The paper examines Conduct disorder as a pattern of behaviour characterized by aggression, rule-breaking, and a disregard for others' rights. Individuals with conduct disorder tendencies can present unique challenges in counselling. They may struggle with impulse control, difficulty following rules, and disruptive behaviour that can disrupt the therapeutic process. Managing these behaviours and helping clients develop healthier coping strategies becomes a central focus in therapy. It is important to note that these issues are complex and can vary significantly among individuals. Each person's unique circumstances, experiences, and motivations will influence the specific challenges they present in counseling. Skilled and experienced therapists are equipped to navigate these complexities and provide appropriate support and interventions tailored to the individual's needs. The treatment option focused on this paper is Parent Management Training (PMT) which is widely recognised and evidence-based therapy for conduct disorder. It focuses on equipping parents with the necessary skills and strategies to effectively manage and address the challenging behaviors exhibited by their children. PMT aims to improve parent-child interactions, enhance parenting practices, and reduce conduct disorder symptoms.

Conduct disorder is a childhood and adolescent psychiatric condition characterised by a persistent pattern of aggressive and antisocial behaviours. Individuals with conduct disorder often display a disregard for the rights of others and violate societal norms and rules. This disorder can have significant negative impacts on the individual's social, academic, and occupational functioning. This response will provide meaning of conduct disorder, its symptoms, causes, effects, and treatment options.

Meaning of Conduct Disorder (CD)

Conduct disorder (CD) is a set of problem behaviours exhibited by children and adolescents, which may involve the violation of a person, their rights or their property. It is characterized by aggression and, sometimes, law-breaking activities (State of Victoria, 2021).

Conduct disorder refers to a group of repetitive and persistent behavioural and emotional problems in youngsters. Children and adolescents with this disorder have great difficulty following rules, respecting the rights of others, showing empathy, and behaving in a socially acceptable way. They are often viewed by other children, adults and social agencies as "bad" or delinquent, rather than mentally ill (American Academy of Child and Adolescent Psychiatry, 2018). Conduct disorder (CD) is a mental health condition that affects children and teens that is characterised by a consistent pattern of aggressive behaviorus and actions that harm the well-being of others. Children with conduct disorder also often violate rules and societal norms. Conduct disorder lies on a spectrum of disruptive behavioural disorders, which also includes oppositional defiant disorder (ODD) which are angry/irritable mood, argumentative/defiant behaviour. In some cases, ODD leads to CD (Cleveland Clinic, 2023).

Types of Conduct Disorder                         

These subtypes are identified in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which is a widely accepted diagnostic manual used by mental health professionals. 

The DSM-5 identifies two subtypes of conduct disorder:

1. Childhood-Onset Type:

This subtype is characterised by the onset of conduct disorder symptoms before the age of 10. Individuals with childhood-onset conduct disorder tend to display more severe and persistent antisocial behaviours throughout adolescence and into adulthood. They are more likely to engage in physical aggression, exhibit callous and unemotional traits, and have a higher risk for developing antisocial personality disorder (American Psychiatric Association, 2013).

2. Adolescent-Onset Type:

This subtype is characterised by the onset of conduct disorder symptoms during adolescence, typically after the age of 10. Individuals with adolescent-onset conduct disorder often exhibit milder forms of antisocial behaviour and may show improvement or desistance from these behaviours as they transition into adulthood. They are less likely to have callous and unemotional traits or develop antisocial personality disorder (American Psychiatric Association, 2013).

It is important to note that conduct disorder subtypes are not strictly distinct categories, and individuals may exhibit features of both subtypes. The subtyping helps in understanding the differences in symptom onset and severity, but it is not based on specific tendencies associated with conduct disorder.

The signs and symptoms of conduct disorder

American Academy of Child and Adolescent Psychiatry (2018), posited that Children or adolescents with conduct disorder may exhibit some of the following behaviours:

1. Aggression to people and animals

1. bullies, threatens or intimidates others
2. delights in being cruel and mean to others
3. starts physical fights
4. has used a weapon that could cause serious physical harm to others (e.g. a bat, brick, broken bottle, knife or gun)
5. physically cruel to people or animals
6. steals from a victim while hurting them
7. forces someone into sexual activity
8. shows no genuine remorse after an aggressive episode

2. Destruction of Property

1. deliberately engaged in fire setting with the intention to cause damage
2. deliberately destroys other's property

3. Deceitfulness, lying, or stealing

1. has broken into someone else's building, house, or car
2. lies to obtain goods, or favours or to avoid obligations
3. steals items without confronting a victim (e.g. shoplifting (yahoo-yahoo), but without breaking and entering)

4. Serious violations of rules

1. often stays out at night despite parental objections
2. runs away from home
3. often stays away from 

Other common signs of conduct disorder include: 

1. Lack of Empathy and Remorse: 

Children and adolescents with conduct disorder often demonstrate a lack of empathy and remorse for their actions. Frick and White (2008), proposed the concept of callous-unemotional traits, which are characterised by a lack of guilt, empathy, and shallow emotions. These traits are associated with a more severe and persistent pattern of conduct disorder.

1. Peer Relationship Problems: 

Children with conduct disorder often struggle with establishing and maintaining positive peer relationships. Dodge et al. (2003), emphasised the reciprocal relationship between peer rejection and conduct problems, suggesting that these difficulties can contribute to the persistence and escalation of conduct disorder symptoms.

In Cleveland Clinic (2023), other common signs of conduct disorder include:

1. Heavy alcohol drinking and/or heavy substance use.
2. Engaging in frequent and risky sex.
3. Becoming easily frustrated.
4. Making no effort to hide their aggressive behaviours.

These behaviours must be present for at least 12 months, and the individual must meet specific age-related criteria. Additionally, the severity of the disorder can be classified as mild, moderate, or severe, depending on the number and frequency of symptoms.

Causes of conduct disorder? 

The exact causes of conduct disorder are not fully understood, but multiple factors contribute to its development. Some of the key factors include:                

• Genetic factors: Conduct disorder has been found to have a hereditary component, with studies indicating that genetics contribute to approximately 40-50% of the risk for the disorder. (Burt, 2012; Rhee & Waldman, 2002)
• Environmental factors: Adverse family environments, such as parental neglect, abuse, or inconsistent discipline, can increase the risk of developing conduct disorder. Other factors include poverty, exposure to violence, and peer influences. (Moffitt et al., 2011; Odgers et al., 2008)
• Parenting Style: Parenting practices and styles can significantly impact the development of conduct disorder. Harsh, inconsistent, and neglectful parenting has been linked to higher levels of conduct problems in children. Mumuni & Abidogun (2021) identified four parenting styles (authoritative, authoritarian, permissive, and uninvolved parenting) and highlighted the importance of authoritative parenting in reducing conduct disorder symptoms.
• Neurobiological factors: Neurodevelopmental abnormalities and deficits in certain brain regions, including the prefrontal cortex, amygdala, and anterior cingulate cortex, have been associated with conduct disorder (Fairchild et al., 2019; Marsh et al., 2008).

In Cleveland Clinic (2023), opined that causes of conduct disorder (CD), is a complex combination of genetic/biological and environmental factors.

Genetic/biological factors:

• Various studies show that certain characteristics of CD can be inherited, including antisocial behaviour, impulsivity, temperament, aggression and insensitivity to punishment.
• High testosterone levels are associated with aggression.
• Traumatic brain injury, seizures and neurological damage can contribute to aggression.

Parental, families and environmental factors:

• Parents of adolescents with CD often have engaged in substance use and antisocial behaviours. They are also frequently diagnosed with ADHD, mood disorders, schizophrenia or antisocial personality disorder.
• A home environment that lacks structure and adequate supervision with frequent conflicts between parents can lead to maladaptive behaviour in children, which can lead to CD.
• Children exposed to frequent domestic violence are more likely to develop CD.
• Living in low social and economic environments with overcrowding and unemployment leads to economic and social stress with a lack of adequate parenting. CD affects more children living in low economic environments than not.

It is important to note that conduct disorder can occur in children from high-functioning, healthy families.

A thorough assessment by a mental health professional is necessary to diagnose conduct disorder. The professional evaluate the individual's behaviour and consider the duration, frequency, and severity of symptoms. The DSM-5 criteria provide specific guidelines for making a diagnosis (American Psychiatric Association, 2013).

• The disturbance in behaviour causes clinically significant impairment in social, academic, or occupational functioning.
• If the individual is age 18 years or older. 
• Criteria are not met for Antisocial Personality Disorder (Barzman, 2017).

Effects of Conduct Disorder

The effects of conduct disorder can have significant impact on individuals, their families, and society as a whole:

1. Academic and Educational Impairment:

Conduct disorder is associated with academic difficulties and impaired educational achievement. Children with conduct disorder often struggle with impulse control, aggression, and defiance, leading to disciplinary problems at school, poor academic performance, and higher dropout rates (Baglivio et al., 2014; Kim-Cohen et al., 2005).

2. Interpersonal Problems:

Individuals with conduct disorder often have difficulty establishing and maintaining positive relationships. They may exhibit aggressive and violent behaviours, engage in bullying, manipulation, and deceit, and show a lack of empathy or remorse. These interpersonal problems can lead to social rejection, isolation, and difficulties forming healthy connections with peers, family, and authority figures (Frick et al., 2014; McMahon et al., 2010).

3. Substance Abuse and Delinquency:

Conduct disorder is strongly associated with an increased risk of substance abuse and delinquent behaviours. Research indicates that individuals with conduct disorder are more likely to engage in early and persistent substance use, including alcohol, tobacco, and illicit drugs. Moreover, they have an elevated risk of involvement in criminal activities, such as theft, vandalism, and physical aggression (Loeber et al., 2012; Pardini et al., 2014).

4. Impact on Mental Health:

Conduct disorder frequently co-occurs with other mental health disorders. Research has found high rates of comorbidity with conditions such as attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), anxiety disorders, mood disorders, and substance use disorders. These comorbidities can exacerbate the negative effects of conduct disorder and further impair functioning (Fergusson et al., 2013; Rowe et al., 2010).

5. Long-Term Outcomes:

Untreated conduct disorder can have long-term consequences into adulthood. Studies have demonstrated that individuals with conduct disorder are at an increased risk for persistent antisocial behaviours, legal problems, poor employment prospects, relationship difficulties, and a higher likelihood of developing other psychiatric disorders in adulthood (Moffitt et al., 2015; Odgers, et al., 2008).

It is important to note that the effects of conduct disorder can vary among individuals, and not everyone will experience all of these outcomes. Early intervention, appropriate treatment, and supportive environments can significantly mitigate the negative impact of conduct disorder.

Treatment Therapy:

There are numerous treatment therapies for conduct disorder which include:

• Multisystemic Therapy (MST)
• Parent management training (PMT)
• Anger management training
• Individual psychotherapy, such as cognitive behavioural therapy (CBT) or social skills training
• Functional Family therapy (FFT)
• Community-based treatment
• Solution-Focused Brief Therapy (SFBT)
• Medication
• Group Therapy
• Motivational Interviewing (MI)

It is important to note that the selection of therapy depends on the individual's specific needs, the severity of conduct disorder, and any co-occurring conditions. A comprehensive and individualized approach that combines different therapies and involves collaboration among professionals, families, and other support systems often yields the best outcomes.

Treatment Option is Parent management training (PMT) 

Overview of Parent Management Training (PMT):

Parent Management Training (PMT) is an evidence-based therapy approach that has been widely used for the treatment of conduct disorder in children and adolescents. PMT focuses on improving parenting skills and techniques to effectively manage and modify the disruptive and antisocial behaviours displayed by children with conduct disorder. 

Parent Management Training (PMT) is a structured and skills-based intervention that aims to enhance positive parenting practices, improve parent-child interactions, and reduce problem behaviours in children and adolescents with conduct disorder. It is grounded in social learning theory and behavioural principles, emphasising the role of reinforcement, modeling, and effective communication in shaping child behaviour.

PMT typically involves a series of structured sessions led by a trained therapist, where parents or caregivers learn and practice specific strategies and techniques for managing their child's behaviour. These strategies often include setting clear expectations and rules, implementing consistent consequences for behaviours, using positive reinforcement, promoting effective communication, and problem-solving (Patterson, Reid, & Dishion, 1992; Chamberlain, Leve, & DeGarmo, 2008; Thomas, & Zimmer-Gembeck, 2011). 

Patterson's Coercion Theory:

PMT is grounded in Patterson's Coercion Theory, which posits that negative parent-child interactions can contribute to the development and maintenance of conduct disorder. According to this theory, a cycle of negative interactions emerges, wherein parents inadvertently reinforce problematic behaviours by providing attention or yielding to their child's demands. The Theory describes a process of how ineffective parenting in early childhood sets the stage for adolescent antisocial behaviour later through association with deviant peers (Patterson, 1982).

Efficacy of PMT:

Numerous research studies have demonstrated the effectiveness of PMT in reducing conduct disorder symptoms and improving parenting skills. Evidence suggests that PMT can lead to positive outcomes in terms of reduced aggression, improved social skills, and decreased conduct disorder symptoms in children (Kaminski, Valle, Filene, & Boyle, 2008).

PMT has been extensively studied and has demonstrated effectiveness in reducing conduct problems and improving parent-child interactions. Here are a few key studies supporting the efficacy of PMT:

a. The Oregon Model of Parent Management Training (OM-PMT):

The Oregon Model of Parent Management Training (OM-PMT) is a well-known and widely used PMT program. One seminal study conducted by Patterson and colleagues in 1992 examined the efficacy of OM-PMT in reducing antisocial behaviour in children with conduct disorder. The study found that compared to a control group, children whose parents received OM-PMT showed significant improvements in conduct problems and social competence. (Patterson, Reid, & Dishion, 1992).

The Oregon Model of PMT, developed by Patterson and colleagues, is one of the most widely used and researched approaches within the field.OM- PMT focuses on teaching parents specific skills, such as effective communication, positive reinforcement, consistent discipline, and problem-solving. The model employs a structured and manualised approach to therapy, ensuring consistency and fidelity in its implementation (Forgatch, & Patterson, 2010).

b. Parent-Child Interaction Therapy (PCIT):

Parent-Child Interaction Therapy (PCIT) is a form of PMT that specifically focuses on improving parent-child interactions through live coaching and feedback. A meta-analysis conducted by Thomas and Zimmer-Gembeck (2011) examined the effectiveness of PCIT for children with conduct problems. The analysis found that PCIT led to significant improvements in child behaviour and reduced parental stress.

c. Treatment Foster Care Oregon (TFCO):

Treatment Foster Care Oregon (TFCO) is another variant of PMT that incorporates parenting strategies within a foster care setting. A randomized controlled trial conducted by Chamberlain and colleagues (2008) compared the effectiveness of TFCO with traditional foster care for children with conduct problems. The study found that children in TFCO showed greater reductions in delinquency and externalizing behaviours compared to those in traditional foster care.

Adaptations and Variations of PMT: 

PMT has been adapted and modified to suit the needs of different populations and contexts. For example, culturally sensitive PMT programs have been developed for specific cultural groups. Some variations of PMT include group-based formats, online programs, and interventions that target specific age groups (e.g., preschoolers, adolescents) (Lundahl, Risser, & Lovejoy, 2006).

Principles of PMT

Eyberg, Nelson, & Boggs, (2008), affirmed Core Principles of Parent Management Training (PMT) as follows:

1. Positive Parenting: PMT emphasizes the use of positive reinforcement, praise, and rewards to promote desired behaviours in children.
2. Consistent Discipline: PMT encourages parents to establish clear and consistent rules, expectations, and consequences for their child's behaviour.
3. Effective Communication: PMT emphasizes effective communication skills, including active listening and assertive communication, to promote understanding and cooperation between parents and children.
4. Problem-Solving Skills: PMT helps parents develop problem-solving skills to address challenging behaviours and conflicts with their child in a constructive manner.

Techniques of PMT

In the view of Kazdin, (2005); Webster-Stratton, & Hancock, (2014); Webster-Stratton, (2016), Techniques Used in Parent Management Training (PMT) are:

1. Building Rapport and Trust: Establishing a strong therapeutic alliance is crucial. The counsellor should create a safe and nonjudgmental space where the individual feels comfortable sharing their thoughts, feelings, and experiences. Building rapport and trust helps facilitate engagement and collaboration in the counselling process.
2. Behaviour Reinforcement: Parents are taught to identify and reinforce positive behaviours through praise, rewards, and privileges, which encourages the child to repeat those behaviours.
3. Time-Out: Time-out is a technique used to remove the child temporarily from reinforcing situations when they display disruptive or inappropriate behaviour.
4. Token Economy: Token economy systems involve using tokens or points as rewards that can be exchanged for desired privileges or items. This technique helps motivate positive behaviour.
5. Effective Commands: Parents learn to give clear, concise, and specific commands to their child, increasing the likelihood of compliance.
6. Differential Attention: This technique involves selectively attending to positive behaviorus while ignoring minor misbehaviors, thereby promoting positive behaviour and reducing attention-seeking behaviours.

Counselling Implications for conduct disorder:

1. Assessment and Diagnosis: Thorough assessment and accurate diagnosis are crucial. Conduct disorder should be diagnosed based on the criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Conducting a comprehensive assessment helps determine the severity, specific behaviours, co-occurring conditions, and underlying factors contributing to conduct disorder.

2. Individualized Treatment Planning: Each individual with conduct disorder may have unique needs and circumstances. It is essential to develop an individualized treatment plan that considers the person's strengths, challenges, developmental stage, and cultural background. Tailoring interventions to the specific needs of the individual can enhance the effectiveness of counselling.

3. Collaboration and Multidisciplinary Approach: Given the complexity of conduct disorder, collaboration with other professionals, such as psychiatrists, educators, and social workers, may be necessary. A multidisciplinary approach allows for a comprehensive assessment, integrated treatment planning, and coordination of care across different settings.

4. Focus on Skill-Building and Emotional Regulation: Counselling should aim to develop and strengthen adaptive skills, including problem-solving, communication, emotion regulation, and impulse control. Teaching individuals with conduct disorder effective strategies to manage anger, frustration, and impulsivity can be particularly beneficial.

5. Family Involvement and Parent Support: Involving the family is vital, as the family environment significantly influences conduct disorder. Providing support and education to parents or caregivers can help improve parenting skills, establish consistent discipline strategies, and promote positive family dynamics. Family therapy can address family conflicts, enhance communication, and strengthen the caregiver-child relationship.

6. Addressing Co-occurring Issues: Conduct disorder often co-occurs with other mental health conditions such as ADHD, oppositional defiant disorder (ODD), or mood disorders. Counselling should address any co-occurring issues and consider integrated treatment approaches to address the complex needs of the individual.

Individuals with conduct disorder often display a disregard for the rights of others and violate societal norms and rules. This disorder can have significant negative impacts on the individual's social, academic, and occupational functioning. It is important to note that conduct disorder are influenced by a complex interaction of multiple factors, and individual cases may vary. Warning signs indicate an increased risk, and a comprehensive evaluation by a qualified mental health professional is necessary for an accurate diagnosis. Thus, the treatment should be individualized, and a comprehensive assessment by a mental health professional is necessary to determine the most appropriate therapeutic approach.

This case study was referred to counselling psychologist by Clinical psychologist have been diagnosed with both Attention-Deficit/Hyperactivity Disorder (ADHD) and Oppositional Defiant Disorder (ODD), to provide counselling service to the parent on strategies needed to help the son.

Title: Parent Management Training (PMT) for a Child with ADHD and ODD

Introduction:

This case study explores the application of Parent Management Training (PMT) as a treatment approach for a child diagnosed with both Attention-Deficit/Hyperactivity Disorder (ADHD) and Oppositional Defiant Disorder (ODD). The focus of the treatment is on empowering the parent, Mrs. Johnson, with effective parenting strategies to manage her son's behaviour and improve their parent-child relationship.

Client Information:

Name: Mrs. Johnson

Age: 49

Occupation: consultant

Child's Name: Adam

Age: 9

Diagnoses: ADHD, ODD

Presenting Concerns:

Mrs. Johnson sought counselling services due to ongoing challenges with Adam's behavior. Adam has been diagnosed with ADHD, characterised by hyperactivity, impulsivity, and difficulty following instructions. Additionally, he exhibits symptoms of ODD, including defiance, argumentativeness, and difficulty accepting authority figures.

Assessment and Treatment Planning:

Upon initial assessment, it was evident that the disruptive behaviours were causing significant stress for the family. The treatment plan involved using Parent Management Training (PMT) to address specific behaviours associated with ADHD and ODD. The primary goals are to improve Adam's behaviour, strengthen the parent-child relationship, and enhance Mrs. Johnson's parenting skills.

Treatment Implementation:

As counsellor will work with Mrs. Johnson to implement the following PMT strategies:

1. Setting Clear Expectations: creating clear and simple house rules. Explain the reasons behind each rule, fostering a sense of ownership and understanding.
2. Positive Reinforcement: To encourage positive behaviour, provided immediate praise and rewards when follow the rules or demonstrated appropriate conduct.
3. Planned Ignoring: Parent learn to avoid engaging in arguments and power struggles when child became defiant or argumentative. Instead, parent should practice planned ignoring and remained calm.
4. Consistent Consequences: For non-compliance, Parent should implement predetermined consequences, such as brief time-outs or loss of privileges.
5. Structured Routine: Parent should introduce a structured daily routine for child, breaking tasks into manageable steps and incorporating regular breaks for physical activities.
6. Designated Calming Space: parent should create a designated quiet space for child to go when feeling overwhelmed or agitated, promoting self-regulation.

Therefore, Parent Management Training (PMT) will prove to be an effective treatment approach for managing the behaviour of a child with ADHD and ODD. By empowering Parent with practical parenting strategies, it will facilitate positive changes in child's conduct and fostered a healthier family dynamic.