Management

One-time interventions affecting a single domain will be ineffective in treating CD. Interventions need to target all affected domains in a naturalistic setting for a long period in a consistent manner. Family interventions (parenting training/guidance, functional family therapy) and social skill training with a behavioral approach seem to be the most effective treatments for the CD patient (Dillon et al., 2007, Steiner, 1997). The focus should be on the child and the family. Individual therapy that focuses on problem-solving skills can also be useful. An environment with consistent rules and consequences is helpful. Proper school placement using behavioral techniques to encourage prosocial behavior and discourage antisocial incidents is appropriate.

Factors that can cause a cognitive-behavioral treatment program to fail include the following: the situation is "too hot to handle"; the youth is "too brittle"; the parents covertly support the youth's behavior; the parents have given up on the youth; the parents are inconsistent and are unable to supervise adequately; the program is poorly designed; rewards are too costly; or the parents have little social support. Factors that can interfere with limit setting of the child or adolescent at home include parental conflict, parental absence, parental psychiatric illness, inconsistent discipline, and vague or minimal expectations regarding appropriate behavior.

Several legal options are available if parents are unable to control their children. Most state laws have a special status that can be petitioned by the county district attorney to the juvenile court judge (i.e., Child/Person in Need of Care laws), that can allow the court to supervise the child by having hearings, placing a child on probation, mandating treatment and monitoring, or eventually taking the child away from the parents and placing the child in a residential treatment facility. However, some dangers must be kept in mind when teenagers with CD are confined to a juvenile detention facility. These patients prefer to be unrestricted and active; they can become depressed and at risk for impulsively attempting suicide when placed in confinement. Inpatient psychiatric hospitalization can be used to assess and initiate treatment for comorbid psychiatric disorders. A homicidal or suicidal patient can be stabilized and then moved to a less restrictive long-term setting. However, the stay is usually too brief to effectively treat CD itself.

Medications used as the sole treatment for conduct disorder have not been demonstrated to be effective. Psychoactive medications are used for the treatment of concurrent psychiatric disorders and concurrent target symptoms (aggression, impulsiveness, mood instability). Some of these medications are lithium, antidepressants, carbamazepine, pro-pranolol, stimulants, clonidine, and antipsychotics (usually haloperidol). The physician should be cautious when prescribing medication to a youth with CD. Medication can be "cheeked," sold or traded, hoarded, and taken all at once in an impulsive suicide attempt.

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