this is the way how people treat each other. Changing normative beliefs in support of aggression may result in decrease of hostile intent attributions. Thus, while working on hostile intentions normative beliefs in support of aggression should be an important topic.
In the interpretation step, CBT therapists may also want to pay attention to children’s difficulties perceiving other’s being harmed. As a result, these difficulties lead to reduced care-based judgements. Indeed, some children with conduct problems, perhaps specifically those with limited prosocial emotions, have deviant care-based norms (i.e., norms concerning actions that can harm others physically or psychologically, including the theft or damage of others’ property) (Blair,
2023). As a result, when they are involved in a conflict with a peer, the conflict threatens to escalate, because they do not pay attention to the damage they are inflicting on their peer. Sharing and discussing care-based norms among children with different types of care-based judgements may help perceiving harm and generate conciliatory behavioral solutions to be used in the midst of conflicts. Sharing and discussing care-based norms may also prevent children with conduct problems from harming others physically or psychologically outside the context of conflicts.
Perceiving others being harmed not only initiates moral thinking (care-based judgements) but empathic concern as well (Decety & Cowell,
2018). It is suggested that CBT may benefit from working on children’s empathic abilities, in particular on feeling with the other or sharing another’s emotional experience (i.e., affective empathy or the emotional component of empathy), understanding of the other’s emotion (i.e., cognitive empathy or the cognitive component of empathy), and urge to taking care of another (i.e., sympathy or the motivational component of empathy) (Decety & Cowell,
2014; Decety & Jackson,
2004; Spinrad et al.,
2023). Learning to distinguish between the three components of empathy is crucial. The motivational component is especially important with a view to deploying prosocial behavior. Children with conduct problems, perhaps specifically those with limited prosocial emotions, must learn to pay attention to the child’s distress towards whom they start displaying aggressive behavior and must experience themselves how it feels like if this is done to them, with the aim of stopping this behavior. This requires a lot of practice, perhaps adding virtual reality, as individuals tend to respond realistically to virtual simulations of real-life events (Dellazizzo et al.,
2019).
In
step 6 children learn setting goals which may build the bridge between the complex interpretation step and the generation of solutions. Goals function as orientations toward particular outcomes and therefore are thought to influence subsequent response generation (Crick & Dodge,
1994). Moral values such as high values for dominance, revenge and self-enhancement, and low values for affiliation may affect goal orientations (Crick & Dodge,
1996; Lochman et al.,
1993). In CBT, therapists need to work with children on setting relationship-enhancing, affiliation goals rather than dominance and revenge goals, in view of generating appropriate solutions (step 7). Also, difficulty to regulate angry and anxious emotions may endorse revenge goals (McDonald & Lochman,
2012) which involves working on emotion regulation (step 3) as well.
In
step 7 children learn generating solutions. In CBT, children are typically encouraged to come up with as many solutions as possible which then are categorized into solution types such as verbal assertion, compromise, conciliation, help-seeking, verbal aggression, and physical aggression. Normative beliefs in support of aggression and antisocial behavior may yield a bias to aggressive and antisocial responses to social problems (Huesmann & Guerra,
1997; Zelli et al.,
1999). Therefore, changing these beliefs into beliefs in support of prosocial solutions is needed here. At the same time, children learn to come up with solutions that bring both the other person and themselves benefits.
Inappropriate solutions may result from atypical social problem-solving steps, including hostile interpretations and the conviction that this is related to how people treat each other, deviant norms concerning actions that can harm others physically and psychologically, difficulty with empathy, and setting goals of dominance and revenge. Therefore, making connections between all preceding social problem-solving steps and appropriate solutions is needed in CBT. These include adequate interpretations, normative beliefs about prosocial solutions, appropriate care-based norms, empathy, and high goal values for affiliation.
Step 8 is about the evaluation of possible solutions based on outcome expectations and normative beliefs. After children have come up with solutions the therapist can ask questions about the consequences of these solutions and about the moral acceptability of the solutions: ‘What do you think will happen if you do or say that? Will that help solve the problem? What is the direct effect for yourself and for the other? And what is the effect in a week or a month? Do I not harm the other person with this solution? Is it correct to do that?”.
Aggressive children expect aggressive behavior to lead to favorable outcomes for they have learned that aggression reduces aversive treatment by other people (see principle of negative reinforcement and Patterson’s Coercive Theory, 1982). Indeed, aggressive children are more confident that aggression will produce tangible rewards and will reduce aversive treatment by others compared to non-aggressive children (Perry et al.,
1986). Children with conduct problems, therefore, should actually experience that appropriate behaviors result in positive consequences on the short and long term for both themselves, the other person, and their relationship. Therefore, in addition to work with children on these themes, therapists in their work with parents and other adults teach them how to elicit and then reinforce appropriate behavioral responses in the child. Subsequently, these children’s experiences with appropriate behaviors and their positive outcomes are shared and discussed in CBT.
In addition, on the basis of their normative beliefs about aggression, children with conduct problems are less likely to reject aggressive solutions once they have thought of them as solutions to social problems (Huesmann & Guerra,
1997; Zelli et al.,
1999). They worry less about not harming other persons (Blair,
2007,
2017). Normative beliefs about aggression, including social acceptability and moral appropriateness of aggression, will change when children with conduct problems experience for themselves that socially appropriate behaviors “work”, in that they result in positive outcomes both for the other person and themselves, on the short and the long term.
The final
step 9 is about decision-making. Cognitive neuroscience studies in children with conduct problems show difficulties in decision-making; uncertainties about positive and negative outcomes can impede these children’s and adolescents’ ability to make decisions about appropriate solutions to social problems (Blair,
2017; Blair et al.,
2018). In line with this, children with conduct problems more often selected an aggressive response among various responses shown in videos even after an extensive assessment of social problem-solving in which examples of appropriate responses were shown and numerous questions about the responses asked (Matthys et al.,
1999; Van Rest et al.,
2020). Thus, in CBT making connections between all preceding social problem-solving steps and appropriate solutions is highly needed to improve children’s decision-making. However, many positive experiences with appropriate solutions are needed to increase their likelihood to decide to use these solutions in everyday life. In addition, these appropriate (cognitive) solutions must be expressed in appropriate behaviors (i.e., social skills). Thus, role-plays are warranted to expand children’s behavioral repertoire.
Discussion and Conclusion
Moral thinking and empathy are not often considered relevant themes in CBT programs for the treatment of conduct problems. Our suggestions about including moral thinking and empathy in CBT for conduct problems are based on current insights into morality from research in developmental psychology and cognitive neuroscience. Moreover, we have attempted to integrate moral thinking and empathy into social problem-solving skills. For example, in view of generating appropriate solutions to social problems normative beliefs in support of prosocial solutions, appropriate care-based norms, empathy, and high goal values for affiliation are considered. The integration of moral themes into social problem-solving and the translation of these themes in terms of their functional meaning for appropriate behavior can aid children with conduct problems to see the usefulness of morality. Importantly, children with conduct problems not only differ in the type of characteristic behaviors and associated problems, but also in social problem-solving skills, as well as in moral thinking and empathy. This heterogeneity is essential from the perspective of achieving changes in social problem-solving and moral functioning through discussions and sharing of new experiences in the course of the psychological treatment.
CBT, therefore, needs to be tailored to target the child’s impaired psychological functions. The latter may differ depending not only on the characteristic symptoms of conduct problems, but also on symptoms of associated conditions (e.g., attention problems, impulsivity, anxiety). Associations between conduct problems and symptoms of attention-deficit/hyperactivity disorder are especially relevant to consider as attention-deficit/hyperactivity disorder and oppositional defiant disorder or conduct disorder often co-occur (Angold et al.,
1999). In this context, additional pharmacological treatment of severe symptoms of attention-deficit/hyperactivity disorder may be needed (e.g., methylphenidate, atomoxetine) (National Institute for Health & Care Excellence,
2018).
Psychotherapists may also want to take into consideration differences in the cognitive and language developmental level of participating children and adolescents. Relatedly, although the various psychological functions targeted in CBT are assumed to be developed in children as young as 7 years old, albeit on a simple level, the interplay between those functions is more difficult for 7 to 8 year old children to grasp than for 10–11 year old children and for adolescents. In addition, there are age-related changes in morality, for example, children mainly focus on avoidance of harm and benefits to others through actions of helping and sharing, whereas adolescents also maintain concepts of justice and rights (Turiel,
2023). However, psychotherapists take age into account when forming groups of children and adolescents.
Concerns have arisen about delivering interventions for children and adolescents with conduct problems in group formats. Dishion and colleagues (
1999) examined potential deviant peer effects in the context of a cognitive-behavioral group intervention for adolescents. At 1-year follow-up, adolescents who had received youth sessions (youth-only group) had higher rates of tobacco use and of teacher-rated delinquent behaviors than did control children (parent-only group, youth and parent combined group, attention placebo group). However, meta-analyses have not found consistent evidence for deviancy training effects within group interventions for youth with conduct problems (e.g., Weiss et al.,
2005). Still, concerns about deviancy training (i.e., during group sessions deviant peers reinforce each other’s antisocial actions and words) remain and may be addressed as follows (Matthys & Lochman,
2017). At the stage of composing a group, some group members serve as solid peer models for how to enact more competent, verbal assertion and negotiation strategies. During the group sessions, enhancing a positive group process is achieved by including positive feedback time from all group members at the end of group sessions. When disagreements and conflicts develop between group members during sessions, these can be opportunities to directly model and reinforce the social problem-solving skills which are the focus of the interventions (Matthys & Lochman,
2017).
One may question whether moral functioning in children with conduct problems can be changed at all. The Fast Track study showed that a multiyear indicated preventive intervention offered at schools including not only the promotion of children’s social-cognitive and social skills but also the improvement of parenting skills and academic mentoring, resulted in a decrease of antisocial behavior. This reduction was mediated by its impact on three social-cognitive processes: (1) Reducing hostile-attribution biases, (2) increasing the generation of socially competent responses to social problems, and (3) improving the evaluation of the outcomes of aggression as detrimental (i.e., devaluing aggression as effective and acceptable) (Dodge et al.,
2013). This study not only demonstrates that devaluing aggression as effective and acceptable (i.e., a normative belief) is feasible, but is also a mechanism of change and as such constitutes an important aspect of cognitive-behavioral oriented treatment approaches. It should be noted that changes were achieved not only by influencing children’s cognitions, but also by improving their social skills and by working with parents on their parenting skills. In this context, it should be added that working on moral values with parents may be needed as well. If youths’ changing moral values are not supported by their parents and siblings, there is a risk that these changes will only be temporary. There is also evidence that school-based interventions to promote empathy-related responding have a small but positive effect on conduct problems (
d = 0.17) (Malti et al.,
2016).
The learning processes to change social problem-solving skills in children with conduct problems, including moral topics such as devaluing aggression as effective and acceptable, need to be intensive and lengthy, though we do not know for how long. Of course CBT cannot be expected to last for years, but treatment could be intensified by involving parents, child care workers, and teachers in CBT in view of allowing the learning processes to take place in everyday life. After termination of CBT, parents and teachers must continue to support the child’s learning processes.
In conclusion, moral thinking and empathy can be part of CBT for conduct problems. A functional integration of moral thinking and empathy into social problem-solving can promote the acceptance of moral topics by children with conduct problems. Here we offered suggestions how to include morality and empathy in CBT. Psychotherapists can use these suggestions in their clinical work with children, their parents and other adults. In addition, extant programs can be adapted accordingly.