Luis Alberto Jimenez-Camargo Chapter 13: Treatment of Conduct Problems and Disruptive Behavior Disorders Nicole P. Powell John 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 effects Substance abuse Delinquency Incarceration Conduct problems tend to be treatment-resistant (Kazdin, 2000)

CBT Approaches: Children Anger Control Training Based on social information processing theory Individual or group setting Taught to use problem-solving strategies across hypothetical and real-life situations In vivo practice used to arouse children’s feelings of anger Coping 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 patterns Manual-based treatments Children 7–12 years old Based on cognitive-behavioral and behavioral concepts Both 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 Child Evaluated in over 40 studies, documented both short- and long-term benefits Parent-Child Interaction Therapy Two RCTs demonstrated positive effects on children’s disruptive behaviors and parent-child interactions Both are: Manual-based treatments for 2- to 7-year-olds Specifically intended to address issues related to parent-child interactions Based on the Hanf model: 1) parent learns to apply positive attention skills; 2) parent learns discipline strategies to address unwanted behaviors

Parent-Management Training Oregon 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 formats Skills 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 Approaches Adolescents Group Assertiveness Training: three-part response model of assertiveness Empathy statement, conflict statement, action statement Based 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 Program Learning self-realization strategies Fewer 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 behavior Assumes 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 adolescents Goal: 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 1 Coercive escalating cycles of harsh parental directives and child noncompliance Harsh, inconsistent discipline Unclear directions and commands Lack of warmth and involvement Lack 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/negative Believe that they are ineffective caregivers Believe 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 intervention 3) 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 adjustment Self 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 effects Transdiagnostic interventions apply the same underlying treatment principles across different disorders

Timing of Measurement Multiple measurement points Clinical setting: frequent (weekly) measurement Gives 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 Power Child and parent groups Taught 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