07 Conduct Disorder

Resources

Phillip C. Kendall, Cognitive-Behavioral Treatment Of Conduct-Disordered Children, Cognitive Therapy and research, vol. 14, No. 3, 1990, pp. 279-297

Robert b. Rutherford, Jr., and C.Michael Nelson, Management of Aggressive And Violent Behavior In The Schools, Focus On Exceptional Children, Volume 27, Number 6, February 1995.

Rick Jay Short and Steven K. Shapiro, Theme Editors’ Comments: Conduct Disorders: Current Research, Theory and Practice, School Psychology Review, Volume 22, No. 3, 1993, pp. 360-361

Rick Jay Short and Steven K. Shapiro, Conduct Disorders: A Framework For Understanding And Intervention In Schools And Communities, School Psychology Review, Volume 22, No. 3, 1993, pp. 362-375

Carolyn Webster-Stratton, Strategies for Helping Early School-Aged Children with Oppositional Defiant and conduct disorders: The Importance of Home-School Partnerships, School Psychology Review, Volume 22, No. 3, 1993, pp. 437-457

Ada Spitzer, Carolyn Webster-Stratton and Terri Hollinsworth, Coping With Conduct-Problem Children: Parents Gaining Knowledge And Control, Journal of Clinical child Psychology, 1991, Vol. 30. No 4, 413-427

John J. DeFrancesco, Conduct Disorder: The Crisis Continues, Shared Perspectives, www.apa.org/monitor/Aug95/spaug95.html

John B. Reid, Prevention of Conduct disorder Before and After School entry: Relating Interventions to Developmental Findings, Development and Psychopathology, 5 (1993) 243-262

INTRODUCTION

It is the nature and frequency of behavior patterns that is used to define a person’s level of social competence. Social competence is defined as capacity to expectation. The ability to draw upon a varied repertoire of socially appropriate behaviors pursuant to goal attainment may be considered an important feature of social competence. Social competence is determined by the degree to which a child finds acceptance from others during social interaction.

There are essentially two broad clusters of childhood disorders which manifest in social incompetence:

1. Over-controlled or internalizers
   This group of children are characterized by manifestations of general and social anxieties, sadness, hopelessness, helplessness and withdrawal. Over-controlled children lack interpersonal skills, but do not offend. They are, therefore, not always easily defined as atypical.
2. Under-controlled or externalizers
   This group is characterized by children who manifest disruptive behaviors that identify them as conduct disordered, oppositional defiant disorder or attention-deficit hyperactivity disorder. The under-controlled child lacks or has insufficient control over, behavior that is expected in a given setting and often offends.

Because the behaviors of externalizers are disruptive, as well as not socially competent, they interfere with the ability of the child to develop mutually satisfactory relationships with adults and peers and are seen by child managers as a more serious problem. It is on this group of children with ‘behavior disorders’, that this protocol will concentrate.

The distinction between difficult behaviors and ‘behavior disorders’ lies in the severity and extent of such behavior. This distinction is based on the degree of the disruption or destruction, the frequency of occurrence of the behaviors in more than one setting, and the persistence of these behaviors over time.

When antisocial behavior endures for at least six months, causes impairment in home, social and school functioning and takes a form deemed more serious and intense than ordinary mischief, a child qualifies for a primary diagnosis of either conduct disorder or severe oppositional defiant disorder [Diagnostic and Statistical Manual].

Kazdin [1987] has outlined several key facets of the syndrome differentiating it from other problems of childhood behaviors [Short & Shapiro, 1993].

• antisocial behavior – as already stated, these children typically and persistently exhibit some combination of physical and verbal aggression, stealing, lying, and violation of social norms and the rights of others. Additionally, they are more likely to abuse substances including alcohol.
• chronicity – such children exhibit these serious disruptive behaviors over months and years and are often unresponsive to treatment.
• impairment of functioning – these children exhibit antisocial behavior in sufficient frequency and intensity to affect significantly their educational performance and interpersonal interactions.

One result of the secondary characteristics of impaired functioning is that markedly antisocial children often experience negative repercussions in the form of peer rejection [Berman, 1986; Cantrell & Prinz, 1985; Shantz, 1986]. Because young children who exhibit such behaviors are so clearly at risk, there is strong justification for the development of effective early intervention strategies.

PREVALENCE

Personal characteristics associated with subsequent conduct disorder often appear in preschool years, sometimes as early as age two. Such characteristics may include resistance to discipline, irritability, developmental cognitive and language difficulties and early aggressive behaviors [Short & Shapiro, 1993].

Estimates of the prevalence of conduct disorder in the general population range from about 3% to 7% and it is the most prevalent form of childhood disorder. As a result, such children represent the most common type of referral for children’s mental health services making up from 33% to 75% of clinical referrals. Whereas internalizing disorders may respond to intervention or ameliorate spontaneously over time, some aspects of conduct disorder may persist in relatively constant form and thus the prognosis has been thought to be relatively poor.

Part of this pessimism may be that the manifest characteristics which define conduct disorder are such that they seem to demand and usually get a negative response from others that reinforces the very basis of the behavior in the first place. Another aspect may be related to the traditional choice of intervention strategies that have been generally ineffective since they are directed at the behavioral symptoms rather than the fundamental cognitive factors.

COGNITIVE FACTORS

Cognitive factors play an important and well-documented role in the primary characteristic of antisocial behaviors in conduct disorders. Both social and antisocial behaviors are learned behaviors, and therefore the etiology and maintenance of the learning need to be identified and addressed. Antisocial children often exhibit a cognitive response bias in which they interpret ambiguous interpersonal stimuli as being hostile. This cognitive bias may result in and justify aggressive responses to the misperceived hostile stimulus.

In addition, such children may also be deficient in problem solving skills, particularly in generating multiple and/or prosocial alternative solutions that results in rigidity of aggressive responses.

Common themes of antisocial thinking include the belief and mind-set that they are being victimized. According to Bush & Bilodeau [1993] many adult offenders are accustomed to feeling angry based on a belief they are unfairly treated and have learned a defiant, hostile attitude as part of their basic orientation toward life and other people. They think they are entitled to a kind of absolute freedom in the way they conduct their lives. From this point of view, any restriction of their freedom is resented as an unjust intrusion.

Relationships with other people are dominated by a struggle for power. Win-lose (‘us and them’) is the dominant form of personal relationship and winning is defined as forcing someone else to lose. They picture themselves as the victim and righteous anger displaces the feelings of loss and failure. The logic is a vicious cycle. Whether they win or lose, the underlying cognitive structure is reinforced.

The hardening of such attitudes over time suggests that early intervention, despite its limited success in the past is a prerequisite to effective outcomes. The goal of primary prevention is to lower the incidence rather than to treat the problem (secondary prevention) or its sequelae (tertiary prevention). School based prevention efforts such as the creation of prosocial cultures may be more effective, productive and economical activities than traditional placement or exclusion strategies. Effective service delivery may need to move from short-term, unidimensional strategies to include comprehensive approaches. This may be particularly true when interventions are not implemented until behaviors occur that are serious enough to call attention to the child.

CORRELATES

Short & Shapiro conclude that conduct disorder represents a class of antisocial and disruptive behaviors that interfere with effective interaction with the environment. This disorder is relatively common, well-documented, and has proven to be difficult to treat successfully. They suggest that reliable correlates can be clustered into personal, family, school, and peer dimensions and that successful interventions may need to address these multiple factors.

These children frequently have moved back and forth among schools and other agencies with no agency or profession accepting responsibility for them. They often have participated in a cycle of uncoordinated assessment and referral from agency to agency yielding frustration for parents and ineffective, inefficient services for their children [Knitzer, 1984]. As a result, school personnel may need to become more involved in service activities occurring beyond the school grounds and outside of school hours. These might include parent training, family interventions, community coordination and group work in addition to more traditional education activities.

Parents traditionally have been relatively passive consumers of educational services and often have had only sporadic contact with school personnel. Although aware of family and community influences on student behavior, relatively little emphasis has been placed on interventions for improving and/or using these influences to remediate educational and behavioral problems. Given the critical role that parents apparently play in the development as well as the treatment of conduct disorders, schools must develop mechanisms for involving and empowering parents in educational activities with, and for, their children emphasizing interventions that improve parenting skills and management practices.

SOCIAL LEARNING

In a comprehensive review of research on intervention for childhood aggressive and antisocial behavior, Kazdin [1987] identified structured family intervention based on behavioral social learning principles as the most promising treatment tested.

The central assumption behind this approach is that conduct disorder is acquired and maintained primarily through social learning processes in the family. However, an ecological approach to family intervention goes beyond intrafamilial or intrainindividual factors and views maladjustment as a problem across entire ecosystems [Haley, 1973]. The aim is to change transactions within and between all pertinent environmental systems that serve to maintain, or to be maintained by, a child’s deviant behaviors. Multimodal intervention is directed at four ecological domains:

• individual adjustment factors,
• interactions in the family
• extrafamilial systems- connections among micro systems, such as home, school and neighborhood, and
• cultural community systems – includes values, laws and customs [Miller & Prinz, 1990].

A child develops within a complex system of relationships affected by multiple levels of the surrounding environment. Further, it is clear that these various influences have differing levels of influence at different points of development. While the family has the earliest and most profound effect on the emerging person, there are really several interrelated affectional systems that influence [shape] and maintain [reinforce] behavior. These include the mother-infant affectional system that is sustained or terminated in varying degrees and include the onset of father affection and the age group or peer affectional system that concludes with the heterosexual affectional system. Wholistic perspectives may be helpful in creative design of corrective interventions.

INTERVENTION STRATEGIES

An underlying problem generates symptoms that demand attention. But the underlying problem is difficult for people to address, either because it is obscure or costly to confront. So people shift the burden of their problem to other solutions – well-intentioned, easy fixes that seem extremely efficient. Unfortunately, the easier ‘solutions’ only ameliorate the symptoms; they leave the underlying problems unaltered. [Senge – 1990]

Historically, attempts to deal with conduct disorders have focused specifically on the child and on the diminishment of offensive symptoms. Such approaches have failed to address the correlate dimensions of personal, family, school and peers. This is probably partially an economic decision as it is less costly [in the short term] to suppress the behaviors rather than to get at the fundamental issues. Such short term decisions, however, ‘shift the burden’ and tend to prove very costly in long term correctional costs as well as the costs in human lives and property.

The following provides guidelines for interventions to comprehensively address the ecological domains of personal, family, school and peer domains.

INDIVIDUAL SERVICES DIRECTED TOWARD THE CHILD

Depending upon the timing of the intervention, there are three levels of options.

REMEDIAL SERVICES

Cognitive Restructuring: an intervention dealing with mental schema [core beliefs about self, other and future prospects] and cognitive errors, which is usually disorder specific and may be combined with behavioral technologies for reinforcement. Cognitive restructuring is generally provided in a one to one relationship by a clinician with such skills. Such services can be provided through a group process following a pattern described in Decisions Manual.

• Awareness: understanding your internal dialogue
• Evaluate the effectiveness of your thoughts
• Explore alternative solutions and consequences
• Weigh risks and benefits
• Decide

DEVELOPMENTAL SERVICES

Prosocial Skill Building: A basic curriculum whose content deals with the social skills required for mutually satisfying interpersonal relations – [See the Prepare Curriculum – Goldstein]

• Interpersonal Problem Solving
• Anger Management
• Moral Reasoning
• Situational Perception Training
• Empathy Training
• Interpersonal Skills Training
  • Skills for dealing with feelings
  • Skill alternatives to aggression
  • Skills for dealing with stress
  • Planning skills

Prosocial Skill Building is predominately offered in a class [group] environment.

Interpersonal Cognitive Problem Solving [Shure]: Although very different from other popular methods of child management, this approach, developed by Myrna Shure, continues the movement toward positive childrearing. As Shure states “In 1965 Haim Ginott sparked interest in positive parenting by suggesting in his book, Between Parent and Child, that instead of telling a child what not to do [“Don’t run!”], parent should emphasize the positive by telling them what to do [“Walk!”]. Then, in 1970, Thomas Gordon wrote the acclaimed book Parent Effectiveness Training [PET], which opened the door to the idea that active listening and using “I” messages [“I feel angry when your room is messy”] instead of “you” messages [“You are too messy”] are learned parenting skills.” These two landmark books paved the way for Shure’s book Raising a Thinking Child to take parents a step further. “ICPS moves from a primary focus on skills of the parent to focus on skills of the child as well. The thinking child does not have to be told how people feel or what to do; the thinking child can appreciate how people feel, decide what to do, and evaluate whether the idea is, or is not, a good one.”

Emotional Literacy: Probably the best know emotional literacy curriculum is the PATHS curriculum popularized by Goleman in his book Emotional IQ, the focus is on development of mediating control over one’s emotions.

PATHs provides a developmental curriculum, oriented toward Howard Gardner’s five main emotional literacy domains:

1. Knowing one’s emotions. Self awareness – recognizing a feeling as it happens – is the keystone of emotional intelligence.
2. Managing emotions. Handling feelings so they are appropriate is an ability that builds on self-awareness.
3. Motivating oneself. Emotional self-control – delaying gratification and stifling impulsiveness – underlies accomplishment of every sort.
4. Recognizing emotions in others. Empathy is a fundamental people skill. People who are more attuned to the subtle social signals that indicate what others need or want are able to be more socially competent.
5. Handling relationships. The art of relationships is, in large part, skill in managing the emotions in others.

PREVENTION SERVICES

Culture Reconstruction: This is a process of seeding the socio-culture with essentially cognitive restructuring language and processes. The primary socio-culture entity is the school. However this process also can be provided to the family and the community at large.

• Batche/McMullen – Stop & Think ritual
• Attribution ‘seeding’
• Prosocial icons & themes

Prosocial cultural reconstruction is a school-wide program that can be adapted for other socio-cultural entities.

Personal Support Network: This entails the development of a Circle of Friends. The research shows that people with severe and persistent problems in living tend to live in smaller networks, to have a greater proportion of their energies involved in kin relations, to have intensely negative or ambivalent kin relationships, to have few clusters and higher density in their networks and to have few long-term relationships except with kin [Cutler, 1983]. The development of such networks is of course, interactive in that such people also provide little reciprocity to their network participants.

The availability of an effective personal support network can provide both personal support in times of distress and the opportunity for learning how to effectively relate to others. For children, such a network needs to make available on a regular basis not only supportive adults, but supportive peers. A circle of friends offers an opportunity for community people to offer natural supports in a formalized way. The Circle can be one way of assuring that the Prosocial Culture is carried in the community and is not just in school.

A Circle of Friends can be developed for the child or the family and can be implemented by any group interested in its development. Initiation by an Interagency Team is helpful for exploring the full range of life domains for potential participants. It is helpful to have an institutional organization to provide support to the group.

Determination of the child’s status with peers can be best obtained through sociometric testing and charting [See Measuring Social Competence Through Sociometry].

Interpersonal Cognitive Problem Solving: ICPS can be used both developmentally and preventatively. It is particularly useful when used to teach parents of four year olds to teach their children to problem solve. As noted earlier personal characteristics associated often appear in preschool years, sometimes as early as age two. Shure has demonstrated that until age four a child is not cognitively capable of absorbing the problem solving concepts, but that at age four this can be done very effectively. The process is, of course, also teaching the mother new ways to relate to the child.

FAMILY INTERVENTIONS

FAMILY SOCIAL LEARNING

Strengthening Basic Parenting Skills

• identify accurately child behavior
• refocus from antisocial behaviors to prosocial goals
• daily track specific child behaviors
• administer tangible and social reinforcement
• use alternatives to physical punishment [differential attention, response cost, time out, etc.]
• communicate effectively
• learn to anticipate and solve new problems

Teaching Parents to Teach Children

• I Can Problem Solve
• conflict resolution

Strengthening Self Control

• goal setting
• self-monitoring
• self-reinforcement

PARENT & INDIVIDUAL FAMILY MEMBER ADJUSTMENT SERVICES

Cognitive Reconstruction:

The central assumption behind this approach is that conduct disorder is acquired and maintained primarily through social learning processes in the family. If this is the case, it may mean that one or more adult family members and/or siblings manifest significant antisocial thought and behaviors as well. Therefore, an intervention that expects to modify this training and maintenance environment, may need to address these secondary clients directly. In addition, individual adult family members &/or siblings may require other specific services, particularly for maternal depression and anxiety, which often contribute to a negative child management environment. Cognitive interventions for an individual family member requires a one to one relationship to a clinician with such skills. The same clinician can modify the ‘Decisions’ program for work with a family group.

Cognitive Behavioral Marital Therapy:

Synthesis Training: emphasis is on the indirect influences of wider social context. Parents are guided to identify and label general commonalities in their reactions to stressful situational events.

Self-sufficiency Training: parents break down their reactions to specific stressful events to find practical solutions.

PEER INTERVENTIONS

Social Group Work with Peer Group:

Three subtypes of conduct disorder have been defined.

1. undersocialized – aggressive or solitary aggressive is characterized by difficulty in interpersonal areas and has been associated with peer rejection and poor social skills.
2. socialized-aggressive or group aggressive is identified with delinquent behaviors carried out in a group context.
3. undifferentiated.

Social relationships are always interactive. Probably the most pervading and important of all the affectional systems in terms of long-range personal-social adjustment is the peer group [Harlow – 1974]. Rejection by the normal peer group not only deprives a child of such learning experiences, but often leaves the child only negative [deviant] peer groups within which to grow and learn social affiliation. Since children with antisocial behaviors are most often removed from valued settings and placed in special settings with other children with similar problems in living, this process is formalized by the helping systems. Group work with the natural peer group can help that group learn how to accept and socialize the antisocial child while helping the child deal with the need to belong and the change required. Work with the resultant group can help all members learn appropriate social interactions and identify their own underlying value systems.

Social group workers [MSW] are required to provide such services. The best place for natural peer group support is in a neighborhood or community center, settlement house, boys club, etc. Obviously work with the resultant group, if caused by human service intervention, lies with the organization that is serving the child.

ACADEMIC CONCERNS

We should not overlook the concern with academics. While Tremblay and his colleagues [1992] found poor academic achievement to be a significant variable in a causal path between early disruptive behavior and later delinquent personality, such causal relationships remain unclear. Regardless of the nature of the causal relationship associated with achievement and conduct disorder, their connection is well demonstrated and has important implications.

School variables long have been associated with delinquency and conduct problems [McGee, Share, Moffitt, Williams, & Silva, 1988] and recently have received attention in theoretical models of the development of antisocial behavior, delinquency and, conduct disorders [e.g., Hawkins & Weis, 1985]. Antisocial and delinquent behavior has been related to poor academic performance [Frick et al., 1992; Hinshaw, 1992; Tremblay et al., 1992], as well as to low school participation and disruptive behavior in the classroom [Finn, 1998; Rincker, 1990; Walker, Stieber & Ramsey, 1990, 1991]. Although causal linkages remain unclear, Tremblay and colleagues [Tremblay et al., 1992] found poor academic achievement to be a significant variable in a causal path between early disruptive behavior and later delinquent personality.

Teachers, as human beings, respond to the information that they receive from other people. Since much of the information received from a child with a conduct disorder is antisocial, it is difficult for the best of teachers to refrain from responding in kind, therefore, reinforcing the cognitions of the student that they are unliked and unlikable.

In addition, such students are typically poor readers and have weak participation in school. Reading skills are critical to all other school achievement and the weak participation may be directly related to the inability to function successfully. Any comprehensive effort at ameliorating conduct disorders must be concerned with a focus on this vital skill. When a cognitive deficit [the belief that one is unworthy and unlikable, that other people are hostile toward you, and that there is no future] is present, it is reasonable to expect that all skills dependent on that cognitive ability will be hindered to at least some degree.

Operating on the central assumption behind our approach, that conduct disorder is acquired and maintained primarily through social learning processes, we can extrapolate the maintenance of behavior to the adults in the school who respond by attempting to control and/or punish the antisocial child.

The conduct disordered child is a difficulty for the school, which can justify that removal of the child will benefit the rest of the children. The act of removal, however, reinforces the maladaptive thoughts of the child. It is this cycle of social reinforcement that must be stopped if the chronicity of conduct disorder and the continued infection of children is to stop. On this basis, school personnel become justifiable as a tertiary client. While there is no responsibility to deal with individual personal difficulties of this clientele, there is a responsibility to influence the behavior of school personnel in regard to the child.

School Interventions

It is important to note that the school can be encouraged to accept help, but cannot be coerced to do so. While it is true that no help can be offered to any client without the sanction of that client, the school as a separate institution has its own requirements that must be met. Therefore, it is important to enter into relations with the school in a formal way, with a contractual agreement and full understanding of the roles and functions of school and clinical personnel [See In-School Home & Community Services: A Handbook for Cognitive Behavior Mentors]

• provide a basic understanding of the fundamental assumption and theory of change.
• provide specific teacher interventions that are specifically designed for the target child and provide training on the implementation of these interventions.
  • scripted attributions
  • behavior plans
• Provide general teacher interventions that may be used by teachers with the entire class.
  • assertive discipline
  • cognitive modeling
  • self-management
  • reality training
  • systematic desensitization
  • token system
  • social skill training
  • ‘time out’ with Individual Behavior Learning Packets
• Provide modeling of the techniques.
• Provide curriculum resources
  • social skills [Goldstein]
  • emotional learning [PATHs}
  • Esteem Builders
  • Interpersonal Cognitive Problem Solving
  • cognitive restructuring [Options]
  • Thinking, Feeling, Behaving [Vernon]
  • depression [Penn Optimism Program]

CLINICAL CONCERNS

All of the interventions listed are based on a fundamental assumption that a person is literally what s/he thinks and character is the complete sum of all thoughts. Acceptance of such an assumption requires that the clinician understand that traditional techniques send messages and cause thoughts or support belief systems that are not particularly helpful to cognitive change. Language control is required as well, for language is one of the wonders of the natural world. “You and I belong to a species with a remarkable ability: we can shape events in each other’s brains with exquisite precision. Simply by making noises with our mouths, we can reliably cause precise new combinations of ideas to arise in each others minds. [Pinker, 1994] Thus, clinicians will need particular training in the use and abuse of language and a sensitivity as to what combination of ideas we intend.

Additionally, children with antisocial behaviors and particularly their families are often seen as resistive to help. Researchers have found a correlation between such resistance following specific therapist behaviors. Moreover, certain therapist behaviors have been shown to significantly affect the probability that a parent will respond with resistance [Alexander et al, 1976; Chamberlain & Baldwin, 1987; Chamberlain et al, 1984; Chamberlain & Ray, 1988]. Clinicians need to receive training in supporting and reframing interactional techniques.

Since working with resistant families and children with problem behaviors is rather tedious work, it is also recommended that a weekly staff support group be convened to help maintain the enthusiasm required to interact effectively.