Prevention and Treatment of Conduct Disordered Youth

• Author: Normand Carrey and Jalal Shamsie
• Pages: 935-954



CHAPTER 44

Prevention and Treatment of

Conduct Disordered Youth

Normand Carrey and Jalal Shamsie

I. INTRODUCTION

e two central psycholegal issues of tness to stand trial and criminal responsibility are, by virtue of

biology, not a principal concern for youths under the age of eighteen years. is is because the rst orid

episodes of major menta l disorder such as schizophrenia and manic-depressive disorders (w ith the rare

exception) do not typically present until the late teens or early twenties. While the law with respect to t-

ness and criminal responsibility as it applies to adults is essentially the same for youths, what the courts

are most oen concerned with in dealing with this population are youths manifesting severe behavioural

diculties. ese, when recognized, are seen as “conduct disorders,” t he result of interacting individual,

family, and other environmental factors. It is thus important to adopt a “developmental framework” in

order to better understand the genesis of these behaviours in youth.

Conduct disorder (CD) is one of the most debilitating child mental health disorders (Loeber et al.,

2000; Frick, 1998; Hill 2002). e disorder is characterized by persistent aggression, violation of rules,

and antisocial acts (DSM-IV, 1994). One severe variant has its onset in early childhood and can persist

throughout the life span, with devastating consequences for society, the family, and the child (Robins,

1991; Mott et al., 2002a, 2003). e prevalence of CD has been estimated as present in between 5 and

10 percent (Angold & Costello, 2001) of children. As many as 50 percent of boys with CD continue to

show antisocial behaviour as young adults and the risk of antisocial personality disorder is even higher

if the antisocial behaviour starts before age ten (Langbehn et al., 1998; Kazdin, 1996). However the 50

percent progression rate raises the question about what “protective factors” account for the desistance

of the other 50 percent of children who do not go on to develop conduct disorder. Understanding the

multiple causes and pathways of conduct problems have serious implications for how the forensic and

mental health systems deal with oending youth either through an emphasis on prevention or evidence-

based interventions.

From a research perspective, Mott (2005a, 2008) points out that the study of antisocial behaviour

in children is stuck at the “risk factor” stage. is is because few studies have used designs capable of

dierentiating environmental from genetic contributions, their relative inuences, and their associa-

tion by correlation or causality. Risk factors are personal or environmental characteristics that increase

the likelihood of problem behaviour as established through scientic studies (Kirby & Fraser, 1997).

Recently there has been a shi to look at protective factors (personal or environmental) that interact with

risk factors to modify the problem behaviour thus emphasizing resilience as well. Longitudinal studies

are beginning to demonstrate how risk and protective factors (cognitive factors, presence of comorbid

internalizing or externalizing disorders, attachment quality, history of sexual or physical abuse, and

susceptibility genes for psychiatric disorders, etc.) interact to shape developmental pathways character-

istic of future young oenders (Vermeiren et al., 2006a, b). us an understanding of causal pathways

informing prevention and early intervention approaches is still lacking but such pathways are being

actively researched (Conduct Problems Prevention Research Group, 20 02, 2004). Cla ssication and diag-

Normand Carrey and Jalal Shamsie

nostic systems are still lagging behind approaches incorporating multiple risk/protective factors and

their interaction with developmental pathways.

With these limitations in mind, the clinica l problem of treating CD in older children and adolescents

is that, once the behaviours are entrenched, there is a high rate of relapse and recidivism. ere are many

treatment approaches (ranging from least to most intrusive such as outpatient group-based interventions

through to residential care) that show improvement dur ing or at the end of treatment, but the results are

not sustainable on a long-term basis. Greenbaum et al. (1998), in a multi-site seven year follow-up study

found that 75 percent of youth treated in a residential setting had either been re-admitted to a mental

health facility or to a correctional institution. e reduction in antisocial behaviour brought about by

even the best prevention programs (such as the FAST Track program, a multi-component program de-

livering interventions in multiple settings including home and school) is modest (Dodge, 2003). is is

indicative of the persistence of aggressive behav iour once it is established as a way of dealing with the

environment.

Prevention of recidivism is only as eective as “treatment generalizability.” at is, the eectiveness

of treatment can be claimed only if the youth can sustain positive change while in a less intensive or

restrictive environment and/or re-exposed to previous risk factors. erefore, the objective of any ap-

proach is rst to intervene early for prevention and, if this is not possible, to reduce the rate of recidiv-

ism on a long-term basis. Curry (1991) in a review of three follow-up studies for residential treatment

centres concluded that progress in treatment is not predictive of functioning aer treatment. Factors that

predicted positive adjustment a er discharge from the residential programs were the degree of support

provided post-discharge, family involvement, and inclusion of learning opportunities that can be gener-

alized to the youth’s community. Hoagwood and Cunningham (1992), in an outcome study of 114 chi l-

dren who were severely emotionally disturbed, found similar results as Curry: t he key factors in positive

outcomes were the availability of community-based services during transition involving family support,

respite care, crisis intervention, and day treatment. More recently, knowledge of factors contributing to

positive outcome in follow-up, current research into etiology, and early intervention, and more focused,

evidence-guided treatment approaches to conduct disorder have yielded more encouraging results and

new directions in treatment approaches.

is chapter starts with developmental factors, oen referred to as developmental trajectories or

developmental pathways, relating early child and family characteristics to later adolescent and adult

conduct/delinquency problems. ere is general agreement among developmental psychopathologists

that there can be multiple developmental pathways or dierent clusters of risk factors leading to a nal

outcome of conduct problems. At the same time, while research eorts treat conduct disorder as a nal

outcome at the behavioural level, the category of conduct disorder is only an umbrella term for a number

of dierent, sometimes divergent behaviours including but not limited to internalizing disorders (com-

orbid anxiety and depression), other externalizing disorders (ADHD), substance abuse (more manifest

in the adolescent age group), post-traumatic stress disorders (child physical and sexual abuse), and per-

sonalit y traits.

Several published longitudinal studies focusing on disruptive behaviour have followed cohorts from

birth to adulthood and will be briey reviewed. While the studies have dierent methodologies empha-

sizing dierent factors, for the rst time, models explaining later violent behaviour are available based

on longitudinal observations. We will then review advances made in specic causal mechanisms of CD

(subtypes). Assessment will be briey touched upon and nally we will review intervention programs. By

reviewing relevant literature on childhood antecedents, forensic psychiatrists and lawyers will be able to

appreciate, from a developmental perspective, how childhood antecedents can aect later susceptibility

to the development of criminal behaviour. us, from this perspective, criminal behaviour is the end

result or negative outcome of vulnerable individuals at risk for negative adaptation due to an interaction