Evidence

Proven treatments include those which singly or in combination address:

• parenting skills

• family functioning

• child interpersonal skills

• difficulties at school

• peer group influences

• medication for coexistent hyperactivity.

Parenting skills

Parent management training aims to improve parenting skills. There are scores of randomized controlled trials showing that it is effective for children up to about 10 years old.(49) They address the parenting practices identified in research as contributing to conduct problems. A more detailed account is given in Scott. (50) Typically, they include five elements.

1. Promoting play and a positive relationship In order to cut into the cycle of defiant behaviour and recriminations, it is important to instil some positive experiences for both sides and begin to mend the relationship. Teaching parents the techniques of how to play in a constructive and non-hostile way with their children helps them recognize the child's needs and to respond sensitively. The children in turn begin to like and respect their parents more, and become more secure in the relationship.

2. Praise and rewards for sociable behaviour Parents are helped to reformulate difficult behaviour in terms of the positive behaviour they wish to see, so that they encourage wanted behaviour rather than criticize unwanted behaviour. For example, instead of shouting at the child not to run, they would praise him whenever he walks quietly; then he will do it more often. Through hundreds of such prosaic daily interactions, child behaviour can be substantially modified. Yet some parents find it hard to praise, and fail to recognize positive behaviour when it happens, with the result that it becomes less frequent.

3. Clear rules and clear commands Rules need to be explicit and constant; commands need to be firm and brief. Thus shouting at a child to stop being naughty does not tell him what he should do, whereas telling him to play quietly, for example, gives a clear instruction which makes compliance easier.

4. Consistent and calm consequences for unwanted behaviour Disobedience and aggression need to be responded to firmly and calmly by, for example, putting the child in a room for a few minutes. This method of 'time out from positive reinforcement' sounds simple, but requires considerable skill to administer effectively. More minor annoying behaviours such as whining and shouting often respond to being ignored, but again parents often find this hard to achieve in practice.

5. Reorganizing the child's day to prevent trouble There are often trouble spots in the day which will respond to fairly simple measures, such as putting siblings in different rooms to prevent fights on getting home from school, banning television in the morning until the child is dressed, and so on.

Treatment can be given individually to the parent and child, which enables live feedback in light of the parent's progress and the child's response. Alternatively, group treatments with parents alone have been shown to be equally effective.(51)

Trials show that parent management training is effective in reducing child antisocial behaviour in the short term, with moderate to large effect sizes of 0.5 to 0.8 standard deviations, and there is little loss of effect at 1- or 3-year follow-up. (52) Parenting skills' interventions are chiefly used with younger children, although there is evidence for their successful use with delinquent boys.(53)

Family functioning

Functional family therapy, multisystemic therapy, and treatment foster care aim to change a range of difficulties that impede the effective functioning of teenagers with conduct disorder. Functional family therapy addresses family processes which need to be present, such as improving communication between parent and young person, reducing interparental inconsistency, tightening up on supervision and monitoring, and negotiating rules and the sanctions to be applied for breaking them. Functional family therapy has been shown to reduce reoffending rates by around 50 per cent. (54) Other varieties of family therapy have not been subjected to controlled trials for young people with conduct disorder or delinquency, so cannot be evaluated for their efficacy.

In multisystemic therapy(55) the young person's and family's needs are assessed in their own context at home and in their relationships with other systems such as school and peers. Following the assessment, proven methods of intervention are used to address difficulties and promote strengths. Multisystemic therapy differs from most types of family therapy, such as the Milan or systemic approach as usually practised, in a number of ways.

1. Treatment is delivered in the situation where the young person lives, for instance at home.

2. The therapist has a low caseload (four to six families) and the team is available 24 hours a day.

3. The therapist is responsible for ensuring appointments are kept and for making change happen—families cannot be blamed for failing to attend or 'not being ready' to change.

4. Regular written feedback on progress towards goals from multiple sources is gathered by the therapist and acted upon.

5. There is a manual for following the therapeutic approach and adherence is checked weekly by the supervisor.

Several randomized controlled trial attest to effectiveness, with reoffending rates typically cut by half and time spent in psychiatric inpatient care further reduced.

Treatment foster care is another way of improving the quality of encouragement and supervision that teenagers with conduct disorder receive. The young person lives with a foster family specially trained in effective techniques; sometimes it is ordered as an alternative to jail. Outcome studies show useful reductions in reoffending rates.

Child interpersonal skills

Most of the programmes to improve child interpersonal skills derive from cognitive-behaviour therapy—three of the most effective are Self-instructional training, (56) the Anger Coping Program,(5Z) and Promoting Alternative Thinking Strategies (PATHS).(58) These and other programmes have in common training the young person to:

1. slow down impulsive responses to challenging situations by stopping and thinking;

2. recognize his or her own level of physiological arousal, and his or her own emotional state;

3. recognize and define problems;

4. develop several alternative responses;

5. choose the best alternative based on anticipation of consequences;

6. reinforce him- or herself for use of this approach.

Over the longer term they aim to increase positive social behaviour by teaching the young person to:

1. learn skills to make and sustain friendships;

2. develop social interaction skills such as turn-taking and sharing;

3. express viewpoints in appropriate ways and listen to others.

Typically, given alone, treatment gains with interpersonal skills' training are good within the treatment setting, but they only generalize slightly to 'real-life' situations such as the school playground. However, when they are part of a more comprehensive programme, which has those outside the young person reinforcing the approach, they add to outcome gains.

Difficulties at school

These can be divided into learning problems and disruptive behaviour. There are proven programmes to deal with specific learning problems such as specific reading retardation, for instance the Reading Recovery Programme. However, few of the programmes have been specifically evaluated for their ability to improve outcome in children with conduct disorder, although trials are in progress. Preschool education programmes for high-risk populations have been shown to reduce arrest rates and improve employment in adulthood (see below).

There are several schemes for improving classroom behaviour, varying from those that stress improved communication such as 'circle time', and those that work on behavioural principles such as the Good Behaviour Game (5§> or are part of a multimodal package. Many of these schemes have been shown to improve classroom behaviour, and some specifically target children with conduct disorder. (60>

Peer group influences

A few interventions have aimed to reduce the bad influence of deviant peers. However, a number have attempted this through group work with other conduct-disordered youths, but outcome studies showed a worsening of antisocial behaviour. Current treatments therefore either see youths individually and try to steer them away from deviant peers, or work in small groups (say three to five youths) where the therapist can control the content of sessions. Some interventions place youths with conduct disorder in groups with well-functioning youths, and this has led to favourable outcomes. (62>

Medication for coexistent hyperactivity

Where there is comorbid hyperactivity in addition to conduct disorder, several studies attest to a large reduction(effect size, 0.8 standard deviations or greater) in both overt and covert antisocial behaviour, (49 both at home and at school/63 However, the impact on long-term outcome is unstudied.

Break Free From Passive Aggression

Break Free From Passive Aggression

This guide is meant to be of use for anyone who is keen on developing a better understanding of PAB, to help/support concerned people to discover various methods for helping others, also, to serve passive aggressive people as a tool for self-help.

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