Children with conduct disorder

Position statement Last updated: Dec 2022 Published in Australia Reference: PS #111

Broad principles to guide governments, agencies, and services in meeting the mental health care needs of children with conduct disorder.

Purpose

The Royal Australian and New Zealand College of Psychiatrists (RANZCP) recognises that children (b) with conduct disorder are a highly complex and vulnerable group who require access to multidisciplinary supports and services.

This position statement describes the circumstances facing practitioners working with young people with conduct disorder and highlights the opportunity to engage with multiple agencies in a timely and transparent fashion. It also underlines the importance of prevention and early intervention (from the patient’s perspective and also from a health economics position) and synthesises a targeted and pragmatic response strategy.

Key messages

Early intervention is key to reducing the lifetime impacts of conduct disorder and the risk of intergenerational trauma.
Children with conduct disorder are a vulnerable group who often present with complex welfare needs relating to early adversity.
Collaborations between service providers and care and protection agencies are key to ensuring these children receive the best possible ongoing care.
Children with conduct disorder have typically experienced neglect and disruptions during their early years. To avoid re-traumatisation providers and agencies should ensure continuity of care and a sense of belonging.
Opportunities exist to take preventative measures with at-risk families (c) and reduce rates of conduct disorder amongst other mental health conditions.
Aboriginal and Torres Strait Islander children, Pacific children and tamariki Māori have unique needs and contexts. These communities need to be well understood, supported and provided with programmes that are tailored to their communities.
Governments and services should focus on coordinating multi-agency input and multidisciplinary assessment and interventions for children with conduct disorder.

Introduction

‘Conduct disorder’ is a repetitive and persistent pattern of behaviour in which the basic rights of others or major age-appropriate societal norms or rules are violated.[1] These conditions are characterised by problems in the self-control of emotions and behaviours. Children and adolescents with this disorder have difficulty following rules, showing empathy, and behaving in a socially acceptable way. Criteria for conduct disorder often focus on poorly controlled behaviour that violates the rights of others or violates major societal norms. Their behaviour may include self-injurious behaviour in addition to other types of challenging behaviour.

Children with conduct disorder are particularly likely to have needs spanning several domains. They have high rates of physical disorders and high rates of comorbid mental health problems, particularly neurodevelopmental disorders such as attention deficit hyperactivity disorder (ADHD), fetal alcohol spectrum disorder (FASD) and intellectual disabilities (ID).[2] There are often educational difficulties, unmet needs, high rates of child protection concerns, drug and alcohol problems, and public protection issues which often include police contact.[3] Multi-agency working is often discussed, but authentic delivery of management to meet the young person’s complex needs across multiple domains is highly challenging.[4] Multi-agency work is especially difficult in regional, rural and remote areas where resources may be geographically dispersed and agencies may have more limited resources compared to agencies in metropolitan areas.

Children exhibiting high degrees of disruptive, oppositional and conduct-disordered behaviours at ages 7-9 are far more likely to experience serious challenges with daily life at age 25.[5] As individuals with conduct disorder develop from ages 10 to 28 they can cost society 10 times the amount of non-conduct-disordered children.[6] 80% of all criminal activity is attributable to people who had conduct disorder as children.[7] These children frequently struggle to access specialist services.[8] They are often from socioeconomically-deprived groups, frequently need to move homes, and may have a difficult relationship with agencies such as police, and health and welfare teams.[9, 10]

Challenges and considerations

The international literature highlights the well-established notion that many challenges accompany conduct disorder. These include housing instability, a reluctance to engage with authority figures or those seen as ‘part of the system’, clandestine trauma and frequent placement in secure facilities far from home. Additionally, their unique needs frequently go unnoticed compared to other groups of children receiving child and adolescent mental health services.[10-12]

There are considerations specific to Aboriginal, Torres Strait Islander, Māori and Pacific populations when examining conduct disorder. The historical legacy of colonisation continues to impact families from Aboriginal, Torres Strait Islander, Māori and Pacific communities. This affects both a child’s parents and their extensive kinship systems and contemporary familial considerations.[11, 13] There can also be cultural differences in the parenting of boys versus girls which can have an impact on the expression of emotions.[14]

Socioeconomic disadvantage, fractured family units and poverty of opportunity resulting from systemic racism can result in conduct disorder having a disproportionate impact on families and whanaungad from Aboriginal, Torres Strait Islander Māori and Pacific communities.[11, 15] Best practice in addressing conduct disorder and associated comorbidities sits within both western and non-western evidence bases. There is emerging evidence for culturally-based intervention programmes to support Aboriginal, Torres Strait Islander, Māori and Pacific young people with complex needs.[13, 16] While some Aboriginal, Torres Strait Islander and Māori-led programmes exist there is a significant need to expand and scale up programmes like these to meet demand. There is also scope for further research looking into appropriate interventions for conduct disorder in Aboriginal, Torres Strait Islander, Pacific youth and Rangatahi Māori and adapting existing programmes for Aboriginal, Torres Strait Islander, Pacific Youth and Rangatahi Māori. For more information on the importance of culturally tailored treatments, please see Position statement 105: Cultural safety.

Where multiple challenges exist, the compounding effect can make symptoms of conduct disorder more severe and difficult to manage. Conduct disorder that is comorbid with other mental health conditions has been associated with greater conduct disorder symptom severity and higher levels of aggression.[17] Families experiencing socioeconomic disadvantage may struggle to afford an adequate number of sessions with a specialist child and adolescent psychiatrist.[18] This may lead to delays or gaps in accessing treatment as the socioeconomic circumstances of a family change. Aboriginal, Torres Strait Islander, Māori and Pacific young people are more likely to experience socioeconomic disadvantage and will also need culturally safe care which may not always be available and families may delay treatment until culturally safe care is accessible. [19, 20] Parents will often be highly involved in the treatment of conduct disorder but may find this difficult where they are also managing their own mental health conditions and stresses. The behaviour of a child with conduct disorder may result in incarceration which can be detrimental to their mental health and further complicate treatment.[21] Psychiatrists and those around the child should be prepared to approach the child’s needs holistically to effectively treat their conduct disorder and improve their wellbeing.

Solutions

Early intervention

The evidence base indicates that early intervention is crucial, with greater investment particularly needed for family practitioners and systemic support for parents.[22] This early support needs to include measures to identify family violence such as assessment for signs of coercive control, and physical abuse and providing appropriate referrals where necessary. The evidence calls for targeted spending on prevention, early intervention and treatment programmes and the training and recruitment of more practitioners. Implementation of holistic approaches to conduct disorder is an ideal that health systems should be working towards.[11, 22]

The New Zealand Advisory Group on Conduct Problems highlighted the need to intervene early, with parent and teacher management training programmes as well as family input for those aged 3-7.[10] Parent management training (PMT), school programmes and family programmes were recommended for those aged 8-12.[10, 11] The Māori committee of the Advisory Group among other New Zealand government reports also highlighted that Tamariki Māori should receive Māori-specific programmes where possible or have overseas programmes adapted to better suit Māori.[23]

Altering the trajectory of just one child can lead to significant cost savings for the government and improved quality of life for the child.(e) Successful and authentic multi-agency working is possible, not just in specific areas of the countries but pervasively across regions, so that no child gets left behind. Multi-agency working is also a practice that aligns well with Te Ao Māori, Pacific (f) and many Aboriginal and Torres Strait Islander worldviews on health.

Prioritising early intervention can result in funding and resources being disproportionately allocated to the treatment of young children with conduct disorder. When implementing a model of early intervention, parties must ensure older children with conduct disorder do not fall between the gaps. Treatment of these older children exhibit some of the highest needs and complexity of children presenting to health, welfare and corrections services.

Improving socioeconomic status

Combatting socioeconomic deprivation is a much wider ambition. Research has shown that conduct disorder is most common amongst those from lower socio-economic backgrounds. Where living standards increase, rates of conduct disorder are likely to decrease as a result of reducing risk factors.[22] Significant opportunities exist to prevent conduct disorder from developing and lowering its severity through supporting parents during a child’s perinatal period and early years. Preparing parents with good parenting techniques and supporting them to stay in education and employment can lower rates of conduct disorder and help parents manage conduct disorder where it arises early.[22] In addition, efforts to improve social and emotional well-being are likely to reduce rates of other mental health conditions for both parents and children.[11, 22]

Children in care reform

Additional challenges may exist amongst children with conduct disorder living in care or at risk of entering care (g). Children in care or at risk of entering care have a high prevalence of conduct disorder and other neurodevelopmental disorders.[25] Carers and staff working in care may not have sufficient education or training to properly care for a child with these conditions. Additional education and training resources should be provided to those caring for children in care to ensure they can provide appropriate care for children with conduct disorder or neurodevelopmental disorders. Research shows that children in care with conduct disorder respond well to trauma-informed wrap-around models of service.[26]

Multi-agency approaches

There are many good examples of systemic practice following research sources internationally that have been inclusive and have allowed for timely and transparent communication between agencies. Complex case reviews, family group conferences and the UK system of Multi-Agency Public Protection Panels are three examples for consideration. The biopsychosocial approach outlined in the 2013 NICE Guidelines on Antisocial Behaviour and Conduct Disorder in Children and Young People contained similar recommendations to those of the Advisory Group on Conduct Problems.[10, 27]

Pharmacotherapy and psychotherapy

While pharmacological approaches can be appropriate, it is stipulated that when medications such as risperidone are used, they should be used carefully, for short timeframes and starting at low doses.[8, 27] It is also demonstrated that psychological therapies such as MST (Multisystemic therapy), CBT (cognitive behavioural therapy), and DBT (dialectical behaviour therapy) have some proven efficiency.[28-30] Functional Family Therapy (FFT) has shown to be an overarching psychosocial intervention that has shown good overall effectiveness, including reducing recidivism in youth who have been incarcerated.[12, 28, 29] [32] Research has also shown that treatments delivered online for conduct disorder can be at least as effective as treatments delivered face to face, making it an effective option for those in rural, regional and remote areas.[33]

The role of psychiatrists

The role of a psychiatrist, across all jurisdictions and contexts, is to use their specialist skills and medical expertise to achieve the highest quality of care, in partnership with their family/whanaunga or carers. To do this, psychiatrists undertake a range of communication, collaboration, clinical leadership and advocacy roles, recognising the complexity of individual clinical presentations in assessment and direct provision of therapy.

Psychiatrists can play an important role in ensuring that children with conduct disorder receive appropriate support and intervention as early as possible. While comorbidities may present challenges, they are not insurmountable. ADHD, one of the most common comorbidities, is highly responsive to medication and can often be managed.[34]

Psychiatrists can use their position to control the prescription of medication to ensure it is only provided where appropriate and start carefully with low doses, for short timeframes when using prescriptions like risperidone. They can work with family and whanaunga to engage with services to manage any socio-economic circumstances and help them navigate between various government agencies and services.

Psychiatrists may consider the following in their practice:

Taking approaches based on MST, CBT, DBT, or FFT for the treatment of children with conduct disorder.
Taking approaches that involve family and whanaunga to give them the tools and support necessary to care for their child such as PMT.
Taking steps to refer the family to social services organisations if appropriate.
Taking steps to be responsive to the needs of children and young people with a conduct disorder and their parents and carers.
Taking an approach that investigates any potential comorbid neurodevelopmental disorders and ensures the patient receives the appropriate treatment as necessary.

Family/whanaunga and carers

Parents, family members, whanaunga, and carers of children with conduct disorder may have significant involvement or responsibility for navigating support systems and interventions to address the needs of children with conduct disorder. Family/whanaunga and carers have a role in co-designing relevant services and support.
Parents, family members, whanaunga, and carers may also be experiencing the emotional challenges of uncertainty and frustration of navigating service gaps and their own difficult socio-economic circumstances and may require support. For more information, see RANZCP Position Statement 76: Partnering with carers in mental healthcare.

It is important to provide support for children with conduct disorder themselves, in addition, to support for their family/whanaunga or carer/s

Recommendations

To meet the mental health needs of children in care or at risk of entering care, the RANZCP recommends the following:

Australian and New Zealand Governments

Investing in early intervention and prevention programmes to reduce rates of conduct disorder and assist children in managing existing conduct disorder.
Adopting systemic practices in government agencies that facilitate cooperation and collaboration between agencies to minimise disruption of the lives of children.
Increasing investment in support for the research and development of targeted preventative interventions for children with conduct disorder and their parents, family/whanaunga and carers.
Investing in training and support for the workforce to provide specialised services for children with conduct disorder, and more opportunities for advanced training to increase the number of psychiatrists specialising in working with children and adolescents.

Health planning authorities (eg. State and territory health departments in Australia and the Ministry for Health in New Zealand)

Improving recognition of and responses to the complex needs of children with conduct disorder within mainstream health services and recognising that service systems have the capacity to re-traumatise children in care and should be trauma-informed to ensure safety.
Providing medication to children with conduct disorder only where appropriate and carefully, for short timeframes and starting at low doses with some medications.[27]
Utilising MST, CBT, DBT and FFT as effective treatments for a child with a conduct disorder.[28, 29, 35, 36]
Implementing early intervention programmes which involve families and teachers is a vital part of managing conduct disorder in young people.[11]
Developing additional resources targeting Aboriginal and Torres Strait Islander, Pacific and Māori and remote and rural communities and scaling up existing programmes. These programmes should be developed at a local level where possible.

Footnotes

(a) Child’ or ‘children’ is defined as those aged 0-17 years of age. However, it is recognised that the needs of children with conduct disorder may extend beyond 17 years of age, especially as young people are transitioning out of care.

(b) This document uses the terms child, children, young person and people to describe those affected by mental health conditions and receiving care. It is recognised that some find terms such as patient, consumer or client more appropriate. The RANZCP is supportive of those receiving care using terms that they find appropriate and empowering. The use of terms in this document is in no way designed to diminish or disregard the choices of others to define themselves by different terms.

(c) ‘Family’ refers to a child’s parents and siblings. It is recognised that in Te Ao Māori, Pacific, Aboriginal and Torres Strait Islander worldviews a child’s immediate family may take different forms and have additional meanings. It is recognised that relationships with parents and siblings may differ from western ideas of family. This Position Statement respects all of these worldviews and definitions of family.

(d) Whanaunga is a Māori word for relative or kin. It has a wider spiritual and emotional meaning that binds an individual to their marae (meeting grounds) and to their tīpuna/tupuna (ancestors).

(e) Early intervention is a population level strategy for addressing conduct disorder which is highly cost effective for heath systems. While treatment of condict disorder can be expensive, it can be significantly cheaper than the costs of managing an adult with conduct disorder which can be 10 times higher than someone without conduct disorder.[34] One study estimated early intervention practices led to cost savings of $17,000 (USD) per family.[21] This was in part attributed to adolescent children of study participants having had fewer arrests than the control group.

(f) Te Ao Māori can be translated to mean Māori world view. Te Ao Māori is shaped by whanaungatanga, based on relationships between individuals, whānau, hapū, iwi, the spiritual world, and the natural world. Everyone and everything are traced to and explained through whakapapa, the ancestral layers that contribute to the ‘people, places, and things’ of the present and into the future. In this space, whānau relationships are based on working together to make decisions and act in ways that benefit whānau. Strong whānau are known to invest their time and energy in activities they can do together.[24]

(g) ‘Care’ encompasses a series of services provided to children/tamariki up to the age of 18 who cannot live with their immediate family/whānau, includes kinship care, foster care and residential care.

Responsible committee: Section of Child and Adolescent Forensic Psychiatry Committee

References

1. Diagnostic and statistical manual of mental disorders : DSM-5-TR. Fifth edition, text revision. ed. Washington, DC: American Psychiatric Association Publishing; 2022.
2. Kerekes N, Lundström S, Chang Z, Tajnia A, Jern P, Lichtenstein P, et al. Oppositional defiant- and conduct disorder-like problems: Neurodevelopmental predictors and genetic background in boys and girls, in a nationwide twin study. PeerJ (San Francisco, CA);2014(1):e359.
3. Matthys W, Lochman JE. Oppositional defiant disorder and conduct disorder in childhood. Second edition. ed. West Sussex, England: Wiley Blackwell; 2017. 21-2 p.
4. Atkinson M, Doherty P, Kinder K. multi-agency working: models, challenges and key factors for success. Journal of early childhood research : ECR;3(1):7-17.
5. Fergusson DM, John Horwood L, Ridder EM. Show me the child at seven: the consequences of conduct problems in childhood for psychosocial functioning in adulthood. Journal of child psychology and psychiatry;46(8):837-49.
6. Scott S, Knapp M, Henderson J, Maughan B. Financial cost of social exclusion: follow up study of antisocial children into adulthood. BMJ : British Medical Journal2001 Jul 28 2016-04-01;323(7306):191. Available from: https://www.bmj.com/content/323/7306/191.
7. Health SCfM. The Chance of a Lifetime. London: Sainsbury Centre for Mental Health; 2009
8. Ford T, Hamilton H, Goodman R, Meltzer H. Service Contacts Among the Children Participating in the British Child and Adolescent Mental Health Surveys. Child and adolescent mental health;10(1):2-9.
9. Patel RS, Amaravadi N, Bhullar H, Lekireddy J, Win H. Understanding the Demographic Predictors and Associated Comorbidities in Children Hospitalized with Conduct Disorder. Behavioral Sciences;8(9):80. Available from: https://www.mdpi.com/2076-328X/8/9/80.
10. Problems AGoC. Conduct Problems: Effective Services for 3-7 Year-olds. Wellington: Ministry of Social Development; 2009
11. Problems AGoC. Conduct Problems: Effective Programmes for 8-12 Year Olds. Wellington: Ministry of Social Development; 2011
12. Trupin EW, Stewart DG, Beach B, Boesky L. Effectiveness of a Dialectical Behaviour Therapy Program for Incarcerated Female Juvenile Offenders. Child and adolescent mental health;7(3):121-7.
13. Togni SJ. The Uti Kulintjaku Project: The Path to Clear Thinking. An Evaluation of an Innovative, Aboriginal-Led Approach to Developing Bi-Cultural Understanding of Mental Health and Wellbeing. Australian psychologist;52(4):268-79.
14. Robinson GW, Tyler WB, Silburn SR, Zubrick SR. Gender, Culture and Intervention: Exploring Differences between Aboriginal and Non-Aboriginal Children's Responses to an Early Intervention Programme. Children & society;27(6):459-70.
15. Azzopardi PS, Sawyer SM, Carlin JB, Degenhardt L, Brown N, Brown AD, et al. Health and wellbeing of Indigenous adolescents in Australia: a systematic synthesis of population data. The Lancet2018/02/24 391(10122):766-82. Available from: https://www.sciencedirect.com/science/article/pii/S0140673617321414.
16. Pae Whakatupuranga : : Functional family therapy cross generations (PW: FFT-CG). Formative evaluation report - Wave 1. Wellington, New Zealand :: Oranga Tamariki, Ministry for Children; 2020.
17. Abikoff H, Klein RG. Attention-Deficit Hyperactivity and Conduct Disorder: Comorbidity and Implications for Treatment. Journal of consulting and clinical psychology;60(6):881-92. Available from: https://pubmed.ncbi.nlm.nih.gov/1360990/.
18. Duckett S, Stobart A, Lin L. Not so universal: How to reduce out-of-pocket healthcare payments. Gratten Institute; 2022
19. Provision) SSCftRoGS. Overcoming Indigenous Disadvantage: Key Indicators 2020. Canberra: Productivity Commission; 2020
20. Marriott L, Sim D. Indicators of Inequality for Māori
and Pacific People. Victoria Business School; 2014
21. Sugie NF, Turney K. Beyond Incarceration: Criminal Justice Contact and Mental Health. American Sociological Review 82(4):719-43. Available from: https://journals.sagepub.com/doi/abs/10.1177/0003122417713188.
22. Olds DL. Preventing Child Maltreatment and Crime with Prenatal and Infancy Support of Parents: The Nurse-Family Partnership. Journal of Scandinavian studies in criminology and crime prevention;9(1):2-24.
23. Hine LCN, Ngapuhi. Te hohounga: Mai i te tirohanga Maori, The process of Reconciliation: Towards a Maori view, the delivery of conduct problem services to Maori. Ministry of Social Development; 2009
24. Ministry of Education. Te Ao Māori New Zealand: Te Whariki Online; 2020 [
25. Akister J, Owens M, Goodyer IM. Leaving care and mental health: Outcomes for children in out-of-home care during the transition to adulthood. Health research policy and systems;8(1):10-.
26. Eadie K. Evolve Therapeutic Services: Outcomes for Children and Young People in Out-of-Home Care with Complex Behavioural and Mental Health Problems. Children australia;42(4):277-84.
27. (NICE) NIfHaCE. Antisocial behaviour and conduct disorders in children and young people: recognition and management: National Institute for Health and Care Excellence; 2017 [Available from: https://www.nice.org.uk/guidance/cg158.
28. Geddes K, Dziurawiec S, Lee CW. Dialectical behaviour therapy for the treatment of emotion dysregulation and trauma symptoms in self-injurious and suicidal adolescent females: A pilot programme within a community-based child and adolescent mental health service. Psychiatry journal;2013.
29. Ontario CsMH. Evidence Based Practices for Children and Adolescents with Conduct Disorder. Ontario: Children's Mental Health Ontario; 2001
30. Carr A. Family therapy and systemic interventions for child‐focused problems: the current evidence base. Journal of family therapy;41(2):153-213.
31. Sexton TL, Alexander JF. Functional Family Therapy. In: Prevention OoJJaD, editor. Juvinile Justice Bulletin. https://www.ojp.gov/2000.
32. Hartnett D, Carr A, Hamilton E, O'Reilly G. The Effectiveness of Functional Family Therapy for Adolescent Behavioral and Substance Misuse Problems: A Meta‐Analysis. Family process;56(3):607-19.
33. Dadds MR, Thai C, Mendoza Diaz A, Broderick J, Moul C, Tully LA, et al. Therapist-assisted online treatment for child conduct problems in rural and urban families: Two randomized controlled trials. Journal of Consulting and Clinical PsychologyAug 2019
2022-01-14;87(8):706-19. Available from: https://pubmed.ncbi.nlm.nih.gov/31204839/.
34. Childress AC, Sallee FR. Attention-Deficit/Hyperactivity Disorder with Inadequate Response to Stimulants: Approaches to Management. CNS DrugsFeb 2014
2019-12-06;28(2):121-9. Available from: https://pubmed.ncbi.nlm.nih.gov/24402970/.
35. Aos S, Phipps P, Barnoski R, Lieb R. The Comparative Costs and Benefits of Programs To Reduce Crime. Version 4.0.
36. Meier R, Murphy M, Singh S, Lamb C. Developing services to improve the quality of life of young people with neurodevelopmental disorders, emotional/neurotic disorders and emerging personality disorder. Occasional Paper OP77 London: The Royal College of Psychiatrist.
37. Dretzke J, Frew E, Davenport C, Barlow J, Stewart-Brown S, Sandercock J, et al. The effectiveness and cost-effectiveness of parent training/education programmes for the treatment of conduct disorder, including oppositional defiant disorder, in children. Health Technol AssessDec;9(50):iii, ix-x, 1-233.

Disclaimer: This information is intended to provide general guidance to practitioners, and should not be relied on as a substitute for proper assessment with respect to the merits of each case and the needs of the patient. The RANZCP endeavours to ensure that information is accurate and current at the time of preparation, but takes no responsibility for matters arising from changed circumstances, information or material that may have become subsequently available.