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Conduct Disorder

Introduction

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According to ego psychology, conduct disorder children experience difficulties within their internal world owing to its structural deficiencies. In psychoanalytic theory these structures have been defined by Sigmund Freud as the ego, the superego, and the id: The id is the domain of impulses; the superego, the voice of conscience and self-control. The ego is the executive agent that acts in coordination with the other structures to effect self-regulation and adaptation to the environment. It is the ego that maintains responsibility for reality testing and validation of thoughts and impulses.

The child with a conduct disorder is understood to manifest major developmental impairments. Psychoanalytic thinking affords the framework within which to view these conduct disorder children, revealing them as deficient in the basic personality structures and relationships that lead to healthy integration. Throughout their development, children with conduct disorders tend to internalize negative parental images associated with negative feelings. Rage, hostility, anxiety, and concomitant negative self-images accrue to form a negative self-concept with low self-esteem and dysphoria. The conduct disorder perpetuates itself, because these introjected negative representations of self and others tend to be projected onto the outside world. Thus, the children come to perceive others as they have been perceived themselves. Identification with good feelings and helpful people is severely hampered as the children’s perception of other people (parents, teachers, friends) is distorted by their projection of aggression and also by the aggression they induce in others as a secondary reaction. In response to provocative behaviors by these children, the adults around them, often unaware of the projections, assume the role of the aggressor. For instance, a parent may begin to command, criticize, or be directly negativistic, thus enacting for the child his own self-criticism, while the child feels himself to be the victim of misunderstanding and blame.

Conduct Disorder and Ego Deficits Perspective

In structural psychoanalytic terms, conduct disorder children have ego deficits in the following areas: cognitive functioning, attention, impulse control, judgment, modulation of affects, language, and tolerance for anxiety and frustration. In the domain of the id, aggression predominates at the expense of integration of impulses with libidinal or affectionate feelings. Finally, although impulses break through the frail equilibrium of the superego, some capacity for remorse, guilt, and more frequently, shame remains, permitting these children to be accessible to therapy.

In their relationships, conduct disorder children are often encumbered by primitive organizational principles that govern their perceptions of themselves and others. They find it difficult to understand that peers have motivations, characteristics, and preferences different from their own, tending instead to attribute to others their own feelings and thoughts. They frequently lack the necessary, age-appropriate social skills for peer interaction. When their need to control their environment is thwarted, they act out, unable to contain their feelings of frustration.

Low Self-Esteem and Sense of Worthlessness

Conduct disorder children share a core feeling of being unloved and uncared for. Although this perception may have no grounding in reality, nonetheless their subjective representational world is constructed around the premise of rejection and abandonment. When they are responded to in a way that is attuned to their needs, they are certain that their low self-esteem and sense of worthlessness will be perceived by others as their true qualities ( Willock 2005, 2002). Therefore, to terminate this tension, they may strive to bring down on themselves what they consider inevitable rejection, often provoking others to be furious at them. Although this negative behavior fills a void and causes others to attend to them, it further alienates them from the love and concern they need.

Moreover, these children expect to see reruns of the dreaded interactions between the rejecting parent and the disregarded self and to induce and repeat endlessly these unrewarding, frustrating interactions. This expectation permeates their relationship to the therapist. The chronic worry of these children is that someone else will suddenly replace them, destroying whatever importance they held in their therapist’s eyes and leaving them totally in the cold. This fantasy, taken as absolute truth, represents the core of their self-image and their representational world. It is a fantasy near the surface, and therefore it is enacted. Because of the child’s deficiencies in organizational structure, there are no defensive layers to be penetrated. In fact, the child does not experience his or her fear as a fantasy at all, but as a straightforward perception of reality and of the therapist’s true feelings. The child’s behavior reflects his or her acceptance of the rejection fantasy as real; he or she experiences no distance from it and no awareness of its origins or its pervasive effects ( Donnellan 2003). It is the deepening of experience to permit new perceptions of self and others to emerge that becomes the essence of treatment.

Aggression Role in Conduct Disorder

To understand the development of conduct disorder behavior, we will trace the earliest manifestations of aggression in the life of a child. The youngest of human beings arrives on the scene not as a tabula rasa but as an active agent interacting with his animate and inanimate environment in various ways designed for survival. Interacting with him are those caregivers responsible for providing the aliments, both psychological and physical, required for his adaptation to his new surroundings.

Earliest aggression is not negative in its intentions. It is neutralized aggression, or assertiveness, that is part of the organism’s program to survive ( Hartmann 1999). It manifests itself as a part of the mobilization of energy in the face of a barrier or obstacle ( Parens 2003; Prelinger 2003). Everyone has seen an infant try to force his way past an obstacle to get at a toy he wants to play with. Similarly, a child will grab at a baseball card held by someone else, exert determination and strength to climb to the jungle gym’s highest rung, or require restraint not to knock the child in front of him off the slide pond. This added push, or shove, to get through a barrier is a major source of aggressive behavior.

Rage Reaction

Another commonplace but more extreme early form of aggression is the rage reaction, which is seen, for example, in the infant’s urgent crying and screaming, face and body taut and red, thrashing about. This state communicates panic, extreme discomfort, and what seems like intense resentment. We recognize this state as akin to the stress of extreme provocation. At this moment the entire world seems like a “zero barrier” ( Prelinger 2003), as if there were nothing in the world that could relieve the discomfort. The barrier being imposed can be conceptualized as existing on three levels: (1) the concrete, physical world; (2) the interpersonal world of human relationships; and (3) the intrapsychic world of one’s inner thoughts and feelings.

In the examples cited at the beginning of the Introduction, in which three children demonstrate conduct disorders, all three levels are present in each case. Bob seems most upset by a reality barrier, not having the homework that he wants and that another child possesses. On an interpersonal level, we can wonder about his peer relationships and feelings of envy. On an intrapsychic level, we can intuit Bob’s feelings of inadequacy and failure that obstruct more positive experiences of self-esteem. Andy, on the other hand, seems to be propelled by primarily internal factors, perhaps temperaments, which have not yet been deciphered. It is the sense of unpredictability experienced by his mother that cues us to the apparent lack of an external clue to the disorder. Although Andy’s omnipotence allows him to exert control over others, it impinges on his interpersonal relationships and compels him to risk his safety with the physical environment. David’s difficulty following rules clearly raises issues regarding all three barriers to adaptation and also raises questions about parental management of frustration and gratification. Not following rules would generate a constant barrage of external difficulties with things as well as people in the environment, with resultant ill effects for the development of David’s internal life.

We are saying that these children’s manifest conduct disorder behavior is the final common pathway for a variety of experiences in their efforts to cope with frustration and to cope with ubiquitous aggressive feelings. These efforts fail because they have not been integrated within a context that could contain them and permit their expression in a manner that is both communicative and safe. An undue sense of frustration and failures of attunement, consistency, and empathy have caused their aggression to take a deviant path and be counterproductive, rather than to be enlisted toward surmounting the difficulty–what we have referred to as overcoming a barrier. It is because of this failure in integration between positive and negative states, or synthesis, that these children exhibit a lack of connectedness between cause and effect and a lack of continuity in their relationships with other people.

Play Behavior and Conduct Disorder

In their play behavior, conduct disorder children are bound to one dimensional, concrete interaction with objects. Within the context of a therapeutic play relationship, however, symbolic meanings emerge, and imagination is used creatively to communicate. Similarly, a line is discernible in the use of language, from words that name and describe action to words that communicate and share experience. Through integration, these children’s actions become connected to their thoughts, ideas, and feelings.

Thus, the behavior of each child no longer exists in isolation but becomes part of the totality of the child’s individuality and his or her unique adaptation to reality.

A second perspective to shed light on the understanding of conduct disorders is attachment theory, which helps to provide a basis for understanding the etiology and development of deviant models of relationship. Characteristic of children with conduct disorders is an underlying pattern of insecure attachment to the significant persons who are responsible for their care. Negative and resistant behaviors maintain their maladaptive responses, which may under extreme stress result in acting-out behavior.

Attachment Theory Scenario

Attachment theory also draws on concepts of object relations as well as concepts of development and dynamic interaction. Through continual transactions with the world of persons and objects, the child constructs increasingly complex internal working models of the world and significant persons in it ( Bowlby 1969, 2003, 2000; Bretherton 2001). These models appraise and guide the child’s experience and behavior. Dyadic interaction patterns form the basis for representation within a working model ( Emde 2005; Emde and Sorce 2005). Once an internal working model is formed, it tends to be resistant to change and to operate outside awareness ( Emde 2003; Sroufe 2002). This formulation complements that of object and self-representation. Joy Osofsky ( 2002) suggests that this developmental aspect of working models parallels the psychoanalytic notion of peeling layers of an onion, the earlier internal working models being more resistant to change than those that develop later. Thus continuation of conduct disorder behavior patterns would indicate ongoing distortions in the internal working models of children as well as longstanding difficulties in relationships with significant persons in their lives.

A third theoretical perspective drawn upon in this research paper is that of temperament theory ( Thomas, Chess, and Birch 2000). Temperament denotes innate characteristics of a child. This viewpoint stresses the importance of the child as contributor and/or initiator in continuing patterns of interaction. We focus particularly upon the characteristics of the difficult child ( Turecki and Tonner 2001) and the effect that these characteristics have upon parent-child relationships. Noted also are parental characteristics that might contribute toward a problem of “fit” or mismatch within the dyad.

A fourth theoretical perspective that lends its concepts to our approach to conduct disorders is that of learning theory. In our discussion of both etiology and intervention, the principles of modeling, reinforcement, extinction, and coercive interaction are central to our proposals. The emphasis upon learned patterns of behavior helps to clarify how object relations and internal working models are acquired through life experience and how they can be altered through therapeutic intervention.

Peer Relations and Psychotherapy

If the main difficulty is with peer relations, then play group psychotherapy is indicated. If the child presents with low self-esteem, depression, or impulsivity, then individual supportive-expressive play psychotherapy is indicated. If the disorder is mild and clearly due to difficulties in parental management, then parent-training procedures are indicated. Frequently, however, these problems present themselves in different combinations and with varying intensities. In each case the choice of modality, or combination of modalities, needs to be individually determined. For training purposes, it is recommended that each treatment approach be learned separately in order to develop in the beginning clinician an in-depth knowledge of the issues tapped by the use of a single modality.

Supportive-Expressive Play Psychotherapy

According to psychoanalytic theory, the ego is a complex structure that mediates between the internal and the external world of the child. It is a structure that attends to the functions of attention, perception, memory, anticipation, integration of functions, and adaptation of the self to changing internal and external circumstances. The ego also discharges impulses in sublimated, or socially approved, ways. Sublimation is the process by which unacceptable primitive impulses are transformed into socially acceptable actions through words, fantasy, or play. SEPP (Supportive-Expressive Play Psychotherapy) focuses on the changes in language and play and on the fantasies that underlie these activities during treatment. These ego functions are monitored by the superego, a personality structure that according to psychoanalytic theory is the voice of conscience. It rewards the ego with approval, raising self esteem, or punishes the ego with disapproval, resulting in shame, remorse, guilt, and lower self-esteem.

Through the treatment procedures of SEPP, the aggressive behavior of children with socialized conduct disorders can be attenuated and integrated adaptively, because the treatment increases the effectiveness of ego and superego functioning. The therapist supports ego functions through  both verbal and nonverbal means. She also increases the effectiveness of the child’s superego by providing a relationship in which the child can become aware that his perceptions of others are partial and/or distorted by his cognitive limitations or that he externalizes his aggression–that is, perceives it as stemming from others (teachers, parents, peers, therapist). Through many interactions with a consistent, empathic therapist, the child may internalize the therapist’s functions of monitoring, approving, and disapproving, and may gain in ego and superego function through identification. Thus, the child’s disorder may be seen in part as a disorder of identification that is repaired through the therapeutic interaction with the therapist.

Personality Structure

It is important to understand that these failures of identification vary in their severity. In the more severely conduct disordered child, the personality structure is distorted or deficient. The ego has relied upon primitive defenses against anxiety, such as denial, projection, and splitting, which interfere with ego and superego development. In these cases, the structure does not permit observation of oneself. The child has little capacity to observe his or her own behavior and relies upon the therapist to provide supports that will eventually lead to a greater differentiation in his or her perception of self and others. It is against this background of gradually emerging new perceptions and understandings that the therapeutic work takes place.

Initially, support is essential as the therapist communicates to the child an attunement to, and an understanding of, his or her feelings. As the feelings are shared in this open and non threatening way, an arena of safety emerges within which the child is free to explore, in play and in words, feelings, wishes, and behaviors he or she had heretofore hidden not only from others but from his or her self-awareness as well. Thus, the expressive aspects of SEPP become clearer as the child becomes increasingly open to deeper understandings of his or her wishes, motives, and thoughts. It is important to stress that the supportive element of SEPP is always present; it is the extent to which deeper feelings are observed and are permitted expression that changes with treatment. In some instances, the expressive component may emerge only minimally, and the main locus of treatment will be supportive.

The extent to which deeper feelings can be shared and examined varies from child to child. What does remain constant is not only the therapist’s steady tolerance for negative and adverse feelings and wishes but for the child’s autonomy. This therapeutic stance allows the child to discover his or her own self and to explore his or her range of adaptive behaviors within the safety of appropriate limits. Thus, the therapist does not impose her values and remains supportive of the child’s initiative and positive self-assertion.

Therapist and Conduct Disorder Patient Relationship

The therapist-child relationship is aimed at correcting specific ego-deficiencies and superego deficits, at first through play and increasingly through verbal interaction. Cognitive functions are facilitated, developed, and practiced through education, encouragement, and empathy. Attention, anticipation, and integration are enhanced through the therapist’s and the child’s observations. Self-esteem improves as a sense of acceptance and mastery develops. Clarifications of behaviors and experiences within the sessions and with the therapist increase the child’s effectiveness in social skills. The child becomes more knowledgeable about his or her styles of responding and, in turn, of contributing to his or her problems.

Conduct disorder children play aggressively and destructively with the therapist in an attempt to express without words why they are the way they are and to see if the therapist will respond to them as others have done in the past. In fact, they do not know how to play in any other way. Their aggressive behavior is often an unconscious effort to ward off the awareness of feelings of being disregarded and devalued. These children demonstrate an impaired capacity to play in a truly reciprocal manner or for problem solving; instead, they use play to control others. The therapist may be confronted with aloofness or a barrage of aggression. These behaviors are the children’s attempts to distance themselves from painful feelings that they find extremely difficult to tolerate. The fantasy of being rejected by others restricts the children’s play to concrete, repetitive themes. The therapist’s task is to facilitate the unfolding of sublimatory play activity.

Conduct Disorder and School Life

Expressions of empathy with the teacher, such as acknowledging how difficult things are for her, with twenty or more children to handle at a time, convey that the therapist understands and appreciates the time the teacher gives for these additional contacts with herself and the child.

In the last stages of the treatment, it is important to include the teacher in the plans for termination, both to inform her and to give her the opportunity to agree or disagree with such plans on the basis of her observations of the child in the school setting.

We have recommended that the therapist communicate with the teacher regularly, in person or by telephone at least once a month. Unfortunately, parents often refuse to allow the therapist to have any direct contact with the school staff. In these cases, it is important to explore the parents’ reluctance. The source of this resistance is often due to the parents’ feelings of shame or mistrust of the school authorities’ reactions to the child in treatment. When parents are not yet ready to consent to direct contact, the therapist can discuss with them the same issues that would be presented to the teacher to allow the parents to assume the responsibility of communicating with the teacher. In their meetings with the therapist, the parents then report their discussion with the teacher.

Superego Functioning

Parents often have questions regarding school placement, as well as placement with one kind of teacher rather than another. It is generally advisable for conduct disorder youngsters to have a teacher who is authoritative, clear, and firm–one who can provide an understandable and predictable structure to the child to avoid situations of anger and punishment. Perhaps the most frequent crisis is an aggressive outburst that leads to physical fighting, hurting others, or destroying property and results in suspension from school. Clear, prompt response to injury to another child or damage to property should be instituted, in accordance with school policies. The parents, in turn, should follow the same disciplinary measures that they have employed on other occasions, making them commensurate with the seriousness of the crisis and the child’s developmental capacities. If the child has sufficient superego functioning, the therapist can encourage the child to suggest an appropriate punishment for his misbehavior. Alternative ways of handling situations can be rehearsed with the parents ahead of time or at the time of the crisis.

It is not uncommon for therapists to have reactions that can interfere with the treatment. Provocative and action-oriented, conduct disorder youngsters test the therapists’ capacity to maintain realistic hopefulness and fondness for them. Time must be allowed for developing the therapeutic alliance at the beginning of treatment. Meanwhile, the therapists may experience boredom, hopelessness, and even anger and impatience with these children. Therapists who do not have the flexibility to interact with youngsters at the motoric and action level may find these mood states particularly stressful and may disengage and even terminate their treatment.

The use of supervision and/or consultation may open some alternative views on the child’s behavior and help to relieve the therapist’s sense of hopelessness, which often echoes the child’s desperation and loss of self esteem. The therapist’s own therapy might contribute even more effectively in providing insight into these reactions to the patient and even into the therapist’s suitability to working with this type of child.

Maladaptive Parent-Child Interactions

Problem behavior is inadvertently developed within the home and sustained by maladaptive parent-child interactions. A common result of these maladaptive patterns of interaction is the development of insecure attachments between parent and child, which can be manifested in a conduct disorder. The goal of the parent training program is to enhance feelings of mastery for the parents, which will in turn enhance their feelings toward their child. The increased sense of mastery is positively reinforcing for the parents and acts to further the growth of secure attachment between parent and child. In describing parent training, we will be following the formulations of social learning theory, which has demonstrated that parents of children with conduct disorders engage in practices that promote aggressive behavior and suppress prosocial behavior. These practices include directly reinforcing deviant behavior, making frequent and ineffective use of commands and punishment, and failing to attend to appropriate behaviors ( Patterson 2002).

As the parents’ skills in parenting improve, a major shift occurs: the parents become increasingly active in initiating and designing strategies. The frequency with which the therapist initiates and designs new strategies decreases as the parents become more confident and have a clearer understanding of the importance of consistency, clarity, and nonpunitive authoritativeness. The most common themes of the work with the parents involve providing a more secure structure and consistency in daily family activities and living patterns, maintaining clarity in verbal messages, being firm but nonpunitive in limit setting, and providing emotional rewards, praise, and empathy for good behavior. In most cases, the parents of conduct disorder children have been focusing almost exclusively on misbehavior. When the child starts being good, they are so relieved that they unwittingly ignore him.

Conclusion

In recent years, social learning approaches ( Barkley 2001; Forehand, 2004) have introduced the use of trained parents as adjunct therapists in the treatment of conduct disorder children. Social learning theorists, however, have invariably neglected to address a fundamental obstacle to the implementation of their programs: patient (or in this case parental) noncompliance. Most behavioral theorists seem to adopt the rational actor perspective so prevalent in economics–that is, people behave rationally to maximize goals that are clearly in their self interest and avoid choices that produce undesirable outcomes or perpetuate problems. Clinicians have known since Freud that the “rational actor” hypothesis is a myth.

Parental psychopathology of certain kinds has been noted as a contraindication for undertaking parent training. It should be added that, in addition to Axis I disorders (DSM-III-R 2002), Axis II psychopathology (personality disorders) constitutes a major obstruction to successful parent training. In particular, borderline, narcissistic, passive-aggressive, and antisocial personality disorders are especially problematic in parent training, owing to the difficulty in treating them psychotherapeutically. Although every effort is made to eliminate these parents in the assessment phase, nonetheless, their pathology may not be detected early on. Among other factors, a pseudo compliant attitude or the forcefulness of the parents’ plea for help may have obscured their underlying pathology.

Parents displaying significant psychopathology of Axis I or II types often experience considerable difficulty in effectively modulating their own behavior in relation to that of their child and thus often do not implement the therapist’s directives or provide productive reinforcement. Moreover, owing to the difficulties in personal relationships created by people with personality disorders, such parents do not relate in a positive, unambivalent way with the therapist. They may, therefore, deliberately or unconsciously undermine the therapist’s efforts and may in turn elicit negative behavior from the therapist, thereby establishing a conflictual, as opposed to a cooperative, relationship between parents and therapist. Obviously, such relationships are counterproductive in reducing conduct disorder behavior.

Exploring how parents feel when their child misbehaves is always helpful. Parental attachment is often strengthened by comments upon how difficult coping with such a child can be, how frustrating for a parent it is, and how such anger and frustration can lead parents to feel inadequate. Moreover, the therapist may wish to comment that many parents become so angry with their children that they feel as though they might hurt the child if pushed much further. These remarks can be made within the context of describing normative parental reactions to a conduct disordered child. Parents are then reassured and can feel the therapist truly understands their plight. Supportive comments should be made at the beginning of the initial phase to communicate, first, that the therapist views the parents’ anger with the child as expectable, given the child’s behavior; and second, that the therapist does not blame the parents for feeling angry, irrespective of how the parents may judge their anger.

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