Application of Cognitive Behavioural Therapy for Conduct Disorder in Children

Full text

*Corresponding Author: MUSAH, Ebikabowei Page 8
Global Scientific and Academic Research Journal of Education and literature.
ISSN: XXXX-XXXX (Online)
Frequency: Monthly
Published By GSAR Publishers
Journal Homepage Link- https://gsarpublishers.com/gsarjel-home-page/
Application of Cognitive Behavioural Therapy for Conduct Disorder in Children
By
MUSAH, Ebikabowei
Government Model Secondary School, Ekeremor, Bayelsa State, Nigeria
Abstract
This library-based paper discusses the need to utilize cognitive behavioural therapy for the treatment of conduct disorder
in children. The increasing rate of conduct disorder among young children in our society today is a source of great
concern for parents and other significant persons that are saddled with the responsibility of child upbringing. Cognitive
behavioural therapy has been discovered by scholars to be a good psychological technique for addressing children and
adolescent behavioural problems. It is on this premise that this paper attempts, at least in part, to fill the vacuum of the
dearth of literature concerning this issue in this part of the world
Keywords: Application, behaviour, cognitive, therapy, conduct disorder, children.
Introduction
Human development is a natural process. The development
process is activated so long as there is some measure of
nourishment for an individual. Also, the nature-nurture
interaction of an individual with their environment is a major
factor and determinant of a certain level of attainment to
which an individual can grow and develop. Moreover, every
phase of an individual‟s growth process has inherent and
peculiar problems. In this regard, children too are no
exception. Children are inexperienced and do not have any
knowledge about self-control or adjustment. That is why,
without an adequate adult or parental care, children
unknowingly derail from the path of life that would benefit
them to the road of self-destruction. Conduct disorder is one
of the problems of children today. It is a dangerous antisocial
behaviour with the potential to destroy the future of children if
an appropriate remedial measure is not instituted to arrest the
problem in time. From the available literature, cognitive
behavioural therapy has been shown to be an effective clinical
tool for treating many psychological disorders and behaviour
problems in children. It is upon the basis that this paper
attempts to highlight the need to adapt cognitive behavioural
therapy for the treatment of conduct disorder in children, with
a discussion on practical applications. Before the main
discourse, however, it is imperative to clarify the basic
concepts discussed in this paper.
Clarification of concepts
Cognitive behavioural therapy
The term cognitive behavioural therapy (CBT) describes a
group of techniques that are used to treat psychological
distress and maladaptive behaviours by changing cognitions
and behaviour. It is about a hybrid of strategies to facilitate
cognitive, behavioural, emotional and social change.
Examples of interventions include social skills training
through role-play, problem-solving techniques, coping skills,
and examining alternative ways of perception and engagement
in verbally mediated self-control.
Available literature provides support for CBT as an effective
intervention for many adolescent and adult problems.
However, there is limited literature on how CBT can be
utilized for children with conduct disorder (CD). This paper,
therefore, attempts to (at least in part) look at how CBT can
be adapted for children with conduct disorder, by focusing on
practical applications.
What is Conduct Disorder?
Conduct disorder refers to a repetitive and persistent pattern
of behaviour in children whereby the rights of others or basic
social rules are frequently violated. A child with conduct
disorder usually exhibits such behaviour patterns in a variety
of settings – at home, at school and in other social situations –
and they cause significant impairment to the child‟s social,
academic and family functioning (Walter & DeMaso, 2020).
The American Psychiatric Association (2013) sees conduct
disorder (CD) as symptoms consisting of aggressive conduct
that threatens physical harm to other people or animals, or
non-aggressive conduct that causes property loss or damage,
deceitfulness, theft and serious violation of rules. It is a
repetitive and persistent pattern of behaviour which violates
Article History
Received: 05/05/2022
Accepted: 08/05/2022
Published:
11/05/2022
Vol – 1 Issue – 1
PP: - 8-12

*Corresponding Author: MUSAH, Ebikabowei Page 9
societal norms or the basic rights of others. Children with CD
tend to be impulsive, hard to control and not concerned about
the feelings of other people (Choo, 2014; AACAP, 2018).
Signs and Symptoms of Conduct Disorder
The behavioural characteristics of conduct disorder, according
to Bhandari (2020) and Kivi (2022) include:
 Aggressive behaviour that causes or threatens harm
to other people or animals such as bullying or
intimidating others, often initiates physical cruelty,
to animals.
 Non-aggressive conduct that causes property loss or
damage such as arson or deliberate destruction of
others‟ property.
 Deceitfulness or theft, such as breaking into
someone‟s house or car, lying or „conning others‟.
 Serious rule violations, such as staying out at night
when prohibited, running away from home
overnight, or often being truant from school.
It is also said that many children with conduct disorder may
have trouble feeling and expressing empathy or remorse and
reading social cues. These children often misinterpret the
actions of others as being hostile or aggressive and respond by
escalating the situation into a conflict. Conduct disorder may
also be associated with other difficulties such as substance
use, risk-taking behaviours, school problems and physical
injury from accidents or fights (Pisano et al, 2017; Stanford
Children‟s Health, 2010).
Frequency or How Common is Conduct Disorder?
Conduct disorder is more common among boys than girls,
with studies indicating that the rate among boys in the general
population ranges from 6% to 16%. It can have its onset early
before age 10, or in adolescence. Children who display early
onset of conduct disorder are at greater risk for persistent
difficulties, however, and they are also more likely to have
troubled peer relationships and academic problems. Moreover,
among boys and girls, conduct disorder is one of the disorders
most frequently diagnosed in mental health settings
(American Psychiatric Association, 2013).
Causes of Conduct Disorder
Conduct disorder can occur in children of all ages but more
often starts early in life. The exact cause of this disorder is not
known but there are a lot of factors that make it very likely to
develop. These are a combination of a child‟s inherited traits
and their environment (popularly called „nature and nurture‟)
(Conduct Disorder, nd; Kliegman, 2020), including:
 A difficult temperament
 Learning or reading difficulties
 Depression
 A history of being bullied or abused/lack of parental
warmth
 Hyperactivity
 Ineffective, inconsistent and/or harsh discipline
 Lack of supervision or parental neglect as well as
parental aggression
 Limitations or developmental delays in child‟s
ability to process their thoughts and feelings
(Kliegman, 2020).
Assessment and Diagnosis of Conduct Disorder
Children with suspected conduct disorder should first be taken
to the doctor to perform a physical examination and have a
complete medical history. Although there is no specific test to
diagnose conduct disorder, the doctor may suggest a blood
test or x-ray rule out illness or any side effects from
medication. If conduct disorder is still suspected, the doctor
may refer the child to a psychiatrist or a psychologist who will
use a variety of interviews and other assessment tools to make
a diagnosis.
Any diagnosis must be made in consultation with the child‟s
family. The assessment process should include observation of
the child, discussion with the child and family, the use of
standardized test instruments or structured diagnostic
interviews and history-taking, including a complete medical
and family/social history. When assessing and diagnosing any
childhood emotions or behaviour, the therapist should
consider the social and economic context in which the child‟s
behaviour occurs. Accurate assessment and appropriate
individualized treatment will ensure that the child will be
equipped to navigate the developmental milestones of
childhood and make a successful transition into adulthood.
Therapy must be provided in the minimum restrictive setting
possible (Conduct Disorder, nd; Murphy et al, 2010; Pisano et
al, 2017).
Prevention of Conduct Disorder
Although it might not be possible to prevent conduct disorder,
many of the problems associated with the condition can be
minimized with early treatment. The provision of a nurturing,
supportive and consistent home environment with a balance of
love and discipline can also help to reduce symptoms and
sometimes prevent episodes of difficult behaviour (Lillig,
2018).
Treatment of Conduct Disorder in Children
Children are different from adults in many ways. But the
primary difference is that the younger person does not have so
much actual control of their life as an adult does. Treatment of
a child must therefore be different from that of an adult.
Cognitive behavioural therapy is a scientifically proven
method of treatment that has the potential to work effectively
for children in the treatment of conduct disorders. It is most
often used for children with behaviour problems and is aimed
at breaking the circle of emotion – thought – behaviour that is
assumed to cause most of the symptoms that the therapy is
intended to eliminate. The idea behind it is that a child feels
an emotion which leads to a thought that is not comfortable
which in turn leads to a behaviour that makes the feeling
better. But the feeling is then affected by the behaviour so that
it leads to another uncomfortable thought which also leads to
yet another feeling and so on (Benjamin et al, 2011).
Cognitive behavioural therapy functions by changing thought
into a more realistic and helpful one, thus breaking the
negative emotional circle. It also assists to improve a child‟s

*Corresponding Author: MUSAH, Ebikabowei Page 10
problem-solving skills, anger management and impulse
control. Conduct disorder may be treated successfully if
diagnosed early enough. Many children with more severe and
frequent symptoms can go on to develop personality disorders
as adults or drug use and legal problems. Other possible
complications of conduct disorder are a tendency towards
violence and suicidal feelings (Dobson & Dobson, 2018).
Cognitive Behavioural Therapy in Practice
In utilizing cognitive behavioural therapy with children, it is
better to use enactive, performance-based procedures as well
as cognitive interventions to produce desired changes in
thinking, feeling and behaviour. Cognitive behavioural
therapy typically involves examining individual appraisal and
beliefs about events and then finding alternatives, with the
aim of altering the resultant feeling and behaviour. When in a
therapeutic involvement with children, their cognitive
development should be put into adequate consideration and
adaptations to be made in spacing the content and speed of
therapy. The therapist should equally have in their mind the
child‟s limitations in meta-cognition and aptitude in labelling
feelings. With younger children, the therapist has to be more
active and make use of a higher proportion of behavioural, as
compared to cognitive strategies.
The decision to use cognitive behavioural therapy with a child
should be made after a clinical assessment which gathers
information about the child‟s emotions, behaviours,
relationships, family, school and friendships. This may
provide the therapist with examples of the way the child
thinks and feels. CBT tends to be delivered in a series of
sessions, usually between eight and twelve with increasing
intervals between sessions to allow new techniques to be
practised or explored. Sessions should be tailored to the
child‟s ability and may have to be short. CBT sessions should
usually begin with the setting of agenda around a mutually
agreed problem list, the therapist may then move on to review
homework tasks about recent events, or learn and practise new
cognitive or behavioural strategies or techniques. The chosen
technique should take into consideration the child‟s capacity
for memory, literacy, self-evaluation, empathy and self-
control.
The sessions may include the use of frequent summaries with
feedback from the child, diagrams in thinking and
communicating formulations, emotional recognition by self-
monitoring to make links between events, mood and thoughts;
activity-scheduling, and affect-enhancing activities for self-
reinforcers, cognitive restructuring and coping skills training.
Other strategies include coping self-talk, reframing of
problems and role-plays. Some approaches should be offered
to the child in the form of an experiment to encourage the
child to try new strategies, or to encourage them to use „self-
statements‟ such as „„this is a bit scary but it‟s okay‟‟
(Lorenzo-Luaces et al, 2016; McHugh et al, 2010; Kaminski
& Claussen, 2017).
Engaging the Child
It is important for the therapist to engage the child and create
an active collaborative working alliance to enable them to
implement the therapy effectively. In cognitive behavioural
therapy, the explicit aims, agenda and collaborative approach
may help the initial engagement. The therapist may use the
child‟s feelings and thoughts about being in the session to
commence explorations of the child‟s perceptions of themself
and their world. The process of cognitive behavioural therapy
models a facilitating relationship with an adult. This may be
particularly important for children who have previously had
poor quality relationships with adults. Attractive published
material may be used or individual tailor-made charts may
also be prepared for use. The therapist also has a role to
increase the child‟s motivation, for instance, by using
supportive phrases like, „‟well done, even though it‟s difficult,
I can see how hard you tried‟‟ (Benjamin et al, 2011).
Overcoming Developmental Limitations
In the opinion of Choo (2014), cognitive behavioural therapy
requires a minimum level of cognitive skills and is most
suitable for those in mid-childhood or older. It requires
linguistic and cognitive skills to assess situations and verbal
reasoning as well as memory to choose the most appropriate
cause of action. In this regard, Zettle & Hayes (2015) believes
cognitive behavioural therapy should take place in the context
of the child‟s level of cognitive development. Therapists need
an understanding of the child‟s psychological and cognitive
functioning. In general, children acquire a more mature style
of self-control, self-evaluation and emotional recognition in
middle childhood. While a bright adolescent‟s grasp of
unmodified adult-type CBT programmes can be rewarding,
younger children may find programmes such as thought
diaries, beyond them, unless they are suitably modified. Many
techniques involve the use of written materials such as
information sheets and worksheets. These techniques need to
be adapted to the child‟s level of cognitive development
(Zettle & Hayes, 2015). In another development, Hofman et al
(2010) proffer that before therapy properly begins, the child
benefits from emotional education, during which they learn to
distinguish different emotional states and link emotions with
thoughts and events. The use of developmentally appropriate
tasks for the child will encourage healthy cognitive
development of them. However, developmental limitations
remain for a child in working with higher-order abstractions
such as reflecting on hypotheses and evaluating evidence for
and against a belief which may not develop till middle
adolescence.
It has been revealed that mental handicap does not preclude
the use of CBT. As a matter of fact, CBT techniques have
been discovered to be effective in the control of conduct
disorder for people with learning disabilities. Kaminski &
Claussen (2017) and Dobson & Dobson (2018) revealed that
non-cognitive procedures are easy‟‟ to minimize the number
of decisions to be made. Information could be presented
visually to make abstract concepts more concrete, such as
using a traffic light to prompt problem-solving and using a
thermometer to measure arousal. The therapist could also
provide increased prompts to generate possible solutions and
use more contextualized and specific perspectives to discuss
the usage of specific CBT techniques.

*Corresponding Author: MUSAH, Ebikabowei Page 11
Cognitive Behavioural Therapy as a Multi-modal
Approach
It is important that the therapist be aware of the family
structure, the systematic implications of any intervention and
psychosocial factors such as the history of abuse or learning
disabilities that may impact on assessment and therapy with
children. Including support from the child‟s school and
engaging their parents is often useful when dealing with
children. Parents' training can reinforce therapeutic
achievement for the children. Similarly, parents can be
educated on the CBT techniques used with their child and
encouraged to offer positive feedback to them when they try
to attempt it at home. With a broad CBT approach, a psycho-
educational element of information-giving by discussions,
supplemented by fact sheets is important. This is likely to
increase compliance and is often appreciated by the child,
family, school and referrer (Choo, 2014; Zettle & Hayes,
2018; Benjamin et al, 2011).
In the therapeutic work, therefore, CBT should be adapted for
children as the content of their cognition is different from that
of an adult. Likewise, for children with cognitive deficits and
deficits in social skills and problem-solving, which are often
concurrent with conduct disorder, an application of adapted
CBT techniques be used to suit their needs (Mancebo et al,
2011; Choo, 2014; Wenzel, 2017).
Conclusion
For conduct disorder, CBT is very useful as a multi-modal
approach with involvement from the parents and school.
Parents may need specific instructions in management
techniques, for example, in using positive reinforcement for
compliance with the child with conduct disorder. Operant
conditioning techniques rewarding pro-social behaviours and
discouraging anti-social behaviours should be supplemented
with instructions, discussions, modelling strategies, rehearsal,
prompting and feedback. Social skills training is used often
and may include emotional education, self-monitoring of
feelings and behaviours, self-instructions, self-reinforcements,
social perspective-taking, and using vignettes to enable the
child to understand the intentions of others in social situations,
and problem-solving. Children with conduct disorder tend to
attribute hostility to others and underestimate their own
aggression in any conflict. They value aggression as effective
in problem-solving and enhancing their self-esteem
(American Psychiatric Association, 2013). Examples of
effective CBT programmes for children should include anger
management strategies to help them identify their aggressive
behaviours and the conditions that provoke and sustain them
and to reinforce the use of effective techniques to manage
their anger.
In conclusion, therefore, this paper supports existing literature
on the importance of adapting CBT for children. It contributes
to existing knowledge by highlighting how CBT can be
modified for use with children as a multimodal approach to
treating children‟s conduct disorders.
of relaxation and monitoring have been found to be
particularly effective with challenging behaviours. According
to them, for children with learning disabilities, the language
used could be modified, the training could be done over a
longer period, and the self-instruction could be narrowed
down to a general one such as „‟take it
References
1. American Academy of Child and Adolescent
Psychiatry (AACAP). (2018). Conduct disorder.
Author.
2. American Psychiatric Association. (2013).
Diagnostic and statistical manual of mental
disorders (5th ed). Author.
3. Benjamin, C. L., Puleo, C. M., Settipani, C. A.,
Edmunds, J. M., Cummings, C. M. & Kendall, P. C.
(2011). History of cognitive-behavioural therapy in
youth. Child and Adolescent Psychiatric Clinics,
Vol. 20 (2), 179-189.
4. Bhandari, S. (2020). Mental health and conduct
disorder. Retrieved from www.webmd.com
5. Choo, C. (2014). Adapting CBT for children and
adolescents with complex symptoms of
neurodevelopmental disorders and conduct
disorders. Journal of Psychological Abnormalities
in Children, 3, 199-124.
6. Dobson, D. & Dobson, K. S. (2018). Evidenced-
based practice of cognitive-behavioural therapy
(2nd). The Guilford Press.
7. Hofmann, S. G., Sawyer, A.T. & Fang, A. (2010).
The empirical status of the “New wave” of
cognitive behavioural therapy. Psychiatric Clinics,
Vol.33 (3), 701-710.
8. Kaminski, J.W. & Claussen, A.H. (2017).
Evidenced-based update of psychosocial treatments
for disruptive behaviours in children. Journal of
Clinical Child and Adolescent Psychology, 46 (4),
477-499.
9. Kivi, R. (2022). Conduct disorder. Retrieved from
www.healthline.com
10. Lillig, M. (2018). Conduct disorder: Recognition
and management. American Family Physician, 98
(10), 584-592.
11. Lorenz-Luaces, L., Keefe, J.R. & DeRubeis, J.R.
(2016). Cognitive behavioural therapy: Nature and
relationship to non-cognitive behavioural therapy.
Behaviour Therapy, 47 (6), 785-803.
12. Mancebo, M.C., Eisen, J.L., Sibrava, N.J., Dyck,
I.R. & Rasmussen, S.A. (2011). Patient utilization
of cognitive behavioural for OCD. Behaviour
Therapy, 42 (3), 399-412.
13. McHugh, R.K., Hearon, B.A. & Otto, M.W. (2010).
Cognitive behavioural therapy for substance use
disorders. Psychiatric Clinics, Vol.33 (3), 511-525.

*Corresponding Author: MUSAH, Ebikabowei Page 12
14. Murrihy, R.C., Kidman, A.D. & Ollendick, T.H.
(eds) (2010). Clinical handbook of assessing and
treating conduct problems in youth. Springer.
15. Pisano, S., Muratori, P. & Gorga, C. (2017).
Conduct disorders and psychopathy in children and
adolescents: aetiology, clinical presentation and
treatment strategies of callous-unemotional traits.
Italian Journal of Pediatrics, 43 (1), 84-93.
16. Stanford Children‟s Health. (2010). Conduct
disorder in children. Retrieved from
www.stanfordchildrens.org
17. Walter, H.J. & DeMaso, D.R. (2020). Disruptive,
impulse-control and conduct disorders. In R.M.
Kliegman (ed). Nelson textbook of pediatrics.
Elsevier.
18. Wenzel, A. (2017). Basic strategies of CBT.
Psychiatric Clinics, 40 (4), 597-609.