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Eye on Psi Chi: Spring 2008
Treatment of Antisocial Behavior in Children and Adolescents
Alan E. Kazdin, PhD, Yale University (CT)

Antisocial behaviors in children refer to social rule violations and actions against others. Such behaviors as fighting, lying, and stealing are seen in varying degrees in many children over the course of development. The behaviors become clinically significant when they are frequent and intense, are not just isolated acts, and interfere with the child’s functioning at home and at school (see Hill & Maughan, 2001; Rutter, Giller, & Hagell, 1998). Conduct disorder (CD) is the psychiatric diagnosis that encompasses antisocial behaviors including those already mentioned plus destroying property, bullying and threatening others, forcing sexual activity, setting fires, and being cruel to people or animals (see American Psychiatric Association, 1994). Parents, teachers, and others usually feel they cannot manage the child; often the child is dangerous (e.g., hitting or endangering siblings) and causes damage (e.g., destroying objects at home). As with many other psychiatric diagnoses, the cutoff criteria for defining the disorder is somewhat arbitrary; individuals who meet the criteria clearly have a significant clinical problem, but those who just miss or who flow in and out of the criteria may be significantly impaired as well.

The behaviors that comprise CD are among the most frequent bases of clinical referrals in child and adolescent treatment services and encompass from one-third to one-half of all referrals. Moreover, children with CD often traverse multiple social services and systems in childhood, adolescence, and adulthood (e.g., special education, mental health, justice). This makes CD one of the most costly mental disorders in the United States. The estimated cost for a child with CD is $10,000–$15,000 (U.S.) per year for social services over the course of childhood and adolescence (Knapp, Scott, & Davies, 1999; Scott, Knapp, Henderson, & Maughan, 2001). These costs are 10 times greater than for a child without the diagnosis.

The core features of the problem (e.g., aggression, property destruction, firesetting) barely scratch the surface of what is presented clinically. More than 70% of children with CD usually meet criteria for more than one psychiatric disorder. Also, they show deficiencies in peer relations, cognitive deficits and distortions that contribute to their aggression, and poor academic functioning. Most children with CD (approximately 80%) continue with a psychiatric disorder and impairment in adulthood. Other long-term outcomes include criminal activity, lower occupational and educational status, and higher rates of serious physical disease (e.g., cancer, heart disease, and respiratory disease).

How and Why Do Children Develop Conduct Disorder?
The diagnosis of CD is heterogeneous; children can show more than 32,000 combinations of symptoms and still meet the criteria of CD. It is unlikely there will be one set of factors leading to "the” disorder. One line of research is to identify subgroups to delineate different types that might reveal patterns leading to one variation or another. For example, CD that emerges in childhood is more likely to be associated with very aggressive behavior and is more common among boys; CD that emerges in adolescence is more likely to include vandalism and property destruction and to be equally distributed among boys and girls (Moffitt & Caspi, 2005).

There is progress in understanding CD and how it may emerge. Some of the progress has come from abandoning traditional views which proposed that children were "acting out” internal conflicts or thwarted psychological development or that the children were expressing complex family dynamics (e.g., mixed roles and communications in the home). Advances in what we do know have helped move beyond these views.

CD encompasses a set of psychological, biological, social, and contextual influences that can converge in different ways (Rutter et al., 1998). This is suggested by the many predictors (also called risk factors) of CD. Risk factors refer to variables that precede and are correlated with the onset of CD. Many such factors have been identified (e.g., family history of aggressive behavior, difficult temperament, poor monitoring and supervision of the child, association of the child with other children who engage in antisocial behavior, parent’s use of harsh punishment, marital conflict, mother’s alcohol abuse or cigarette smoking during pregnancy, and others). Corporal punishment is more than a correlate of antisocial behavior and may play a causal role. Harsh punishment is associated with aggressive behavior; also changing punishing practices in the home can reduce child aggression (Reid, Patterson, & Snyder, 2002). However, in most clinical referrals harsh punishment is not present and when it is present, many other untoward factors are likely to be involved.

There are promising leads that convey novel gene-environment interactions and have advanced our understanding. Individuals with a history of abuse and a particular genetic characteristic (polymorphism related to the metabolism of serotonin) are at much greater risk for antisocial behavior (Caspi et al., 2002). Among boys with the allele and maltreatment, 85% of them developed some form of antisocial behavior (by their mid 20s). It is the gene-environment combination that confers great risk, rather than either characteristic by itself. Replication and extension of these effects to family adversity have underscored the critical role of gene-environment interactions in antisocial outcomes (Foley et al., 2004; Jaffee et al., 2005). Nonhuman animal work (e.g., with rhesus monkeys) also has conveyed the importance of early environment and serotonin metabolism in relation to the emergence of aggressive behavior (e.g., Suomi, 2003). The scope of this work, well beyond the present discussion, conveys that progress is being made in understanding the emergence of and possible mechanisms underlying antisocial behavior.

Treatment
Progress in identifying treatments. If we really do not understand what the causes of CD are, how can we make progress in treatment? It is important to keep separate, theories of etiology (what caused the condition) and theories of change (what can be done to ameliorate the condition). We always want to know the causes for purposes of prevention and treatment. Yet, there are many instances in medicine in which we have effective treatment where we are not at all clear what the cause is (e.g., headaches, many cancers). In psychology the situation is similar—many effective treatments (e.g., evidence-based treatments [EBTs]) where we have models that explain how the treatment might work but no real evidence about how the problem came about (e.g., obsessive-compulsive disorder, panic attacks, unipolar depression). In relation to CD, several treatments now have solid evidence on their behalf and are listed in Table 1. These treatments have been applied with severely impaired cases including inpatient children, adjudicated violent and chronic juvenile offenders, and youths presenting for psychiatric emergencies, apart from outpatient referrals.

The work of our research group began on a children’s psychiatric inpatient service. Children (ages 5-12) were being admitted primarily for severe conduct problems. We worked with two treatments: parent management training provided to the parent(s) and problem-solving skills training provided to the child. For many families, there was no parent who could participate because of severe impairment (e.g., psychiatric disorder, substance abuse, serving in prison), or we were about to remove the child permanently from the home (e.g., parent cruelty, criminal activity run out of the home). We began both treatments on an inpatient basis and continued after discharge. We expanded the program to outpatient treatment and have continued outpatient work for the past 20+ years (Parenting Center and Child Conduct Clinic; http://www.yale.edu/childconduct clinic). Both treatments focus on altering child functioning in everyday life. They are learning based and include extensive rehearsal, practice, and shaping of desired performance. Coaching and skill building take place in the treatment sessions, but much of the "therapy” is carried out in everyday life where the skills are practiced. Several treatment trials have shown that these treatments reduce aggressive and antisocial behavior and improve prosocial behaviors at home and at school; the changes are maintained at least up to 1–2 years later (Kazdin, 2003). The impact of treatment also is reflected on decreases in parent depression and stress and on improvements in family relations.

Dissemination of Evidence-Based Treatments: The Major Challenge
The most common treatment delivered in outpatient services for aggressive and antisocial children tends to be a general relationship, expressive therapy that includes efforts to understand and discuss why the child is aggressive and the need for improved communication in the home. EBTs have yet to become standard practice. Clearly, the major task is to disseminate effective treatments to mental health professionals (e.g., psychologists, psychiatrists, social workers, nurses) in training or currently in clinical practice. This is an enormous challenge.

TABLE 1 | Evidence-Based Treatments Currently Available for Oppositional, Aggressive, and Antisocial Behavior (Conduct Disorder)
Parent Management Training is directed at altering parent-child interactions in the home, particularly those interactions related to child-rearing practices and coercive interchanges.

Multisystemic Therapy focuses on the individual, family, and extrafamilial systems and their interrelations as a way to reduce symptoms and to promote prosocial behavior.

Multidimensional Treatment Foster Care Model focuses on youth who are in placement and who are to return to their parents or more permanent foster care. Behavioral treatments in the placement and in the setting to which the child is returned are part of a comprehensive effort to integrate treatment and community life.

Cognitive Problem-Solving Skills Training focuses on cognitive processes that underlie social behavior and response repertoires in interpersonal situations. Anger Control Training includes problem-solving skills training in the context of groups in the schools.

Brief Strategic Family Therapy focuses on the structure of the family and concrete strategies that can be used to promote improved patterns of interaction. This treatment has been developed with Hispanic children and adolescents and has integrated culturally pertinent issues to engage the families.

Functional Family Therapy utilizes principles of systems theory and behavior modification for altering interaction, communication patterns, and problem solving among family members.

Each of these treatments has multiple outcome studies and with clinic samples (see Kazdin, in press).

There are resources that inform, list, and described EBTs (http://ucoll.fdu.edu/apa/ lnksinter.html). Perhaps the most well known is the web-based resource by the Substance Abuse and Mental Health Services Administration (www.nationalregistry. samhsa.gov). There are scores of treatment manuals, conferences and workshops, and continuing education experiences, each of which is very helpful in making people aware of treatments, showing what treatments look like, and promoting interest. These resources are quite different from training individuals to administer treatment competently, which is likely to require more intense training and some supervised experience. Graduate programs in clinical and school psychology occasionally discuss EBTs, but rarely provide practical training (e.g., Shernoff, Kratochwill, & Stoiber, 2003; Woody, Weisz, & McLean, 2005). Internship programs and practicum placements usually are not positioned to provide supervised training in EBTs; the supervising clinical faculty and staff are not likely to have training in the techniques.

Our model of intervention development and dissemination in the mental health professions is sharply contrasted with the model that governs the development and promotion of medications. Once research and development of new drugs are complete, the dissemination baton is passed to marketing staff (e.g., massive media blitz) and drug detailers (e.g., 85,000 to 100,000 individuals who visit physicians). Some of the mass marketing (e.g., TV and magazine pieces) leads consumers to request, demand, and occasionally pressure their physicians to provide the medication. Without a formal means of spreading psychological interventions, many of our treatments are all dressed up with no place to go. There are many issues to learn about current treatments, to make them better, and make sure they are relevant, culturally sensitive, feasible, and user friendly. At the same time, our profession has developed effective treatments and their delivery ought to be in everyone’s interest. We need mechanisms that allow this to happen more efficiently.

Closing Comments
I have highlighted treatment of CD and some of the clinical issues involved. It is remarkable that we can help children who are significantly impaired. Moreover, current evidence suggests that helping children improves family relations and reduces stress in the home. There are children and families who desperately need our help. As we invariably say at the end of our research papers, much more work is needed to address unanswered questions and to pursue new leads. Here is a case where we have made palpable progress, and if we could extend what we know now, there would be a significant public benefit.

There are obstacles to dissemination of effective treatment well beyond those I have mentioned. Structures for reimbursing and funding treatment, lack of insurance coverage for any services for millions of children, and lack of access and barriers to treatment based on ethnicity, culture, and geography (rural areas) are strong forces that impede the delivery of any services, leaving aside for the moment those services based on our best evidence. Two or three decades ago, the major challenge in relation to CD was as follows: what can be done that is known to help children with severe aggressive and antisocial behavior? Years later, we now have several treatments with demonstrated impact. Our challenge now is to extend these treatments to the children and families in need.

References
American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

Caspi, A., McClay, J., Moffitt, T. E., Mill, J., Martin, J., Craig, I., Taylor, A., & Poulton, R. (2002). Role of genotype in the cycle of violence in maltreated children. Science, 297, 851–854.

Foley, D., Wormley, B., Silberg, J., Maes, H., Hewitt, J., Eaves, L., & Riley, B. (2004). Childhood adversity, MAOA genotype, and risk for conduct disorder. Archives of General Psychiatry, 61, 738-744.

Hill, J., & Maughan, B. (Eds.). (2001). Conduct disorders in childhood and adolescence. Cambridge: Cambridge University Press.

Jaffee, S. R., Caspi, A., Moffitt, T. E., Dodge, K., Rutter, M., Taylor, A., & Tully, L. (2005). Nature °— nurture: Genetic vulnerabilities interact with physical maltreatment to promote behavior problems. Development and Psychopathology, 17, 67-84.

Kazdin, A. E. (2003). Problem-solving skills training and parent management training for conduct disorder. In A. E. Kazdin & J. R. Weisz (Eds.), Evidence-based psychotherapies for children and adolescents (pp. 241-262). New York: Guilford Press.

Kazdin, A. E. (in press). Psychosocial treatments for conduct disorder in children and adolescents. In P. E. Nathan & J. M. Gorman (Eds.), A guide to treatments that work (3rd ed.). New York: Oxford University Press.

Knapp, M., Scott, S., & Davies, J. (1999). The cost of antisocial behaviour in younger children. Clinical Child Psychology and Psychiatry, 4, 457-473.

Moffitt, T. E., & Caspi, A. (2005). Life-course persistent and adolescence- limited antisocial males: Longitudinal follow up to adulthood. In D. M. Stoff & E. J. Susman (Eds.), Developmental psychobiology of aggression (pp. 161-186). New York: Cambridge University Press.

Reid, J. B., Patterson, G. R., & Snyder, J. (Eds.). (2002). Antisocial behavior in children and adolescents: A developmental analysis and model for intervention. Washington, DC: American Psychological Association.

Rutter, M., Giller, H., & Hagell, A. (1998). Antisocial behavior by young people. New York: Cambridge University Press.

Scott, S., Knapp, M., Henderson, J., & Maughan, B. (2001). Financial cost of social exclusion: Follow up study of antisocial children into adulthood. British Medical Journal, 323, 191-194.

Shernoff, E. S., Kratochwill, T. R., & Stoiber, K. C. (2003). Training in evidence-based interventions (EBIs): What are school psychology programs teaching? Journal of School Psychology, 41, 467-483.

Suomi, S. J. (2003). Gene-environment interactions and the neurobiology of social conflict. Annals of the New York Academy of Sciences, 1008, 132-139.

Woody, S. R., Weisz, J. R., & McLean, C. (2005). Empirically supported treatments: 10 years later. The Clinical Psychologist, 58, 5-11.

Alan E. Kazdin, PhD, is the John M. Musser Professor of Psychology and Child Psychiatry at Yale University, Director of the Yale Parenting Center and Child Conduct Clinic. He is also President of the American Psychological Association (APA). Kazdin is a licensed clinical psychologist, a diplomate of the American Board of Professional Psychology, and a fellow of APA, the APS, and the Association for the Advancement of Science. His honors include Research Scientist Career and MERIT Awards from the National Institute of Mental Health and awards for Distinguished Scientific Contribution to Clinical Psychology and Distinguished Professional Contribution to Clinical Child Psychology (APA, Division 12), and Outstanding Research Contribution by an Individual (Association for Advancement of Behavior Therapy). Currently, he teaches and supervises graduate and undergraduate students and runs a clinical research program for children and families. His research focuses on childhood antisocial behavior, child and family therapy, and processes that contribute both to clinical dysfunction and therapeutic change. He has authored or edited over 600 articles, chapters, and books. His 44 books focus on child and adolescent psychotherapy, aggressive and antisocial behavior, and methodology and research design.

Author Note. The author’s work has been supported in part by grants from the National Institute of Mental Health (MH35408, MH00353, MH59029).

Copyright 2008 (Volume 12, Issue 3) by Psi Chi, the International Honor Society in Psychology



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