Conduct Disorders and Severe Antisocial Behavior

157 Pages·1998·3.61 MB·English

by  Paul J. Frick (auth.)

Conduct Disorders and
Severe Antisocial Behavior
Clinical Child Psychology Library
Series Editors: Michael C. Roberts and Annette M. La Greca
ANXIETY AND PHOBIC DISORDERS
A Pragmatic Approach
Wendy K. Silverman and William M. Kurtines
AUTISM
Understanding the Disorder
Gary B. Mesibov, Lynn W. Adams, and Laura G. Klinger
CONDUCT DISORDERS AND SEVERE ANTISOCIAL BEHAVIOR
Paul J. Frick
INFANT AND EARLY CHILDHOOD NEUROPSYCHOLOGY
Glen P. Aylward
MANAGING MANAGED CARE
Michael C. Roberts and Linda K. Hurley
PARENT-CHILD INTERACTION THERAPY
Toni L. Hembree-Kigin and Cheryl Bodiford McNeil
SEXUALITY
A Developmental Approach to Problems
Betty N. Gordon and Carolyn S. Schroeder
A Continuation Order Plan is available for this series. A continuation order will bring delivery
of each new volume immediately upon publication. Volumes are billed only upon actual
shipment. For further information please contact the publisher.
Conduct Disorders and
Severe Antisocial 8ehavior
Paul J. Frick
University of Alabama
Tuscaloosa, Alabama
Springer Science+Business Media, LLC
Library of Congress Cataloging-in-Publication Data
On file
ISBN 978-0-306-45841-5 ISBN 978-1-4615-5343-4 (eBook)
DOI 10.1007/978-1-4615-5343-4
© 1998 Springer Science+Business Media New York
Originally published by Plenum Press, New York in 1998
Softcover reprint of the hardcover 1s t edition 1998
http://www.plenum.com
10987654321
AII rights reserved
No part of this book may be reproduced, stored in a retrieval system, or transmitted in any
form or by any means, electronic, mechanical, photocopying, microfilming, recording, or
otherwise, without written permission from the Publisher
Preface
As reflected in the title, the purpose of this book is to guide clinicians in
understanding and treating youth with severe antisocial behavior. Children and
adolescents with conduct disorders operate at quite a high cost to society. In
many opinion polls, juvenile crime and violence is rated as one of the most
pressing concerns for many in our society. This widespread concern has
prompted professionals from many disciplines to search for more effective
interventions to prevent and treat youth with such disorders. This book is my
attempt to summarize the current status of this very important endeavor.
In providing this guide to clinicians, I have attempted to emphasize the
critical link between understanding the clinical presentation, course, and causes
of conduct disorders and designing effective interventions for children and
adolescents with these disorders. Many past books, book chapters, and review
articles have emphasized one or the other of these objectives. Some have
provided excellent summaries of the vast amount of research on youth with
conduct disorders without explicitly and clearly describing the clinical applica
tions of this research. Others have focused on the implementation of specific
interventions for youth with conduct disorders that is divorced from a basic
understanding of the many diverse and clinically important characteristics of this
population. The overriding theme of this book is that successful clinical inter
vention requires an integration of both bodies of knowledge.
Past works on clinical intervention for youth with conduct disorders have
also tended to emphasize single-treatment approaches. This orientation fits with
the most common way of conceptualizing mental health treatment, namely, that
one searches for the most successful and cost-effective treatment approach for a
disorder and then attempts to implement such treatment for all those with the
disorder. This typical mental health model has not proven effective for guiding
the treatment of children and adolescents with conduct disorders. For youth with
these disorders, successful intervention requires a comprehensive approach to
treatment that (1) is tailored to the individual needs of the child, (2) utilizes
multiple treatments that have proven effective for a large number of children and
adolescents with conduct disorders, and (3) is implemented in a coherent and
v
vi Preface
intensive manner. The content of this book was designed to emphasize those
bodies of knowledge that are critical to implementing such interventions.
In writing this book, I also had the opportunity to reflect on my career as
a clinical psychologist. As both a clinician and a researcher, I often don't get the
opportunity to look at the big picture. Like many psychologists, I frequently get
so wrapped up in understanding and treating individual cases, or in completing
the next set of studies, that I don't take sufficient time to reflect on how my work
fits into a broader context. I would like to thank Mike and Annette, the editors
of this series, for giving me the opportunity to write this book and reflect on
where my work, both clinical and scientific, fits into our body of knowledge on
conduct disorders.
In the course of writing this book I also became aware of the many people
who have greatly influenced my training as a psychologist and my early career
development. They may not want to take credit (or blame!) for what I have
written but, like it or not, this book reflects their influence on me. The first group
of people are the clinical faculty at the University of Georgia who instilled in me
a deep appreciation for the scientist-practitioner model of clinical psychology. I
owe a special thanks to my mentor and friend Ben Lahey, who not only trained
me in the methodology of research, but instilled in me a great respect and love
for the scientific process.
The second group of people to whom lowe a debt of gratitude are the
faculty and staff of the Department of Psychology at the University of Alabama,
where I have worked for the past 7 years. They have created an environment that
has encouraged, nurtured, and supported my development as a clinical psycholo
gist. Very few academic departments are able to strike the right balance between
striving for academic excellence and nurturing a collegial and friendly atmos
phere in which to work. I believe that this has been accomplished at the
University of Alabama.
Last but not least, I need to acknowledge the contributions of the students
with whom I have had the pleasure to work. I recognize the tremendous role that
they have played in my professional development. As an instructor, clinical
supervisor, and research mentor, my students have provided me with some of the
best continuing education that I could ever hope to receive. They have also made
my work fun!
Contents
1. An Introduction to Conduct Disorders ...•......•...•......... 1
Our Fascination with Antisocial Behavior ....................... . 1
A Complex and Important Construct ........................... . 2
An Applied-Science Orientation .............................. . 3
Overview of the Book's Structure ............................. . 6
2. The Nature of Antisocial Behaviors and Conduct Disorders ..... . 9
Basic Characteristics ........................................ . 9
Distinguishing Normal and Abnormal Patterns of Conduct
Problems ............................................... . 9
Dimensional or Categorical Views of Conduct Problems .......... . 11
Prevalence of Antisocial Behaviors and Conduct Disorders ........ . 12
Developmental Trajectories of Conduct Disorders ................ . 14
Stability of Conduct Disorders ................................ . 17
Chapter Summary .......................................... . 19
3. Classification of Conduct Disorders .......................... . 21
The Basics of Classification .................................. . 21
Oppositional Defiant Disorder and Conduct Disorder ............. . 22
Subtypes Based on Patterns of Behavioral Covariation ............ . 25
Subtypes Based on Socialization and Aggression ................. . 28
Callous-Unemotional Traits and Conduct Disorders .............. . 29
Conduct Disorders and Co-occurring Conditions ................. . 32
Chapter Summary .......................................... . 38
4. The Etiology of Conduct Disorders ........•....•.............. 41
Understanding the Development of Conduct Disorders: Some
Basic Issues ............................................. . 41
Dispositional Correlates ..................................... . 43
Environmental Correlates .................................... . 49
vii
viii Contents
Integrating Correlates into Causal Models ....................... 58
Chapter Summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66
5. Clinical Assessment .................•..•...............••.. 67
A General Assessment Framework. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67
Specific Assessment Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69
Combining Information into a Clear Case Conceptualization. . . . . . . . 87
Case Example Illustrating the Multistep Procedure for Integrating
Assessment Information ................................... 87
Chapter Summary ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91
6. Treatment I: The Basic Techniques. . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Overview of Treatment ...................................... 93
Contingency Management .................................... 95
Parent Management Training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 98
Cognitive-Behavioral Skills Training ........................... 106
Stimulant Medication ........................... . . . . . . . . . . . .. II I
Chapter Summary. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 113
7. Comprehensive Approaches to Treatment. . . . . . . . . . . . . • . . . . . .. 115
Initial Tests of Combined Treatments. . . . . . . . . . . . . . . . . . . . . . . . . .. 115
Fast Track Program ......................................... 117
Multisystemic Therapy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. 119
Flexible Multimodal Treatment of Conduct Disorders ............. 122
The Future oftbe Treatment of Conduct Disorders. . . . . . . . . . . . . . .. 132
References .........•............•.......•...................• 135
Index ..•••.•••••..•••...•.....•..•.•••.•..•...•..........•.• 149
1
An Introduction to Conduct
Disorders
OUR FASCINATION WITH ANTISOCIAL BEHAVIOR
There are many images of the "juvenile delinquent" portrayed in fictional
literature. There is Mark Twain's lovable and mischievous Tom Sawyer whose
rebelliousness and lack of respect for authority caused great concern to his family
and friends but whose obvious charm and intelligence made him an endearing
figure. Tom always seemed to push the limits of what was socially acceptable
but it always was done in a spirit of playfulness rather than being driven by base
motives, like greed or a need for dominance and power. There is also Charles
Dickens' Oliver Twist, a tragic hero. Oliver is portrayed as basically a good child
who was never provided with the advantages ofa caring and stable home life. It
is hard to blame poor Oliver for being led astray by his antisocial companions.
given the hardships that he had to endure throughout his childhood. In contrast.
there are the brief glimpses we have of the childhood of Hannibal Lecter from
the novels of Thomas Harris. One is alternatively fascinated and horrified by the
depths of cruelty displayed by Hannibal without a shred of guilt over his deeds
and with a callous disregard for the suffering of his victims. He is portrayed as
the "human monster" that now comes to haunt our dreams because, as adults, we
can no longer be scared by ghosts and bogey men.
All of these images are based on fictional characters. However, they
illustrate a number of important points that help to introduce the subject matter
of this book. First, they illustrate the fascination that many people have with
trying to understand what motivates people to act in ways that are "antisocial";
in ways that ignore societal norms or in ways that ignore the rights of others. I
am one of these people and this fascination has helped to define my career as a
clinician and researcher. I can think of no area of research that would be as
intrinsically interesting to me as attempting to understand the factors that
underlie antisocial behavior. As a clinician, there are few endeavors as intriguing
and rewarding to me as trying to apply this research to understanding the
2 Chapter 1
behavior of an individual child and then designing an intervention approach
based on this understanding.
Second, these fictional characters illustrate the great diversity in the ways
in which antisocial behavior can be expressed in children and adolescents and
the diversity in causal factors that may underlie these behavior patterns. Many
in the lay public, and even some clinicians and researchers, expect all delinquent
youth to fall into a single causal pathway, whether it be a mischievous Tom
Sawyer pattern of behavior, or a misguided Oliver Twist pattern of behavior, or
a psychopathic Hannibal Lecter pattern of behavior. My clinical experience in
working with antisocial youth quickly made it apparent that any single concep
tualization of antisocial youth was woefully inadequate. This realization led me
to conduct research in an attempt to better define the many diverse pathways
through which antisocial behavior develops. To emphasize this point, I use the
plural tenn "conduct disorders" throughout this book to emphasize that there are
many distinct patterns of antisocial behavior that can be exhibited by children
and adolescents.
A COMPLEX AND IMPORTANT CONSTRUCT -----------
Given the many different causal processes that may underlie conduct disorders,
it is not surprising that aggressive and antisocial behavior has been the focus of
a massive amount of research across numerous disciplines. Developmentalists
have studied the processes through which children normally develop prosocial
attitudes and behaviors and the processes through which children develop the
capacity to inhibit aggressive and antisocial impulses. Psychologists and psy
chiatrists have studied the phenomenology, course, and etiology of extreme
deviations from this normal developmental pattern. They have also tested a host
of interventions spanning many different treatment modalities to treat antisocial
youth. Epidemiologists and sociologists have studied social, ecological, and
political forces that influence the prevalence of antisocial and aggressive behav
ior in many diverse cultures. Criminologists have focused on the interface
between antisocial behavior and our legal systems, providing infonnation on the
prevalence, causes, and management of criminal behavior in juveniles.
Even this very broad delineation of some of the major lines of research on
antisocial behavior ignores the great diversity of research within each of these
areas. As a result, the difficult issue in writing this book was not in finding a
sufficient body of research to discuss. The challenge was to find the most
appropriate way of integrating these diverse areas of research, each of which
captures an important aspect of a very complex phenomenon, in a manner that
leads to clear and usable clinical applications. However, I firmly believe that
such an integration is critical if one is to adequately understand severe antisocial