Treatment 135 display antisocial conduct have a higher probability of engaging in antisocial behav- iors in adulthood than preschool and elementary school children who do not exhibit antisocial behaviors (Kazdin,1987).
Using a national, representative sample, Goldstein et al. (2006) found that com- pared to persons with adolescent-onset CD, individuals with childhood-onset CD were more likely to show aggression against people and animals and vandalize property before the age of 15. Those with childhood-onset CD were more likely to exhibit violent behaviors throughout their lifetime than those with adolescent- onset CD. Persons with childhood-onset CD were more likely to have a variety of disorders, including lifetime social phobias, generalized anxiety disorder, substance dependence, and personality disorders, such as paranoid personality disorder.
Donovan et al. (2000) showed that adolescent girls with conduct-related prob- lems had a greater likelihood of becoming young, single mothers and to have children with behavioral difficulties at an early age.
Because of the overlap of ODD with CD and the high prevalence of co-existing disorders, especially ADHD, treatment of CDs requires different types of psychoso- cial interventions and psychopharmacology (Kutcher et al.,2004; Maughan et al., 2004; Office of Child and Family Policy, 2008). Psychosocial methods include parent and child training, dyadic skill training, cognitive behavior therapy (CBT), family therapy, multi-system therapy (MST), group therapy, day treatment, and wilderness training. Medication also may be employed under certain conditions, especially to control symptoms related to the behavioral problem or co-existing medical problems. (Please note that all of the interventions mentioned above are discussed in detail further on in this section.)
Behavioral parent training is an effective treatment for parents of children with ODD and CD (Chronis et al.,2004). Parent and child training seek to modify inad- equate parenting, which has been found to be a risk factor for CD and ODD (Office of Child and Family Policy,2008; Conner,1998–2000).
Parent training for families of children with ADHD and conduct-related prob- lems includes training sessions that discuss the characteristics and causes of ADHD and its association with defiant and aggressive behaviors as well as techniques to enhance parenting skills (Danforth et al.,2006).
The Triple P Positive Parenting program, a multi-level parent training program, is designed to prevent and treat severe behavioral, emotional, and developmental difficulties in children aged 0–16 years (de Graaf et al.,2008; Sanders,1999). The program attempts to improve parents’ knowledge, skills, and confidence. The Triple P Positive program takes into account the fact that children experience different levels of behavioral dysfunction and parents may have varying needs in terms of the intervention’s type and intensity. The program is based on social learning principles, child and family behavior therapy, developmental research, and social information- processing models.
The Triple P Positive program offers five levels of intervention (de Graaf et al., 2008; Sanders, 1999). Level 1 offers psychoeducational information on parenting skills to parents who are interested in the intervention. In Level 2, one to two sessions are offered to parents of children with mild conduct problems. Level 3, a four-session program, provides an intervention for children with mild to moder- ate behavioral problems. This intervention also offers parents active skills training.
Treatment 137 In Level 4, parents of children with more severe conduct problems or who are at risk for developing these difficulties receive eight to ten intensive training sessions.
These parent training sessions focus on child management skills and can be pre- sented to individual parents or to groups of parents. Level 5, an enhanced behavioral family intervention, is designed to assist families who have parenting problems that are complicated by other stressors, such as domestic violence and parental depression.
Hahlweg et al. (2010) assessed the effectiveness of the Triple P Positive program using a sample of 280 families randomly assigned to either the Triple P Positive program or control group. At a 2-year follow-up, both the mothers and fathers in the Triple P Positive program had fewer dysfunctional parental behaviors, and moth- ers in the intervention reported more positive parenting behaviors. Mothers in the experimental group also indicated that their children exhibited fewer internalizing and externalizing behaviors. However, single-parent mothers in the Triple P Positive program did not experience changes in parenting behaviors or child behavior diffi- culties. The lack of changes in single-parent mothers and their children may be due to the high positive effects in the single-parent mothers in the control group.
Based on a meta-analysis of 15 studies, de Graaf et al. (2008) evaluated the effectiveness of the Triple P Positive Level 4 intervention. The authors found that the Triple P Positive Level 4 programs limited the children’s conduct problems.
These reductions in the children’s behavior problems were maintained over time and additional improvements occurred in follow-up over the long term.
Sanders et al. (2000) evaluated the effectiveness of the delivery modes of the Triple P Positive Level 4 intervention using a sample of 305 preschoolers at high risk for acquiring behavior problems. Children in Level 5 (enhanced behavioral family intervention), Level 4 (standard behavioral family intervention), and Level 3 (self-directed behavioral family interventions) and those on the waitlist improved in their disruptive behaviors. However, the children in the enhanced behavioral fam- ily intervention (Level 5) and standard behavioral family intervention (Level 4) improved more in parent-observed child behavior problems than children on the waitlist.
Parent–child interaction therapy (PCIT), a family-centered treatment approach, is designed to treat major behavior problems, such as CD and ODD, and ADHD in children aged 21/2to 12 years and dysfunctional parenting behaviors (Child Welfare Information Gateway,2007). The program is designed for abused and at-risk chil- dren and their biological or foster parents. PCIT involves having therapists coach parents while they relate to their children. Therapists help parents adopt strate- gies that reinforce their children’s positive behaviors. Therapists may sit behind a one-way mirror and coach the parent using “ear bug” audio equipment.
PCIT seeks to reduce negative parent–child interactions that may cause behav- ior difficulties in young children (Child Welfare Information Gateway,2007). The approach is designed to help parents learn to model and reinforce positive parenting techniques for responding to negative emotions. Children, in turn, will develop positive behaviors because of these healthier parent–child interactions.
The therapy is delivered in 14–20 sessions that last about 1 h. Additional therapy may be added as needed. The intervention consists of two phases: (1) relation- ship enhancement and (2) discipline and compliance. Phase 1 seeks to enhance the parent–child relationship by helping parents follow the acronym “PRIDE” (praise, reflection, imitation, description, and enthusiasm). In Phase 2, parents are taught to discipline their child in a structured and consistent manner. For example, parents learn how to give clear and direct commands to their child and offer consistent con- sequences for their child’s compliance or non-compliance. Parents learn these skills in play situations where they must give commands and discipline or reward their child appropriately.
Investigations have shown that PCIT can reduce children’s conduct problems at home and in school settings (Thomas and Zimmer-Gembeck,2007; Gallagher, 2003; Child Welfare Gateway Information,2007). In a review and meta-analysis of 24 investigations of PCIT and Triple P Positive parenting programs, Thomas and Zimmer-Gembeck (2007) discovered that participation in PCIT programs resulted in significantly fewer parent-reported child conduct and parent difficulties. However, the abbreviated PCIT program was associated with only moderate effect sizes. All types of the Triple P Positive parenting programs, except the Media Triple P Positive parenting program, had moderate to large effect sizes based on parent-reported child activities and parenting behaviors. The Media Triple P Positive parenting had only small effect sizes.
Based on a review of 17 studies that included 628 preschool-aged children, Gallagher (2003) showed that PCIT programs produced significant improvements in child functioning. The investigations revealed that children who participated in the PCIT programs had less frequent and less intense conduct problems based on teacher and parent reports. Participation in PCIT interventions also was associ- ated with more behavioral compliance in the clinics, less inattention problems and hyperactivity, less crying or whining, and less disruptive behavior.
In an investigation of families of children with ADHD and conduct-associated problems, Danforth et al. (2006) evaluated the outcome of group parent training which used the parameters of the Behavior Management Flow Chart. The use of skills learned in the group parent training not only reduced the children’s symp- toms of ADHD and CDs, but succeeded in having a favorable impact on parenting behavior and lowering the stress among parents.
Social skills training for youth is another type of intervention for children with CD and ODD (Maughan et al.,2004; Conner,1998–2000). This strategy emphasizes social skills training and experiences that help the youngsters deal effectively with conflict. For example, children are taught how to start conversations, react to the needs of others, and set limits on their behavior.
The Incredible Years (IY) training program is a program for parents, teachers, and children (The Incredible Years, 2009,http://www.incredibleyears.com). The IY parent training program attempts to enhance parents’ competencies, including their ability to provide positive discipline for their child and facilitate parents’
involvement in their child’s educational experiences. The goals of the curriculum are
Treatment 139 to foster their children’s success in educational, social, and emotional functioning and limit the development of conduct-related problems.
The IY training for babies and toddlers, aged 0–3, is designed to support par- ents and their babies (The Incredible Years, 2009,http://www.incredibleyears.com).
Consisting of a six-part curriculum, the IY Parents and Babies program seeks to help parents learn how to observe and identify their babies’ behavioral cues and learning processes so that the parents can be more responsive in terms of the physical, tactile, and visual stimulation and verbal communication.
The IY teacher training curricula help teachers to improve their classroom man- agement techniques, foster appropriate children’s behaviors, improve the children’s reading skills and other school readiness skills, and limit children’s aggressive and non-compliant behavior in the classroom (The Incredible Years, 2009,http://www.
incredibleyears.com). The IY teacher intervention program also helps teachers to work effectively with parents to enhance their school involvement and foster con- sistency in behavioral management and skill improvement from the school to the home.
The IY Dina Dinosaur classroom-based curriculum is designed to enhance peer interactions and limit aggressive behaviors for students aged 4–8 years (The Incredible Years, 2009, http://www.incredibleyears.com). Based on 120 lesson plans, the curriculum teachers can present the curricula two to three times a week using 15–20 min circle time discussions, which is followed by small group exercises. The program also consists of children’s home detective club activities manuals, which are designed to foster parents’ participation in educating their children about school rules, social skills, and problem-solving techniques.
Based on a total of 153 teachers and 1,768 socioeconomically disadvantaged students, Webster-Stratton et al. (2008) evaluated the IY teacher classroom manage- ment and the Dinosaur programs. They discovered that teachers who participated in the intervention relied on more positive classroom management techniques than the control teachers. Intervention teachers were more likely to have students who were more socially competent, more likely to control their emotions, and less likely to have behavioral problems.
Jones et al. (2007,2008) analyzed the efficacy of the IY basic parent training program using a sample of families with preschool children who were at risk for acquiring CDs and ADHD. The findings indicated that participation in the IY basic parent training was related to a decrease in ADHD and conduct problems, such as inattention and impulsive behaviors.
Using a sample of students from five basic schools in Kingston, Jamaica, Baker- Henningham et al. (2009) assessed the impact of the IY teacher training program supplemented by 14 lessons on social and emotional skills presented in the class- room. The investigators discovered that the intervention reduced behavior problems, hyperactivity, and peer difficulties. In addition, the intervention produced more positive teacher–parent contacts than the control group.
Since symptoms of ODD are prevalent in clinical samples of children with tic disorders, Scahill et al. (2006) evaluated the impact of a structured parent training on the children’s disruptive behaviors. Using data from the parent-rated
Disruptive Behavior Rating Scale, the researchers discovered that disruptive behav- ior decreased significantly. Parents also showed improvement in managing their children’s negative behavior based on the Improvement scale of the Clinical Global Impression instrument.
A study of children with early-onset behavioral problems revealed that com- bining both child training and parent training produced better outcomes than either intervention by itself (Webster-Stratton and Hammond,1997). According to Maughan et al. (2004), parent training is most beneficial for controlling opposi- tional conduct. Kazdin and Wassell (2000) showed that skills training for young people that consisted of cognitive problem-solving, along with parent management training, yielded positive results. The investigators found that parents who were will- ing to take part in the training were more likely to have children who maintained long-range positive effects of the intervention.
Dyadic skill training consists of 12–18 1-h sessions per week for children of preschool age and their parents (Speltz, 1990). This method assumes that the children’s behavior problems are due to the fact that they had faulty caregiving.
Researchers have not found that CBT consistently controls children’s conduct problems (Koegl et al.,2008; Munoz-Solomando et al., 2008; van de Wiel et al., 2002). In their meta-analysis of randomized controlled studies, Munoz-Solomando et al. (2008) discovered that CBT has not been shown to be effective in the treat- ment of conduct-related behaviors. However, they suggest that clinical guidelines and systematic literature reviews can enhance the mental health of children and adolescents.
Turner et al. (2005) assessed the usefulness of CBT in assisting foster carers in the management of foster children’s difficult behavior. Based on a review of five eligible trials (N=443), they showed that CBT-based training did not signifi- cantly improve the foster children’s conduct problems and relationship difficulties.
However, the CBT-based programs were associated with some improvement in the foster carers’ behavioral management skills, attitudes, and psychological function- ing. Nevertheless, the authors conclude that the effectiveness of CBT for foster carers has not been demonstrated.
Maughan et al. (2004) found that CBT, along with social skills training, was use- ful in treating aggressive and impulsive behaviors. CBT tries to solve disruptive behaviors and impaired emotional expressions using a systematic, goal-oriented approach. CBT consists of a variety of approaches, including cognitive therapy, rational emotive behavior therapy, and multimodal therapy. These techniques vary in the extent to which they rely on a combination of behavioral and cognitive research findings. Some CBT techniques are based on manuals and provide the patients with brief, direct, and time-limited therapies. CBT approaches may consist of having the patients keep a diary of major events and related feelings and have the patients test their cognitions, assumptions, and beliefs. CBT techniques may also use relaxation, mindfulness, and distraction methods.
Another method that has produced some favorable results for children with anti- social behavior is family therapy (Kazdin,1985; Jacob,1987). This approach seeks to modify problematic family systems and improve roles and communication within
Treatment 141 families. Adolescents who have not evidenced the most severe conduct behaviors such as being truant and running away may benefit the most from family therapy.
Alexander and Parsons (1982) showed that for youth who committed low-level con- duct problems, family therapy produced lower rates of repeat offenses for a 6–18 month period after therapy. In follow-up investigations, siblings in family therapy also had lower rates of contact with police.
MST has produced favorable results for treating mid-to-late age adolescent youth who engage in antisocial behaviors and externalize their problems (Schoenwald and Henggeler, 1999). The goal of this approach is to alter systems such as family, school, peers, and community that foster antisocial behaviors. MST offers par- ents and caregivers the resources, including skill development, and referrals to help them resolve their children’s difficulties. Clinicians can make changes in the child’s school environment. Also, therapists can assist the caregiver by finding suitable transportation, childcare, and other services. Clinicians provide action and treatment plans for the family and assign goals for the family and themselves. The therapists provide on-going treatment and assessment.
Some research has shown that MST has been useful with children who face institutionalization because of their persistent antisocial behaviors. According to Henggeler et al. (1999), MST costs less than a psychiatric hospitalization and seems to lead to improvements in school attendance and family dynamic and a reduction in the negative behaviors exhibited by the youth. MST has also been found to be more effective in reducing repeat offenses than eclectic individual therapy that involved psychodynamic, client-focused, or behavior-based approaches (Office of Child and Family Policy,2008).
Group therapy is another form of treatment for children with externalizing and antisocial behaviors (Office of Child and Family Policy,2008). Group therapy is designed for school-age children and can include community center groups. It tries to change the youth’s behaviors in different group situations. The community- center form of group therapy assumes that conduct-related problems occur in large part because of involvement with deviant subcultures (Feldman,1992; Office of Child and Family Policy,2008). The community-center approach, therefore, uses a supervised setting to reduce the youth’s relationship with antisocial friends and acquaintances and foster relationship with conventional peers. This type of group therapy can follow either the social learning model or the traditional model (Office of Child and Family Policy,2008). In the social learning model, antisocial behaviors are controlled through the principles of behavior modification, such as reinforce- ment and modeling of appropriate behaviors. In contrast, the traditional model relies on rules and consequences. Groups of 10–15 children meet for 3 h weekly during the school year for both the social learning and traditional approaches.
Dishion and Andrews (1995) found that youth with CDs are more likely to ben- efit from group therapy if they are placed with conventional youth than if they are exposed to other children who exhibit antisocial behaviors.
Community-based residential programs have been used in the treatment of children with CD and ODD (Conner,1998–2000). In these community-based resi- dential programs, children and parents participate in a home or residential treatment
setting. Facilitators serve as teaching parents. To achieve behavior change, youth with CDs participate in a point system, family conferences and other forms of self-government, and training in social skills. These young people are tutored in aca- demic subjects and their progress is carefully monitored. Home-based reinforcement strategies are used to encourage that progress.
School-based interventions can be employed to treat youth with ODD and CD (Conner,1998–2000). These strategies rely on classroom contingency management.
However, Conner (1998–2000) notes that these school-based approaches can be dif- ficult to initiate for certain youth since Public Law 94-142 excludes children who only suffer from behavioral problems.
For CD youth who do poorly in outpatient settings, day treatment has shown to be helpful (Kolko et al., 1999; Grizenko, 1997). Based on a study of a day treatment program that consisted of drug therapy, different types of individual and group therapy, and family therapy, Grizenko (1997) discovered that the positive outcomes lasted over 5 years. In an investigation of the effectiveness of a partial hospitalization program, Kolko et al. (1999) discovered that combining the medica- tion, methylphenidate, with behavior treatment reduced ODD-related behaviors and increased conventional behavior.
Wilderness school interventions can help youth with CD and ODD (Conner, 1998–2000). These programs remove the child from environmental influences that promote or maintain antisocial and externalizing behaviors. Wilderness school pro- grams seek to develop and maintain new conventional attitudes, behaviors, and skills. Counselors and therapists seek to achieve these goals by creating a struc- tured and rigorous environment for the youth. Effective programs use themes such as honesty, awareness, skills, and responsibility.
Cowles et al. (1995), Steiner (1997), and Kazdin (1985) have found no evi- dence for the use of psychodynamic or insight-oriented individual and group psychotherapy in treating CD or ODD.
According to Conner (1998–2000), family-based treatments are more beneficial than individual-based interventions that involve the child only and not the parents and family. For pre-adolescent youth, training parents to use behavioral approaches can be effective. Peer group-based interventions and individual approaches are effective for adolescents with CDs. Family-based strategies are less effective with older children because the negative family interactions probably have lasted for much of the adolescents’ life, and they are beginning to rebel against family pres- sure. If other strategies have been ineffective and the antisocial behavior continues or escalates, wilderness training can be helpful.
Drug therapy by itself has not been shown to be effective in the treatment of CD and ODD (Office of Child and Family Policy,2008). Conner (1998–2000) notes that medication is ineffective when treating CDs since the conditions deal with behaviors. However, psychopharmacological interventions may be useful in treating co-existing mental disorders, such as ADHD, and some symptoms of conduct- related behaviors (Turgay,2009). Controlling ADHD symptoms could make it easier to treat conduct-related behaviors.