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Conduct Disorders: Assesssment & Diagnosis
Conduct Disorders continuing education psychologist CEUs

Section 18
Five Guidelines for Interventions with Conduct Disordered Youth

CEU Question 18 | CEU Answer Booklet | Table of Contents | Conduct Disorders
Psychologist CEs, Counselor CEUs, Social Worker CEUs, MFT CEUs


Guideline 1: Interventions Need to Address the Biological Characteristics of the Child
Interventions focused primarily on the environment of the family and child have been criticized because they have not addressed the underlying biological characteristics of the child. Clarke and Clarke (1988) pointed family and child Conduct Disorders psychology continuing educationout that a prevailing popular belief is that "there are no problem children, only problem parents" (p. 16). This assumption leads the school social worker away from assessing problems of a biological nature in the child. Recent research addressing this issue of biology versus environment has focused on determining who is causing the dysfunctional relationship--that is, who owns the problem, the child or the parent (Lytton, 1987, 1990).

This issue is of particular significance to the school social worker, because historically, the social work profession has been criticized for a "blame the parent, remove the child" philosophy that characterized the child-saving movement of the early 1900s (Costin, 1985). The ideology of the era declared that children needed to be saved from their "bad" environments, with parents considered to be the source of their children's problems (Petr & Spano, 1990). In addition, the unique social work focus on person-in-environment has led to an overemphasis on the person with the neglect of the environment or vice versa, with the pendulum swinging according to the latest theories.

Researchers in the field of child development emphasize that underlying biological factors contribute to the development of conduct disorders in children far more than the environment alone (Lewis, 1990; McCord & Tremblay, 1992). These underlying characteristics are defined as biopsychosocial vulnerabilities (Lewis). Unfortunately, the underlying pathology in the child is often overlooked because the child's behavior is so upsetting to parents, counselors, and professionals (Lewis; Lytton, 1990).

Aggression is an example of a temperamental factor that is integral to the conduct disorder diagnosis. Olweus (1979) found that aggressiveness in children is a highly stable personality trait across settings and comparable to intelligence quotient in terms of stability. Other researchers support this finding (Kazdin, 1987; Loeber, 1982; Quay, Routh, & Shapiro, 1987). In addition, Margalit and Shulman (1986) found a developmental delay in boys diagnosed with conduct disorder in regard to behavioral control and inhibition of aggression. Their study suggested that aggressiveness is caused by slow maturation. A gap existed between expected behavior and the boys' ability to control their behavior. This gap created frustration that led to "acting out" behavior.

These findings support the idea that the biological characteristics of the child drive the relationship. The child's aggressive temperament, as well as his or her unresponsiveness to parenting strategies, may exhaust the parents so that they become more permissive of the child's behavior, serving to increase the child's aggressiveness. It may appear that it is the parenting style causing the problem, but the parent is merely responding functionally to the child's aggressive temperament expressed through aggressive behavior. Patterson (1974) referred to this as the "coercive spiral."
In addition to temperament, neurological difficulties such as hyperactivity have been the focus of numerous studies of conduct disorder. A 60 percent overlap was found in the diagnoses of attention deficit hyperactivity disorder (ADHD) and the conduct disorder diagnosis, with the overlapping characteristics being inattentiveness, impulsivity, and overactivity (Farrington, Loeber, & Van Kammen, 1990). Studies that follow children from the early years to late adolescence indicate not only that the prenatal, postnatal, and perinatal environment is an indicator of future conduct disorder, but also that children identified as hyperactive in childhood are more likely to be diagnosed with adolescent conduct disorder (Lambert, 1987; Lewis, 1990).

Studies of the psychiatric functioning of children and adolescents diagnosed with conduct disorder indicate that clinical depression, psychosis, and anxiety disorder are prevalent in this population (Lewis, Pincus, & Lovely, 1987; Robins, 1966). Research has indicated an exceptionally high correlation (.73) between conduct disorder and depression (Cole & Carpentieri, 1990; Marriage, Fine, Moretti, & Haley, 1986). Identification of both disorders is also important because of the possibility of the use of a pharmacological intervention to treat the disorder. Research has shown that when medication was used to treat depression, conduct problems remitted, only to reoccur when medication was withdrawn (Marriage et al.). DuPaul and Barkley (1992) also investigated the efficacy of medication with children identified with ADHD and diagnosed conduct disorder. They found that counselors and parents responded more positively when the child was on medication.

Guideline 2: Interventions Need to be Multimodal
There has been extensive research in the field of child development that focuses on environmental interventions with children who have conduct disorders. As noted in guideline 1, the development of a conduct disorder is an interactive process between the biological makeup of the child and his or her environment. As children grow up, they increasingly interact with more systems that influence their development outside of the family, such as peers, the school system, and community facilities. Kazdin (1997a) noted that interactions are dynamic rather than static, thereby contributing to the complexity of treating the disorder as the child grows older.

Traditionally, parent interventions and school interventions have taken place separately. Ramsey, Patterson, and Walker (1990) studied the generalization of child behavior from the home setting to the school. They found that aggressive behavior in children was consistent in both the home and school settings. They concluded that treatments need to be delivered in more than one setting for effective change to occur. Ramsey et al. recommended that intervention be focused in three primary areas: "teaching family management techniques to parents, decreasing academic deficits, and remediating the peer-related and adult-related interactional social problems of the child" (p. 221). Because of the importance of addressing both the home and school settings, parental involvement is viewed as critical to the success of these interventions. Parents or primary guardians are an integral part of the treatment process and should be involved in all phases, from assessment to intervention and follow-up.

Guideline 3: Interventions Need to be Multisystemic
The following studies point to the importance of multisystemic intervention. A multisystemic intervention is one that takes place in more than one large (macro) system--that is, the school, social services agencies, or corrections and community agencies such as the YMCA. The influence of the schools as a systems variable can be demonstrated in a study conducted by Garmezy (1991). Particular school factors were identified as contributing to better outcomes in the children attending those schools. Schools with equal resources in poverty areas were compared, with findings indicating that there were high-achieving schools and low-achieving schools among this group.

The high-achieving schools demonstrated high expectations for clients, class-based participatory instructional methods, positive management, and disciplinary control. School variables were identified as being an important part of an intervention process that can redirect a child who has antisocial tendencies to a more competent path.
Beyond determining the effects of schools, other systemic factors in the child's life need to be addressed, such as poverty, history of child abuse or neglect within the family, and lack of social support (insularity). Whittaker, Schinke, and Gilchrist (1986) advocated the ecological paradigm and stated that effective programs are those that address skills training and social supports for families.

A treatment program entitled multisystemic treatment (MST) was developed, based on the ecological model, using family systems theory to work with the family and other systems to reduce the delinquent behavior of their child (Henggeler & Borduin, 1990). Others, primarily researchers, in the field identified MST as one of the most promising intervention programs for children with conduct disorders (Kazdin, 1997b; Tolan & Gorman-Smith, 1997).
Aftercare and community resources also are essential in maintaining effective interventions. Many researchers indicate that support systems after treatment have been neglected, although these systems are crucial to maintaining gains (Lewis, 1990; Maluccio & Marlow, 1973; Whittaker et al., 1986). Lewis stated that "it makes no sense to provide a troubled adolescent with sophisticated medical, psychological, and educational assistance while in residence, only to deprive him of these supports following discharge to the community" (p. 208). Maluccio and Marlow reviewed the literature on residential treatment for emotionally disturbed children and found that often the programs lacked a way to involve families in the treatment plan. These programs commonly neglected to provide an aftercare plan and failed to coordinate between various agencies once the child was discharged.

Guideline 4: Interventions Need to Focus on Prosocial Skills with Prosocial Peers
Peer networks are a crucial link in a child's resistance to behavior change. Failing to address the social networks of conduct-disordered youths has been linked to treatment failure for these youths. The research that follows suggests that interventions are successful only if they target peer networks by including prosocial peers in the intervention process.

O'Donnell (1992) studied intervention programs that were not successful to understand why the results were not more positive. He found that what the unsuccessful programs had in common was that they brought delinquent youths together so that they were able to form social networks with other delinquent youths. Friendships formed in the programs were likely to continue when the program ended and contributed to an increase in future antisocial acts rather than a decrease after the intervention. As an example, the Group Guidance Project was targeted toward members of four gangs. Its first attempt at intervention involved dances and group activities at a community center. When negative gang activity increased, the researchers changed the intervention to involve individual treatment, such as helping gang members get jobs or employment training. This approach decreased their gang activity and delinquent behavior. Another example is the work of Chamberlain and Friman (1997) who analyzed a randomized field study that focused on boys in residential care. They found that the more time boys spent associating and being influenced by antisocial peers during treatment predicted the number of serious crimes committed after discharge.

Guideline 5: Interventions Need to Include Cognitive Processing
In addition to the inclusion of prosocial peers, child development research suggests the need to address more than just behavior. Interventions also must focus on the beliefs and the decision-making process of the child. The importance of addressing cognitive processing has been studied extensively by Dodge, although his studies were specific to boys (Dodge, 1986; Dodge & Frame, 1982). His research focused on how the aggressive child interprets environmental stimuli and then acts on them. Dodge (1986) found that the behavior of the aggressive child was related more to an interpretation of the situational stimulus than to the stimulus itself. An example of this is when an aggressive child is bumped by another child by accident. The aggressive child will interpret being bumped as a purposeful act by the other child and respond aggressively. Another example is when a peer is looking at the aggressive child with a neutral facial expression; the aggressive child will interpret that expression as being hostile.

Most often school social workers in elementary schools observe these interactions during recess. During this time children are physically active and less actively supervised; therefore, accidental bumping or balls hitting children are likely to occur, as well as children ganging up to pick on or bully other children. For more detail, Dodge and Schwartz (1997) provided an explanation of the social information-processing model.

Schonfeld, Shaffer, O'Connor, and Portnoy (1988) suggested that the origins of cognitive deficits reside in the learning environment of youths with conduct disorder, not in inherited cognitive abilities. Although this perspective contradicts other research findings cited earlier, it suggests that the child's deficits in cognitive functioning can be improved through environmental intervention. School interventions can address inherent cognitive deficits and deficits that might be attributed to the environment. For example, Arllen and Gable (1992) recommended several school interventions that have been based on the research of Dodge and others that pointed to skill deficits in the child. These interventions share several common elements: teaching anger control, problem solving, and social skill training. In addition, group management systems are taught to the counselors to change inappropriate classroom behaviors. Furthermore, Kazdin (1997b) emphasized that problem-solving skills training programs conducted in schools have documented success, indicated by replicated field studies. Finally, Pepler and Rubin (1991) reported the success of cognitive skills training in inpatient and outpatient settings.

Closely related to a cognitive focus on skills is moral motivation training, advocated by two researchers who attributed the failure of most programs to a lack of attention to the belief systems of youths. These authors based their work on Kohlberg's levels of moral development. Arbothnot (1992) stressed that a cognitive process precedes every antisocial act. If the child is operating from a preconventional level of moral development, he or she may not take into account the victim's perspective and may only view the situation from an egocentric perspective. The results of this research intervention, which focused on moral decision making, demonstrated a significant drop in antisocial behavior in the participants, with these changes maintained at a one-year follow-up. Arbothnot stressed that the reason these programs, which only addressed behavior, failed is that they do not address the adolescent's worldview. Changing the youth's belief system, however, addresses the cognitive processes that permit the immoral and illegal behavior (Arbothnot, 1992). Schulman (1990) also advocated interventions that emphasized teaching adolescents how to behave morally and scrutinize their belief systems.
- Mpofu, Elias and Ralph Crystal, Conduct disorder in children: challenges, and prospective cognitive behavioral treatments, Counselling Psychology Quarterly, Mar2001, Vol. 14 Issue 1, p21-32, 12p
The article above contains foundational information. Articles below contain optional updates.

Personal Reflection Exercise #4
The preceding section contained information about five guidelines for interventions with conduct-disordered youth. Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 18
According to Mpofu, what is the “coercive spiral”? Record the letter of the correct answer the CEU Answer Booklet.

 
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