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Shane R. Jimerson, Roslyn Caldwell, Melvina Chase & Artemis Savarnejad
University of California, Santa Barbara
DSM-IV Criteria of Conduct Disorder
Children with conduct disorder diagnosis may
vary in symptoms and behaviors. The following are a list of symptoms
relevant to this particular disorder according to the Diagnosis and Statistical
Manual of Mental Disorders (DSM-IV) criteria:
A repetitive and persistent pattern in which the rights or societal norms or rules are violated as manifested by the presence of three or more of the following criteria in the past 12 months, with at least one criterion present in the past 6 months:
Aggression to people and animals
often bullies, threatens, or intimidates others
often initiates physical fights
has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken
bottle, knife gun)
has been physically cruel to people
has been physically cruel to animals
has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed
has forced someone into sexual activity
Destruction of property
has deliberately engaged in fire setting with the intention of causing serious damage
has deliberately destroyed others' property (other than by fire setting)
Deceitfulness or theft
has broken into someone else's house, building or car
often lies to obtain goods or favors or to avoid obligations (i.e., "cons" others)
has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without
breaking and entering; forgery)
Serious violation of rules
often stays out at night despite parental prohibitions, beginning before age 13 years
has run away from home overnight at least twice while living in parental or parental surrogate
home (or once without returning for a lengthy period)
is often truant from school, beginning before age 13 years
The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
If the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder
Type based on age at onset:
Childhood-Onset Type: onset of at least one criterion characteristic of Conduct Disorder prior
to age 10 years
Adolescent-Onset Type: absence of any criteria characteristic of Conduct Disorder prior to
age 10 years
Mild: few if any conduct problems in excess of those required to make the diagnosis and
conduct problems cause only minor harm to others
Moderate: number of conduct problems and effect on others intermediate between "mild" and
Severe: many conduct problems in excess of those required to make the diagnosis or conduct
problems cause considerable harm to others.
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One of the most frequent diagnosable psychiatric
disorders in children is conduct disorder (Doll, 1996). Conduct disorder
(CD) encompasses a class of chronic, severe antisocial behavior that typically
begins in early childhood and extends into adulthood (Robins & Ratcliff,
1979). Academically, children that exhibit these problematic behaviors
usually are difficult to teach in the traditional classroom environment,
resulting in poor academic performance. They oftentimes present learning
disabilities and attention deficit hyperactivity disorder (ADHD).
Research also shows that antisocial behavior is related to truancy and
dropout rates. Adolescents diagnosed with CD also appear more susceptible
to alcohol and substance abuse (Short & Shapiro, 1993). The significance
of conduct disorder results in part from the fact that it constitutes one
of the most frequent bases for referral of children and adolescents for
psychological and psychiatric problems, criminal behaviors, and social
maladjustment by the time they become adults (Kazdin, 1995). In addition,
research has shown that the characteristics of this disorder can be passed
on as antisocial behavior in offspring, forming a cyclical pattern (Kazdin,
1995). Therefore, the knowledge and research pertaining to this childhood
disorder can serve as a useful tool to clinicians, professionals, teachers,
and the community.
Epidemiology is crucial for preventive approaches to intervention (Doll, 1996). Therefore, it is beneficial to begin with the epidemiology of conduct disorder. The prevalence rate of conduct disorder is estimated between 2% to 6% among youths, with boys showing higher rates of conduct disorder than girls. Prevalence of conduct disorder is estimated at about 2% for girls and 9% in boys (Russo & Beidel, 1994). Thus, conduct disorder occurs 3 or 4 times more likely in boys than girls. Even though conduct disorder is classified as a childhood disorder, the particular behaviors may occur over the course of a life span. Generally, conduct disorder occurs at a higher rate for adolescents (approximately 7% for 12 to 16 year olds) than for children (4% for 4 to 11 year olds) (Kazdin, 1995; Cohen et al., 1993).
Historically, empirical evidence has shown that sex differences exist in the age of onset of this disorder. The median age of onset for this disorder has been found in the 8 to 10 year old range. Most boys had an onset before the age of 10, while girls had onset ranging from the age of 14 to 16 years. More recent research has suggested that the onset of conduct disorder may be significant in relation to clinical course. Conduct disorder symptoms emerging in childhood are more likely to have a poorer prognosis than those emerging during adolescence. It appears that conduct disorder continues to prevail in more boys than girls overall. The prevalence of boys tends to be higher in childhood and declines over the ages 10-20. Symptoms in girls appear to peak up to age 16 and decline thereafter. This seems to occur two or three years after menarche, and appears to be related to societal factors rather than hormonal changes.
Barclay and Hoffman (1990) present an overview of conduct disorder in relation to other disorders, prevalence, stability of the disorder and other variables that may affect one's diagnosis. Specifically, they present good correlates of how this particular disorder affects other psychological variables that appear to be associated with this disorder. These include intelligence and cognitive skills, perceptual processes, impulsivity, need for stimulation, empathy, moral development, and interpersonal relationships.
In further exploration for epidemiology of conduct disorder, Cohen et al. (1993) present empirical information about the prevalence of oppositional disorder, conduct disorder and depression across genders and age groups. This provides important information about the populations served for these disorders. Moreover, it provides significant implications for the stages of implementing intervention and prevention services. Cohen et al.’s (1993) study revealed that conduct disorder was about twice as prevalent for boys than girls. However, the prevalence for boys was highest at younger ages (10-12) and higher for girls at older ages (14-16). The findings for the other disorders were consistent with those for conduct disorders. These results suggest that developmental trends in boys and girls differ throughout the pre-adolescence and adolescence stages and may directly impact the rates of behavior problems.
Since it is crucial to understand the epidemiology of a disorder in order to provide prevention, intervention, and treatment programs, we must consider the validity, accuracy, and applicability of such information. In studying the epidemiology of conduct disorder, Doll (1996) provides an analysis of the construct validity of epidemiological studies and by the end utilizes this information to provide an agenda for school psychologists to provide mental health services for children at the school, district, and the governmental levels. Doll (1996) states that in reviewing the methodology value of an epidemiological study, two factors must be considered. One is the degree that the sample represents the population of all children and youth (a criticism of earlier epidemiological studies, pre-1986 studies, is that they failed to evaluate the degree to which their sample represented the community, which they studied), and the other is the degree of accuracy to which the disorders are identified. In addition to these two factors, comorbidity may have important implications and should therefore be addressed. Doll (1996) concludes that school psychologists should advocate to have a role in conducting epidemiological research with the National Institute on Mental Health in order to more effectively meet he needs of their targeted population.
Due to the multiple factors that may contribute to a diagnosis of conduct disorder, Kazdin (1995) provides a comprehensive overview about the characteristics, events, and/or processes that may increase the risk for the onset of conduct disorder. The discussed risk factors include: child factors (child temperament, neuropsychological deficits and difficulties, subclinical levels of conduct disorder and academic and intellectual performance); parent and family factors (genetics, psychopathology and criminal behavior within the family, parent-child interaction, parental separation, divorce, and marital discord, birth order and family size, and socioeconomic disadvantage); and school related factors. In addition, Kazdin (1995) explores the protective factors that are apparent with this behavior, which oftentimes leads to the mechanisms and processes leading to conduct disorder. Furthermore, Kazdin (1995) talks about the characteristics of conduct disorder over the life span, particularly in adulthood including specific behaviors related to one's social, occupational, and educational environment with particular characteristics and patterns of this behavior.
In an article by Russo and Beidel (1994), comorbidity issues of anxiety and externalizing conditions in children and adolescents explored. One of the externalizing factors discussed in length is that of conduct disorder. Russo and Beidel (1994) note that since some children have co-diagnoses, it is therefore important to examine the area of comorbidity of diagnoses in the study children and adolescents. Therefore, a review of studies concerning the co-occurrence of childhood anxious and externalizing conditions in samples of epidemiological and clinic-referred children and adolescents is provided.
Russo and Beidel (1994) state that the reviews of the epidemiological and clinic-referred studies demonstrate that there appears to be a significant rate of comorbidity of anxiety and externalizing disorders (including conduct disorder) with an evidence of age trends. As children mature to adolescence, the comorbidity rate drops to a non-significant level. In addition, gender too seems to play a role in the comobidity rate. Russo and Beidel (1994) report for example that a study has indicated conduct disorder in females to be of more predictive value for adult internalizing disorders when compared to the same childhood conditions in males. Furthermore, psychopathology among family members may also contribute to the diagnoses and comobidity status of children and adolescents. In conclusion, Russo and Beidel (1994) suggest that age, gender, and familial psychopathological differences appear to be related to the discussed comorbid conditions.
Short and Shapiro (1993) provide a comprehensive view of the epidemiology of conduct disorders as well as an examination of the personal, family, school, and peer effects. They note that conduct disorders differ from other childhood challenges due to the antisocial behavior, the chronicity of such behavior as well as the impairment of functioning of those exhibiting such behaviors. This disorder tends to exist in a stable form with continual development into adulthood. Historically research suggests that most treatments are minimally effective, however, new efforts containing a multidimensional approach are being explored.
Examination of the collaboration of personal, family, school and peer components provides information on the complex of CD as well as an avenue for providing interventions. Personal characteristics and features, such as irritability, aggressiveness, and cognitive difficulties, are crucial for identifying markers for the onset of antisocial behavior. The perpetuation of these characteristics is mitigated by experiences with parents, school and peers. Each of these components can intensify or minimize the extent to which antisocial behaviors are developed. Parent and family effects can range from familial stress to member criminality or psychopathology to discipline practices. Additionally, the quality of parent-child interactions can create, inadvertently encourage, or negate antisocial behavior. This is often a common area of change employed in interventions and a primary area of prevention. The school environment is also utilized in the diagnosis and treatment of conduct disorders. Ironically, it is the place where antisocial behavior has the most dramatic and devastating effects. The relationship between poor academic achievement and antisocial behaviors is greatly documented. Along with interactions with parents, school personnel, peer group relations are impacted by antisocial behaviors. Children may be rejected by peers in response to negative behaviors. On the other hand, children exhibiting conduct disorders may join with other similar children, which results in a further manifestation of the problem.
In sum, gaining epidemiological data, will allow us to better understand, assess, treat, and prevent conduct disorders. Therefore, it is important that special attention is given to the gathering of this information, as it is the building block for the plan of action to follow. In evaluating the epidemiological information of conduct disorder, it is apparent that there are many factors that affect the development of conduct disorder in children and adolescents. Therefore, a multidimensional assessment of educational, personal, familial, societal influences are necessary in order to provide a comprehensive examination of one's behaviors and characteristics. Research suggests that children exhibiting conduct disorders are more likely to develop life-long problems involving education, occupations, interpersonal relations, health, criminality, and mental health (Kazdin, 1987).
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Several theories exist regarding the causes
of conduct disorder. These theories include genetic predispositions,
physiological influences, social, familial and environmental influences,
and individual characteristics. Research suggests that these factors
tend to exist in combination rather than isolation. In addition,
the prevalence of these factors may increase or decrease the likelihood
of this disorder. The section provides supportive information regarding
the onset and the genetic influences associated with conduct disorder among
children and adolescents.
Various types of family dysfunction contribute to the formation of conduct disorders in children. Frick (1993) explores three types of family dysfunction as well as implications for studying models that depict family causal relationships with conduct disorder. Parental adjustment, marital situation, and socialization processes are shown as influential. Parental adjustment is examined over three domains: depression, substance abuse and antisocial behavior. Although not directly related, parental depression may contribute to adjustment problems in children, which may lead to behavior difficulties. Substance abuse in isolation does not place the child at risk for conduct problems. However, when determining the relationship of substance abuse, it is important to recognize the broader implications of subsequent parent behaviors and interactions with children. Unlike depression and substance abuse, research has shown a direct relationship between parental antisocial behavior and the manifestation of similar behavior practices in children.
The relationship of family dysfunction can be viewed from a three causal type relationships: mediational, bi-directional and third-variable where the family may directly influence the development of a conduct disorder, the child's antisocial behavior may attribute to the family's dysfunction or an unrelated variable may negatively affect the family and child. These models reflect the notion that parent/family effects on childhood conduct disorders are correlational not directly causal. However, the influence of the parent/family is worthy of further research and examination when designing and prescribing services for children with conduct disorders.
Furthermore, Clarizo (1997) highlights the heterogeneous nature of conduct disorders. Conduct disorders are expressed differently in children due to the age of onset as well as the issues of comorbidity. Developmental courses of conduct disorders include childhood-onset and adolescent-onset types. The childhood-onset is characterized by neurological or family deficits that cause antisocial behavior, whereas, the adolescent-onset involves more normalized behavior that is reflected by biological and societal changes. Clarizo (1997) further describes the individual and environmental factors that may influence the initial development, severity, and chronicity of conduct disorders during childhood and adolescence.
Comings (1997) explores the notion that conduct disorder may be genetically related. Previous research assumed that disruptive disorders in general and conduct disorders in particular are learned behaviors. However, Comings (1997) provides empirical support, which suggests that there may be genetic influences that cause this behavior. Evidence shows that this childhood behavior as well as other disruptive disorders have a strong genetic component, are inherited by both parents, and share a number of genes in common that affect certain levels of dopamine in the brain.
Dodge (2000) describes some risk factors for the onset of conduct disorder. These risk factors include biological factors, sociocultural contexts, and life experiences. An example of a provided biological risk factor is that there may be a function deficit in behavioral inhibition, which can be linked to conduct problems. However, Dodge (2000) notes that the findings related to biological factors are by no means conclusive and that other factors must be recognized and explored in the development of conduct disorder. Therefore, the sociocultural environment in which the child is born must be explored. There are many ecological (e.g. low SES) conditions that can dispose the child toward manifesting conduct problems. These conditions display their effects at different points in the child's development. Additionally, life experiences such as parenting styles, peers, and schooling can also affect a development toward conduct disorder. Dodge (2000) continues to emphasize that a single factor alone cannot account for the development of conduct disorder. But rather, it is crucial to examine how these factors cooperate with each other to provide the risk for the on-set of conduct disorder. As a result of this view, the interactive model is presented where the belief is that certain distal factors function only in presence or absence of another risk factor.
Phelps and McClintock (1994) take the biosocial approach to conduct disorder. The biosocial approach states that neither social nor biological factors alone can explain the complexity of such behaviors as manifested by conduct disorder. But rather, it is the interaction between the social and the biological factors that can shed light on this disorder. As a result, these factors must be examined both independently as well as in interaction with one another. In their article, they address the issue of inappropriate research design that often result in faulty conclusions about the etiology of conduct disorder. Phelps and Mclintock (1994) believe that the biosocial approach is helpful in identifying important interactive variables that place children and adolescents at risk.
The developmental approach involves a variety of influences that affect the prevalence and onset of a particular behavior. Specific to conduct disorders, a multi-dimensional approach must be taken in assessing the etiology of this behavior. This approach includes such factors as sociological, environmental, and physiological aspects, which tend to influence the development of behaviors among children and adolescents. These factors tend to be interrelated in nature and may manifest themselves at different points in the child's development. This view can further be explored by adopting the transactional developmental model. This model holds that we need to acknowledge the ways that distal risk factors correlate with each other and may even cause one another across time (Dodge, 2000). Understanding the nature of conduct disorders from a multi-dimensional approach will help to determine the normalcy of the antisocial behavior. In addition, understanding the various dimensions involved with this disorder aids in implementing appropriate interventions.
Based on the information provided, conduct disorders can be frequent, intense and chronic among children and adolescents, thus raising a potential problem or concern. This concern is due to the fact that the problems that exist in childhood and adolescence can potentially result in adult psychopathology. The complexity of developmental factors requires an extensive examination of such factors as life experiences with parents, peers, and social institutions imposed by biological dispositions and sociocultural contexts (Dodge, 2000) that influence the onset of this behavior. The perspective of the examiners is based upon a multi-dimensional approach due to the comprehensive and complex nature of conduct disorders.
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According to Frick (1998b), the goal of assessment
in conduct disorder is to go beyond the paradigm of diagnosis in order
to provide a better view of the child and adolescent’s psychosocial strengths
and needs. When assessing conduct disorder, it is important to use
assessment techniques that consider the age and the cognitive level of
the child being tested. Conduct disorders involve a heterogeneous
group of behaviors that range in type and severity and ultimately have
strong implications for treatment. Furthermore, there are a number
of causes that lead to the development of conduct disorder. Therefore,
it is important to keep these factors in mind when selecting the assessment
tools and criteria for the individual child. Ultimately, there is
a framework that can be followed when assessing conduct disorders.
However, it is crucial to think of the individual child when assessing
and recommending for the needs of the child. In this next section,
the different assessment strategies used with children and adolescents
will be discussed.
The behavior rating scale allows for a time-efficient way of collecting reliable information (Frick, 1998a). This assessment tool uses the rating scales obtained from parents, teachers, and children in order to obtain comparable information. This allows the evaluator to achieve an understanding of the severity of conduct disorder in relation to the normative group. This rating scale also assesses the child’s emotional and behavioral functioning as well as the contextual factor that could be contributing to the conduct disorder. For example, one commonly used family functioning rating scale is that of Family Environment Scale (FES) where there is a focus on gaining information about family structure, organization, communication, and affective expression (Frick, 1998a).
Another assessment tool used is clinical interviews. Clinical interviews assess the duration and age of onset of behavior problems. These interviews can also help shed light on the developmental progression and the degree of impairment with regard to the child’s conduct disorder (Frick, 1998b). Again, as with the behavioral rating scales, clinical interviews provide a detailed description of the child or adolescent’s emotional and behavioral functioning by interviewing multiple informants. In addition, such interviews are constantly updated in order to adapt to the changes made in the DSM system (Frick, 1998b). One commonly used interview form is called the DISC where there is also an available computerized version that eliminates the need for a trained interviewer to administer it.
Behavioral observations are also another important assessment tool that is utilized. By using behavioral observations, the evaluator is able to assess the child’s behavior without having to filter it through the informant’s perception. In addition, the child’s behavior can be observed within the environmental context providing further insight to the causation and the overall assessment of the conduct disorder with regard to the observed child (Frick, 1998b). One example of such interview tool is called FICS (The Family Interaction Coding System) where child behaviors and responses of others to this behavior are obtained. There are however, some limitations to this assessment tool. First, it can be very time consuming and costly. Secondly, there is the concern that the child may not display “true” behaviors to the knowledge that they are constantly being observed (Frick, 1998a).
It is very important when assessing children and adolescents with conduct disorder to keep in mind the developmental level as this can have a great impact on the assessment of the individual. Assessments must be appropriate in all areas of development including cognitive, social, and emotional. It may be that conduct disorder may not even be diagnosed until a certain age where such behaviors are then seen to be age inappropriate. For example, conduct disorder may not be possible to diagnose in very young children (preschool) due to their inadequate level of social understanding and the allowances that are made for them as a result of it. Preschool children may not yet have the cognitive abilities to understand the ramifications of their behaviors, which will in turn make it very difficult to provide them with such label as having conduct disorder.
In choosing an optimal assessment tool, the literature appears to state that there is no one method that can fully capture all the necessary elements for the assessment of conduct disorder. In order to gain a comprehensive view of the child or adolescent’s level of impairment, it would seem that a multiple methods approach should be taken. This includes the assessment techniques stated above which are behavior rating scales, clinical interviews, and behavioral observations. Within, each of these areas of assessment, there exist several options of assessment. These options should be carefully selected by keeping the individual in mind.
In conclusion, when selecting the appropriate assessment technique, the individual child should be the focus rather than utilizing one standard method for a large population. Therefore, the best possible form of assessment would include multiple informants in addition to the child, and use a qualitative as well as a quantitative method of obtaining information about the child’s strengths and needs. One final point that must not be forgotten is that the child’s overall developmental level must be considered at all times during the assessment.
Table 1: Assessments of Conduct Disorder
Behavior Assessment Systems for Children (BASC) Reynolds & Kamphus (1992)
Child Assessment Schedule (CAS) Hodges, Cool, & McKnew (1989)
Child Behavior Checklist (CBCL) Achenbach (1991)
Conflict Tactics Scale (CTS) Straus & Gelles (1990)
Conners Rating Scale Conners (1997)
Diagnostic Interview Schedule For Children (DISC) Shaffer et al. (1993)
Dyadic Parent-Child InteractionCoding System (DPICS) Eyberg & Robinson (1983)
Eyberg Child Behavior Inventory(ECBI) Eyberg & Robinson (1983); Robinson, Eyberg, & Ross (1980)
Family Environment Scale (FES) Moos & Moos (1986)
Family Interaction Coding System (FICS) Reid, Baldwin, Patterson, &Dishion (1988)
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Treatment refers to systematic efforts to reduce,
eliminate, or alleviate a particular problem or set of problems.
Treating children and adolescents who suffer from conduct disorder appears
to be a difficult task due to the complexity of factors associated with
this particular behavior (Frick, 1998a; Kazdin, 1995). Treatment
procedures are said to be most effective when the child is young and early
in the development of problem behaviors (Frick, 1998a). A variety
of treatments have been applied to children and adolescents with conduct
disorder. However, a small number of treatments have been shown to
reduce conduct disorder in this particular population. One treatment
that has had varying affects is pharmocotherapy (i.e., lithium carbonate).
The most effective treatments that have been used with conduct disorder
among children and adolescents has been cognitive problem-solving skills
training, parent management training, functional family therapy, and multisystemic
therapy (Kazdin, 1995). In this section, these treatment techniques
will be discussed along with their reported efficacy through the available
In an article by Kazdin (1997), the previously mentioned methods of treatment are discussed along with their strengths and limitations. With regard to the Cognitive Problem-solving Skills Training (CPST), the children are taught to take a step-by-step approach to solve interpersonal problems. These steps include 1) recognizing problem situations, 2) the use of self-statements to reduce impulsive behaviors, 3) generating multiple solutions to problems, 4) evaluating possible consequences to actions, and 5) taking the perspective of others (Frick, 1998a). Although, the key features of CPST make this type of treatment a very promising approach, it must be noted that there is no evidence that changes in the cognitive processes is correlated with improvements in treatment outcome (Kazdin, 1997). Additionally, a major limitation to the effectiveness of Cognitive Problem-solving Skills Training is that often times children do not use the CPST skills outside of the CPST group or fail to sustain treatment gains over an extended period of time (Frick, 1998b).
A key characteristic of Parent Management Training (PMT) includes meetings with the parents and therapist in order to teach the parents more effective ways of interacting with their children in order to promote prosocial behaviors and to decrease problem behaviors (Kazdin, 1997). An important focus of PMT is on consistent and low power-assertive types of discipline because parent of children with conduct disorder most often are inconsistent with their application of discipline (Frick, 1998b). The PMT highly encourages the participation of both parents in addition to providing long-term follow-up sessions where interventions are reviewed and modified as needed (Frick, 1998a). The PMT is known to be one of the most researched treatment techniques for conduct disorder where outcomes have been studied with children of varying ages and degree of severity of dysfunction (Kazdin, 1997). This has resulted in evidence of clear improvements in the child’s behaviors. However, limitations also exist with the PMT. One of the greatest limitations of PMT is that there are very few training opportunities available for professionals to learn this technique (Kazdin, 1997).
Kazdin (1997) also discusses the Functional Family Therapy (FFT), which consists of an integrative approach to treatment involving the systems, behavioral, and cognitive aspects of conduct disorder. FFT focuses on changing interaction patterns for more adaptive functioning. This is done through the use of specific stimuli and responses in order to produce change. Only a few outcome studies have been conducted with FFT. Some studies have illustrated that improved family communication and interactions result from FFT. However, more research is needed for the FFT in order to gain greater insight on the outcome of this treatment method.
A fourth type of treatment that Kazdin (1997) discusses is called the Multisystemic Therapy (MST) geared primarily toward older children and adolescents (Frick, 1998b) where a family-systems based approach is taken because the child is believed to be embedded in a number of systems including the family, peers, schools, neighborhood and so forth (Frick, 1998b; Kazdin, 1997). With regard to the family, the goal of MST is to extinguish negative interactions between parent and adolescent and to foster emotional warmth and cohesion among the family members. Overall, several outcome studies have shown MST to be very effective in reducing delinquency, emotional and behavioral problems while improving family functioning, and therefore making this type of treatment a very promising one.
Webster-Stratton and Hammond (1997) discuss the effects between four types of therapy for conduct disorder in children. These conditions are parent training, child training, a combined child and parent training, and medication. The results indicate that significant improvement was made in the child's behavior at home when parent training was implemented rather than medication. This illustrates that parental involvement and training is necessary and affective with children with conduct disorders.
Eyberg et al.’s (1995) study examined the effectiveness and generalizability of Parent-Child Interactive Treatment with families of preschool children with conduct disorder problems. The overall purpose of the treatment was to build positive parent-child relationships that would directly affect the behavior of the child. At the first assessment stage the children's behavior showed positive changes. However, the authors conclude that this type of treatment is most effective if it is continued in the home and other important environments.
In another study, Carlin (1996) presents theoretical information that supports the implementation of group psychotherapy as a form of treatment for teenagers who exhibit conduct disorder. Carlin (1996) argues that large groups of psychotherapy are most effective because it positively influences behavior, and facilitates and alters perception of self and others.
On the other hand, with regard to pharmocotherapy, in an article by Rifkin et al. (1997), it is stated that psychosocial treatments are ineffective for treating conduct disorders. Rifkin et al. (1997) provide support for the use of medication such as bupropion, and methylphenidate. This study uses lithium in treatment of adolescents’ aged 12-17 who were diagnosed with CD. The subjects are inpatients at a hospital. They were administered lithium and placebos in a double blind fashion. Only one-third of the participants responded positively to the lithium treatment. The researchers conclude that lithium is not the most beneficial medical treatment for conduct disorders.
It is important to note that each treatment type has specific developmental concerns. When implementing psychotherapeutic treatments, age and cognitive level of children are important considerations. Therefore, many common treatments include developmental considerations. For instance, when using CPST, it is imperative to design a program that is age appropriate in order to provide for the developmental level and needs of the child or adolescent being treated. Another treatment method that considers the developmental level of the youth is the MST. This treatment is primarily used with older children and adolescents who show severe behavior problems. The MST tailors treatment according to the individual need of the children and youth being treated acknowledging that individuals vary in terms of their needs and the systems that their lives are embedded in.
In more severe cases of conduct disorder, medication is used to modify behavior. However, due to the fact that conduct disorder is not usually diagnosed earlier than age six, medication is not prescribed in this age range compared to older children and adolescents. Thus, caution needs to be used when considering medication for children with conduct disorder, so that the effects does not stifle the normal development of the child.
In selecting an optimal treatment for the child or adolescent with conduct disorder, the individual being treated must be the focus of assessment. The developmental perspective implies that social training type treatment is effective because focus is on the developmental pathways of this particular disorder. The use of group therapy seems to assimilate real life interactions. Within this type of environment, children and adolescents are able to practice the skills learned and receive constructive feedback. In addition, this environment allows them to normalize their behaviors and provides examples of the positive effects of change in behavior. Research shows that social skills training provides appropriate alternative behaviors to express negative thoughts and feelings that are manifested in actions by children and adolescents with this disorder. The effects of this form of treatment are withstanding because the goals of treatment focus on the change of cognitive schemas. Thus, the skills learned are generalizable across all areas of the child's life. Therefore, improvement can be expected in academic, social and personal arenas.
However, research also demonstrates that parent involvement in the treatment technique is key to achieving effective outcome for children with conduct disorder. Therefore, it seems that in order for the behaviors to be reinforced at home as well as in the school setting, parent participation and training is critical. If children with conduct disorder are taught to behave a certain way in one setting but these behaviors are not reinforced in another setting, such as at home, then this would prove to be inconsistent for the child or adolescent, which in turn would very likely hinder treatment effectiveness due to the lack of applicability and reinforcement. Furthermore, several studies have demonstrated strong results that when positive parent participation is incorporated into the treatment program, the child’s behaviors are markedly improved. Frick (1998a) states that when PMT was utilized in the treatment, the children’s behaviors were brought to the same level as the normative group. Therefore, the PMT appears to be a crucial element for the treatment of conduct disorder in children and adolescent as it provides reinforcement as well as consistency across settings.
Thus far, several treatment techniques for the treatment of conduct disorder have been discussed. When selecting a treatment technique for a child or adolescent with conduct disorder, it is imperative to focus on the needs of the individual child in order to provide the most appropriate and effective outcome. Whereas the literature suggests that medication is appropriate in severe cases, the treatment is temporary and does not address the salient issues and symptoms of conduct disorder. The literature appears to suggest that treatments should provide developmentally appropriate methods that are reinforced across all settings, especially at home, and to different contexts. Parents are key to the treatment outcome because they provide a model of behaviors for the child/adolescent to follow. Parents need to be supplied with the tools and the skills necessary in order to help modify their children’s problem behaviors rather than inadvertently contributing to them. It is important to note that no one-treatment technique is appropriate for all children or adolescents. Rather, the individual must be assessed appropriately in order to gather valuable information about the needs, strengths, and the degree of impairment. In turn, this information can be used to provide the most appropriate treatment technique which may often times include different types of treatment techniques rather than one single type of technique.
According to the literature, further research is needed in the area of conduct disorders in order to provide more effective outcomes. Treatment programs are needed that encompasses the multivariate components of this disorder: family, child, peer group and the community. It appears that treatment plans that are offered need to focus on altering the proximal childhood processes (cognitive processes) that are connected to the high-risk behavior.
Conduct disorder has proven to be a very complex
type of disorder in children and adolescents in terms of diagnosis, treatment
and assessment. One primary reason for this being that there is a
great deal of comorbidity with other dysfunctions, such as ADHD.
In addition, many factors need to be considered when diagnosing and treating
a youth with conduct disorder. Some of these primary factors to consider
include personal characteristics, cognitive development, the family system,
peers, school environment, ecological elements (such as SES), and so forth.
As a result of these factors, it is then crucial to focus on the child’s
developmental level and the developmental progression of conduct disorder.
The child or adolescent’s dysfunction and problem behaviors cannot b taken
in isolation of these factors. Rather, several of these elements
need to be considered in combination of one another in order to attain
a comprehensive view of the child/adolescent’s strengths and degree of
impairment. The degree of impairment is an important piece to attend
to as it provides information about the areas of difficulty and how such
difficulties have come about which in turn can provide vital information
for the appropriate treatment techniques to use with the youth.
In conclusion, information about the epidemiology and etiology of conduct disorder provides much needed knowledge regarding the appropriate assessments to be used with the individuals and in turn allowing for effective treatment plans and outcomes. It is important to note again that no single factor contributes to conduct disorder and that there is no one type of assessment or treatment that is best to use with all children. Rather, a combination of factors must be analyzed in combination and in isolation of one another in order to achieve knowledge about this very commonly diagnosed dysfunction and the ways to treat it.
American Psychiatric Association. (2000).
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Frick, P. J. (1998a). Conduct Disorder. In T. Ollendick and M. Hersen (Eds.). Handbook of Child Psychopathology (3rd ed.) (pp. 213-337). NY, NY: Plenum Press.
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World Wide Web Sites for Conduct Disorder
WWW Sites for Etiology of CD
Site Name: American Academy of Child and Adolescent Psychiatry
This site is geared towards providing information to parents and families regarding conduct disorders among children and adolescents. This site presents specific examples of behaviors and actions that are recognizable in children. Lastly, an overview is given of behavior modifications and psychotherapy interventions.
Site Name: Unknown
This web site provides information on several behavior disorders among which include CD. A list of specific symptoms is provided for this disorder along with information on CD and comorbidity. In addition, vignettes are provided that are related to CD. This web site is helpful as it provides comprehensive information on CD and treatment possibilities. Also, the vignettes help the reader better understand CD and it's form in youth. Information on other childhood and adolescent disorders are available through this site.
Site Name: Internet Mental Health
This site provides comprehensive information regarding conduct disorders. Specifically, the web page gives the description of conduct disorders in a European and American version. This site also provides a summary of current research, booklets and magazine articles that can serve as useful tools of information regarding this behavior.
Site Name: Find Articles
This web site provides article summaries on the topic of conduct disorder (CD) from the Journal of the American Academy of Child and Adolescent Psychiatry. In this particular article, a self-report screener is utilized to identify adolescents with a lifetime diagnosis of CD and to predict anti-social behavior by age 24. This site is especially helpful to those in search of current empirical studies regarding CD. In addition, links to other child and adolescent disorders related to CD are available.
Site Name: Harvard Medical Schools Consumer Health Information
This web site provides a wealth of information on physical and mental health related topics among which include CD. The information provided on this site appears to be targeted toward the general public. A link to behavior disorders in children and adolescents provides further information on CD; it's symptoms, treatment, and prognosis. This site is helpful because information on other child and adolescent disorders are provided along with what can be done for treatment. Additionally, through this web site, information on other child and adolescent health topics and issues are available.
Site Name: Conduct Disorders
This web site provides a large array of information regarding conduct disorders as well as a parent message board where parents and educators can share their experiences with children and adolescents with conduct disorder. Furthermore, a search engine on this web site can provide specific help and information. Book references and purchases are also available through this web site. This is a beneficial site to visit because as it provides information to many different types of conflict disorders. It is also useful to use because it is updated frequently and provides web links to other related conduct disorder sites.
Site Name: School Psychology Resources Online
This site provides links and information to many different areas of conduct disorders including the assessment of conduct disorders. This site provides information for parents, educators from an empirical and educational perspective. It also informs parents regarding information that they need to be aware of when their child is assessed. This is very beneficial site because interested viewers can gain access to an on-line assessment tool. It would be highly recommended to visit this site since comprehensive information and links regarding conduct disorder and its assessment are provided.
WWW Sites for Assessment of CD
Site Name: Associates 2000 P. A. A Multispecialty Neurodevelopmental Clinic
This web site provides information regarding a wide range of behaviorally related issues in children and adolescents. Conduct disorder is also included among them. In addition, information regarding psychological and developmental assessments can be provided. They sate that their commitment is to state of the art evaluations combined with family-centered long-term follow up. This web site is a good tool to utilize in order to gain information regarding behavioral concerns that parents have about their children. The web site provides informational help regarding specific behavioral questions, and the public can e-mail staff members with their questions. The majority of the staff members seem to possess doctoral degrees in the related field. In conclusion, this web site can provide a helpful starting pint for parents and individuals who have concerns about conduct disorder and other behavioral issues.
WWW Sites for Treatment of CD
Site Name: Juvenile Forensic Evaluation Resource Center
This web site provides information regarding effective common treatment methods for conduct disorder. The information provided on this web site is similar to the information provided in the treatment section of this current project (for ED 264B). In addition, a table is provided with information regarding the summary of empirically evaluated treatment for conduct disorder. This table is beneficial because it addresses the very important aspect of treatment outcomes. Therefore, a visit to this site is recommended for the up to date information presented on the treatment of conduct disorder in addition to providing empirical information for such treatments.
Site Name: Internet Mental Health
This is a very beneficial site as it provides current information to many disorders in addition to conduct disorder. It is a particularly good site to visit because it provides information on current research for the treatment of conduct disorder. In addition, links and abstracts are provided for related articles.
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