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Abstract
Conduct disorders are among the most common disorders encountered in child and adolescent psychiatry. They represent a heterogeneous group of disorders, each with a different psychopathology and a different life-course.
Several risk factors for later development of substance abuse, violence, or delinquency can be identified at a young age. Children at highest risk for later problems include those who start early with high rates of conduct problems, including oppositional defiant, aggressive, and antisocial behaviours .
It is apparent that there is not one single causative factor for conduct disorder; thus it is not likely that one single modality will suffice to treat it.
Although genes bring children into contact with environmental risk via processes of passive and active gene–environment correlation, once contact is made, it is reasonable to expect the environment to have consequences of its own, cutting off opportunities to develop healthy behaviors, promoting the persistence of pathological behavior, and exacerbating its seriousness.
It is unlikely that there will turn out to be genes for these behaviors, in the sense that a specific genetic constellation would provide necessary and sufficient cause. Rather, the path from genes to behavior is likely to be a complex one involving environmental stresses and individual differences in liability.
Different environmental factors that were studied as risk factors contributing to conduct disorder include: Deprived neighborhood & low socioeconomic status, Domestic violence, marital discord and family adaptability, maternal depression, Physical maltreatment, Parental attributions, Parental monitoring, Bad parenting, Parent– child conflict.
Bad parenting statistically predicts Children’s aggression and bad parenting plays a central causal role in leading theories of antisocial behavior.
It is also evident that children who have conduct problems at a young age are three times more likely to have serious and chronic violent careers than those who begin antisocial behaviour later.
The risk of developing later antisocial problems is further increased if early onset conduct problems are combined with harsh and inconsistent parenting, low parental monitoring, and low parental involvement in school. If these early risk factors are not prevented or treated children may develop a cascading set of secondary risk factors, including academic failure, social exclusion, school DROP out, and membership of deviant peer groups, which, in turn, accelerate their risk for future violence. Thus it is important to manage the earliest risk factors. It was concluded that without early family treatment, aggressive behaviour in children ”crystallises” by the age of 8, making future learning and behavioural problems less responsive to treatment and more likely to become chronic.
Yet recent projections suggest that fewer than 10% of young children who need treatment for conduct problems ever receive it and an even smaller percentage receive empirically validated treatments.
Many policymakers and commissioners are still unaware that effective programmes exist, or that when implemented, insufficient attention is paid to the need for fidelity to the model used and to the development of therapist skill. Effectiveness is then often disappointing in ’real life’ conditions. However, when these factors are addressed, the evidence is clear that substantial gains can be made.
Parenting plays a key part in children’s emotional and behavioural development. Good parenting helps children adjust to change and adversity and establishes healthy patterns of emotional, social, and cognitive functioning. Harsh, unpredictable parenting that relies on manipulation, threats, punishment, and passivity is strongly associated with conduct behaviour in children. Children with uncontrolled conduct behaviour are at markedly increased risk of morbidity during adolescence and beyond. They are more likely to play truant, leave school without qualifications, and offend during adolescence or adulthood and are less likely to form meaningful, lasting relationships.
Basic parent-training interventions are well established (e.g. Helping the Noncompliant Child programme; Parent-Child Interaction Therapy ; and the Incredible Years . They produce good effects: typical effect sizes have been 0.3-1.0 SD.
Adding a treatment component that addresses the child’s problem-solving abilities can enhance its efficacy. Thus, adding a child-training component to a parent-training programme for children referred with CD demonstrated a long-term improvement in outcome compared with parent training alone.
A multidisciplinary approach to the treatment of conduct disorder, which includes behavioural parent training, interpersonal skills training, family therapy and the use of psychotropic agents targeted at a particular cluster of symptoms, can increase the overall effectiveness of each of the applied interventions. Aggression, hyperactivity, impulsivity and mood symptoms are the most sensitive proximal targets. Evidence suggests that antipsychotics, antidepressants, mood stabilisers, antiepileptic drugs, stimulants and adrenergic drugs can be well tolerated and effective therapeutic options for individuals with conduct disorder and comorbid psychiatric conditions. However, the most successful therapeutic outcomes are likely to be achieved by combining the current advances in psychopharmacology with behavioural and psychosocial interventions, aimed at modifying the excessive patterns of maladaptive behaviours observed in conduct disorder.
Many factors affect the outcome of treatment in children and adolescents diagnosed with conduct disorder e.g Treatment engagement, Parental attributions, alliance and retention in family therapy, Parent training and comorbidity.
This review takes an overview on most recent evidence based management of conduct disorder with special focus on family (systemic) therapy. A concise history of family therapy history and its different types is presented followed by a more detailed review of applications of different forms of family therapy in treatment of Conduct Disorder .This is divided into two main categories i.e Family based therapy& Parenting Programmes, with examples for each as follows:
I. Family based therapy
1-Brief strategic family therapy
2- Multisystemic Family therapy
II. Parenting Programmes
1- Triple –P
2- Parent-Child Interaction Therapy
3- Incredible Years basic parenting programme
Each type of therapy or parenting program is discussed concerning its theoretical foundation, structure of intervention and outcome as revealed by different recent studies