Edited by Shane R. Jimerson,
Ph.D.
Contributed to by the Graduate
Students in the Counseling, Clinical, and School Psychology Program at
the University of California, Santa Barbara.
Ongoing design and publication of this site is completed by Shane R. Jimerson, Jeff R. Klein and Angela Whipple. Please forward comments regarding this site to Shane R. Jimerson. This page was last updated 1.11.02. © 2002
Symptoms
Epidemiology
Etiology
Assessment
Treatment
Authors
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
robbery)
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
Severity:
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"
Severe: many conduct problems in excess of
those required to make the diagnosis or conduct
problems cause considerable harm to others.
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).
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.
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)
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
literature.
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.
CONCLUSION
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.
REFERENCES
American Psychiatric Association. (2000).
Diagnostic and statistical manual of mental disorders (4th ed.) (pp. 98-99).
Washington, DC: American Psychiatric Association.
Barclay, M., & Hoffman, J. (1990). Conduct
disorders. In M. Lewis and S. Miller (Eds.), Handbook of Developmental
Psychopathology Development and Psychopathology (pp. 109-118). New York:
Plenum Press.
Carlin, M. (1996). Large group treatment of
severely disturbed and conduct-disordered adolescents. International
Journal of Group Psychotherapy, 46(3), 379-397.
Clarizo, H. F. (1997). Conduct disorder: Developmental
considerations. Psychology in the Schools, 34(3), 253-265.
Cohen, P., Cohen, J., Kasen, S., Velez, C.,
Hartmark, C., Johnson, J., Rojas, M., Brook, J., & Streuning, E.
(1993). An epidemiological study of disorders in late childhood and adolescence-
I. Age and gender specific prevalence. Journal of Child Psychology
& Psychiatry, 34 (6) 851-867.
Comings, D. E. (1997). Genetic aspects of
childhood disorders. Child Psychiatry and Human Development, 27(3), 139-150.
Dodge, K. (2000). Conduct Disorder.
In A. J. Sameroff, M. Lewis, S. M. Miller (Eds.), Handbook of Developmental
Psychopathology (2nd Ed.) (pp.447-463). New York: Kluwer Academic/Plenum
Publishers.
Doll, B. (1996). Prevalence of
psychiatric disorders in children and youth: An agenda for advocacy
by school psychology. School Psychology Quarterly, 11(1), 20-47.
Eyberg, S., et al. (1995). Parent-child interaction
therapy: A psychosocial model for the treatment of young children with
conduct problem behavior and their families. Psychopharmacology Bulletin,
31(1), 83-92.
Frick, P. (1993). Childhood conduct
problems in a family context. School Psychology, 22(3), 376-385.
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.
Frick, P. J. (1998b). Conduct
disorders and severe antisocial behavior. NY, NY: Plenum Press.
Kazdin, A. (1987). Conduct disorders
in childhood and adolescence. Beverly Hills, CA: Sage.
Kazdin, A. E. (1995). Risk factors, onset,
and course of dysfunction. In Conduct Disorders in Childhood and Adolescence
(2nd Edition) (pp. 50-74). Thousand Oaks, CA: Sage Publications.
Kazdin, A. E. (1997). Practitioner
Review: Psychosocial treatments for conduct disorder in children.
Journal of Child Psychology and Psychiatry, 38(2), 161-178.
Phelps, L., McClintock K. (1994). Papa
and peers: A biosocial approach to conduct
disorder. Journal of Psychopathology and Behavioral Assessment, 16(1),
53-67.
Rifkin, A. et al. (1997). Lithium treatment
of conduct disorders in adolescents. The American Journal of Psychiatry,
154(4), 554-555.
Robions, L. & Ratcliff, K. (1979).
Risk Factors in the continuation of childhood antisocial behavior into
adulthood. International Journal of Mental Health,7, 96-116.
Russo, M. F. & Beidel, D. C.
(1994). Comorbidity of childhood anxiety and externalizing disorders:
Prevalence, associated characteristics, and validation issues. Clinical
Psychology Review, 14(3), 199-221.
Short, R. & Shapiro, S. (1993). Conduct
disorders: A framework for understanding and intervention in schools
and communities. School Psychology, 22(3), 362-375.
Webster-Stratton, C. & Hammond, M. (1997).
Treating children with early-onset conduct problems: A comparison of Child
and parent training interventions. Journal of Consulting and Clinical Psychology,
65(1), 93-109.
World Wide Web Sites for Conduct Disorder
WWW Sites for Etiology of CD
http:/www.wb/aacap/factsFam/conduct.htm
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.
http://www.drsoft.com/chandler/pamphlet/oddcd/oddcdpamphlet.html
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.
http:/www.mentalhealth.com/pr20.html
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.
http://www.findarticles.com/m2250/7_39/63787257/p1/
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.
http://www.intelihealth.com
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.
http://www.conductdisorders.com
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.
http://www.schoolpsychology.net/p_02.html
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
http://www.associates2000pa.com
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
http://www.ilppp.virginia.edu/juv/ConDis.html
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.
http://www.mentalhealth.com/dis-rs/frs-ch02.html
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.