biology & criminal behavior
CHAPTER 1 | || | |OVERVIEW 1 one one one one one conduct disorders:
an overview Key messages • Conduct disorders are the most common reason for referral of young children to mental health services.
The prevalence of conduct disorders in 5–10-year-olds is 6.5% for boys and 2.7% for girls.
Sixty-two per cent of three-year-olds with conduct disorders were found to continue these problems through to the age of eight.
Children who become violent as adolescents can be identified with almost 50% reliability as early as age seven.
Approximately 40–50% of children with conduct disorders may develop antisocial personality disorder as adults.
The estimated annual cost per child if conduct disorder is left untreated is £15,270.
Five aspects of parenting which have been repeatedly found to have a long-term association with antisocial behaviour are: poor supervision, erratic harsh discipline, parental disharmony, rejection of the child, and low parental involvement in the child’s activities. DEFINITIONS AND TERMINOLOGY The term ‘conduct disorder’ is generally used to describe a pattern of repeated and persistent misbehaviour. This misbehaviour is much worse than would normally be expected in a child of that age. The essential feature is a persistent pattern of conduct in which the basic rights of others and major age-appropriate societal norms and rules are violated (American Psychiatric Association, 2000).
Professionals and researchers use a variety of terms to describe conduct disorders. These include disobedient, aggressive, antisocial, challenging behaviour, oppositional, defiant, delinquent and conduct problems. For the purposes of this report we have chosen to use the term ‘conduct disorders’ to cover children who are described as having either conduct disorder (CD) or, as is more frequently the case in young children, oppositional defiant disorder (ODD). For the full ICD– 10 and DSM–IV classifications for CD and ODD see Appendix 1.
Obviously there are a frequency and a severity of certain disruptive behaviours which are expected in young children and are considered part of ‘normal’ development, and children will usually grow out of them. These behaviours occur as part of the child’s developmental process; although they may be difficult for the parents to deal with, they will not be discussed in this report. A number of programmes are provided by various voluntary organisations to address less severe behaviour problems (Smith, 1996). PARENT-TRAINING PROGRAMMES | || | |FINDINGS FROM RESEARCH 2PREVALENCE Epidemiological studies suggest that approximately half of those who meet diagnostic mental health criteria for CD will also meet criteria for at least one other disorder. The most frequent combination of problems is hyperactivity with CD, found in about 45–70% of those with CD.
The prevalence of CD in children between the ages of 5 and 10 years is 1.7% for boys and 0.6% for girls (Meltzer et al, 2000). Meltzer et al (2000) found the prevalence of ODD in 5–10-year-olds to be 4.8% for boys and 2.1% for girls. Although symptoms are generally similar in each gender, boys may have more confrontational behaviour and more persistent symptoms. There are also differences regarding gender in relation to the age of onset of conduct disorders. Robins (1966) found that the median age of onset for children referred to mental health clinics with antisocial behaviour was in the 8–10-year age range. Fifty-seven per cent of boys had an onset before the age of 10 years, whereas for girls the onset was mainly between 14 and 16 years of age.
LONG-TERM OUTCOMES Conduct disorders have been described as being either those which start in young children and become persistent for the life course or those which emerge in adolescence. Research has shown that there is a particularly poor prognosis attached to early onset, which indicates that early treatments in these groups are essential (Moffit et al, 1996). Early starting patterns of conduct disorder are remarkably stable (Farrington, 1989). Richman et al (1982) found that 62% of 3- year-olds with conduct disorders continued these problems through to the age of 8. Almost half of all youths who initiated serious violent acts before the age of 11 continued this type of offending beyond the age of 20, twice the rate of those who began their violent careers at age 11 or 12 (Elliott, 1994).
A number of theorists have suggested there should be strong links between disruptive and externalising behaviours in pre-school years and externalising behaviours in adolescents (Rutter, 1985; Loeber, 1990). The hypothesised early-onset pathway begins with the emergence of ODD in early pre-school years and school years and progresses to both aggressive and non-aggressive symptoms (e.g. lying and stealing) of conduct disorders in middle childhood and then to the most serious symptoms by adolescence.
The Isle of Wight study showed that children with conduct disorders at ages 10 and 11 fared worse at follow-up at ages 14 and 15 than children with other problems (Graham & Rutter, 1973). Farrington (1989, 1990), in the Cambridge Study in Delinquent Development, found half of the most antisocial boys at ages 8–10 were still antisocial at age 14 and 43% were still among the most antisocial at age 18. The Conduct Problems Prevention Research Group (1999a), which consists of a group of American researchers involved in the Fast Track project (described in more detail in Chapter 5), argues that although there will be false positives, the probability of identifying the majority of those children who are at serious long-term risk at school entry is high.
Loeber et al (1993) demonstrated that children who became violent as adolescents could be identified with almost 50% reliability as early as age 7, as a result of their aggressive and disruptive behaviour at home and at school. Robins (1966, 1978) noted that it was rare to find an antisocial adult who had not exhibited conduct disorders as a child, even though no more than half of the children identified as having conduct disorders go on to become antisocial adults. Studies have CHAPTER 1 | || | |OVERVIEW 3 shown that approximately 40–50% of children with conduct disorder go on to develop antisocial personality disorder as adults (Robins, 1966; Loeber, 1982; Rutter & Giller, 1983; American Academy of Child and Adolescent Psychiatry, 1997). Children with conduct disorders who do not go on to develop antisocial personality disorder may develop a range of other psychiatric disturbances, including substance misuse, mania, schizophrenia, obsessive–compulsive disorder, major depressive disorder and panic disorder (Robins, 1966; Maughan & Rutter, 1998). Higher rates of violent death have been shown to occur in young people diagnosed with conduct disorder (Rydelius, 1988). Farrington (1995) found that, as well as developing psychiatric problems, many children with conduct disorder develop non-psychiatric antisocial behaviours, which include theft, violence to people and property, drunk driving, use of illegal drugs, carrying and using weapons, and group violence.
Conduct disorders in childhood have also been linked to: failure to complete schooling; joblessness and consequent financial dependency; poor interpersonal relationships, particularly family break- up and divorce. They have also been shown to lead to abuse of the next generation of children, thus increasing the chance of them developing conduct disorders (Rutter & Giller, 1983; Robins, 1991).
Robins (1991) states, ‘because conduct disorder is common and has pervasive long-range effects, it is a very important public health problem’.
COST OF TREATING CHILDREN The cost of conduct disorders, both in terms of the quality of life of those who have conduct disorders (and the people around them) and in terms of the resources necessary to counteract them, is high. It is therefore important that treatment for conduct disorders is both effective and cost-effective.
Knapp et al (1999) state that the NHS resources spent on children with conduct disorders are considerable. Thirty per cent of child consultations with general practitioners are for conduct disorders. Forty-five per cent of community child health referrals are for behaviour disturbances, with an even higher level at schools for children with special needs and in clinics for children with developmental delay, where challenging behaviour is a common problem. Psychiatric disorders are present in 28% of paediatric out-patient referrals.
Social services departments expend a lot of energy trying to protect disruptive children whose parents can no longer cope without hitting or abusing them. Often this may include a brief time with a foster family or the placement of the child in residential care.
Education costs include funding special schools for emotionally and behaviourally disturbed children, as well as providing extra staff to support and provide special-needs education. Law enforcement agencies and the probation service have to detect and prevent delinquency and bring the delinquents to justice. The rate of unemployment and receipt of state benefits is also high among young people with conduct disorders (Rutter et al, 1998).
All agencies will spend considerable amounts of money in supporting a child or young person with conduct disorder over the life span if nothing is done to treat the child. Knapp et al (1999) PARENT-TRAINING PROGRAMMES | || | |FINDINGS FROM RESEARCH 4 examined the cost of treating children diagnosed with conduct disorder. The total direct costs for all agencies (see Fig. 1 for a breakdown) were £8258. The indirect costs, which included loss of employment for some parents, additional housework and repairs, and allowances and benefits, were estimated to be £7012. The total cost annually per child with conduct disorder was likely to amount therefore to a staggering £15,270.
The House of Commons Health Committee (1997), in its report on child and adolescent mental health services, cited two recent outcome studies of projects in the US aimed at improving the behaviour of children from disadvantaged backgrounds. The two studies also looked at the costs saved by early intervention for conduct disorders.
The Perry Pre-school Project worked with 3–4-year-olds and looked at real-life outcomes to 19 years of age. This study found fewer delinquent acts, less use of special education and better peer relationships. Compared with controls, there were savings of $14,819 per child (Barnett, 1993; Schweinhart & Weikart, 1997).
The Yale Project ran a family support programme in the pre-school years and found that at the age of 13 years the children involved got better grades, attended school more regularly and had fewer behaviour problems. Compared with controls, there were savings of $20,000 per family in community resources expended (Seitz et al, 1985).
A consultation document for the National Assembly for Wales (2000) explains that if the NHS were successfully to treat a child with conduct disorder, with an expensive investment in childhood, this would not only save the NHS money over the person’s lifetime, but also other public sector Fig. 1. Annual costs (£) per child with conduct disorder.
Data from paper by Knapp et al (1999), based on a sample of 10 children. Local authority social services 991 Voluntary sector 56 National Health Service 2457 Local authority education services 4754 CHAPTER 1 | || | |OVERVIEW 5 organisations could save significant amounts of money in the long run. This approach emphasises the importance of multi-agency working.
RISK FACTORS Conduct disorders present a significant public health problem for both the individual and the economy. To reduce the frequency of conduct disorders, the first step is to recognise the risk factors for them. These may in turn suggest the causes of conduct disorders and help to identify the children most likely to develop them. Risk factors for the development of conduct disorders may be considered in terms of child, parenting and environmental factors. The interaction of these factors is outlined in Fig. 2.
Child factors T TT T T emperament emperamentemperament emperament emperament Temperament refers to a number of characteristics that show some consistency over time (Normand et al, 1996). These characteristics appear soon after birth (Coffman et al, 1992). A number of studies suggest that infants assessed as having a difficult temperament are more likely to show problems with behaviour later on (Greenberg & Speltz, 1993; Prior et al, 1993). A difficult temperament may make children more likely to be the target of parental anger, which in turn may be linked to conduct disorders later on (Marshall & Watt, 1999). However, Wooton et al (1997) demonstrated a possible strong relationship between ‘callous-unemotional’ temperament and behaviour problems despite good parenting practices. The authors concluded that these children, with a lack of empathy, lack of guilt and emotional constrictedness, develop conduct disorders through causal factors distinct from other children with conduct disorders.
Genetic GeneticGenetic Genetic Genetic Conduct disorder is thought to differ from attention-deficit hyperactivity disorder (ADHD) in terms of genetic influence. For children with ADHD, the magnitude of the genetic influences is thought to be 60–90% (Goodman & Stevenson, 1989; Thapar et al, 1995; Silberg et al, 1996). There is, however, little evidence to suggest that genetic factors alone contribute to conduct disorder.
Plomin (1994) found genetic factors accounted for half the variation of externalising behaviour.
Genetic factors plus adverse environmental factors accounted for more of the variation in children with conduct disorders (Eaves et al, 1997). As Walters (1992) states, it is very unlikely that a single gene or even a simple genetic model can account for complex behaviours such as conduct disorders or criminal activity.
Physical illnesses Physical illnessesPhysical illnesses Physical illnesses Physical illnesses Rutter et al (1970) found that children with epilepsy or other disorders of cerebral function are at increased risk for conduct as well as emotional disorders. Rutter (1988) found that chronically ill children have three times the incidence of conduct disorders than their peers; if the chronic condition was found to affect the central nervous system (CNS), the risk factor rose approximately fivefold.
It has also been shown that perinatal complications such as long labour, delivery with instruments and asphyxia predict conduct disorders and delinquency, although the effects of these complications may vary with other risk factors (Mednick & Kandel, 1988; Raine et al, 1994). PARENT-TRAINING PROGRAMMES | || | |FINDINGS FROM RESEARCH 6 Fig. 2. Influences on antisocial behaviour seen at home and at school, and how the consequences may perpetuate it. (From Spender & Scott, 1997.) Cognitive deficits Cognitive deficitsCognitive deficits Cognitive deficits Cognitive deficits A number of studies have examined the cognitive correlates of conduct disorders in younger children and have found that they often have delays in language development and cognitive functioning (Cantwell & Baker, 1991; Hinshaw, 1992). Language problems, however, could also be considered not to be a child factor, as many factors associated with language development involve the parents’ and the child’s environment. An example of this is a study which found mother–child interactions and the home environment to be good predictors of language skill by the age of three years (Bee et al, 1982).
Cognitive deficits do lead to school underachievement and this has been found to be associated with conduct disorder. Rutter et al (1970, 1976) in the Isle of Wight study of 10–11-year-olds found that a third of children with severely delayed reading levels had conduct disorder and a third of children with conduct disorder were severely behind in their reading. Scott (1995) emphasises the importance of turning around educational underachievement in conduct-disordered children due to cognitive deficits, as this leads to a continuing feeling of low self-esteem in the child. This low self-esteem and belief that they are bad (when often the appropriate assessments are not made and so specific reading and learning disabilities may easily be missed) can cause marked misery and unhappiness and, as a result, a higher incidence of depression (Scott, 1995). It Antisocial behaviour at school Disruptive in class Fights or bullies Hostile attitude Difficulty making friends Difficulty making academic progress Antisocial behaviour at home Refuses to obey requests Temper tantrums Behaves in a way to annoy or anger adults Social context Poverty Unemployment Poor neighbourhood support Large family size Distal parental factors Own upbringing inadequate Psychiatric disorder Unsupportive partner Social isolation Child–parent interaction Inconsistent discipline High parental criticism Low parental warmth Mutually coercive cycles Insecure or disorganised child attachment pattern Child constitution Difficult temperament Attention-deficit/hyperactivity Language or reading difficulty Bad reputation of child in local community Parental discouragement and helplessness Parental isolation from school Peer rejection Deviant peer group Negative image with teacher School failure CHAPTER 1 | || | |OVERVIEW 7 has been suggested that academic failure is a cause rather than a consequence of antisocial behaviour; however, programmes that have improved the academic skills of these children have not achieved reductions in antisocial behaviours (Wilson & Herrnstein, 1985). Similar results have been found for peer rejection, despite these children having been given social skills training (Kazdin, 1987).
Poor social skills Poor social skillsPoor social skills Poor social skills Poor social skills Some of these children lack the social skills to maintain friendships and may become isolated from peer groups (Kazdin, 1995). Children engaging in problem behaviours are thought to have underlying distortions or deficits in their social information processing system (Dodge & Schwartz, 1997). Dodge & Price (1994) found that aggressive children were more likely to interpret social cues as provocative and to respond more aggressively to neutral situations. Children who are aggressive or antisocial are often rejected by their peers (Marshall & Watt, 1999). As Dishion et al (1991) show, peer group rejection is often a prelude to deviant peer group membership, which reinforces deviant behaviours. It has also been found that aggressive, antisocial children are socially inept in their interactions with adults. They are less likely to defer to adult authority, show politeness and to respond in such ways as to promote further interactions (Freedman et al, 1978).
Parenting factors According to Carr (1999), neglect, abuse, separations, lack of opportunities to develop secure attachments, and harsh, lax or inconsistent discipline are among the more important aspects of the parent–child relationship that place youngsters at risk of developing conduct disorders. Parenting behaviour and parent characteristics such as depression are among the strongest predictors of child behaviour problems (Marshall & Watt, 1999).
Poor parenting skills Poor parenting skillsPoor parenting skills Poor parenting skills Poor parenting skills Scott (1998) showed that five aspects of how parents bring up their children have been found repeatedly to have a long-term association with conduct disorders. These are:
poor supervision; erratic harsh discipline; parental disharmony; rejection of the child; low parental involvement in the child’s activities.
Such parenting appears to be a major cause of conduct disorders in children.
Webster-Stratton & Spitzer (1991) found parents of children with conduct disorders lack fundamental parenting skills and exhibit fewer positive behaviours. Their discipline involves more violence and criticism, and they are more permissive, erratic and inconsistent, and more likely to fail to monitor their child’s behaviour, to reinforce inappropriate behaviours and to ignore or punish pro-social behaviours. PARENT-TRAINING PROGRAMMES | || | |FINDINGS FROM RESEARCH 8 Patterson’s work shows that parents of antisocial children are deficient in their child-rearing skills (Patterson, 1982; Patterson et al, 1989):
they do not tell their children how they expect them to behave; they fail to monitor the behaviour of their children to ensure it is desirable; they fail to enforce rules promptly and clearly with positive and negative reinforcement.
Attachment AttachmentAttachment Attachment Attachment According to the attachment model proposed by Bowlby (1969), parental responsiveness is conceptualised as critical to the development of self-regulation skills. Therefore, differences in caregiver sensitivity and the resultant bond between the parent and infant are important factors in later patterns of the child’s behaviour (Lyons-Ruth, 1996). Greenberg & Speltz (1988) found that children who had received insufficient caregiving will act more disruptively to obtain the attention of their parent. They have less to lose in terms of love (Shaw & Winslow, 1997). Shaw & Winslow (1997) examined infant attachment security and observed the responsiveness of caregivers, and found that the parent–infant relationship correlated with externalising behaviour at a later age.
Poor interactions between mother and child can influence the child in many ways (Marshall & Watt, 1999): the mother’s inappropriate modelling of interactional behaviour (Bandura, 1986); the child’s development of unrealistic goals and lack of knowledge of social rules within relationships with adults and peers (Goodman & Brumley, 1990); the establishment of coercive patterns of interaction within the parent–child relationship that are carried forward to the peer group (Patterson, 1986); and the impact of a lack of warmth on the child’s self-concept (Patterson et al, 1989).
Separation and disruption of primary attachments through neglect or abuse may also prevent children from developing internal working models for secure attachments.
Mental health problems in parents Mental health problems in parentsMental health problems in parents Mental health problems in parents Mental health problems in parents Offord et al (1989), in their longitudinal study of single- and two-parent families, found that mothers with psychological distress, major depression or alcohol problems were more than twice as likely to have children with externalising problems directed at others. Stein et al (1991) and Beck (1998) found that children older than one year whose mother is postnatally depressed display problems such as insecure attachment, antisocial behaviour and cognitive deficits. Depressed mothers are highly critical of their children, find it difficult to set limits and are often emotionally unavailable. Hall et al (1991) report that mothers who are depressed are more likely to perceive their child’s behaviour as inappropriate or maladjusted.
West & Farrington (1973) report strong links between the presence of an antisocial personality in one or both parents and similar behaviour in the child.
Substance misuse and criminality in parents Substance misuse and criminality in parentsSubstance misuse and criminality in parents Substance misuse and criminality in parents Substance misuse and criminality in parents Children coming from families where parents are involved in substance misuse or criminal activities are at particular risk of developing conduct disorders (Patterson et al, 1989; Frick et al, 1991). CHAPTER 1 | || | |OVERVIEW 9 Research has shown that when both parents are alcoholics this increases the chances of children developing ODD and CD (Earls et al, 1988). A number of researchers suggest that a combination of risk factors play a role in increasing behaviour problems. Miller & Jang (1977) found that children of alcoholics tend to come from lower-class homes with other problems, including parental mental illness, criminal activity, more marital breakdowns and more welfare assistance. Parents involved in crime may provide deviant role models for children to imitate and substance misuse may compromise parents’ capacity to care for their children correctly (Carr, 1999).
T TT T T eenage parents eenage parentseenage parents eenage parents eenage parents Marshall & Watt (1999) highlight the research showing that children of teenage mothers had more conduct disorders at age 8, 10, and 12 years compared with older mothers. However, as the research goes on to point out, the effects of teenage pregnancy may be due to the fact that children with teenage mothers tend to live on lower incomes, have absent biological fathers and suffer from poor child-rearing practices. Fergusson & Lynskey (1995) found maternal age, socio- economic status, number of siblings at the time of the child’s birth and punitive parenting practices were all significant in the relationship between maternal age and conduct disorders.
Marital discord Marital discordMarital discord Marital discord Marital discord Marital problems, as previously mentioned, are a risk factor. Marital conflict leading to divorce can have detrimental effects on children (Marshall & Watt, 1999). Marital disruption is often associated with a change in economic circumstances and adjustments to altered living conditions; parents may be distressed and this may affect their parenting practices. Also, separated parents may not agree on rules and how they should be implemented. This may lead to a lack of communication about discipline and in turn to inconsistent disciplinary practices.
Some research suggests that when there is persistent conflict in families in which the parents do not separate, there are high levels of child behaviour problems and poor self-esteem in children (Marshall & Watt, 1999). In a recent study, negative marital conflict management skills on the part of parents (defined as the inability to collaborate and problem solve, to communicate positively about problems and to regulate negative affect) were a key variable in contributing to child conduct disorders (Webster-Stratton & Hammond, 1999).
Marital violence Marital violenceMarital violence Marital violence Marital violence Marshall & Watt (1999) also provide evidence that marital conflict involving physical aggression is more upsetting to children than other forms of marital conflict. Children exposed to marital violence may imitate this in their relationships with others and display violent behaviour towards family, peers and teachers. Carr (1999) goes on to suggest that where children are exposed to negative emotions, their safety and security may be threatened and therefore they may express anger towards their parents.
Abuse AbuseAbuse Abuse Abuse Abusive and injurious parenting practices are regarded as the most influential risk factors for conduct disorders (Luntz & Widom, 1994). Physically maltreated children were found to be commonly aggressive, non-compliant, to use acting-out behaviour and to perform badly on cognitive tasks. Sexually abused children had a variety of problems, including aggression and withdrawal, PARENT-TRAINING PROGRAMMES | || | |FINDINGS FROM RESEARCH 10 and were not liked by their peers (Erickson et al, 1989). Child maltreatment is a highly specific risk factor (Finkelhor & Berliner, 1995).
Single parents Single parentsSingle parents Single parents Single parents Where parents are living alone, they may find the constant pressure of looking after a child, along with domestic and work-related issues, difficult to manage, which can result in inconsistent discipline due to emotional exhaustion and lack of social support networks to help with the children. Parents of children with conduct disorder report major stressors two to four times more often than parents of children without conduct disorder (Webster-Stratton, 1990a).
Environmental factors Social disadvantage, homelessness, low socio-economic status, poverty, overcrowding and social isolation are broader factors that predispose children to conduct disorder (Hausman & Hammen, 1993; American Academy of Child and Adolescent Psychiatry, 1997; Carr, 1999). It seems that the longer the child has been living in poverty within the first four years of life, the more prevalent externalising behaviour problems become (Duncan et al, 1994). According to Graham (1991), children from large families and those living in homes where divorce or separation has occurred are at greater risk of conduct disorders. Children with conduct disorders are more likely to come from troubled neighbourhoods. Urban areas have higher rates of conduct disorders; Rutter et al (1975) found that conduct disorder was twice as high in inner London than on the Isle of Wight.
It becomes apparent that conduct disorders are extremely complex and pervasive. There are a number of risk factors for conduct disorders, and these can occur in combination. Apart from the direct link between poverty, socio-economic status and child behaviour problems, other factors, which include maternal depression, exposure to violence and poor parenting practices, seem to act as mediators to additional factors (Loeber & Dishion, 1983; Yoshikawa, 1994).
Resilience: protective factors for conduct disorders Some children appear to have a number of risk factors associated with an increased risk of developing behavioural problems and yet do not go on to have conduct disorders. Rutter (1985) highlighted the importance of vulnerability and protective factors that modulate responses to stress. Werner’s (1992, 1994) longitudinal study investigated resilience in over 200 babies born in 1955 on a Hawaiian island, following and assessing the children at various times up to the age of 32 years. Werner found that the resilient children – those with the ability to cope with the internal stresses of their vulnerabilities and the external stresses of their environment – were similar in that they:
had the ability to elicit positive responses from others and the skills and values that led to an efficient use of their abilities; were engaging to other people; had good communication and problem-solving skills; were able to respond and relate to substitute caregivers; had a high IQ, had good abilities and good dispositions; CHAPTER 1 | || | |OVERVIEW 11 had a hobby valued by their peers or elders; grew up with five children or less, with at least two years between the child and the next sibling, had parents with caregiving skills that led to competence and increased self-esteem.
Pro-social peers and a school that creates success, responsibility and self-discipline have also been shown to be important in preventing behaviour problems (Rutter, 1979).
ASSESSMENT According to the American Academy of Child and Adolescent Psychiatry (1997), assessment requires the collection of data from a number of informants in multiple settings using multiple methods.
The assessment process is very important and other conditions (such as hyperkinetic disorder) need to be ruled out before a diagnosis of CD or ODD is made (see Appendix 1 for ICD–10 criteria). There are a number of assessment tools used to diagnose children with conduct disorders.
Some of the most commonly used assessment tools are:
the Child Behavior Checklist (Achenbach & Edelbrock, 1991), the Eyberg Child Behaviour Inventory (Eyberg, 1992), the Conners’ Parent–Teacher Rating Scales (Conners, 1989; Conners et al, 1998a,b).
TREATMENT It has been shown that parent-training programmes are most effective for young children (under 10) with conduct disorders (Bank et al, 1991; Kazdin, 1995). This type of intervention is examined in greater detail throughout the rest of the report.
Most services will use the general principles in their practice if not specific parenting programmes.
Chapter 7 presents the results of a survey which aimed to ascertain where parent-training pro- grammes are available around the UK and whether current services vary from region to region.
The other main treatments offered to young children with conduct disorders include:
behavioural therapy; psychotherapy; family therapy; cognitive therapy; medication.
