Introduction
Conduct
disorder is a psychological disorder diagnosed in children and adolescents in
the presence of three or more characteristic symptoms, i.e. destruction of
properties, deceitfulness or threat and aggression to the humans or animals
(American Psychological Association, 2000).
These symptoms persist for one year, and one symptom lasts at least within the last six months. The prevalence of conduct disorder in America reported to be 10% to 15% respectively (Azimah, & Khairani, 2009). Multiple risk factors found to be associated in the development of conduct disorder such as ineffective parenting practices, parenting styles, age, gender, socioeconomic status and biological aspects. The children with conduct disorder not merely harm themselves other but others as well (American Psychological Association, 2000). They show poor academic performance and drop out of school on, a high scale.
Case Illustration
The child was referred by her teacher for
the assessment and management of her behavioural problem such as, stealing,
hyperactive, restless, self-injurious, stubborn behaviour, and hitting others. It was reported by the teacher that the
child did not show compliance; she refuses to work in the class or did not show
response when any task was given to her. She did not complete her school work
and indulged in damaging behaviour with others and herself as well. It was also
reported by the teacher that the child did not try to speak in the class; even
she did not make sounds. According to teacher-child had less sleep than normal,
which affecting her performance.
The child was ten years old girl. The
child seemed to be weak, and the height of the child was not adequate to her
age. She had not combed hair and washed face that manifested her poor hygienic
condition. In the classroom, it was observed that the child had stubborn
behaviour like when her teacher said to change your seat she refused. The child had the problem since her birth; it
was reported that the child’s mother diet was not appropriate during pregnancy
because they belong to low socioeconomic status; there was the deficiency of
diet was reported. Child’s delivery was normal, and there were no complications
were reported, but after delivery her first cry was late. The child was treated
by various doctors and remained on different medication until the age of 9.
The child has less sleep than normal as she
sleeps late at night but awake early in the morning, but she remains
hyperactive in spite of lack of speech from 4 years. She had self-injurious
behaviour as she hit herself with scissor two times during the session. It was
reported by the teacher that the child showed tantrum in class, she fights with
class fellows when anybody touches her things and try to snatch things of
others.
The temperament of the child was
aggressive, as she used to hit peers and herself as well. The child likes to
play with toys, paper pencil but did not like to follow instructions. It makes
her annoy when anybody calls her or indulge her any activity. It was reported
by the teacher that the child did not sleep properly, as after-school timing
she plays outdoor, as her mother does a job, and there was nobody restrained
her from staying home, that’s why her hygienic condition was not appropriate.
The child belongs to a joint family system
and low socioeconomic status. There were six family members in a child’s
family; mother, father and two sisters. The parents of the child were
uneducated and belonged to shelter home.
The father of the child 45 years old, and
he was uneducated. He was labour by profession and works on low wages; his
income was not enough to fulfil the necessities of life. Father-Child
relationship was not much healthy, they were not attached, but it was reported
that he loves the child. The father of the child used abusive language and had
an authoritarian parenting style. The child used to avoid his father, and
prefer to stay out in his absence.
The mother of the child was 40 years old
lady and works on daily wages, due to her job she could not take care of the
child, lack of attention and ignorance affecting child behaviour. The
mother-child relations were appropriate as she had concerned about a child’s
future. The child was attached to her mother as she used to take monetary
advantage from her mother. The parenting styles of the mother were submissive
which were worsen the child condition.
Child
relationship with her siblings was not appropriate as she fights with them (for
things like toys or other tangible things), and her age fellows as well. The schooling of the child started at the
age of 8 years. The child quite one year from school, (information was missing)
then she took readmission in the school. The child was in the group of junior girls,
and she was learning the basic familiarities with the syllabus.The class
performance of the child was not satisfactory, as she was a slow learner and
could not promote to the next class, and she shows tantrum in the class.
The child had an unhealthy relation with
peers and family as she disobeyed her teacher when she asked her to don’t touch
toys or other things. The child’s relationship with peers was not appropriate
as it was observed that she had no friends; she goes to other children to see
their toys, and snatch their things. The child used to steal things of her
classmates and has been punished several times. The ratio of absentees from
school was high, and it was reported by the peer that the child smoke cigarette
with boys outside the school.The mother
of the child has a psychotic feature, and the father was suffering from
depression due to low socioeconomic status.
Provisional Formulation
As the child violate the rules and social laws and
found to be indulged in the self-harm and harm to others oriented activates. As
she cannot read or write anything, which showed her cognitive delays and poor
adaptive functioning so it could be hypothesised that she has Conduct Disorder.
Case Formulation
The child was ten years old girl. The child
was referred by his teaching for the assessment and management of her
behavioural problem such as hyperactive, lack of speech, restless, stealing,
self-injurious, and stubborn behaviour. The formulation was made on the bases of
the biopsychosocial model. According to the bio model a genetic abnormality
that may interfere with the growth, as her mother was a psychotic patient.
The child reported as stubborn and
hyperactive it might be that in the early month of life her relations may be
relatively ‘’spared’’ the effect of limitation in their capacities for
information-processing. The quality of mother-child relationship interaction
during the early developmental period affects the quality of interaction of the
child with others and leave an effect in his socialisation. Community labelling
and ignorance increased their frustration which creates a scene of self-complex
and disruption among children; that’s why it might be the reason for aggressive
child behaviour (Leicester, 2017).
As the child belongs to low socioeconomic
status, poverty with no facility of physiological need also leads toward
intellectual disability. Studies indicate that child born into poverty is more
likely to have impaired cognitive and language development, poor experience
health, be less successful in school, experience psychological and behavioural
issues (Emerson, 2004). Families living
in poverty have fewer formal resources and support than other families. They
have less time and money available to meet the additional needs of a child with
adequate and regular prenatal care, to have a healthy diet, or to exercise, and
they are more likely to suffer from psychological disruption (Bartely 2004).
As the child mother works outside the home,
so the child has been ignored, proper attention was not paid to her due to a
disturbed family environment. If the situation remains still, it can be the
risk factor for child further appropriate functioning. Due to poverty, the
child was not able to take proper treatment and diet that is maintaining factor
of problems.
Diagnosis
The conduct disorder was reported in the fourth edition of the
diagnostic and statistical manual of mental disorder. According to the
assessment, it was mentioned that the child was having a mild to moderate level
of conduct disorder.
Child’s Prognosis
The child was able to learn the self-help
skills and can benefit from vocational training, and then she will be able to
live independently in the community by performing the job under little
supervision. It was observed that the child could perform a task as if any task
was given to her she performed it beautifully, e.g. as she like scissoring (the
reinforce of the child which was observed through different activities) so she
could cut under the supervision of tailor, so the prognosis was guarded.
Intervention plan
Intervention plan was used to achieve the
goals of the child.
Implementation
of the Therapeutic Strategies
The therapeutic techniques were used
according to child problems.
Psychoeducation. The rational of the psychoeducation was to teach the teacher and
parents how to overcome the child problems and improve the behavioral and cognitive functioning
of the child. Psycho-education involves anything that teaches people about
mental health issues (Ong 1998). The mother and teacher of the child were
psycho educated on how to control the undesirable behaviour of the child.
Parenting Skills. Parenting interventions improve parenting skills.
In particular, parenting based on social learning theory enhances the parenting
practice to decrease the risk of conduct disorder among children (Leicester,
2013). The social learning theory primarily focuses on the five steps such as
promoting play and positive relationship between parent and child. Appraisal,
or reward for socially desirable behaviour, consistent consequences for
unwanted behaviours, and re-organising child day to avoid trouble through clear
rules or commands increases the probability of desirable behaviours.
Secure and
authoritative parenting brings positive results among students. As in the above
case, the maternal parenting of the child was submissive and paternal was
authoritarian. Therefore the child was encountering trouble. The psychologist
psycho educated the mother of the child how their parenting is playing a
significant role in increasing the problematic behaviour of the child.
Behavioural Change. The behavioural change through behaviour
modification technique brings positive results. The implementation of positive
and negative punishment to decrease or strengthen the behaviour of the child
found to be effective. The child was negatively reinforced each time for her
steal and aggressive behaviour. The three-month session depicted a moderate
positive behavioural change in self-harm and harm to others behaviour.
Anger Management. Anger management focuses on the cognitive process,
physiological responses, and behavioural responses. Slowing down the
physiological or impulsive responses to a threatening or challenging situation by
stopping thinking can help in control anger. The child was taught to say stop
to her aggressive or impulsive thoughts by recognising her arousal level and
emotional states. Furthermore, the child was taught how to modify or replace
the response by anticipating the consequences (punishment). Her smoking habit
and skipping school were also strived to stop through cognitive behaviour
therapy and behaviour modification.
Overcoming difficulties in school. The difficulties in schools can be divided into two
categories, disruptive behaviour and academic issues (Leicester, 2013). The
child-teacher relationship was promoted so that the child feels no hesitation
in asking any question.
Ameliorating peer group influence. Studies suggested that peer influence plays a key
role in the development of conduct disorder (Leicester, 2013). The child peer
relationship found to be unhealthy and to irritate their friend child used to
steal their things. The psychologist tried to build a positive relationship between
the child and her friend through play activities. The friendship jar,
friendship ship and friend circle were used to understand the positive
assessment of friendship.
Medication. The medication works effectively to treat the conduct disorders such as
mood stabilisers, neuro leptonic's, and CNS stimulants (Rani, & healthy,
2017). The child was not recommended any medication as the disorder was on the
mild to moderate stage.
Teacher’s Account
According to a teacher, the academic
performance of the child has increased. She did not steal or snatch things and
harm others.
Limitations and Recommendations
The child could not be observed in all three settings, e.g. classroom,
playground and lunch or break. The follow-up session should be carried out, and
the child will be observed in all three settings. Father was not available for
taking history or psycho-education; the parents must be approached for making a
management plan of the child.