Conduct Disorder – What’s in a name?

So today the first ever guidelines from NICE in relation to ‘Conduct Disorder’ are released See (http://www.nice.org.uk/nicemedia/live/14116/63308/63308.pdf).  Also today I’ve had the chance to read some interesting insights into IAPT from @drmurphypsy on his blog and a subsequent conversation and the gist is this: IAPT is increasing the medicalisation of children.  This sounds abhorrent but it is being construed as a medical intervention and that, to me is very concerning.  It is focused on diagnoses, one of them, is conduct disorder.

I have a myriad of concerns about the use of the use of the term disorder generally which are summed up by my colleagues Peter Kinderman, Richard Bentall, Joanna Moncrieff and John Read title of their excellent piece ‘ It’s time to drop the language of disorder’.( http://www.madinamerica.com/2012/09/a-call-to-drop-the-language-of-disorder/) but in relation to children and in particular ‘Conduct Disorder’  this needs further exploration.

I do wish to make one point abundantly clear: I am in no way against parents or carers receiving support to assist them in supporting their children.  Parenting is the hardest job in the world and we all need help from time to time.  What I am fundamentally against is the concept that the child has to be diagnosed with a ‘mental health disorder or condition’ before the family can receive help and placing the problem within the child.

In fact I’m fundamentally against the diagnosing of children with ‘disorders’ in general (yes even Autistic Spectrum Disorder, I have no issue with Autistic Spectrum but why call it a disorder?)

It does seem that the language used, even by those who developed the guidelines can be confused at times.

To illustrate my point, I am copying text from the NICE website which refers to the new guidelines.

“Conduct disorders are a serious, but frequently unrecognised, mental health condition characterised by repeated and persistent misbehaviour that may include stealing, fighting, vandalism and harming people or animals.”

Indeed it is serious, but is it a condition? Do all problems with well being have to be a condition/disorder/disease/illness? If so which is it?

“In the first national guideline in this area, NICE recommends group parent training programmes be offered to help support parents and carers of children and young people aged between 3 and 11 years who have been identified as being at high risk of developing oppositional defiant disorder or conduct disorder, or have oppositional defiant disorder or conduct disorder or are in contact with the criminal justice system because of antisocial behaviour.”

“Group social and cognitive problem-solving programmes should be offered to children and young people aged between 9 and 14 years who are at high risk of developing oppositional defiant disorder or conduct disorder, or have oppositional defiant disorder or conduct disorder, or are in contact with the criminal justice system because of antisocial behaviour.”

Right so it’s a disorder now, along with Oppositional Defiant Disorder, (I know, I know) but hang on, so they think that people in contact with the criminal justice system should be offered this help, that’s, good.  But who is going to do this?  CAMHS are being cut and asked to see more and more kids, who on earth is going to also see all the kids in contact with CJS? Does that mean that criminal behaviour is a mental health disorder?  Doesn’t this have rather large implications for the CJS amongst many others?

“If left untreated, many children will go on to have serious mental health problems as adults. The cost of not treating these children early on is huge not just to the NHS but also to society.”

I agree and intervention is so clearly needed and the outcome of lack of early intervention can be significant.

So what is the aetiology of this serious mental health/criminal/behavioural disorder/condition/problem?

“Professor Stephen Pilling, Director, National Collaborating Centre for Mental Health and facilitator of the Guideline Development Group, said: “The new guideline highlights the importance of supporting the child’s parents or guardians in the treatment of the condition – recommending training programmes tailored specifically for them – as aspects of parenting have been repeatedly found to have a long-term association with antisocial behaviour.”

No argument there, aside from the condition bit, but I can see that may be a little pedantic on my part.

“Many parents do an excellent job in caring for a child with a conduct disorder, but it can be incredibly challenging. Parent training programmes provide them with strategies for dealing with difficult children and how to better handle them going forward.”

Hang on, it’s a disorder again now.  Where did that come from?

“Professor Gillian Leng, Deputy Chief Executive, NICE, said: “The new NICE guideline includes a number of recommendations to support healthcare professionals to accurately diagnose and treat conduct disorders. It aims to significantly improve the lives of young people with a conduct disorder, which is a serious but frequently unrecognised mental health problem.”

So you need to diagnose and then treat.  And there it is.  The medical model in all its glory.  This is a beautiful illustration of why the medical model is not appropriate for mental distress. The diagnose and treat model is not fit for purpose and is damaging (this is for another post, in fact posts).

To be clear, this is not about doctors and nurses in mental health services,  it’s about the dominance of the model and like it or not, it is dominant.

Some better reflection comes at the end:

“Andrea Sutcliffe, Chief Executive, Social Care Institute for Excellence, added that collaborating with NICE enabled the social care perspective to be brought directly into the guideline.

“It is important not to concentrate solely on their clinical needs but also to consider their whole lives – as part of a family, school and local community.

“That is why it is crucial that everyone in health, social care and education work well together to provide the information and person-centred care necessary to improve the quality of life and life chances for children, young people, their families and carers.”

I was so pleased, the Social Care perspective brought in the SCIE.  Nicely put, person centered care.  Is labelling them with a disorder person centered?  Which person are we talking about?

There isn’t room to do a literature review here sadly, but I would recommend a look at the NICE guidance itself, which states amongst other things:

“In addition to specific tests of Patterson’s reinforcement model there is ample evidence that conduct problems are associated with hostile, critical, punitive and coercive parenting.” P25.

So why then do we seek to place this problem within the child?

My admittedly crude illustration of this is that if someone punched me in the face would it be right to label me with ‘Punched in the Face Disorder?’  That sounds ridiculous, doesn’t it?

There are also references to gene/environment interactions which always give way to people stressing the genetic aspect, not the environmental, but that’s a post for another day.  Just one comment, because something ‘runs in the family’ does not make it genetic.

Why is it a requirement of support that a child is diagnosed with a disorder? What century are we living in here?  The very path of diagnosis is incredibly flawed, I have been concentrating my efforts on DSM5 recently (dsm5response.com) but the ICD10 is no better in fact it’s worse on this issue.

This is taken from the ICD criteria for Conduct Disorder (F91):

“Examples of the behaviours on which the diagnosis is based include the following: excessive levels of fighting or bullying; cruelty to animals or other people; severe destructiveness to property; firesetting; stealing; repeated lying; truancy from school and running away from home; unusually frequent and severe temper tantrums; defiant provocative behaviour; and persistent severe disobedience. Any one of these categories, if marked, is sufficient for the diagnosis, but isolated dissocial acts are not.”

Anyone working with children with a degree of understanding of children would look at those behaviours (which if marked, is sufficient for diagnosis) and ask, what’s troubling this child? Surely.

It gets worse, much worse and the argument that ICD10 is not as bad as DSM5 goes out the window (flung by a conduct disordered child probably) because they have another diagnosable condition:

Conduct Disorder Confined to the Family Context (F91.0). 

Yes, a disorder which is only present at home.  As soon as the door opens to the outside world it vanishes.  Magic. But what if the child was half way out? Would he be semi-disordered, or would only his feet be disordered?  I just don’t know.  Sorry for the defensive, poor humour, it’s masking my anger.  Here’s the criteria, please sit down:

“Diagnosis requires that there be no significant conduct disturbance outside the family setting and that the child’s social relationships outside the family be within the normal range.

In most cases these family-specific conduct disorders will have arisen in the context of some form of marked disturbance in the child’s relationship with one or more members of the nuclear family. In some cases, for example, the disorder may have arisen in relation to conflict with a newly arrived step-parent. The nosological validity of this category remains uncertain, but it is possible that these highly situation-specific conduct disorders do not carry the generally poor prognosis associated with pervasive conduct disturbances.”

So mum gets a new boyfriend and the child gets a diagnosis of a mental health disorder?  What on earth?  The disorder may have arisen in relation to conflict? Like the sword in the lake?

They do at least acknowledge that it’s pretty crap, but then, why do it?

This has to stop.  This systematic labelling of children as disordered when they are simply trying to get by in the world is inhumane and extremely unhelpful and potentially damaging.

People often say to me “stop nit picking, what does it matter what it’s called?” It does matter.  When the school are asked why is Tom behaving like that, they’ll say ‘he has conduct disorder’.  It places it in him, this happens throughout society, children are demonised and labelled with disorders and it does not help.

He will be told, ‘you have conduct disorder’ what does that mean to Tom?

What does it mean to the parents? I know that they’re offered parenting courses, which is good but why?  The reason is “Your child has a disorder”.  This is wrong.

They need our understanding, they don’t need us telling them they’re mad.

Yes, help children who display problematic behaviours and of course, offer help to parents, they need more, a lot more, but this should not require a diagnosis and a stigmatising label.

I joked on twitter earlier that it ought to be called Parenting Disorder and rightly I was brought to task.  I was joking (not great I know) but the idea of blaming parents is unhelpful and we’re rightly against it so why do we allow children to take the blame?

As clinicians we must never stop being the 4 year old ourselves (as I constantly tell my trainees/assistants) and ask one simple question,

Why is this happening?

 

Dr Gordon J Milson

Clinical Psychologist

P.S. if you like me are against DSM5 please visit dsm5repsonse.com and sign the petition, if that goes through, things will get worse.

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10 comments

  1. Didn’t get beyond “I have no issue with Autistic Spectrum but why call it a disorder?“.

    The reason it is called a disorder ism in the words of Digby Tantam “it is disabling as treatment resistant schizophrenia”. (Quote from a presentation, at I believe, B’ham University, some years ago).

    1. I would suggest that because something can be disabling doesn’t mean it has to be a disorder. I work with many families with difficulties on the Autistic Spectrum but I don’t necessarily see it has to be labelled a disorder. Sorry you didn’t read on.

  2. Language is so important, negative language is something all professionals have a responsibility to eliminate. I have just blogged yesterday on the use of labels in mental health, you may find it an interesting read https://thestrongestsmile.wordpress.com
    Claire

    1. Thanks for your reply Claire and your blog, It was a very good read and you write very eloquently.

      1. Many thanks, as I am sure you know feedback on a blog somehow validates the words that are written.

  3. great post. I am fed up with all the emphasis on change being placed on the child….I’m not a clinician but I’ve worked with enough families to know that all the focus is on labelling and getting a diagnosis for the child and the enormous disappointment from the parents (and schools sometimes) when the referral to CAHMs is not accepted…treating just the child never works. We must look at the child in the context of the family and include the family in any therapy/support/behaviour change strategies….have a look at this website – http://www.schoolandfamilyworks.co.uk – this approach seems to be working.
    cheers Maeve

  4. I think clinical psychologists need to separate the conceptual viability of psychiatric diagnosis from its political/ethical desirability. Even if you don’t appeal to a medical/genetic explanation of distress, it is still possible to cluster groups of problems together on the basis of similarities they share and arbitrarily draw a cut off for those you want to label “disordered”. This often happens in physical medicine, and it is probably why psychiatrists respond with bemusement when psychologists argue that diagnosis is untenable. It has already been cogently argued that a lack of validity for diagnosis does not translate into a lack of utility. Schizophrenia has stuck around as a label partly because there are (weak) similarities among those people so labelled, and common approaches to treatment (sometimes even helpful treatment) are indicated. As for the “punched in the face syndrome”, a doctor could argue that in this example it could be perfectly valid to treat you for a condition called “broken nose”, and they could draw comparisons between that and the idea of personality disorders, which even when conceptualised as trauma reactions, still get viewed as “pathological” responses (not because they aren’t understandable, but because they aren’t optimal for the person experiencing them).

    If we are to win the fight against the DSM-V, it is necessary to accept that diagnosis is conceptually viable, and focus instead on arguing that it is clinically undesirable. Diagnosis can have negative effects on clinicians’ views of service users and on service users’ views of themselves. It can blind clinicians to the other aspects of the “presenting problem” (read “distress”) and prevent the delivery of care that would actually improve a person’s situation. Many service users don’t like to receive diagnoses (although it should be admitted that some do). If they are to be abandoned it is because we don’t find it helpful to see people in that way, not because classifying people’s problems is impossible to do.

    1. Hi Huw,

      thanks for your comments but I would like to reply to some. Where would the cut off be for a disorder? Research shows that people with 6/8 symptoms are not significantly less distressed than those with 4/8 in BPD (for example) Who is to say which one is disordered? Especially for something which is so personal as distress? This is a real issue for me, the grouping of symptoms is another one. It is fraught with scientific and practical validity and simply does not offer anything of significant value. It is possible to have 2 people with the same diagnosis of Paranoid Schizophrenia and not have a single symptom in common. What is that doing for them?

      The lack of validity, for me, does impact on utility. If you have hundreds of variations for what a ‘condition’ is which is true of the polythetic models currently used then how can effective treatment decisions be made? I would argue that this approach is hindering advances in research into helping people with their distress.

      I called it punched in the face disorder, syndrome is not as stigmatising IMO and part of this piece was about stigma and the attaching onto people labels which are not helpful and at times detract from the real focus. I would also avoid using pathological responses, I agree that they can be troubling to the individual but I’d be mindful of language again.

      Conduct disorder is significantly associated to adverse early experiences including parenting, it cannot be right to label kids with that and shift the focus from the family. I also feel that classifying and medicalising distress is not in the best interest of people generally. I think that the piece was emphasising that although I do feel that diagnosis is more problematic than you perceive at this time. But those are just our different opinions.

      Thanks again for your comments and thank you for reading the blog.

      1. I don’t dispute that DSM is flawed in the ways that you describe, but nonetheless these flaws seem to be considered in some way irrelevant to the psychiatric community that produces it. I suspect that this is partly because for the crass medical interventions that pass as treatment (i.e. anti-psychotics) can be roughly mapped onto the categories that exist, and then seem to have some effectiveness in helping those people so labeled.

        My main point is that catergorisation per se is theoretically workable-even Richard Bentall’s book Madness Explained acknowledged that research points to a smaller number of categories than their complete abolition. This being so, the most significant question pertaining to diagnosis is not whether it can be made to work, but rather whether it is the sort of thing we want to be doing to patients even if it does.

        I pick this up in your post too, you seem to be saying that something resembling a conduct disorder does in fact occur and can be apprehended by clinicians. The problem comes from labeling it a “disorder” (though Post Traumatic Stress Disorder somehow seems less offensive) and thereby somehow giving the child the responsibility for what, as you point out, is largely the product of their environment. I am coming to share your view of diagnosis as harmful to people, and at the moment I place more emphasis on this aspect of it rather than its “unworkability”.

  5. […] Psychologist Dr Gordon Milson has read the guidelines, and isn’t impressed. […]

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