Evaluating Conduct Disorder and Whether It is a Psychological Case

Mary Jane is a 13 year old female attending the St. Andrew High School for girls. Her stepmother, accompanied by her mother, carried Mary to The Child Protection Services and Family Agency after she was caught by soldiers having sex with two boys in an abandoned building during school hours. The stepmother describes carrying Mary Janes to the agency as being the last straw. Mary is described as physically hurting her siblings, persistently steal items such as cell phones and books from her classmate on an almost daily basis and compulsively lies, even when she is not trying to get something in return. She has ran away from home on multiple occasions and is absent a significant amount of days from school despite her parents sending her. According to the stepmother, she has also received reports from the school that Mary Jane has coerced other girls to engage in sexual activities with herself or other boys.

Mary originally lived with her mother, father and an unspecified amount of siblings. Her mother and father are separated and now Mary lives with her stepmother and father but on occasions visits her mother.

On arrival to the agency, Mary’s uniform was not neatly attired, her eyes were red and puffy and she was extremely quiet during the interview. Her head was held down and she avoided eye contact. On the few occasions that she spoke, she did so in a low voice and appeared unconcerned about being there, as did her mother. Her stepmother on the other hand was very animated, frustrated and gave detailed accounts of everything that she could remember.

Mary Jane was diagnosed with adolescent onset of severe conduct disorder code 312.81, with limited prosocial emotions on the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013). She was diagnosed with conduct disorder because she met six out of the 15 requirements necessary which included; being physical cruel to people, forcing people into sexual activities, lies to obtain goods or favours, stolen items of nontrivial value without confronting the victim, is truant from school before age 13 and has ran away from home at least twice while living with her parents. The diagnosis is severe because she displays more than the minimum of three conduct problems required to make a diagnosis and these conduct problems cause considerable harm to others such as physical cruelty to her siblings and coerced sex. She was given the specifier of ‘with limited prosocial emotions’ because she displayed three of the required characteristics as described by her stepmother. She was described as showing no remorse or guilt when she did something wrong, only when she was caught. She was also described as being callous, specifically, being cold, uncaring and unconcerned about the feelings of others. On one occasion, she had hurt her sister and she carried on with her day, while watching the sister cry. She is also unconcerned about her school performance and does not put in the effort to do well. Jane has been displaying these limited prosocial behaviours for more than the 12 months required by the DSM.

On axis one of the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM–4., Text Revision; Washington DC, 2000), Mary Jane was also diagnosed with adolescent onset of severe conduct disorder code 312.81 with limited prosocial emotions. The requirements for a diagnosis of conduct disorder are the same in Mary’s case, as mentioned in the DSM V above. Mary displays no personality disorder or mental retardation necessary for axis two and she has no general medical condition for an axis three diagnosis. On axis four, the major psychosocial and environmental problem is problems with her primary support group due to the separation of her parents which results in Mary having to transition between living with her mother and stepmother. On axis five, she was given a Global Assessment of functioning of 61-70 because despite her conduct problems, she is functioning well and has meaningful interpersonal relationships.

In understanding conduct disorder, multiple modalities and theoretical perspectives have to be used. There needs to coordination between the school, parents and therapists to decrease or eliminate as much of the identified problems as possible. In understanding Mary’s case, a behavioural approach can be employed. Prochaska and Norcross broke down behavioural therapy into three C’s but in treating Mary, focus will be place on contingency management and cognitive-behaviour modification.

The basic idea behind contingency management is that behavioural patterns are learned through exposure to rewards and consequences, and therefore, inappropriate behaviours can be unlearnt and replaced by more appropriate pro-social behaviours through the manipulation of rewards and consequences that promote pro-social behaviour and discourage antisocial behaviour. According to Frick (2001), a major rationale for the use of contingency management is that children with conduct disorder come from families that do not provide a consistent and contingent environment where misdeeds are punished and good deeds rewarded. This is evident in Mary’s mother as she appeared complacent with most of her daughter’s actions. Another rationale is that children with conduct disorder are often overly concerned with the positive consequence of an action, such a Mary obtaining a phone but she is not as concerned about the negative consequences of getting in trouble for stealing said phone. A form of contingency management that would be used is a behavioural contract. In this contract, an agreement would be made between Mary and her parents, which would explicitly state that a behaviour, such as stealing, should be eliminated. She would be search daily upon reaching home and at the end of the week, she would be rewarded if she does not steal anything and punished if she did not uphold the contract.

According to Barkoukis, Reiss and Dombeck (2008), it is as important to address children's thoughts as it is to address their actual problem behaviours. If children have a wrong, overgeneralized or otherwise exaggerated understanding of a situation, this can make them more likely to misbehave. Cognitive-behavioural approaches to therapy teach children and parents both to identify and address faulty beliefs that make conflict more likely and to help dismantle those beliefs. In dismantling those beliefs, Prochaska and Norcross pointed out Donald Meichenbaum’s self-instructional training which can be used to help children with conduct disorder. During this training, Mary would be taught how to reduce negative self-statements that produces negative emotions and at the same time work to develop positive self-statements that facilitates adaptive self-control. The therapist would perform a task such a doing a homework assignment while speaking aloud to himself. Mary would then do that assignment while receiving instructions from the therapist. Next she would do the assignment while speaking the instructions aloud, the she would whisper the instructions to herself until they become covert self-instruction. The purpose of this is to allow Mary to control her cover self-speech which would in turn allow her to control her individual behaviour. Mary would have learnt how to slow herself down when performing a task, such as doing her homework and this also serves as a coping skill to control future behaviour.

Another form of cognitive-behavioural therapy would be Parent Management Training. This would involve teaching Mary’s parents how to develop and implement contingency management programs at home. It would also teach them how to be more varied and consistent with their punishment, how to identify and change antecedents to enhance the likelihood of a positive behaviour and how to improve parent-child communication (Frick, 2001). Frick (2001) however pointed out that because there are limitations parents are often unable to implement the strategies that they have learnt for various reasons. He therefore recommended functional family therapy as a way to address issues embedded in the larger family context.

Functional family therapy focuses on intervention to address risk factors within and outside of the family that impact the adolescent (Sexton & Alexander, 2004). The Functional Family takes a cognitive-behavioural approach to issues such as communication. Communication change would initially be based on source responsibility. Mary and her family would be taught how to take responsibility for what they say. This reduces blame and defensive reactions. Statements such as “kids shouldn’t do this” and “it would be nice if people around” here should be avoided. Brevity is also important in communication as messages need to be short to avoid overloading and encourage listening. Congruence is also important as it helps to reduce confusion by implementing ways to decrease the discrepancies between messages. The family will also be taught how to present alternative views when they are communicating. Presenting alternatives promotes cooperation and an atmosphere of working together. It is the atmosphere that is developed when alternatives are presented that is even more important than the alternatives themselves. Finally the family will be taught how to actively listen. Active listening does not have to follow the prototypic, “What I hear you saying is…” but even a grunt is sufficient to acknowledge that the message is received. Another cognitive-behavioural technique proposed by the functional family therapy manual and Prochaska and Norcross is problem solving therapy. This is where clients are taught more effective ways to solve problems.

The first step is to identify the problem in terms of stimulus, response and consequence. Mary would be asked to describe the stimulus that cause her to run away from home on occasions, followed by her response and then the consequence. This would be done as a family and should be based on the communication skills of source responsibility and active listening. When the problem is adequately understood, the family will generate alternative responses to the situation that causes Mary to want to run away. Mary herself will also generate alternative responses. The next stage is to choose the best alternative action. The final stage is to verify if the chosen alternative is having the desired consequence. If this is not the case, then either a different alternative needs to be chosen or new alternatives generated.

Throughout therapy, it is hoped that Mary’s conduct disorder will be eliminated before it escalates into something worse. There are no treatment plans readily available at the Child Protection Services and Family Agency. It is likely that Mary would be referred elsewhere for counselling after an officer visits her to do a follow up. There are however a few remaining question that I would like to ask if given the opportunity. These include; how was Mary’s behaviour before her parents got separated, was she temperamental during infancy, were there problems during pregnancy such as alcohol or drug use, do Mary’s siblings provoke her, was there a history of severe corporal punishment, was there a history of sexual abuse, what are Mary’s specific behavioural problems at school, how does she relate to her peers, does she have a specific learning problem, what is the family’s coping style, how are their parental, conflict resolution and problem solving skills, what are the financial and social resources of the family and what are the teachers and parent’s perceptions of Mary’s strength and weaknesses.