Conduct disorder is a common childhood psychiatric problem that has an increased incidence in adolescence. The primary diagnostic features of conduct disorder include aggression, theft, vandalism, violations of rules and/or lying. For a diagnosis, these behaviors must occur for at least a six-month period. Conduct disorder has a multifactorial etiology that includes biologic, psychosocial and familial factors. The differential diagnosis of conduct disorder includes oppositional defiant disorder, attention-deficit/hyperactivity disorder (ADHD), mood disorder and intermittent explosive disorder. Family physicians may provide brief, behaviorally focused parent counseling, pharmacotherapy and referral for more intensive family and individual psychotherapy.
Clinical Features of Conduct Disorder
Four types of symptoms of conduct disorder are recognized:
- Aggression or serious threats of harm to people or animals;
- Deliberate property damage or destruction (e.g., fire setting, vandalism);
- Repeated violation of household or school rules, laws, or both; and
- Persistent lying to avoid consequences or to obtain tangible goods or privileges.
Treatments for conduct disorder are designed to decrease or eliminate as many identified problem behaviors as possible in the short-term and also to work towards the long-term goal of preventing children’s behavioral problems from worsening over time (for instance, into a full blown adult Antisocial Personality Disorder). Short-term behavioral interventions designed to address behavior problems with potentially extreme negative consequences (e.g., physical aggression or theft) are usually given more priority than interventions for problems which are less likely to cause wider troubles (e.g., talking back to parents). Multiple treatment modalities are often useful for providing effective treatment. To be successful, therapy for conduct disorder cannot be confined to once-a-week sessions in a therapist’s office (as can many adult-oriented therapies). Instead, close coordination between therapists and parents is important, as is the consistent use of treatment (by parents) during every day family situations.
Behavioral and Cognitive-Behavioral Therapy
Behavioral therapy for children with Conduct Disorder is based on scientifically-derived learning theory. The basic idea is that behavior patterns are in large part learned from exposure to rewards and consequences, and therefore, inappropriate behaviors can be “unlearned”, and replaced by more appropriate pro-social behaviors through the systematic manipulation of rewards and consequences that promote pro-social behavior and discourage antisocial behavior.
Behavioral strategies used during treatment of Conduct Disorder focus on reducing blame (parents often blame themselves for creating the problem in addition to blaming their child), increasing parental monitoring and supervision of children’s behavior (e.g., role-playing, teaching), and on implementing behavioral contracting. In behavioral contracting, a specific agreement is drawn up between caregivers and children. Each behavioral contract describes in explicit detail exactly what behavior changes are desired. For example, a contract designed to reduce disrespectful behaviors might describe multiple ways that disrespect can be conveyed, such as mumbling under one’s breath, talking back, rolling one’s eyes, etc. The consequences for engaging in a disrespectful behavior are spelled out, as are more desirable alternative behaviors and the rewards that will accompany these appropriate behaviors. Though this focus on rewards and punishments can seem totalitarian at first glance, it is actually not that way at all. By spelling out consequences in detail, the behavioral contract actually discourages parent’s tendency to punish arbitrarily, replacing it with a consistently applied program of rewards and punishments that can be clearly anticipated by children.
In addition to addressing specific problem behaviors, therapy also tends to focus on helping parents understand how to be more effective and fair disciplinarians. Parenting skills such as figuring out which minor problematic behaviors to ignore and which to address, giving children clear rather than vague instructions for how to behave, and developing and communicating specific rules are often taught to parents as part of the therapy, as are conflict resolution (problem solving) and communication skills.
Modern behavior therapists recognize that it is as important to address children’s thoughts as it is to address their actual problem behaviors. This is because thoughts can serve a motivating function. If children have a wrong, overgeneralized or otherwise exaggerated understanding of a situation, this can make them more likely to misbehave. Cognitive-behavioral approaches to therapy teach children and parents both to identify and address faulty beliefs that make conflict more likely and to help dismantle and debunk those beliefs.
As a part of cognitive behavior therapy, therapists work with children to help them develop several important cognitive skills, including cognitive reframing of stressful events (e.g., helping children to generate alternative, more peaceful ways of thinking about the meaning of stressful situations so that anger is not an automatic consequence). Anger management training, which generally involves teaching people to better manage frustration feelings by learning to recognize and defuse anger sensations with reframing and relaxation techniques such as muscle relaxation or deep breathing, may also be taught.