1. 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

2. 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)

3. 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

4. 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

5. 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

6. 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

7. 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

8. 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

9. 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

10. 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)

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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