Disruptive Behaviour 75addressed if treatment is to progress, for example, ‘There’s something
wrong in his head,’ or, ‘He’s just like his father. He was rotten too.’
Find out about the family history, especially ‘the four Ds’:
Devianceand criminality in the father (who may use abusive discipline,
or transmit antisocial values).
Depressionin the mother (she may be able to be reasonably bright and
responsive during the assessment, but spend half the day in bed and not
be able to respond to her child’s needs).
Drugmisuse by either parent.
Domesticviolence between the two.
Direct observation of parents with their children is invaluable in getting
a picture of their interactions, albeit in atypical circumstances. Are clear
boundaries set, or is the child allowed to get away with almost anything?
For example, how do the parents react when the child tries to leave
the room? Is good behaviour praised or ignored? Is the child handled
sensitively?
A school report is essential, covering antisocial behaviour, ability to
concentrate and sit still, peer relations, and scholastic attainments, in-
cluding test results. There are occasions when troublesome behaviour in
class can take up so much of the teacher’s time that significant intellectual
disability or reading difficulty can be overlooked or simply regarded as a
consequence of the bad behaviour. Poor school attainment should lead to
serious consideration of psychometric tests being carried out.
Treatment
Family- and school-focused
1 Family workis essential to engage with the parents and come to a shared
formulation about the causal factors. Parents of children and adolescents
with conduct disorder are likely to feel ashamed and may be suspicious
of authority – so considerable skill is required to form a working alliance
with them and their child, thereby setting the scene for more specific
therapeutic work.
2 School.Often class teachers appreciate advice on management strategies
and are glad the problem is being tackled. Feedback about significant
results of psychometric testing should lead to a different teaching ap-
proach. If there are significant comorbid problems such as ADHD and
autistic traits, the school needs to know this.
3 Parent management trainingis the best established approach, with scores
of randomised controlled trials attesting to its effectiveness. It makes
parents pay attention to desired behaviour rather than get caught up in
lengthy slanging matches; positive aspects of parent–child relationships
are promoted, and parents are also taught effective techniques for han-
dling undesired behaviour. It can be given more economically in groups
while maintaining effectiveness. It is based on behavioural methods, see
Chapter 39.