Conduct Problems

The effectiveness of psychological interventions for four distinct but related categories of conduct problems will be considered in this section. These are:

• oppositional behavioural difficulties;

• attentional and overactivity problems;

Handbook of Evidence-based Psychotherapies: A Guide for research and practice. Edited by C. Freeman & M. Power. Copyright © 2007 John Wiley & Sons, Ltd.

• pervasive conduct problems in adolescence;

• adolescent drug abuse.

Oppositional Behavioural Difficulties

Preadolescent children who present with oppositional behavioural problems, temper tantrums, defiance and non-compliance confined largely to the family constitute a third to a half of all referrals to child and family mental health clinics. Prevalence rates for clinically significant levels of oppositional behavioural problems in the community vary from 2% to16% (American Psychiatric Association, 1994; Kazdin, 1995; World Health Organization). Oppositional behavioural problems are of particular concern because in the longer term they may lead to pervasive adolescent conduct problems and later life difficulties. Oppositional behavioural difficulties tend to develop gradually within the context of coercive patterns of parent-child interaction and a lack of mutual parental support (Patterson, 1982).

Serketich & Dumas (1996), in a meta-analysis of over 100 studies of behavioural parent training, concluded that for childhood oppositional behavioural problems it was a highly effective treatment. Behavioural parent training focuses on helping parents develop the skills to monitor specific positive and negative behaviours and to modify these by altering their antecedents and consequences (Forehand & Long, 1996; Forehand&McMahon, 1981). For example, parents are coached in prompting their children to engage in positive behaviours and preventing children from entering situations that elicit negative behaviours. They are also trained to use reward systems such as star charts or tokens to increase positive behaviours and time-out to reduce negative behaviours. Behavioural parent training is probably so effective because it offers parents a highly focused way to supportively co-operate with each other in disrupting the coercive parent-child interaction patterns that maintain children's oppositional behaviour problems. It also helps parents develop a belief system in which the child's difficult behaviour is attributed to external situational characteristics rather than to intrinsic characteristics of the child.

The impacts of a variety of formats on the effectiveness of behavioural parent training have been investigated and the results of these studies allow the following conclusions to be drawn. Behavioural parent training is most effective for families with children who present with oppositional behavioural problems when offered intensively over at least 20 sessions; exclusively to one family rather than in a group format; and as part of a multisystemic and multimedia intervention package that includes concurrent individual child-focused problem-solving skills training with video-modelling for both parents and children (Kazdin, Siegel & Bass, 1992; Webster-Stratton & Hammond, 1997). Such intensive, exclusive, multisystemic, multimedia programmes are more effective than less intensive, group-based, behavioural parent training alone, child-focused problem-solving skills training alone, or video modelling alone with minimal therapist contact. An argument may be made for offering more intensive treatment to cases with more severe difficulties. Where a primary caretaker (typically a mother) is receiving little social support from her partner, then including a component to enhance the social support provided by the partner into a routine behavioural parent training programme may enhance the programme's effectiveness (Dadds, Schwartz & Sanders, 1987).

Attentional and Overactivity Problems

Attention deficit hyperactivity disorder is now the most commonly used term for a syndrome characterized by persistent overactivity, impulsivity and difficulties in sustaining attention (American Psychiatric Association, 1994; Hinshaw, 1994; World Health Organization, 1992). The syndrome is a particularly serious problem because youngsters with the core difficulties of inattention, overactivity and impulsivity which are usually present from infancy may develop a wide range of secondary academic and relationship problems as they develop through the lifecycle. Available evidence suggests that vulnerability to attentional and overactivity problems, unlike oppositional behavioural problems discussed in the preceding section, is largely constitutional, although the precise role of genetic, prenatal and perinatal factors in the aetiology of the condition are still unclear. Using DSMIV criteria for attention deficit hyperactivity disorder, a prevalence rate of about 3 % to 5 % has been obtained in community studies (American Psychiatric Association, 1994).

Hinshaw, Klein & Abikoff (1998) and Barkley (1999), following extensive literature reviews, have concluded that family-based multimodal programmes are currently the most effective for children with attentional and overactivity problems. Multimodal programmes typically include stimulant treatment of children with drugs such as methylphenidate combined with family therapy or parent training; school-based behavioural programmes and coping-skills training for children. Family-based multimodal programmes are probably effective because they provide the family with a forum within which to develop strategies for managing a chronic disability. As in the case of oppositional behavioural problems discussed above, both behavioural parent training and structural family therapy help parents and children break out of coercive cycles of interaction and to develop mutually supportive positive interaction patterns. Both family therapy and parent training help parents develop benign belief systems where they attribute the child's difficult behaviour to either the disability (attention deficit hyperactivity disorder) or external situational factors rather than to the child's negative intentions. School-based behavioural programmes have a similar impact on school staffs' belief systems and behaviour. Stimulant therapy and coping skills training help the child to control both their attention to academic tasks and their activity levels. Stimulant therapy, when given in low dosages, helps children to both concentrate better and sit still in classroom situations. High dosage levels have a more marked impact on overactivity but impair concentration and so are not recommended. Coping-skills training helps children to use self-instructions to solve problems in a systematic rather than an impulsive manner.

In cases of attentional and overactivity problems, effective family therapy focuses on helping families to develop patterns of organization conducive to effective child management (Barkley et al., 1992). Such patterns of organization include a high level of parental co-operation in problem solving and child management; a clear intergenerational hierarchy between parents and children; warm supportive family relationships; clear communication and clear, moderately flexible rules, roles and routines.

Parent training, as described in the previous section on oppositional behavioural problems, focuses on helping parents develop the skills to monitor specific positive and negative behaviour and to modify these by altering those interactions and events that occur before and after them (see, for example, Barkley, 1987). School-based behavioural programmes, in cases of attentional and overactivity problems, involve the extension of home-based behavioural programmes into the school setting through home-school, parent-teacher liaison meetings (DuPaul & Eckert, 1997; Braswell & Bloomquist, 1991). Coping skills focus largely on coaching children in the skills required for sustained attention and systematic problem solving (Baer & Nietzel, 1991; Kendall & Braswell, 1985). These skills include identifying a problem to be solved; breaking it into a number of solvable subproblems; tackling these one at a time; listing possible solutions; examining the costs and benefits of these; selecting the most viable solution; implementing this; monitoring progress; evaluating the outcome; rewarding oneself for successful problem solving; modifying unsuccessful solutions; and monitoring the outcomes of these revised problem-solving plans.

Pervasive Conduct Problems in Adolescence

Pervasive and persistent antisocial behaviour, which extends beyond the family to the community, involves serious violations of rules or law-breaking and is characterized by defiance of authority, aggression, destructiveness, deceitfulness, cruelty, problematic relationships with parents, teachers and peers and typically leads to multiagency involvement is referred to as conduct disorder (American Psychiatric Association, 1994; World Health Organization, 1992). Conservative prevalence rates for conduct disorder range from 2 % to 6 % (Kazdin, 1995).

From a developmental perspective, persistent adolescent conduct problems begin during the preschool years as oppositional behavioural problems, described in an earlier section. For about a third of children these evolve into pervasive conduct problems in adolescence and antisocial personality disorder in adulthood (Loeber & Stouthamer-Loeber, 1998). Three classes of risk factors increase the probability that preschool oppositional behaviour problems will escalate into later life difficulties: child characteristics - notably impulsivity and learning problems, poor parenting practices and family organization problems (Lehmann & Dangel, 1998).

Kazdin (1998), in a review of empirically supported interventions for conduct disorders, concluded that functional family therapy and multisystemic therapy were among the more promising treatments available for adolescents with pervasive conduct problems. Chamberlain & Rosicky (1995) in a review of family-based interventions, concluded that treatment foster care may be the most effective intervention for cases of conduct disorder where outpatient family-based approaches have failed.

Functional family therapy aims to reduce the overall level of disorganization within the family and thereby modify chaotic family routines and communication patterns which maintain antisocial behaviour (Alexander & Parsons, 1973,1982; Gordon etal., 1988; Parsons & Alexander, 1973). Functional family therapy focuses on facilitating high levels of parental co-operation in problem-solving around the management of teenagers' problem behaviour; clear intergenerational hierarchies between parents and adolescents; warm supportive family relationships; clear communication and clear family rules, roles and routines. Within functional family therapy it is assumed that if family members can collectively be helped to alter their problematic communication patterns and if the lack of supervision and discipline within the family is altered, then the youngsters conduct problems will improve (Alexander & Parsons, 1982). This assumption is based on the finding that the families of delinquents are characterized by a greater level of defensive communication and lower levels of supportive communication compared with families of non-delinquent youngsters (Alexander, 1973), and also have poorer supervision practices. With functional family therapy, all family members attend therapy sessions conjointly. Initially family assessment focuses on identifying patterns of interaction and beliefs about problems and solutions that maintain the youngsters conduct problems. Within the early therapy sessions parents and adolescents are facilitated in the development of communication skills, problem-solving skill and negotiation skills. There is extensive use of relabelling and reframing to reduce blaming and to help parents move from viewing the adolescent as intrinsically deviant to someone whose deviant behaviour is maintained by situational factors. In the later stages of therapy there is a focus on the negotiation of contracts in which parents offer adolescents privileges in return for following rules and fulfilling responsibilities.

Functional family therapy focuses exclusively on altering factors within the family system so as to ameliorate persistent conduct problems, but multisystemic therapy also addresses factors within the adolescent and within the wider social system. Effective multisystemic therapy, offers individualized packages of interventions that target factors that maintain conduct problems within the multiple social systems of which the youngster is a member (Henggeler, 1999). These multiple systems include the self, the family, the school, the peer group and the community. Multisystemic interventions integrate family therapy with self-regulation skills training for adolescents; school-based educational and recreational interventions; and interagency liaison meetings to co-ordinate multiagency input. In multi-systemic therapy it is assumed that if conduct-problem maintaining factors within the adolescent, the family, the school, the peer group and the wider community are identified, then interventions may be developed to alter these factors and so reduce problematic behaviour (Henggeler & Borduin, 1990). Following multisystemic assessment where members of the adolescent's family and wider network are interviewed, a unique intervention programme is developed that targets those specific subsystems which are largely responsible for the maintenance of the youngster's difficulties. In the early stages of contact the therapist joins with system members and later interventions focus on reframing the system members' ways of understanding the problem or restructuring the way they interact around the problems. Interventions may focus on the adolescent alone; the family; the school; the peer group or the community. Individual interventions typically focus on helping youngsters develop social and academic skills. Improving family communication and parents' supervision and discipline skills are common targets for family intervention. Facilitating communication between parents and teachers and arranging appropriate educational placement are common school-based interventions. Interventions with the peer group may involve reducing contact with deviant peers and increasing contact with non-deviant peers.

In contrast to functional family therapy, which focuses exclusively on the family system, or multisystemic therapy, which addresses both individual factors and the wider social network in addition to family factors, treatment foster care deals with the problem of pervasive conduct problems by linking the adolescent and his or her family to a new and positive system: the treatment foster family. In treatment foster care, carefully selected and extensively trained foster parents in collaboration with a therapist offer adolescents a highly structured foster-care placement over a number of months in a foster-family setting (Chamberlain, 1990; Chamberlain & Reid, 1991; Kirgin etal., 1982). Treatment foster care aims to modify factors that maintain conduct problems within the child, family, school, peer group and other systems by placing the child temporarily within a foster family in which the foster parents have been trained to use behavioural strategies to modify the youngsters deviant behaviour (Chamberlain, 1994). Adolescents in treatment foster care typically receive a concurrent package of multisystemic interventions to modify problem maintaining factors within the adolescent, the birth family, the school, the peer group and the wider community. These are similar to those described for multisystemic therapy and invariably the birth parents complete a behavioural parent training programme so that they will be able to continue the work of the treatment foster parents when their adolescent visits or returns home for the long term. A goal of treatment foster care is to prevent the long-term separation of the adolescent from his or her biological family so, as progress is made, the adolescent spends more and more time with the birth family and less time in treatment foster care.

With respect to service development, it may be most efficient to offer services for adolescent conduct problems on a continuum of care (Chamberlain & Rosicky, 1995). Less severe cases may be offered functional family therapy. Moderately severe cases and those that do not respond to circumscribed family interventions may be offered multisystemic therapy. Extremely severe cases and those who are unresponsive to intensive multisystemic therapy may be offered treatment foster care.

Adolescent Drug Abuse

While experimentation with drugs in adolescence is widespread, problematic drug abuse is less common. A conservative estimate is that between 5 % and 10 % of teenagers under 19 have drug problems serious enough to require clinical intervention (Liddle & Dakof, 1995). Drug abuse often occurs concurrently with other conduct problems, learning difficulties and emotional problems and drug abuse is also an important risk factor for suicide in adolescence.

Liddle & Dakof (1995) and Waldron (1996) in literature reviews of a series of controlled clinical trials, concluded that family-based therapy (which includes both family therapy and multisystemic therapy) is more effective than other treatments in engaging and retaining adolescents in therapy and also in the reduction of drug use. From their meta-analysis of controlled family-based treatment outcome studies Stanton & Shadish (1997) concluded that family-based therapy is more effective in reducing drug abuse than individual therapy; peer group therapy; and family psychoeducation. Furthermore, family-based therapy leads to fewer dropouts from treatment compared with other therapeutic approaches. Their final conclusion was that family-based therapy is effective as a stand-alone treatment modality but it can also be combined effectively with other individually based approaches and lead to positive synergistic outcomes. Thus, family therapy can empower family members to help adolescents engage in treatment; remain committed to the treatment process; and develop family rules, roles, routines, relationships, and belief systems which support a drug free lifestyle. In addition family therapy can provide a context within which youngsters could benefit from individual, peer group or school based interventions.

Family systems theories of drug abuse implicate family disorganization in the aetiology and maintenance of seriously problematic adolescent drug taking behaviour and there is considerable empirical support for this view (Hawkins, Catalano & Miller, 1992; Szapocznik & Kurtines, 1989; Stanton, & Heath, 1995). Family-based interventions aim to reduce drug abuse by engaging families in treatment and helping family members reduce family disorganization and change patterns of family functioning in which the drug abuse is embedded.

Effective systemic engagement, involves contacting all significant members of the adolescent's network directly or indirectly, identifying personal goals and feared outcomes that family members may have with respect to the resolution of the adolescent's drug problems and the family therapy associated with this, and then framing invitations for resistant family members to engage in therapy so as to indicate that their goals will be addressed and feared outcomes will be avoided (Santisteban et al., 1996; Szapocznik et al., 1988). Once families engage in therapy, effective treatment programmes for adolescent drug abuse involve the following processes, which although overlapping may be conceptualized as stages of therapy: problem definition and contracting; becoming drug free; facing denial and creating a context for a drug-free lifestyle; family reorganization; disengagement and planning for relapse prevention (Stanton & Heath, 1995). The style of therapy that has been shown to be effective with adolescent drug abusers and their families has evolved from the structural and strategic family therapy traditions (Haley, 1980; Minuchin, 1974). Effective family therapy in cases of adolescent drug abuse helps family members clarify communication, rules, roles, routines hierarchies and boundaries; resolve conflicts; optimize emotional cohesion; develop parenting and problem-solving skills and manage lifecycle transitions.

Multisystemic ecological treatment approaches to adolescent drug abuse represent a logical extension of family therapy. They are based on the theory that problematic processes, not only within the family but also within the adolescent as an individual and within the wider social system including the school and the peer group may contribute to the aetiology and maintenance of drug abuse (Henggeler & Borduin, 1990). This conceptualization of drug abuse is supported by considerable empirical evidence (Hawkins, Catalano & Miller, 1992; Henggeler et al., 1991). At a personal level, adolescent drug abusers have been shown to have social skills deficits, depression, behaviour problems and favourable attitudes and expectations about drug abuse. As has previously been outlined, their families are characterized by disorganization and in some instances by parental drug abuse. Many adolescent drug abusers have experienced rejection by prosocial peers in early childhood and have become members of a deviant peer group in adolescence. Within a school context drug abusers show a higher level of academic failure and a lower commitment to school and academic achievement compared to their drug-free counterparts. Multisystemic ecological intervention programmes for adolescent drug abusers, like those for adolescents with pervasive conduct problems described earlier, have evolved out of the structural and strategic family therapy traditions (Henggeler & Borduin, 1990). In each case treated with multisystemic therapy, around a central family therapy intervention programme, an additional set of individual, school-based and peer-group based interventions are offered that target specific risk factors identified in that case. Such interventions may include self-management skills training for the adolescent, school-based consultations or peer-group based interventions. Self-management skills training may include coaching in social skills, social problem-solving and communication skills, anger control skills and mood regulation skills. School-based interventions aim to support the youngsters' continuation in school, to monitor and reinforce academic achievement and prosocial behaviour in school, and to facilitate home-school liaison in the management of academic and behavioural problems. Peer group interventions include creating opportunities for prosocial peer group membership and assertiveness training to empower youngsters to resist deviant peer group pressure to abuse drugs.

With respect to service development, the results of controlled treatment trials suggest that a clear distinction must be made between systemic engagement procedures and the process of family therapy, with resources devoted to each.

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