How can we prevent behavioural disorders with the use of CBT? - Chapter 20

What is this chapter about?

Behavioural disorders are characterized by persistent antisocial behaviour in children and adolescents and occur regularly, in 5% of the population. In the DSM-IV-TR, ODD (oppositional defiant disorder) is a separate disorder; in the ICD-10, ODD is a subtype of behavioural disorders. A behavioural disorder often persists into adulthood and is related to crime, drug and alcohol abuse, and unemployment, among other things.

Since behavioural disorders are accompanied by a huge cost to the government, it is important to take preventive action. For this, a disorder 1) should be noticed early, 2) be preventable or can be quickly reduced with the help of interventions, and 3) in most cases develop further into a more severe disorder.

In addition to the cost, it is also important to tackle behavioural disorders preventively, because the current approach does not produce the desired result. This is due to the following five facts:

1. Only a quarter of people who meet the ODD/behavioural disorder criteria receive specialized help.
2. Most current treatments are not proven effective.
3. The treatments that have been proven effective are effective in the "lab" and not in practice.
4. Many children and families receive treatment only later in childhood or adolescence, when the chance of a positive outcome is less.
5. Most children-health centres are only meant for children who have been referred: there are few routinely delivered prevention programs.

In order to make a prevention program more than a theoretical concept, there must be recognition of the problem at government level (national level) and for possible solutions. The American Institute of Medicines (1994) has developed a classification on prevention levels:

• Universal prevention is for the entire population of a specific area.
• Targeted prevention is provided for specific groups.
• Targeted selective prevention is aimed at children with a general risk factor, such as poverty, or being a (single) teenage mother.
• Targeted indicated prevention is aimed at children who are already showing the first signs/symptoms, such as aggressive behaviour at school.

Prevention can also be classified in other ways, such as timing. This refers to the development period in which the intervention takes place: prenatal, childhood, infancy, infancy, primary school age or adolescence.

There are many factors associated with the onset of behavioural disorders. According to Moffitt and Scott (2008) there are no less than 24! This includes intra-individual factors (genetics, temperament, insecure attachment pattern, reading difficulties), family functioning (lack of warmth, inconsistent discipline, violence between parents), and social factors (being bullied, poor school, unsafe neighbourhood). Treatment (preventive or curative) should focus on as many factors as possible that are known to have influence.

Some current treatment programs offered at group level are not only ineffective, but can also backfire! It is therefore important that there is sufficient supervision in group treatments to prevent the promotion of anti-social attitudes and behaviours.

What are examples of effective programs?

Programs aimed directly at the child

Anger management is a treatment program that can be offered at the individual or group level. It is base on the assumption that aggressive children cannot properly recognize their emotions, that these children hold false beliefs about the effectiveness of aggression, and quickly become emotionally aroused when they find themselves in a situation they see as threatening. The best known preventive anger management program was developed by Lochman (2011) and is called Coping Power. This consists of five steps:

1. Identify the problems and the emotional responses.
2. Analyse the possible intentions of the other party.
3. Come up with possible solutions to the conflict.
4. Analyse the short- and long-term consequences of each solution.
5. Make a plan and execute it.
6. Evaluate the effectiveness of the plan and learn from it.

Limitations of anger management programs are as follows: some children simply do not want to do this, in addition there are few therapists who have the necessary set of skills, and some children do fine in the therapy room but cannot yet control their anger when they are actually faced with a difficult situation out of the therapy room.

Programs aimed at parents

The parenting style plays a huge role in behavioural disorders, which is why many parenting programs have been developed. These parenting programs are very effective in the prevention of behavioural disorders. The programs based on social learning theory are the most effective. The best-known targeted selective prevention program is that of Olds and colleagues (2007) and is called Nurse-Family Partnership. Expectant mothers who are at risk (because they are poor, or a teenager) are visited at home by a sister before the child is born, and then regularly for two years. Three goals are:

1. To promote maximum prenatal health, for example by helping the mother to quit smoking;
2. To stimulate the health and development of the child by making parents more competent in their care for the child;
3. To improve the life course of the parent(s) by making future plans (with regards to education, future pregnancies, etc.).

The most commonly used targeted prevention program was developed by Webster-Stratton and Reid (2010) and is called Incredible Years. See p. 1. 316, Table 20.2 for all components that contain an effective program. Webster-Stratton and Reid's program (2010) consists of four parts:

1. Make it a child-focused treatment: play!
2. Reinforce the desired behavior of the child: provide compliments and rewards!
3. Provide clear punishments/rules: be the boss in a calm, clear way.
4. Reduce unwanted behavior of the child: be consistent in punishing. The consequences of the unwanted behaviour must be appropriate and only in the short term (not: a month no TV)! Ignoring the child is an effective technique! Also a time out works very well (1 minute for each year of life).

Programs for teachers and schools

On a universal level, Social and Emotional Learning (SEL) programs are aimed at developing five competencies (all of which consist of a cognitive, affective and behavioural component): self-awareness, self-management, social awareness, skills for entering into and maintaining relationships, and making responsible decisions. When the child has the SEL competencies, a shift takes place: instead of being controlled by external factors, the child learns to act in accordance with the internalized beliefs and values. The most widely used SEL program was developed by Domitrovich and colleagues (2007) and is called Promoting Alternative Thinking Strategies (PATHS). In weekly sessions at school, children are stimulated with the help of stories and role-playing games to identify their emotions and to learn how to deal with difficult situations in a problem-solving way.

Programs that combine multiple approaches

Combinations of certain approaches, such as combining a training for the parents with a social skill training for the child, can be very effective.

What problems arise in practice during the implementation of prevention programmes?

According to Nation and colleagues (2003), there are nine qualities of prevention programs that actually make these programs effective in practice:

1. Completeness: use combinations of interventions, partly to stimulate the skills optimally. Focus on the individual, the family and also the school. Address risk factors and increase or stimulate protective factors. All in all: ensure a treatment that is complete in the broadest sense of the word.
2. Variation in learning methods: Use multiple learning methods with an emphasis on building skills.
3. Adequate dosage: do the interventions last long enough and are they intensive enough?
4. Base the treatment on explicit theoretical models.
5. Foster positive relationships with others.
6. Note the right timing: 1) the problem may not yet be fully developed, so the trajectory can still be affected, 2) pay attention to the child's level of development.
7. Ensure sociocultural relevance.
8. Evaluate the outcome of the treatment.
9. Provide training and support for the employees.

Behavioural disorders are characterized by persistent antisocial behaviour in children and adolescents and occur regularly, in 5% of the population. In the DSM-IV-TR, ODD (oppositional defiant disorder) is a separate disorder; in the ICD-10, ODD is a subtype of behavioural disorders. A behavioural disorder often persists into adulthood and is related to crime, drug and alcohol abuse, and unemployment, among other things.