In the EFCAP congress in Porto (www.efcap2016.com), a lot of attention was dedicated to neurobiological deficits in children and adolescents with conduct disorder. Callous-unemotional personality traits already in childhood have for quite some time been associated with violent behaviours in childhood, adolescence and in adulthood, and it has been shown that conduct disordered kids with callous-unemotional traits also react differently than others of same age on expressions of fear in others. Callous-unemotional traits have also been associated with low autonomic arousal. The low arousal in stressful situations and failure to appreciate and empathize others’ distress may give way to behaving violently without being hindered by external or internal warning signs. However, more recently it has been shown that not only conduct disorders with callous-unemotional features associate with neurobiological deficits. Conduct disordered kids at large show deficiencies in emotional empathy, emotional learning and emotion dysregulation.

It is not uncommon in psychiatric and social services that children and adolescents with conduct disorder are seen as not appropriately disordered and in need of help but as designedly manipulative and attention-seeking. There is an air that those kids have cheated their way to the ward and use the professionals to obtain some hidden goal. But who would, if capable of so much clever manipulation, choose to reside, for example, in mental hospital?

However, acknowledging the considerable deficits and need for treatment in children and adolescents with conduct disorder definitely does not mean that they should be excused from their wrongdoings such as aggressive and violent behaviors. On the contrary, they need more than average external support to withdraw from aggression and to learn age appropriate behavioral control and social skills.

In Finland, we are planning a major health and social care reform. One burning issue discussed in planning future child and adolescent psychiatric and child welfare care are adolescents with severe conduct disorders on their way to permanently antisocial lifestyle and criminality.  These young people are often most unmotivated to any treatment. With an increasing emphasis of self-determination and the society’s willingness to see all the younger adolescents as fully competent to decide about a range of matters such as their own health we are happily creating a situation where adolescents are a group of people who only have rights – but when it comes to responsibilities they are suddenly too young and immature.  Old enough to have right to choose – too young to bear the consequences?

Adolescents at large, not to mention those with severe conduct problems, do not need such imbalanced existence. Given the current knowledge of neurobiological deficits and consequent inability to age appropriate behavioural control in conduct disorder, more external control and less self-determination might be more appropriate. It is known that the frontal lobes, the part of the brain where impulse control, self-control, ability to consider consequences – simply reason, sense, intellect resides – are the last to develop. If a conduct disordered adolescent is allowed to cherish the lifestyle dedicated at indulging to overt aggression, letting impulse control out of hands, using substances and committing antisocial acts, he is allowed to strengthen corresponding neural networks and such behavior becoming automated. At the same time, substance use and repeated small head injuries – from fights and intoxication – ensure that the potential of the frontal lobe is never reached.

Thus, be it in child welfare, in psychiatric care or elsewhere, there needs to be adults who have the right to prevent an adolescent with conduct disorder from joining antisocial activities on a Saturday night, stop him from using violence, limit his access to antisocial gangs, and prevent him from preparing further crimes.  This is therapeutic: it prevents automation of antisocial behaviour, and gives frontal lobes time to mature undamaged.