The prevention and early intervention of conduct disorder

Author: Narelle Smith, 2005

The DSM-IV-TR classifies Conduct Disorder under the Disruptive Behaviour Disorders alongside Attention Deficit/Hyperactivity Disorder and Oppositional Defiance Disorder. The diagnostic criteria for Conduct disorder is a repetitive and persistent pattern of behaviour which violates the basic rights of other people or society’s norms and rules (American Psychiatric Association, 2000, cited in Sadock & Sadock, 2005). There is the presence of three or more of the following behaviours in the past twelve months with at least one behaviour present in the last six months:

  • Aggression to people and animals

Bullying, threatening or intimidating; initiating physical fights; using a weapon and causing physical harm to others; physically cruel to people or animals; stolen from and confronted a victim; sexual assault

  • Destruction of property

Setting fires; deliberate destruction of other’s property

  • Deceitfulness or theft

Breaking into another’s house, building or car; lying to obtain goods or favours; stealing items of value without confronting a victim

  • Serious violation of rules

Staying out at night against parent’s wishes, before the age of thirteen years; running away from home overnight at least twice, or running away once and not returning for a lengthy period; truancy from school before thirteen years of age; clinically significant social, academic or occupational impairment.

The childhood-onset type of conduct disorder requires at least one of the above criterion prior to the age of ten years (ibid). The adolescent-onset type is specified by an absence of any criteria prior to ten years of age.

The multiple parent and family risk factors for a child developing conduct disorder include (Kazdin, 1998 cited by Davis et al., 2000; Dadds, 1997 cited by Davis et al. 2000; Sawyer et al., 2000; Morrell & Murray, 2003): pregnancy and birth complications; postnatal depression; unresponsive and insensitive parenting; parental psychopathology, criminality and substance abuse; punitive, coercive and inconsistent punishment; poor parental supervision of children; marital discord and domestic violence; step/blended families and sole parent families; large numbers of children in the family; a sibling with antisocial behaviour; and socioeconomic disadvantage (poverty, unemployment, poor housing, social isolation).

.

Conduct disorder accounts for up to fifty per cent of referrals for psychiatric services (Kazdin 1985, cited in Davis, Martin, Kosky, & O’Hanlon, 2000). The behaviours of conduct disorder can vary in both frequency and severity, and they need to be pervasive across all environments and affect the child’s social functioning. Conduct disorder is rarely diagnosed in children younger than six years old (Davis et al, 2000). Children younger than six years of age with disruptive behaviours are usually diagnosed with Oppositional Defiance Disorder and/or Attention Deficit Hyperactivity Disorder (ibid). The long-term psychosocial outcomes for children diagnosed with conduct disorder in middle childhood are criminal activity, poor mental health, substance use, and dysfunctional relationships (Fergusson, Horwood & Ridder, 2005).

In the general population, the incidence of conduct disorder for children aged six to twelve years is 4.8 per cent of boys and 1.9 per cent of girls (Sawyer, Arney, Baghurst, Clark, Graetz, Kosky, Nurcombe, Patton, Prior, Raphael, Rey, Whaites,  & Zubrick, 2000). In young people aged thirteen to seventeen years, boys with conduct disorder are 3.8 per cent and girls are 1 per cent (ibid). Boys are four to five times more likely than girls to develop conduct disorder, however there are concerns that conduct disorder in girls is not recognised and treated early due to the tendency of girls to develop internalising behaviours (anxiety, depression, somatisation) as opposed to externalising behaviours in boys (Keenan, Loeber, & Green, 1999).

The pathway for young children in developing conduct disorder begins with aggressive and oppositional behaviours (Davis et al, 2000). The risks for the progression of conduct disorder are dependent upon the interactions between the individual child, the parent and family, and social contexts such as childcare, school and community. The continuum and severity of the disorder depend on the age of onset, the breadth of the settings in which the behaviour is displayed, the frequency, intensity and diversity of the behaviours, characteristics of the child and family, and the presence of ADHD (Webster-Stratton, 1997, cited by Davis, et al., 2000).

The sensitive period for developing problems is younger than two years (Morrell & Murray, 2003). Up to four months of age, infant behaviour is flexible to differing environments and can accommodate unresponsive and insensitive parenting, but begins to decline thereafter. Morrell and Murray (2003) assert that an emotionally dysregulated infant at nine months of age is positively correlated to disruptive behaviours at the age of three years. This research has implications for policy on the prevention and early intervention with families with high psychosocial risk, and also for child protection authorities working with birth families.

Parents’ internal working model and regulation strategies influence how they behave with their children and this shapes or reinforces the child’s internal working model (Keiley, 2002). A parent with avoidant tendencies will be a bully – controlling, rejecting, angry, and emotionally unavailable or will use emotional withdrawal as a strategy, and will be conflictual (ibid). A parent with ambivalent tendencies will be easily victimised by the child – dependent, unresponsive, submissive, neglectful, and inconsistent (ibid). Both of these insecure styles lead to disruptive behaviour in children.

Longitudinal studies demonstrate that the early detection and intervention of disruptive behaviours in early childhood is the most effective way of preventing and treating conduct problems (Davis et al, 2000; Sanders et al, 2000). Children at risk of developing conduct problems must be identified early before they become established in a cycle of aversive behaviour followed by rejection (from parents, carers and peers) which leads to further aversive behaviour (Keiley, 2002). Programmes that commence when the child’s behaviour first comes to notice and target the multiple contexts (family, peers, childcare, school, community) and domains (affective, behaviour, social, achievement, problem-solving, coping and competence) in which the child interacts have prospects for greater success than singular interventions (Davis et al, 2000).

Dadds (2005) reports success in redirecting children from a developmental pathway of conduct disorder with the Griffith Early Intervention Program (GEIP). The programme incorporates social learning theory, attachment theory, family systems theory and cognitive/attributional theory to address family dynamics. Parenting strategies for working with families experiencing early onset conduct disorder encompass (ibid): positive involvement; rewards for prosocial behaviour; secure attachment; effective discipline strategies; modelling of non-aggressive interpersonal style; monitoring the child’s activities; and positive social engagement.

Family therapy models that have proven effective in treating families experiencing conduct disorder are Functional Family Therapy and Multisystemic Family Therapy (Keiley, 2002). Functional Family Therapy focuses on parenting skills, and family cohesion, organisation, and relationships. Multisystemic Family Therapy devises individual treatment plans, analyses the family’s resources and deficits, and is centred in the family’s home. Home-based interventions have the benefit of working with the family in their own environment and providing interventions as difficulties arise.

Due to the ongoing nature of family dysfunctional patterns, children’s needs may extend beyond the prevention and early intervention phases to ongoing treatment and continuing care on the mental health intervention spectrum (Mrazek & Haggerty, 1994, cited by Commonwealth Department of Health and Aged Care, 2000).

Childcare is used as a form of respite for families needing a break from the ongoing demands of young children in their care. However, it is also in these settings that children can be isolated and stigmatised further if childcare staff and management are not aware of the effects of early childhood abuse and neglect on the presentation and behaviour of children. Childcare workers are at risk of misinterpreting children’s communications and behaviours and reinforcing a child’s internal working model of incompetence and unworthiness. The lower child to staff ratios, flexible care and learning environments, inclusive practice, emphasis on partnerships with parents, and learning plans based on the child’s individual needs, in a high quality early childhood setting are conducive to early intervention for children with disruptive behaviours prior to the transition to a more structured school environment.

Based on the Circle of Security model (Marvin, Cooper, Hoffman & Powell, 2002) the Benevolent Society and Kindergarten Union (Swan & Dolby, 2003) implemented a programme in socioeconomically disadvantaged areas whereby childcare staff were trained to recognise the underlying needs of children’s behaviours and were supported by a family therapist to act as a secure base for the children. Parents were also offered information, parent training and support from the family therapist.

The Incredible Years programme for young children diagnosed with oppositional and conduct problems (Webster-Stratton & Taylor, 2001) is a targeted intervention using small groups to teach children about emotion, empathy, friendship, communication, anger management, problem solving and achievement. It also has a parent and teacher training component. The Learning, Enjoying, Growing, Support model, used the Incredible Years programme for parents in conjunction with a children’s play and social skills group, and transition to school component, targetting families with young children who were at risk of developing conduct disorder (Hourihan & Hoban, 2004). Families were referred from community services and family support services, and the programme was run in community facilities. At the end of the programme, families received follow-up support from family support services.

Children with conduct disorder are also at risk of school failure. The difficulties described above with childcare workers miscuing children’s emotional needs and behaviours can also occur in the school environment with teachers, aides, and administration staff. The Incredible Years also has a programme for primary school aged children, parents, and teachers.

Aussie Fast Track (Huggett, Skesteris, & Lawson, 2002) is an intervention for school age children with conduct problems incorporating a universal level classroom program (Pathways Towards Alternative Thinking Strategies – PATHS), social skills training, academic tutoring in reading, parent training and a home visiting programme that has proven to be effective in supporting children to achieve social and educational competencies.

Young people who are displaced from family may find themselves placed in substitute care or a residential facility. Many residential facilities are short-term placements due to the trend away from institutionalised settings for young people. Residential care workers and management are required to implement a programme that will train the young person to develop prosocial behaviours to support their transition into the birth family or to a foster family. The stop-gap model of residential treatment (McCurdy & McIntyre, 2004) is a short-term intervention involving behavioural assessment and support planning, academic and social skills interventions, anger management and coping skills training, and intensive case management. Residential care workers are trained to implement the programme to work with the child in the residential setting rather than employ external professionals who have greater distance from the child’s everyday needs. Prior to discharge of the young person, their family receives parent training. The programme has demonstrated effectiveness in shortening the young person’s stay in a residential facility and greater prospects for reintegration into family life.

The promotion of long-term mental health outcomes for children and young people and the links with early environment and parenting, need to be widely distributed, recognised, and integrated into health policy and procedures to ensure child and family focused practices which are both supportive and timely. This requires the education of parents on: the causal links between child disruptive behaviour; conduct disorder; positive parenting skills; and family environment. The potentially pervasive nature of Conduct Disorder requires a multi-pronged and collaborative approach involving the child, family, childcare centre, school, community services, etc., to achieve greater mental health outcomes, competence, and capacity for the child and family. The components of successful programmes have been highlighted to facilitate understanding of evidence-based supports and treatment options.

REFERENCES

Commonwealth Department of Health and Aged Care. (2000). Promotion, prevention and early intervention for mental health: A monograph. Canberra ACT: Commonwealth Department of Health and Aged Care, Mental Health and Special Programs Branch.

Dadds, M. R. (2005). Treatment of Conduct Disorder via parent training: Innovation and process. Lecture presented on 15 August 2005. Westmead NSW: The Children’s Hospital at Westmead.

Davis, C., Martin, G., Kosky, R., & O’Hanlon, A. (2000). Early intervention in the mental health of young people: A literature review. Commonwealth of Australia: Department of Health and Aged Care.

Fergusson, D. M., Horwood, L. J., & Ridder, E. M. (2005). Show me the child at seven: The consequences of conduct problems in childhood for psychosocial functioning in adulthood. Journal of Child Psychology and Psychiatry. 46(8), pp 837–849.

Greenberg, M. T., Domitrovich, C., & Bumbarger, B. (2001). The prevention of mental disorders in school-aged children: Current state of the field. Prevention and Treatment. 4(1), March 2001.

Hourihan, F. & Hoban, D. (2004). Learning, enjoying, Growing, Support model: An innovative collaborative approach to the prevention of Conduct Disorder in preschoolers in hard to reach rural families. Australian Journal of Rural Health, 12, pp. 269-276.

Huggett, K., Skesteris, B., & Lawson, C. (2002). Aussie fast Track. The prevention of childhood Conduct Disorder: A cross agency community approach. Kelmscott WA: Child and Adolescent Mental Health Clinic.

Keenan, K., Loeber, R., & Green, S. (1999). Conduct Disorder in girls: A review of the literature. Clinical Child and Family Psychology Review. 2(1).

Keiley, M. (2002). Attachment and affect regulation: A framework for family treatment  of Conduct Disorder. Family Process. 41(3), pp. 477-487.

Kemp, L. (2005). Antenatal risk…postnatal intervention: What’s the link? Presentation on the Miller Early Childhood Sustained Home Visiting programme, at the New South Wales Institute of Psychiatry, Parramatta. 2nd August 2005.

Marvin, R., Cooper, G., Hoffman, K., & Powell, B. (2002). The Circle of security Project: Attachment-based intervention with caregiver-preschool dyads. Attachment and Human Development. 4(1), pp. 1-17.

McCurdy, B. L. & McIntyre, E. K. (2004). ‘And what about residential . . . ?’ Re-conceptualizing residential treatment as a stop-gap service for youth with emotional and behavioral disorders. Behavioral Interventions. 19, pp. 137-158

Morrell, J. & Murray, L. (2003). Parenting and the development of Conduct Disorder and hyperactive symptoms in childhood: A prospective longitudinal study from 2 months to 8 years. Journal of Child Psychology and Psychiatry. 44(4), pp. 489-508.

Sadock, B. J. & Sadock, V. A. (2005). Kaplan & Sadock’s comprehensive textbook of psychiatry. 8th ed. Philadelphia: Lippincott Williams & Wilkins.

Sanders, M. R., Markie-Dadds, C. & Turner, K. M. T. (2003). Theoretical, scientific and clinical foundations of the Trple P – Positive Parenting Program: A population approach to the promotion of parenting competence. University of Queensland: Parenting and Family Support Centre.

Sawyer, M. G., Arney, F. M., Baghurst, P. A., Clark, J. J., Graetz, B. W., Kosky, R. J., Nurcombe, B., Patton, G. C., Prior, M. R., Raphael, B., Rey, J., Whaites, L. C.,  & Zubrick, S. L. (2000). The mental health of young people in Australia: Child and adolescent component of the National Survey of Mental Health and Wellbeing. Commonwealth of Australia: Mental Health and Special Programs Branch, Commonwealth Department of Health and Aged Care.

Sharp, S. (2001). Peer-led approaches to care. Pastoral Care. December 2001.

Swan, B. & Dolby, R. (2003). The first five years: Strengthening relationships in the preschool setting. Developing Practice, Autumn 2003, pp. 18-23.

Advertisements

About Narelle Smith

Child & Family Worker

No comments yet... Be the first to leave a reply!

Leave a Reply

Fill in your details below or click an icon to log in:

WordPress.com Logo

You are commenting using your WordPress.com account. Log Out / Change )

Twitter picture

You are commenting using your Twitter account. Log Out / Change )

Facebook photo

You are commenting using your Facebook account. Log Out / Change )

Google+ photo

You are commenting using your Google+ account. Log Out / Change )

Connecting to %s

%d bloggers like this: