Disruptive Behaviour Disorders (Disorders of Conduct)

Fast facts

• Early intervention at a younger age is more effective and costs less. Conduct problems are reliably identifiable from the age of 3 years.
• Parent training programmes are the most effective intervention for pre-school and primary school aged children.
• Older children and adolescents are likely to need adjunctive, multimodal and/or individual interventions.
• Medication isn’t recommended as a first-line treatment.

Interventions that work – at a glance

This table represents a compilation of information from several different sources (Blissett et al. (2009a), Fonagy et al. (2015), The Matrix (2015), and Dunnachie (2007)) and is designed to provide an overview only. Directly consulting these sources will provide considerable additional information. The Evidence-Based Interventions (EBI) page has more detail on these categories.

The fine print

1. Based on behavioural management principles drawn from social learning theory, examples include The Incredible Years, Triple P, Parent-Child Interaction Therapy (under 8 year old children), and the Oregon Social Learning Centre programme. There is substantial research evidence that parenting programmes can improve parent-child relationships, prevent maltreatment of children, and improve child conduct problems (Gardner et al., 2015).  About two-thirds of children whose parents have attended parenting programmes show improvement in their parenting skills (Fonagy et al., 2015). Group-based parenting programmes are an effective and cost-effective way of treating children’s conduct problems, improving parenting skills, and parental mental health (Furlong et al., 2012). The NICE clinical guidelines for the management of conduct disorders in children and young people (2013) provide specific evidence-based advice around how interventions should be structured. Research has also gone beyond naming specific effective parenting programmes, and has clarified which elements of programmes are the most useful. The Centers for Disease Control and Prevention (CDC) identified several key aspects that effective programmes have in common:

• Teaching parents emotional communication skills
• Teaching parents to interact positively with their child
• Requiring parents to practice with their child during programme sessions
• Teaching parents the correct use of time out
• ­Teaching parents to respond consistently to their child

2. Individual therapy to improve self-control, e.g. anger management, social skills training, such as the Coping Power programme (see Larson & Lochman, 2002).

3. Examples include Multi-systemic Therapy (MST), Multidimensional Family Therapy (MDFT), Functional Family Therapy, which are comprehensive multi-modal interventions that are all available in New Zealand.

4. Child focussed social and cognitive problem solving programmes, effectiveness is enhanced when combined with parent management training.

5. School-based interventions don’t produce significant improvements in children’s conduct problems across settings, unless combined with other interventions.

6. NICE guidelines recommend that pharmacological interventions are not used for the usual management of children and adolescents with conduct problems (NICE, 2013). However, if a young person has co-existing ADHD, this ought to be treated with methylphenidate or atomoxetine (NICE, 2013). There is a little evidence from clinical trials that suggests risperidone can be useful to reduce aggression and conduct problems in 5-18 year olds in the short term (Loy et al., 2012). More specifically, it is recommended that risperidone can be helpful for young people with a conduct disorder who have difficulties with severe emotional dysregulation and explosive anger, who have not responded to non-pharmacological interventions (NICE, 2013). In summary, medication is not recommended as a first line intervention for treatment of conduct problems.

Description and demographics

The Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American Psychiatric Association, 2013) describes a collection of formal diagnoses that relate to difficulties with emotional and behavioural control- including Conduct Disorder and Oppositional Defiant Disorder. Conduct Disorder is divided into two subtypes in DSM-5, namely childhood-onset type (at least one of the 15 behaviours must be present before age 10) and adolescent-onset. The new revision also includes a specifier, for young people who (for over one year) have demonstrated limited prosocial emotions, or a callous and unemotional interpersonal style. Oppositional Defiant Disorder refers to a pattern of behaviour involving angry or irritable mood, an argumentative, defiant or vindictive perspective, of at least six months’ duration. DSM-5’s revision included these emotional features alongside the behavioural aspects. Intermittent Explosive Disorder is a newer DSM-5 diagnosis, which describes recurrent impulsive or anger-based aggressive outbursts in over-6 year olds (American Psychiatric Association, 2013).

It is estimated that 5-10% of New Zealand children and young people will have behavioural difficulties that are significant enough to warrant intervention at any one time (Blissett et al., 2009a). The majority (around 75%) are male. Estimates suggest that around 15-20% of Māori children present with conduct problems (Blissett et al., 2009a), a significantly higher rate than for non-Māori children.

There has been a recent wave of interest in effective interventions to both prevent and treat child conduct problems in New Zealand. This is outlined in four best practice reports, produced by the Advisory Group on Conduct Problems (Blissett et al., 2011, 2009a, 2009b; Church et al., 2013). With early intervention, conduct problems are very treatable. What’s more, it’s argued that the development of the science behind treatments for conduct difficulties represents one of the major achievements of the mental health sciences (Dadds, 2012).

Several recent studies have explored whether the compelling results from international effectiveness studies can be achieved in New Zealand. A study which specifically explored whether parenting programmes developed in the USA and Australia could be transported internationally found that parenting programmes were at least (if not more) effective when transported to other countries, including non-Western countries (Gardner at al., 2015). One New Zealand study followed 136 families who had participated in the Incredible Years group parent programme for 30 months. Results showed that the Incredible Years Parent programme for 3-8 year old children is very effective in treating child behaviour problems and changing parenting in New Zealand (Fergusson, Horwood & Stanley, 2013d). The programme was effective for children with conduct problems in both the clinical range, and the non-clinical range. And gains for Māori families were very similar to gains for non-Māori families (Sturrock et al., 2014). Impressively, the follow-up data suggests that gains are maintained for at least 30 months (Fergusson, Boden & Horwood, 2015).

References

• American Psychiatric Association (2013). Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-V). Arlington, VA: American Psychiatric Association.
• Blissett, W., Church, J., Fergusson, D. M., Lambie, I., Langley, J., Liberty, K.,...Werry, J.
• (2009a). Conduct problems: Best practice report 2009. Wellington, New Zealand: Ministry of Social Development.
• Blissett, W., Church, J., Fergusson, D. M., Lambie, I., Langley, J., Liberty, K.,...Werry, J.
• (2009b). Conduct problems: Effective programmes for 3–7 year olds. Wellington, New Zealand: Ministry of Social Development.
• Blissett, W., Church, J., Fergusson, D. M., Lambie, I., Langley, J., Liberty, K., ...Werry, J.
• (2011). Conduct problems: Effective programmes for 8–12 year olds. Wellington, New Zealand: Ministry of Social Development.
• Centers for Disease Control and Prevention. Parent Training Programs: Insight for Practitioners. Atlanta (GA): Centers for Disease Control; 2009.
• Church, J., Fergusson, D. M., Lambie, I., Langley, J., Liberty, K., Macfarlane, A. H.,...Werry, J.
• (2013). Conduct problems: Adolescent report 2013. Wellington, New Zealand: Ministry of Social Development.
• Dadds, M. (2012). Helping troubled children: Seven things you should know about the origins of mental health disorders. InPsych 34 (3).
• Dunnachie, B. (2007). Evidence-based Age-appropriate Interventions – A guide for child and adolescent mental health services (CAMHS). Auckland: The Werry Centre for Child and Adolescent Workforce Development.
• Fergusson, D.M., Boden, J.M., Horwood, L.J. (2015) From Evidence to Policy: Findings from the Christchurch Health and Development Study. Australian and New Zealand Journal of Criminology, 48(3) 386–408.
• Fergusson, D. M., Horwood, L. J., & Stanley, L. (2013d). A preliminary evaluation of the Incredible Years Teacher Programme. New Zealand Journal of Psychology, 42 (2), 51–56.
• Fonagy, P., Cottrell, D., Phillips, J., Bevington, D., Glaser, D., & Allison, E. (2015). What Works for Whom? A critical review of treatments for children and adolescents (2^nd Ed). New York: Guilford.
• Furlong, M., McGilloway, S., Bywater, T., Hutchings, J., Smith, S., & Donnelly, M. (2012). Behavioural and cognitive-behavioural group-based parenting programmes for early-onset conduct problems in children aged 3-12 years. Cochrane Database of Systematic Reviews (2).   
• Gardner, F., Montgomery, P., & Knerr, W. (2015). Transporting evidence-based parenting progams for child problem behaviour (age 3-10) between countries: Systematic review and meta-analysis. Journal of Clinical Child and Adolescent Psychology, 1-14.
• Larson, J., & Lochman, J. E. (2002). Helping schoolchildren cope with anger: A cognitive-behavioural intervention. New York: Guilford Press.
• Loy, J. H., Merry, S. N., Hettick, S. E., & Stasiak, K. (2012). Atypical antipsychotics for disruptive behaviour disorders in children and youths. Cochrane Database of Systematic Reviews (9).
• NICE (2013). Antisocial Behaviour and Conduct Disorders in Children and Young People: Recognition and Management. Clinical Guideline (CG158). Obtained from www.nice.org.uk/guidance/cg158 on 23rd August 2017.
• Sturrock, F., Gray, D., Fergusson, D., Horwood, J., & Smits, C. (2014). Incredible Years Follow-up Study. Long-term follow-up of the New Zealand Incredible Years Pilot Study. Wellington: Ministry of Social Development.
• The Matrix (2015). A Guide to Delivering Evidence-based Psychological Therapies in Scotland. Scotland: NES.