Treatment Modalities for Conduct Disordered Adolescent Males

¶ … treatment modalities for conduct disordered adolescent males has primarily been focused on comorbidity. Adolescent males with conduct disorder typically receive individual and family therapy, but when overt behaviors are extreme, pharmacotherapy may supplant insight-based therapy. Cognitive Behavioral Therapy and social skills training are complementary approaches to intervention. Using an experimental approach, this study examines the impact of combined intervention approaches on perceived and observed improvement in the expression of problem behavior and life change strategies of adolescent males with conduct disorder.

Adolescents, across the board, experience a range of emotions. Negative impacts of these emotions include struggling with acceptance, self-esteem, isolation, confusion, anxiety, and depression, which can also be a result of instability at home (Searight, et al., 2001). In addition to these social effects, many adolescents experience a distorted perception of reality (Searight, et al., 2001). On occasion, this distortion may cause them to make poor choices, which demonstrates an "acting-out" behavior (Searight, et al., 2001). All of these behavior conditions can lead to a diagnosis of Conduct Disorder (CD) (Searight, et al., 2001). A diagnosis of CD is based on DSMR-IV_TR criteria, which include the presence of aggressive conduct, non-aggressive conduct, deceitfulness, theft, severe violations of rules, and difficulty responding appropriately to negative experiences (Searight, et al., 2001).

Many types of interventions and treatment modes have been applied to the therapeutic challenge of assisting adolescent males with CD (Searight, et al., 2001). This research proposal, addresses two of these therapeutic processes: Cognitive-Behavioral Therapy and Pharmacotherapy. The research compares these intervention types, each of which is considered best practice when working with individual adolescent males between the ages of 14-16 who exhibit conduct disorder.

Problem Statement

Research shows that various therapeutic modes and methods can positively impact the expression of problem behaviors and the disordered thinking of patients with CD. However, there is a dearth of research that demonstrates the effectiveness of combined therapeutic approaches with adolescent males with CD. Therapeutic interventions that address the expression of problem behavior in social settings, that provide methodical approaches to altering patients' destructive thinking, and pharmacological support for mood lability have been utilized by therapists in clinical settings -- however, these interventions have not been systematically combined with this population.

Background

Cognitive Behavioral Therapy (CBT) is a comprehensive theory of psychopathology and personality, in which specific disorder treatment models were developed (Beck & Weishaar, 2000). An empathic and active clinician, who is typically a psychotherapist, collaborates with patients to define specific treatment goals and a therapeutic life changing plan (Beck & Weishaar, 2000). Treatment sessions are structured to enhance the development of new cognitive and behavioral skills in the patient's repertoire (Beck, 1987; Beck & Weishaar, 2000). Application of Cognitive Behavioral Therapy (CBT) reduces symptoms and learned disordered thinking in cooperative patients, and it has been shown to be effective for individual, couple, family, and group therapy (Beck & Weishaar, 2000; Corey, 2009). CBT is based on the premise that feelings and behaviors stem from thoughts, not external things, like people, situations, and events. Thus, CTB can be used by to change the irrational thinking patterns of individuals with CD to more rational and constructive thinking, through self-counseling and correcting underlying assumptions (Pucci, 2010).

A recent study (Ducharme & Shecter, 2011) found that "modification of keystone behaviors leads to collateral improvements in a range of other behaviors" (p. 273). Moreso (XXXX) argues that, "by improving attention and increasing inhibitory activity, medication may improve children's capacity to benefit from other treatment modes" (p. XX ). Most studies of the use of pharmacological interventions for conduct disorder involve patients with cormorbid conditions, such as ADHD or depression (Riggs, 2007; Searight, Rottnek, and Abby, 2001; Trowell, 2007). Although stimulants, anti-depressants, lithium, anticonvulsants and clonidine have all been used in the treatment of conduct disorder, there are no formally approved medications for CD. Research is needed to evaluate the role of pharmacotherapy for individuals with conduct disorder.

Further, while many adolescent males with CD require pharmacological intervention to cope with their underlying social and emotional impairments, counseling has been shown effective in increasing the ability of patients with CD to adapt and cope with the pressures and demands of their environments. Cognitive-Behavioral Therapy (CBT) is a structured and collaborative means of providing self-help strategies that can be utilized during individual and family therapy and carried over to daily living. "Evaluation of efficacy and effectiveness of CBT with regard to the treatment of adolescents has focused on the utility of CBT alone and the use of CBT as an adjunct to pharmacological treatment." (Gledhill & Hodes, 2011).

Maag (2006) researched social skills training (SST) in a public school setting, and concluded that therapists frequently lack the expertise, resources, personnel or inclination to effectively use the method (p. 14). The overall ineffectiveness, according to Maag (2006) may be attributed to methodological flaws, including the tendency to over-generalize, and resistance to the institution of long-standing recommendations for enhancing the effectiveness of SST therapy. The factors that appear to inhibit the effectiveness of an SST approach are not present in a clinical setting. Further research is needed to explore the influence of SST on outcomes for patients with CD who are also engaged in CBT.

Study Purpose

The purpose of this study is to explore the effectiveness of combined individual interventions for adolescents with Conduct Disorder (CD). The research shows that Cognitive Behavioral Therapy (CBT) used in individual and family therapy, social skills training (SST), and pharmacological treatment with Fluoxetine have all been effective in reducing the symptoms and behaviors associated with Conduct Disorder. All subjects were assessed and treated for substance abuse problems regardless of group assignment. Follow along interventions for substance abuse will continue throughout the duration of the study. The objective of the study is to determine whether combined social skills and cognitive intervention approaches are more effective than pharmacotherapy alone, or more effective when paired with pharmacotherapy.

Research Questions & Hypothesis

The literature provides evidence of the effectiveness of various therapeutic approaches to treating conduct disorder (CD) in adolescents; however, the research has tended to focus on single therapeutic intervention types rather than combined therapeutic interventions. To further the research on effective therapeutic interventions for adolescent males with CD, the following research questions are proposed.

Does the use of CBT in family therapy provide an effective approach to intervention for adolescent males with CD? To what degree are unacceptable behaviors of adolescent males with CD mediated by the use of CBT in family therapy? Do adolescent males with CD perceive that the use of CBT in family therapy effectively alters their disordered thinking of in the short-term?

Does SST in combination with CBT provide an effective approach to intervention for adolescent males with CD? To what degree are unacceptable behaviors mediated by SST in combination with CBT in family therapy? Do adolescent males with CD perceive that the use of SST in combination with CBT in family therapy effectively alters their disordered thinking in the short-term?

Are there measurable differences in the level or frequency of expression of unacceptable behaviors, and perceptions of self-esteem and self-control in adolescents with CD across the three treatment groups?