Chapter 13: Treatment of Conduct Problems and

Disruptive Behavior Disorders

Nicole P. PowellJohn E. Lochman

Caroline L. Boxmeyer

Luis Alberto Jimenez-Camargo

Megan E. Crisler

Sara L. Stromeyer

Overview

Conduct and disruptive behaviors are some of the most common reasons children and adolescents are referred for psychological treatment

Long-term effectsSubstance abuseDelinquencyIncarceration

Conduct problems tend to be treatment-resistant (Kazdin, 2000)

CBT Approaches:Children

Anger Control TrainingBased on social information processing theoryIndividual or group settingTaught to use problem-solving strategies across

hypothetical and real-life situationsIn vivo practice used to arouse children’s feelings of

angerCoping Power: 34 child sessions and 16 parent

sessions; effective in reducing delinquent behaviors and improving teacher reports of behaviors that are maintained after 1 year

Problem-Solving Skills and Parent-Management Training

PSST: focuses on child’s cognitive experience and how the child is interpreting the environment

PMT: focuses on parent-child interactions and how parental behavior may modify or alter the child’s behavioral patternsManual-based treatmentsChildren 7–12 years oldBased on cognitive-behavioral and behavioral conceptsBoth considered reliable and efficacious treatments—in

isolation or used together

Incredible Years

Children 3–10 years old

Present with clinically significant externalizing problems

Based on cognitive social learning theory

Focuses on social/emotional deficits observed in children with conduct-related disorders

Modules for parents, teachers, and children Methods: video modeling, discussion opportunities, rehearsal techniques

12-week program

Strong reductions in behavioral difficulties at home and at school, including at a 10-year follow-up

Behavioral Approaches

Helping the Noncompliant ChildEvaluated in over 40 studies, documented both short- and long-term

benefits

Parent-Child Interaction TherapyTwo RCTs demonstrated positive effects on children’s disruptive

behaviors and parent-child interactions

Both are: Manual-based treatments for 2- to 7-year-oldsSpecifically intended to address issues related to parent-child

interactionsBased on the Hanf model: 1) parent learns to apply positive attention

skills; 2) parent learns discipline strategies to address unwanted behaviors

Parent-Management TrainingOregon Model

Teaches parents how to model their child’s behavior through monitoring and modifying behavior using specific behavior modification plans in six key areas: Skills encouragement, positive reinforcement, discipline,

monitoring, problem solving, positive involvement

Based on social interaction learning: negative environmental/relationship factors may adversely affect child interaction styles (Reid et al., 2002)

Affective changes in parents documented after being taught the model and found to be related to reduction in child behavior problem

Positive Parenting Program

Systematically modified treatment plan that allows for five different levels of treatment intensity/focus: universal prevention to enhanced formatsSkills targeted include: parenting skills (e.g., positive

attention), problem solving, coping strategies for parents and children

Reduces disruptive behavior over 12-month period

Evidence-Based ApproachesAdolescents

Group Assertiveness Training: three-part response model of assertivenessEmpathy statement, conflict statement, action statementBased on premise that adolescents exhibiting frequent

aggression lack the appropriate skills to deal with interpersonal frustrations

After training, significantly less aggression (Huey & Rank, 1984)

Rational Emotive Mental Health ProgramLearning self-realization strategiesFewer disruptive behaviors following treatment and four-month

follow-up

Family and Community Based Approaches

Multisystemic Therapy (MST): family and community based intervention for adolescents with antisocial behaviorAssumes adolescents have problems in multiple settings;

most efficacious treatment has to intervene within and across these systems

Combines evidence-based approaches (e.g., cognitive-behavioral, behavioral, parent training)

1 year post treatment, those who received MST reported fewer conduct problems and less likely to be arrested or incarcerated (Henggeler et al., 1992)

Multidimensional Treatment Foster Care

Comprehensive and systemic intervention targeting chronic delinquent behavior in adolescentsGoal: to prevent more restrictive placements (e.g., residential

treatment) and ultimately to return to biological family

For 6 to 9 months, adolescent placed with foster parents who have been trained to enforce clear, consistent rules and implement a behavioral point system

More effective than usual care

Parental Involvement

Certain parenting practices place children at risk for disruptive behavior: Nonresponsive parenting at age 1Coercive escalating cycles of harsh parental directives and

child noncomplianceHarsh, inconsistent disciplineUnclear directions and commandsLack of warmth and involvementLack of parental supervision and monitoring as children

approach adolescence

Positive parent-child interactions and instruction in limit setting are key factors associated with prevention and remediation of conduct problems

Barriers to Involving Parents

Lower socioeconomic status (SES) is associated with poorer parental engagement (Morrissey-Kane & Prinz, 1999)

Parents are less involved in child’s life outside of treatment when they: Are uncooperative/negativeBelieve that they are ineffective caregiversBelieve that their child’s behavior is unchangeable

Adaptations and Modifications

Service setting adaptations: reduced number of sessions, addition of active treatment strategies to increase engagement of youth with attention programs, increased communication with parents about skills taught to youth

Delivery format adaptations: take more active role in role-plays, provide more specific feedback and examples, Internet-based sessions, fewer face-to-face sessions

Adaptations

Developmental: extend to preschool or early adolescents—change activities, new content

Cultural: translation to other languages; using culturally relevant examples, provide culturally appropriate context for material

Treatment Targets and Measures

Key concerns: 1) Identifying the specific outcomes that will be

hypothesized 2) Identifying central active mechanisms that are the

critical targets of an intervention3) Identifying how many measures and tests of treatment

effects will be conducted

Outcomes: measuring delinquent acts and arrests, substance use initiation, substance abuse, measures of academic adjustmentSelf report, parent report, grades

Measuring Mechanisms

Externalizing disorder mechanisms: both child (e.g., hostile attributions) and family (e.g., harsh, inconsistent parenting) functioning

Important for developing an effective treatment plan

Measure active mechanism that leads to behavior change

Number of Measures

Multimethod-multisource measurement

Multisource measurement (e.g., parent and teacher reports)Determine if behaviors occur across situations

Too many varied measures: concerns for “fishing expeditions”

Can assess transdiagnostic intervention effectsTransdiagnostic interventions apply the same underlying

treatment principles across different disorders

Timing of Measurement

Multiple measurement points

Clinical setting: frequent (weekly) measurementGives information if child is improving, whether behavioral

improvements have stalled, or whether child is responding in a consistently positive way to the intervention

Multiple assessments over longer-term follow-up periods important for intervention research

Clinical Case: Wes

10-year-old boy, 4th grade

Difficulties with parent-child interactions

Difficulties at school

Treatment: Coping PowerChild and parent groupsTaught strategies for handling emotional arousal in child group,

picking friends wisely, and other relevant topics

Outcome: improvement in grades and behavior at school, continued to have angry outbursts (less frequent), parents working better as a team, reduced family conflict