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Teaching Parents Strategies for Difficult Teens
Difficult Teens continuing education MFT CEUs

Section 20
The Treatment of Disruptive Behavior Disorders

CEU Question 20 | CEU Answer Booklet | Table of Contents | Parenting
Counselor CEUs, Psychologist CEs, Social Worker CEUs, MFT CEUs

Treatment of disruptive behavior disorders seems to be the least researched in terms of gender differences. This is unfortunate due to the evidence that women have their own needs and preferences in counselors and that not all counselors are best suited to counsel women (Hanna, Hanna, Giordano, & Tollerud, 1998). No research could be found on treatment programs designed specifically for girls with ODD or CD, whereas several included boys only. Despite this lack of gender-specific information for treating girls, many programs seem to be applicable to both sexes as long as the counselor is sensitive to gender differences that have been reported in the literature up to this point. Among the interventions used with children are psychotherapy; medication; home, school, and community-based programs; residential and hospital treatment; and social services (Kazdin, 1995). Kazdin indicated that caution is necessary in selecting the most appropriate intervention. He alluded to this when he stated that all of the treatments are "well intentioned," with most being reasonable and "appealing to common sense," but that most of them have "no evidence in their (children's) behalf" (p. 77). The individual must be considered when choosing a treatment plan. No one treatment method is going to cure every person with a particular disorder. Thus, it is important to provide a broad spectrum of interventions whenever possible. We emphasize that this population can derive benefit from group, family, and individual counseling and should receive as much as possible in all of these modalities (Hanna, Hanna, & Keys, 1999). In addition, many families should be linked with community resources whenever appropriate.

The Therapeutic Relationship
A major consideration when working in any context with defiant, aggressive adolescent girls is the establishment of a therapeutic relationship based on mutual respect. There is a large amount of research supporting an empathic relationship as a vital aspect of counseling (e.g., Orlinsky, Grawe, & Parks, 1994; Sexton & Whiston, 1994). Perhaps more to the point, Hanna et al. (1999) suggested that this is the key to any consistent work with this population and that the relationship may be more important with this group than with adults. In our experience, adolescents will not easily disclose if they do not feel understood--the essence of empathy (Van Kaam, 1966). They also noted the importance of managing countertransference with defiant and aggressive adolescents.

Adolescent girls and boys have a way of evoking irritation, disgust, anger, resentment, sympathy, feeling defeated, and many other emotions in counselors (Church, 1994). Although these feelings--in themselves--are perfectly acceptable, giving in to them and acting on them is a major error that leads to ineffectiveness with these clients. Research has suggested that the difference between a mediocre and an effective counselor is the ability to manage these feelings of countertransference (Van Wagoner, Gelso, Hayes, & Diemer, 1991). One of the most damaging consequences of failing to manage countertransference is the harm brought to the relationship. It is also important to attend to the projective process through which clients can attribute emotional characteristics "onto" and "into" the counselor, which then become played out by the counselor in turn (Ginter & Bonney, 1993).

Without a viable therapeutic relationship, even simple counseling techniques may not be effective (Hanna et al., 1999) because the ODD or CD client may view techniques as adult manipulation threatening to undermine her or his freedom and independence. In some cases, the counselor must alter his or her usual routines to take into account a client's needs. For example, with hyperactive clients it is helpful to get out of the office and talk to them while walking through halls or around the building. This method is much more suited to interaction with these clients and seems to allow them to disclose more comfortably and easily, free of the constraint of having to sit still in a chair. Whatever it takes, establishing a strong empathic relationship is the first order of business and paves the way for future success.

Cognitive Problem Solving
Once the relationship has been established, an approach that has proven successful is cognitive problem-solving skills training (Kazdin, 1995). This method examines thought processes and interpersonal cognitive problem-solving skills related to social behavior. Kazdin noted the use of modeling, practice, rehearsal, and role-play applied to interpersonal situations in order to find solutions to problems in this form of therapy. The focus in cognitive problem-solving skills training seems to be more on the process not the product of behavior. Kazdin also stated that several studies have shown that this approach leads to therapeutic change and therefore makes it highly promising. However, components of this treatment might be more appropriate for older children than for younger children. Clark et al. (1993) reported that preschoolers' cognitive processes might not be developed enough to actively conceptualize and initiate self-modeled behavior. However, children in the fifth and sixth grades have responded to cognitive and social skills approaches in the prevention of depression (Gillham, Reivich, Jaycox, & Seligman, 1995).

Social Skills Training
Another treatment approach for this population is social skills training. Frankel, Myatt, and Cantwell (1995) discussed the effectiveness of social skills training in increasing the popularity of children who were least accepted by their peers. This acceptance would be likely to promote more "normal" behavior in children and less aggressive acts. This study included only outpatient boys in Frankel et al.'s brief social skills training program. It did, however, yield significant immediate improvements according to the reports of parents and teachers. It seems probable that such a program would be beneficial to girls as well, as long as attention is paid to differences in the ways girls and boys manifest symptoms (and the reasons such symptoms may be expressed differently). Related to social skills training is assertiveness training (Alberti, 1977), which we have found to be helpful in teaching clients who are oppositional to learn to assert their own rights and interests without being aggressive or overwhelming. This seems especially helpful when done in group counseling (Ohlsen, 1970).

Parent Training
Parent training seems to be an important component in several treatment programs. Frankel et al. (1995) included the training of parents to act more like parents of popular children in their social skills training program (as cited in Frankel et al., 1995, Park & Ladd found that parents play important roles in children's relationships with peers, including direct intervention and social networking). Parent management training is a program used to train parents to alter their child's behavior in the home (Kazdin, 1995). The principles of this approach are based on the belief that disruptive behaviors stem from and are sustained by maladaptive interactions between parent and child (Kernberg & Chazan, 1991). Kazdin reported that this is "probably the best researched therapy technique" (p. 84) for children and adolescents with CD and that it has proven to be quite effective. It is suggested that this approach is more effective with younger children than with adolescents (Kazdin, 1995).

Family Systems
Family systems counseling is a treatment option that seems logical in the case of disruptive behavior disorders because not only the child is affected by his or her behaviors but also the family members and peers are affected. It takes into account the idea that parental factors and parent-child interactions affect the likelihood of conduct problems. One form of systems approach is "functional family counseling." This approach addresses the "clinical problem from the relational functions it serves within the family" (Kazdin, 1995, p. 87). Kazdin stated that an increase in positive reinforcement and reciprocity in family members is the main goal of therapy. Another systems approach to treatment of behavior disorders is multisystemic therapy. Kazdin noted that this type of treatment could be viewed as "a package of interventions that are deployed with children and their families" (p. 90). Studies with extremely aggressive and antisocial youths have shown multisystemic therapy to be superior, decreasing behavioral and emotional problems and increasing family functioning (Kazdin, 1995). Systems counseling seems to take the many facets of disruptive behavior disorders into account and to treat them as a whole, not as separate pieces of a problematic puzzle.

One of the most difficult challenges in family systems approaches is procuring the involvement of the father or male guardian. Hecker (1991) addressed this issue by listing various ways to involve fathers. Among them were making a special effort to join with fathers, pointing out the importance of the father's participation for change in the family, educating the father about the benefits of counseling, normalizing the father's lack of enthusiasm, and challenging the father's priorities. The father (or male guardian) may prove especially important considering the way male and female (e.g., mother) caretakers differ in what they consider to be problematic, based on the gender of the child or adolescent.

Unfortunately, there are many instances when a family as a whole does not become involved in the child's or adolescent's counseling. This can happen for various reasons, such as drug use by parents, criminal involvement by parents, battering or other abuse of a female head of household by male sexual partners, or other high stress situations. In such cases, a counselor can use role-plays and empty chair work representing the absent family members. We have found that this approach can be quite helpful in exploring issues and working through family relationship problems.

Wenning, Nathan, and King (1993) reported the increasing emphasis in the literature on multimodal approaches to treating children with disruptive behavior disorders. Such approaches incorporate psychodynamic, psychoeducational, and family systems perspectives on children's behavior. One such program (Grizenko, Papineau, & Sayegh, 1993) was created as a day treatment program that integrated play therapy; social skills and task groups, psychodrama, pet, art, occupational; and group therapies; as well as weekly integrative family therapy sessions. Children who attended the program had significantly fewer maladaptive externalizing and internalizing behaviors than those in the control group at the completion of treatment, as well as higher self-esteem, less depression, and improved future outlook. Multimodal treatment seems to provide one safety net after another so that if one approach is not successful with an individual, a backup will be right there to "catch" the child. With such a variety of therapy formats, it seems almost impossible for a client not to be helped in some way.

The Use of Supportive, Positive Reframes
However, given the delicate self-esteem issues that most clients with ODD and CD display, it is extremely important to use supportive reframes in any context, whether in individual, group, or family counseling. Providing positive, noncritical new perspectives on negative behaviors with these clients is extremely important. This approach requires that even the most manipulative and annoying behaviors be reframed positively. The purpose of this is to supply the child or adolescent with a way of looking at their behavior that is not in the context of being a worthless or "bad" person. Examples of reframes can include suggesting to a girl who self-directs her aggression that she must be a good person because she is not directly hurting others. A girl who is highly defensive is merely protecting herself from more hurt. A manipulative, controlling girl is displaying many of the skills of an executive or manager but using those skills in a selfish way, which could be redirected. Similarly, we have found that influential adolescents and children with ODD and CD who take over and sabotage groups can often be recruited as assistant group leaders by informing them that they must be natural leaders and that they could use their leadership qualities to help as well as hinder. In a large number of cases we have found that this approach works well in restoring order to a group.

It is unfortunate that the information available on treatment approaches tends to exclude girls and often does not account for gender differences in results when girls were included. It seems likely that all of the aforementioned treatment plans could work with girls, but research has provided little direction as to which approach would be best suited for girls. However, it is safe to assume that the sensitive, relationship-oriented systems therapy approaches would be more successful with girls because they seem to be more relationship-oriented than boys (Jordan, Kaplan, Miller, Stiver, & Surrey, 1991). Similarly, women in general seem to especially value a counselor with highly developed relationship skills (Hanna et al., 1998). Regardless of gender, however, it is important to note that there are various treatment methods that can be applied to adolescents and children with conduct problems. Being sensitive to individual client needs, whether those needs are gender related or not, will enhance the probability of successful treatment.

Summary
Although there may be similarities in causal factors, diagnosis, and treatment of boys and girls with disruptive behavior disorders, it is clear that little attention has been given to these facets of behavior disorders in girls. Without substantial equitable research, it is more difficult to accurately diagnose and treat girls with ODD and CD. Some may believe that it is not as critical to research girls with aggressive and antisocial behaviors because the boy-to-girl ratio for CD (assuming accurate diagnosis) is 2 to 1 and as much as 3 to 1 (Atkins et al., 1996). However, when one considers even the prevalence rates of 4% to 9% of their age groups and the tragic results that many of these girls face, this amounts to thousands of girls who potentially could be better served by counselors. The central theme of this article has been to point out that to more fully comprehend the gender differences existing within these two behavior disorders, girls must be included in future studies. The diagnosis and effective treatment of these disorders will suffer until this situation has been remedied.
- Kann, Traci & Fred Hanna; Disruptive behavior disorders in children and adolescents: how girls differ from boys; Journal of Counseling & Development; Summer 2000; Vol. 78; Issue 3.
The article above contains foundational information. Articles below contain optional updates.

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Personal Reflection Exercise #6
The preceding section contained information about various factors affecting parent roles.  Write three case study examples regarding how you might use the content of this section in your practice.

Online Continuing Education QUESTION 20
Why are certain components of “cognitive problem-solving” more appropriate for older children than for younger children? Record the letter of the correct answer the CEU Answer Booklet.

 
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The article above contains foundational information. Articles below contain optional updates.
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