Conduct Disorder

Conduct disorder (CD) is a broad and overarching term describing a condition in which a child or young person persistently engages in antisocial behavior that violates the rights of others, such as fighting, using a weapon, physical cruelty to people or animals, running away from home, and stealing with the use of force. CD has sometimes been defined separately from oppositional defiant disorder (ODD), which is a less serious variant typically seen in younger children and involving high levels of irritable mood, temper tantrums, and refusal to carry out instructions. CD and ODD are the most common mental health disorders in childhood and adolescence and the most common reasons for referral to child and adolescent mental health services in the Western world

Early intervention to prevent lifelong consequences of childhood antisocial behaviour and social exclusion

Book chapter. No Abstract available

The management of antisocial behaviour in childhood

Antisocial behaviour is the most common reason for referral to child mental health services (National Institute for Health and Care Excellence, 2013). It is a clinical problem of considerable importance, because there is a marked tendency for it to persist, and the long-term outcome includes antisocial personality disorder and criminality. Longitudinal studies have shown that children with conduct disorder at the age of 7 are ten times more likely to be criminals in adulthood (Fergusson et al, 2005). Effective treatments are now available, although not yet widely used in the UK. We use the term ‘antisocial behaviour’ to include children who do not necessarily meet the strict definitions of conduct disorder or oppositional defiant disorder, for which DSM-5 (American Psychiatric Association, 2013) and ICD-10 (World Health Organization, 1993) have quite similar diagnostic criteria. For both schemes, the diagnosis of conduct disorder requires a repetitive and persistent pattern of behaviour in which the basic rights of others or major age-appropriate social norms are violated. DSM-5 stresses that the disturbance must cause clinically significant impairment in social, occupational or academic functioning, which is implicit in ICD-10. DSM-5 requires that three of the symptoms/behaviours in Box 5.1 be present during the preceding 12 months and one during the preceding 6 months, whereas ICD-10 merely specifies that three symptoms must be present, but requires one symptom to have been present within the previous month. For oppositional defiant disorder, both DSM-5 and ICD-10 require four symptoms/behaviours from the list in Box 5.2 to have been present for the preceding six months. Although DSM-5 views oppositional defiant disorder as a common precedent to conduct disorder, ICD-10 regards it as a milder form of conduct disorder, and stipulates that no more than two of the symptoms in Box 5.1 should be present. The one major change from DSM-IV (American Psychiatric Association, 1994) to DSM-5 is the inclusion of a specifier to designate youths ‘with limited prosocial emotions’ (American Psychiatric Association, 2013). To meet this criterion, individuals must show two or more characteristics of callous-unemotional traits, such as shallow affect, lack of empathy, lack of remorse or guilt, or lack of concern about their performance at school or work during the preceding 12 months

Sensitivity to parenting in adolescents with callous/unemotional traits: Observational and experimental findings

Children and adolescents with callous-unemotional (CU) traits have been distinguished as a subset of individuals with disruptive behavioral disorders who may be less sensitive to parenting influence; we test this hypothesis using multiple methods and assessment paradigms. Two hundred seventy-one adolescents (mean age 12.6 years) from 3 samples at elevated risk for disruptive behavior disorders were studied. Symptoms of CU behavior were derived from standard questionnaire; assessments of behavioral adjustment were derived from clinical interview with parent, and parent-report, teacher-report, and self-report questionnaire. Parent–child relationship quality was based on observational assessments in which adolescent and parent behaviors were rated in 3 interaction tasks: (a) low conflict planning task; (b) problem-solving conflict task; (c) puzzle challenge task; parent interview and parent-report and child-report questionnaires of parenting were also assessed. Results indicated that the associations between parent–child relationship quality and behavioral adjustment were comparable in adolescents with and without CU traits. More notably, observational data indicated that adolescents with elevated CU traits showed comparatively greater within-individual variability in observed angry/irritable behavior across interaction tasks, suggesting greater sensitivity to and emotional dysregulation in challenging interpersonal contexts. The findings suggest that adolescents with CU are not less sensitive to parental influence and may in contrast show greater context-sensitive disturbances in emotional regulation. The results have implications for family-based assessment and treatment for adolescents with disruptive behavior disorders

Use of miltefosine in the treatment of visceral leishmaniasis in children at a tertiary care hospital of Karachi

Existing standard treatment options for visceral leishmaniasis are less than optimal. We report here the use of oral miltefosine in the treatment of two paediatric cases of visceral leishmaniasis at a tertiary care hospital in Karachi, Pakistan. One patient came from Balochistan while the second patient was from Northern Pakistan. Both presented with a prolonged history of fever, massive hepatosplenomegaly, anaemia and thrombocytopenia. Visceral leishmaniasis was diagnosed with bone marrow studies. Amphotericin B was first started in the first patient; however severe hypokalaemia and allergic reaction occurred. Oral miltefosine was then administered. The child showed clinical improvement with regards to signs of leishmania infection but succumbed to a nosocomial infection during the hospital stay. In the second patient, miltefosine was started in the first instance. He showed remarkable clinical improvement. At 2 months follow-up, the child showed adequate weight gain along with successful resolution of hepatosplenomegaly and fever. Miltefosine has the potential to be considered a first line therapy for visceral leishmaniasis in developing countries; however larger studies are warranted to validate the trends observed in this small case series

Functional family therapy-gangs for young people at risk of child criminal exploitation and county lines involvement: feasibility and pilot study

Executive Summary The project Functional Family Therapy Gangs (FFT-G) is an intensive, home-based, family therapy programme for the families of young people with severe behavioural challenges. It aims to improve the safety, wellbeing and stability of children and families and reduce offending. Developed by FFT LLC, the programme in this project was delivered by Family Psychology Mutual (FPM) and targeted at 10-17 year olds at risk of involvement in County Lines Drug Networks or child criminal exploitation. Trained family therapists provided a bespoke number of therapy sessions to families over three to five months, beginning with an Engagement and Motivation phase to secure participation. This was followed by a Behaviour Change phase to teach new skills designed to interrupt problematic relational patterns, before a Generalisation phase asked families to practise the skills they had learned in other contexts (such as in school, in the community or in relationships with other professionals). Which family members were involved depended on who was regarded as important to the problem being addressed. In the early stages, contact was provided to families several times a week, with home visits lasting 60-90 minutes; in later stages of the intervention, contact was reduced to weekly. The YEF funded a feasibility and pilot study of FFT-G. The feasibility study aimed to ascertain how feasible a randomised controlled trial (RCT) of the programme would be, exploring whether caseworkers would refer young people to an RCT, analysing what the most productive referral pathways were and evaluating whether enough referrals would be received to ensure adequate therapist caseloads. These questions were explored using 19 interviews with key professionals, organisational data gathering and a document review, and the intervention was delivered to 48 families in the London Borough of Redbridge (LBR). The Family Intervention Team (FIT), part of specialist services for vulnerable children within social care, referred young people to the programme. The feasibility study was delivered between October 2019 and March 2021. The pilot study then aimed to explore how many families were eligible for FFT-G; analyse the barriers to and implementation of trial recruitment; and examine a range of questions relating to the design of a potential future large-scale RCT (such as how many families can be randomised and how often, the rates of missing data at baseline testing, attrition rates and the effect sizes associated with the intervention). These questions were explored via the delivery of a pilot RCT, again delivered in LBR. Twenty-three young people’s families received the intervention, while 22 received services as usual (SAU). Nine interviews were also conducted with families. The pilot took place between March 2021 and July 2021. Both the feasibility and pilot studies were impacted by the COVID-19 pandemic, requiring both the delivery and evaluation teams to adapt to challenging circumstances. In the feasibility study, FFT-G received a reasonable number of referrals (100 over 13 months), although this was lower than anticipated by therapists. The evaluator deemed completion rates to be adequate; where treatment data were collected, 61% of families enrolled completed the treatment. The pilot study found that 95 families were identified over nine months in LBR to receive the programme – 73% (69) of them were eligible for the programme after full screening, out of which 66% (45) progressed through recruitment to be randomised into the pilot RCT. In the pilot study, 74% of families received eight or more sessions, and 83% completed the programme. In terms of what the families in the service as usual group were receiving, approximately one third received an alternative parenting programme; 27% do not appear to have received any services. Key conclusions Interviews with caseworkers in the feasibility study suggested that they would, albeit reluctantly, refer young people and their families to the programme to participate in an RCT. The most common reason given was to ensure the continuation of the service. A waitlist control was preferred by some caseworkers, but the evaluator adjudged a parallel RCT to be preferable. Missing data rates in the pilot RCT were low at baseline. The RCT then measured parent-reported family functioning and young person-reported conduct problems. There was a 20% attrition rate. The evaluator deemed that in a small efficacy RCT, recruitment would be possible using only one local authority (LA). Given sample size calculations, they predicted that a sample between 51 and 248 would be required and advised aiming for the higher end of this range. Interpretation Social workers who were interviewed in the feasibility study felt that FFT-G complemented their services well. They would, albeit reluctantly, refer young people to the programme to participate in an RCT. Those most familiar with the intervention were more likely to refer, while the most common reason given for accepting an RCT was the continuation of the service. Most social workers had only a basic understanding of RCTs, and some had concerns about carrying out an RCT with vulnerable young people. They worried about causing frustration among those not receiving FFT-G, while FFT-G therapists were also wary of the disappointment experienced by social workers if the families they had taken time to recruit and refer were not part of the intervention group. After the evaluator explained the design of a waitlist control trial (where the control group would also receive the programme later), social workers were open to this possibility, recognising the need to evidence impact to secure funding. However, the evaluator concluded that a parallel RCT (where all receive some service as usual, and the intervention group also receive FFT-G) is preferable; concerns were noted that families’ waiting to receive FFT-G in a waitlist design could alter their engagement with other usual services, while the wait for any support could be too long for such vulnerable young people. In the feasibility study, FFT-G received a reasonable number of referrals (100 over 13 months). This was lower than expected by FFT-G therapists due to a number of reasons, including a lack of awareness by social workers around FFT-G, the cases not fitting the inclusion criteria and the length of time it takes to refer. The evaluator deemed completion rates to be adequate; where treatment data were collected, 67% received over eight sessions, and 61% of families completed treatment. The average number of sessions completed by families was 10.7. The pilot study found that 95 families were identified over nine months in LBR to receive the programme. These were referred either by a Family Intervention Team panel, identified in meetings with service teams, or identified via screening of the borough’s case management system. Seventy-three per cent (69) of them were eligible for the programme after full screening, out of which 66% (45) progressed through recruitment to be randomised into the pilot RCT. Recruitment to the RCT began slowly; after simplifying the communication to potential families, expanding the age eligibility range (from 10-14 to 10-17) and conducting a screen of the case management system, recruitment improved. Missing data rates in the pilot RCT were low at baseline (0% for 16 out of 21 measures and between 2% and 16% for the remaining five). The RCT then measured parent-reported family functioning and young person-reported conduct problems. These measures were deemed to be broadly suitable, but the evaluator encourages caution when drawing firm conclusions on the future suitability of these measures given the small sample size. There was a 20% attrition rate (with eight families in the SAU arm and one in the FFT-G arm of the trial not completing assessments after six months). The evaluator deems that in a small efficacy RCT, recruitment would be possible using only one LA. Given sample size calculations, they predict that a sample between 51 and 248 would be required and advise aiming for the higher end of this range. The dominant view expressed in interviews with families was that the randomisation process was acceptable, and getting additional attention and support for their child was a recurring motivation for many participating in the study. Some families also expressed a desire to participate in giving feedback on services with a view to them improving in future. Of those who received support during the study, the common view was that the support was useful, although some young people were unable to say what was helpful to them. Of those who received service as usual, most perceived the support on offer to be helpful. However, some families who received usual service expressed negative experiences with professionals and the wider system. In the pilot study, 74% of families received eight or more sessions, and 83% completed the programme. The average number of FFT-G sessions per family was 11.4. Approximately one third of families in the SAU group received an alternative parenting programme; 27% do not appear to have received any services. The study met the requirements for a full efficacy RCT by meeting four out of five ‘stop-go criteria’. The YEF has, therefore, opted to fund a further evaluation of FFT-G and will be setting up an efficacy RCT

Cool and hot executive functions at 5-years-old as predictors of physical and relational aggression between 5- and 6-years-old

To study the role of executive function (EF) in the early development of aggression, the role of cool and hot EF skills at 5 years-old in the development of physical and relational aggression between 5 and 6 years-old was explored. Typically-developing children (N = 80) completed tasks assessing their cool (inhibition, working memory, planning) and hot EF (affective decision making, delay of gratification) skills at 5-years-old. Longitudinal data were collected from teachers that rated children’s aggression when they were 5-, 5.5- and 6-years-old. Inhibitory control at 5-years-old predicted changes in physical and relational aggression between 5- and 6-years old. Early cool EF, but not hot EF, may therefore be associated with aggression and inhibitory control specifically with changes in aggression during early childhood

The feasibility of providing remote functional family therapy with adolescents during the COVID-19 pandemic

Background: Due to the recent COVID-19 pandemic, mental health care has largely transferred its services to online platforms, using videoconferencing (VC) or teletherapy. Within the field of family therapy, however, there is little evidence on the feasibility of using VC, especially when working with whole families at the edge of care. Objective: This study investigated the feasibility of remote Functional Family Therapy (FFT), using a mixed-method approach. Methods: Study 1 consisted of semi- structured interviews with 23 FFT professionals (18 female) about their experience of providing remote FFT during the COVID-19 pandemic. Study 2 included monitoring data of 209 FFT clients (46% female, M age = 14.00) who participated in FFT during the pandemic. We compared families who received mainly in-person, mainly remote or a mix of remote and in-person on client-reported alliance, drop-out, therapist-rated outcomes, and treatment intensity using MANCOVA’s and chi-square tests. Results: In Study 1 two themes emerged around experienced challenges, namely ‘Feeling in control’ and ‘Engagement and alliance’. Two other themes emerged around adaptations, namely ‘Being more on top’ and ‘Connecting in different ways’. In Study 2, we found that the therapeutic alliance was not related to using VC. Also, families had less between-session contact during the Engagement and Motivation Phase when receiving mainly VC, but had more sessions and longer therapy when receiving a mix of in-person and remote therapy. Conclusions. The current study suggests that providing systemic family teletherapy to families on the edge of care is feasible. Further development of systemic family teletherapy is warranted

Comparative bioavailability analysis of oral alendronate sodium formulations in Pakistan

Alendronate sodium, a bisphosphonate drug, it is used to treat osteoporosis and other bone diseases. The present study was designed to conduct comparative bioavailability analysis of oral formulations of alendronate sodium through an open-label, randomized, 2-sequence, 2-period crossover study. Healthy adult male Pakistani volunteers received a single 70 mg dose of the test or reference formulation of alendronate sodium followed by a 7 day washout period. Plasma drug concentrations were determined using a validated HPLC post column fluorescence derivatization method. AUC0-t, AUC0-8, Cmax and Tmax were determined by non-compartmental analysis and were found within the permitted range of 80% to 125% set by the US Food and Drug Administration (FDA). Results show that both in vitro and in vivo assays of all test brands were within the specification of the US Pharmacopoeial limits and were statistically bioequivalent. No adverse events were reported in this study