Conduct Disorder is an incredibly problematic issue for clinicians who work with children due to its harmful nature and difficulty regarding treatment (Evans, 2010). Ongoing and persistent treatment is required to prevent further behavioral issues, in addition to assistance and education for parents and/or guardians, teachers and counselors who interact with the child on a day-to day basis. (Evans, 2010). This creates many barriers to effectively aiding these children with their behaviors, including cost, time considerations and difficulties creating a therapeutic alliance with both the client and their parent(s) and/or guardian(s). (Evans, 2010). Additionally, factors not measured by the diagnostic criteria for Conduct Disorder may influence both treatment efficacy, and the type of treatment recommended. These factors include things like Callous Unemotional traits on the responsiveness to treatment (Milone et al., 2019), whether the child engages in proactive aggression vs reactive aggression (Boxer and Butkus, 2005) and early childhood psychopathy specifiers (Romero et al., 2019). All of these factors can lead to problems providing adequate long-term care for these children, which in many cases can lead to the development of Antisocial Personality Disorder when they become adults. (Evans, 2010). ASPD is highly associated with violence, criminality and incarceration, meaning the treatment of Conduct Disorder to effectively curb Antisocial behavior could be a crucial tool to preventing at-risk individuals from becoming chronic offenders (Evans, 2010). In this paper I will examine the various treatment methods for Conduct Disorder, their strengths and weaknesses, in addition to the difficulties and limitations that make treatments for Conduct Disorder less effective than many other mental disorders. I will also look to the future and examine recommendations for the expansion of treatments and diagnostic tools available to clinicians and researchers alike.
Conduct Disorder is characterized as “a repetitive and persistent pattern of behavior in which the basic rights of others or other age-appropriate societal rules or norms are violated.” (Evans, 2010, p. 1). The main features of this disorder include violence and aggression towards people and/or animals, destruction of property and arson, deceitfulness and theft, and serious violation of rules often resulting in suspension or expulsion from school (Evans, 2010). This can lead to serious social and personal life maladaptions, including isolation, peer rejection, poor scholastic performance and physical and/or mental abuse by parental figures (in a failed attempt to discipline their child’s antisocial behaviors) which can exacerbate these antisocial behaviors and beliefs, removing what little support systems they do have and often leading to a life of criminality (Evans, 2010). Some research has suggested that almost 50% of children with Conduct Disorder will go on to develop ASPD, and Conduct Disorder must be identified for a diagnosis of ASPD in the first place, making the link between the two undeniable (Evans, 2010).
Research into the root and causes of Conduct Disorder has also found that the age of onset is crucial to the course and severity of the disorder, indicating that an earlier onset of Conduct Disorder symptoms is highly correlated with more chronic and severe behavioral issues, in addition to more resistance to treatment (Evans, 2010). Conversely, those diagnosed with Conduct Disorder in adolescence may prove harder to create a therapeutic alliance with but are shown to also have a much higher drop-off of maladaptive and antisocial behaviors come adulthood than those diagnosed pre-puberty (Evans, 2010). In fact, some of the temperamental Conduct issues are observable as young as infancy and have a high correlation with behavioral issues once entering school (Evans, 2010). Studies have also consistently shown that children with Conduct Disorder exhibit traits of low self-control, poor planning, inhibited or inappropriate responses, inattention and difficulties with concentration (Evans, 2010).
The behavioral issues associated with Conduct Disorder do not simply stop with willful disregard for the rights of others either, but also careless and negligent behaviors which can be just as destructive. Motor vehicle collisions are the leading cause of death for people 15-19 years old, and even when controlling for other demographic characteristics which could lead to a higher-than-average rate of car accidents, research has found that those with CD symptoms prior to age 15 correlated with a 77% increased the chance of an individual having been involved in a motor collision. (Wickens et al., 2019). CD is also seen “as a risk factor in driver aggression, impaired driving, roadway violations and traffic violations.” (Wickens et al., 2019, p.38).
In addition to all this, some psychologists recommend the integration of a screening test for psychopathic traits in children exhibiting Conduct Disorder, claiming these traits are observable as young as preschool and are relatively stable and consistent over time. All three elements of the 3-factor model of psychopathy, including Grandiose-Manipulative (GM) traits, Callous Uncaring (CU) traits and Daring-Impulsive (DI) traits can be observed in children and all augment and influence the presentation of Conduct Disorder related behavioral issues (Lopez-Romero et al., 2019). The most relevant of these factors in creating resistance to treatment is the Callous Uncaring dimension, which involves a lack of guilt or empathy, disconcert towards personal performance and a shallow, deficient affect. (Milone et al., 2019). High scores on the CU factor, more than either of the other 2 factors, have been associated with adult psychopathy, general resistance to treatment and more severe and harmful antisocial behaviors. (Milone et al., 2019). CU factors are also seen to be less correlated with abuse and active maltreatment than the GM and DI factors. (Milone et al., 2019).
Interestingly, children who exhibit a high prevalence of CU traits have been shown to not lack empathy altogether, but rather the affective element of empathy alone. (Milone et al., 2019). Empathy as a construct can be spit up into two distinct functions, affective empathy and cognitive empathy. Affective empathy is the ability to share emotions with others, even nonverbally, and involves the amygdala, the anterior insular and the cingulate cortex (Milone et al., 2019). Effectively, this is what allows us to feel what another is feeling and share what we are feeling with them. Cognitive empathy, on the other hand, is the ability to identify and report emotions in others accurately. (Milone et al., 2019). This also relates to the general Theory of Mind that allows us to understand other’s thoughts and motivations, and involves the dorsolateral prefrontal cortex, posteromedial cortex and the superior temporal sulcus. (Milone et al., 2019). Where affective empathy is shown to be inhibited in those diagnosed with CD, they show no lack or inhibition in their wielding of cognitive empathy, meaning that children with Conduct Disorder are able to identify the feelings and thoughts of others but are not affectively moved or motivated by them. (Milone et al., 2019). It is worth mentioning that while there was no inhibition of cognitive empathy present in boys with CD, there were cases of inhibited cognitive empathy in girls diagnosed with CD, implying some difference in the role of empathy on gendered expression of CD. (Milone et al., 2019).
In discussing the Etiology of Conduct Disorder, one must never discount the role of environment and parenting on the development of antisocial behavior. “Ineffective parenting practices have also been associated with conduct problems in children. These practices include punitive harsh discipline practices, inconsistency, low parental warmth and involvement, physical and verbal aggression, and poor supervision. Parent’s with Antisocial behavior are also more likely to have children with conduct problems.” (Evans, 2010, p. 146). These parenting styles, combined with the behavioral issues themselves, lead to negative feedback loop in which the antisocial behaviors are reinforced rather than discouraged via the parent’s punishments (Evans, 2010). Effective treatment, therefore, requires training for not only the child, but the parent or guardian as well, including a crucial importance for a therapeutic alliance between said parental figure and the clinician. (Evans, 2010).
The treatments for Conduct Disorder are generally long-term and multidimensional, costing a lot of time and money for families that often have neither to spare (Evans, 2010). Early treatments for CD focused on curbing the harmful conduct itself, often in the form of reaction formation training and anger management (Lochman et al., 2019). While anger-reaction focused therapies proved effective in the short-term for stemming behavioral disturbances and aggression, follow-ups on adults who underwent these therapies showed that criminality and social inhibitions seemed to reemerge in late adolescence and early adulthood (Lochman et al., 2019). Responses to these facts have led to the suggestion that treatment for CD, as well as the understanding of CD and the traits that make up CD, need to be more multidimensional and adaptive to the specific nature of the child’s maladaptive behaviors (Bakker et al., 2017). For example, in a case study of a young boy from the United States (Boxer and Butkus, 2005), the identification of his aggression as either reactive or proactive was seen as crucial to appropriately treating his behavioral issues.
Aggressive behavior is not universally borne from anger, and in many cases aggression has more to do with scripting and social modeling than feeling, particularly in proactive acts of aggression (Boxer and Butkus, 2015). Scripts are described as thought patterns that create expectations and form appropriate reactions to that event, and they are generally gathered from early life experiences of observing conflict-resolution between caretakers and other adults. (Boxer and Butkus, 2015). The boy in the case study identified himself as proactively aggressive, and through sessions with him they found that he felt a sense of control and power when he acted aggressively with others (Boxer and Butkus, 2015). He had developed a script that associated victimization and aggression with control and security. (Boxer and Butkus, 2015). Over sessions they had him role-play instances where he picked on or attacked someone, and at one point had him draw a picture of the engagement with a keen focus on the facial expression of the boy’s victim (Boxer and Butkus, 2015). Through this, he was able to identify the feeling of fear and discomfort his actions created in others and slowly began to question the behavioral scripts he’d come to rely on and perform automatically (Baker et al., 2015). This approach to dismantling and reassessing scripts is firmly rooted in social-cognitive theory and is seen as one of the most effective strategies in the treatment of Conduct Disorder. (Baker et al. 2015).
Unfortunately, for most, treatment is not as simple and effective as it was the boy in the case study. For most children diagnosed with Conduct Disorder, their lived environment, caretakers, access to care and economic status are all barriers to treatment (Lochman et al., 2019). The most effective treatments focus on education for the individual on mindfulness, impulse control and the development of positive self-schemas and prosocial scripts. (Lochman et al., 2019). Of key importance is aiding the child in gaining the skills to accurately perceive and interpret harmful situations or behaviors and developing methods to lower arousal in said moments through self-soothing and breathing excesses. (Lochman et al., 2019). In many cases children with CD have cognitive distortions regarding aggression (such as if I don’t fight I’m weak) that must be addressed before the behaviors can be curbed, and for many of those with CD, it is more difficult to interpret the accidental behaviors of others as not actively aggressive towards themselves (such as someone bumping into them in the hall at school) (Lochman et al., 2019).
A treatment program known as the Coping Power program has shown great success in the short-term reduction of harmful and antisocial behaviors in children with CD and has also shown some long-term efficacy through 1 and 3 year follow ups. (Lochman et al., 2019). Based off an anger management plan known as the Anger Coping program, Coping Power takes a more social-cognitive and transdiagnostic approach to treating Conduct Disorder, treating each case as a unique presentation of the disorder which must be responded to with a customized action plan tailored to the individual child’s needs and behavioral imbalances (Lochman et al., 2019). Some of the transdiagnostic features of Coping Power include “contingency management, personal goal setting, emotional awareness and regulation, perspective taking, social problem solving, and rehearsal and master opportunities, all of which can be flexibly applied to individual treatment at the therapist’s direction.” (Lochman et al., 2019, p. 802). “Coping Power does not focus on specific diagnoses and has no exclusionary criteria for comorbid conditions, which can be treated concurrently. It addresses a number of common risk factors that predict both externalizing and internalizing problems, including difficult temperament (irritability, restlessness, irregular patterns of behavior, lack of persistence, low adaptability), psychosocial stressors in varied environmental contexts (school, neighborhood, peer group), social-cognitive deficits and distortions, and family factors such as harsh discipline practices, low levels of parental warmth and acceptance, multiple changes in family composition, and parent psychopathologies, and lower levels of both externalizing and internalizing problems have been found after Coping Power intervention.” (Lochman et al., 2019, p. 802).
Briefer versions of the Coping Power program have been developed for those without the time or money for the full 34 session application, including a shortened version, a hybrid online and in person version, one that allows for fewer sessions for the parental guardian, and an animated online cartoon that applies the Coping Power principles into a series called, The Adventures of Captain Judgement. (Lochman et al. 2019). “The hybrid version of Coping Power had a 60% reduction in the frequency of councilors’ face to face meetings (a savings in cost of intervention of 44%) while still producing significant intervention effects on children’s conduct problems.” (Lochman et al., 2019, p. 802).
Finally, factors such as therapist warmth, interest, openness and genuine care greatly increase the efficacy of any chosen treatment. (Lochman et al., 2019). The better the relationships between the therapist and the child, as well as the relationship between the therapist and the primary caretaker, the more effective the treatment it seems. (Lochman et al., 2019). Children with high scores on the Callous Unemotional factor tend to resist this kind of relationship higher than any other subfactor. (Milone et al., 2019) and are therefore often the hardest to treat.
While there are varying degrees of success with various methods of therapy for CD, the overall prognosis and treatment efficacy for CD is poor. (Bakker et al., 2017). A meta-analysis of studies on the treatment efficiency of various CD interventions showed that while some methods do show a notable reduction in the presentation of antisocial and harmful behavioral issues, there is too little information to say that any one treatment is most effective or should be considered the first-line standard for CD. (Bakker et al., 2017). What is clear is that treatment for CD needs to be (1) multidimensional and transdiagnostic, (2) adaptable and customizable to the individual’s needs and (3) focused on the development of a close relationship between the client and their therapist. (Lochman et al., 2019). Future research into this matter should focus on how to better identify and describe the ways in which CD is heterogeneous within itself, and how factors like traits high in CU and even psychopathic specifiers can effect and interfere with treatment.
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