Therapeutic Risk Factors

The emphasis is on the presence and interplay of both social and biological risk factors in the increasing of the rates for anti-social and violent behaviour.

Identifiable risk factors for Childhood onset of conduct disorder are:

• Parental antisocial behaviour
• Parental substance abuse
• Younger maternal age (what age they had first birth, this would continue onto latter births as a risk factor)
• Low IQ (Silverthorn,1999)
• Sexual abuse
• Early menstrual onset (Moffit et al, 2001)
• Limited or lax parental supervision
• Harsh discipline (and abuse)
• Social risk factors
• Low social economic status (SES)
• Lower maternal education
• Does not vary by race when SES and neighbourhood characteristics are controlled

Overall findings are that risk factors are similar for both genders, but being male is a risk factor in itself and in girls the risk factors also include running away from home (McLaren, 2000) and Child abuse (Leve, in press).

Treatment (Chasidim, 2000; Lesley, 1992; Waslick 1999)

"I’m afraid we won’t be able to do much about prison reform until we start getting a better grade of prisoner" Lester Maddox, during his tenure as the Governor of Georgia

Most evidence-based interventions are not only intensive but require being comprehensive, multi-focussed and multi-disciplinary in delivery but then being only partially effective. These approaches are viewed as being better at controlling the undesirable behaviour than the actually changing of attitudes or increasing of social values.

There is at present no simple or sure fire fix to the problem of SCD and most interventions need to be in place for months or even years.

Above all there needs to be intervention and whether in family or if child is looked after there is opportunity to make a difference in creating an experience which will assist in gradually changing the internal working model of the child.

Some practical interventions carer can begin with are:

• Treat comorbid substance abuse first.
• Structure children’s activities and implement consistent behaviour guidelines.

Emphasize parental monitoring of children’s activities (where they are, who they are with), encourage the enforcement of curfews and boundaries/containing structures.

Discuss and demonstrate clear and specific parental communication techniques.

Help caregivers establish appropriate rewards for desirable behaviour.

Help establish daily routine of child-directed play activity with parent(s).

Treatments that don’t work and viewed as not meriting government funding are:

• Shock treatments
• Peer counselling
• Excellent delivery of “ordinary” social services (APA. 1997)
• Boot camps

Treatments that do work (at least some positive treatment outcome) tend to be

• Behavioural
• Skills oriented (moral reasoning, problem solving, anger management)
• Multi model
• Programmes with family based components e.g. parent training, family therapy, couples therapy (opportunity for the excellent delivery of therapeutic residential child care services to provide attuned care required)
• Treatment of parent child interactions
• Multi-systemic therapy (MST)

Some promising research is also starting to provide an insight into detectable behaviours that can be identified that may indicate the possible presence of SCD. These have been termed as possible gateways and therefore treatment can be directed towards the following area’s fire setters, graffiti, sexual offenders, sexually abused, and theft, The use of medication is understudied but it is generally targeted towards the management of reactive aggression, explosive temper, hostility / negative mood, co morbidity and ADHD. Stimulants (amphetamine, methylphenidate or Ritalin) are seen to help manage ADHD and might also reduce aggression.

In conclusion there is a wide range of initiatives for addressing the problems which have began to provide promising results and demonstrate efficancy at targeting needs from pre-school years into adulthood.

It must be kept in focus when it comes to allocating resources, that early conduct disorder problems have long lasting effects that can impact on us all in terms of crime, mental health, driving, sexual outcomes, education and employment. With the possible exception of IQ, no other factor that can be present during childhood has as far reaching consequences in terms of development.

Recommendations:

1. Identify the most at risk children preferably before they start school
2. Trial interventions through the wider use of validated intervention programmes (“don.t put all your eggs in the one basket”).
3. Target 1 – 5 % of very young children
4. Interventions with those assessed as highest risk, needs to be intensive and sustained
5. Co-existent psychiatric disorders must be treated
6. Programmes need to be developed for females based on evidence based protocols as opposed to placing them on programmes developed for males e.g. do better on one-to-one placements where they are isolated from the anti-social peers.
7. Education system needs to provide a safe and controlled stimulating learning environment for the pupils (inclusion not exclusion where at all possible)

If you let young people trash their lives, they will trash your society

Peter Garrett, singer with Midnight Oil

By Richard Cross

Richard is currently working for Five Rivers Child Care Limited as Head of Practice Development.

He is a UKCP registered psychotherapist who has also worked with high risk adolescents for many years and was the co-author of a therapeutic programme Invitations to change. (Focus EQUIP) for the New Zealand Corrections Department, which is used with high risk adolescent offenders.

e-mail: Richard.cross@five-rivers.org

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