Abstract
Psychiatry is ambivalent toward Conduct Disorder. We dignify the condition with listings in the major psychiatric classification systems, but there is less than subtle discrimination against patients with the disorder through exclusion criteria for inpatient and outpatient services, and even treatment trials. As noted by Costello and Angold in the first chapter of Conduct disorders in childhood and adolescence, our institutional responses to the condition are heavily weighted towards isolation and control, the ‘contagion model’ of public health that we associate with diseases that we don't understand very well, or have not learned to prevent or to cure. As psychiatrists, we would often prefer that other agencies manage these young people, and justify the position with the assertion that there is little psychiatry can do to help. To some extent this attitude is understandable. Many psychiatrists would resonate with the experience of seeing a young person with Conduct Disorder in an emergency situation, only to be badgered for months afterward for reports to assist welfare, educational and juvenile justice services in finding a suitable placement for the young person. However, if psychiatry will not demonstrate an interest in these young people, and to strive against the conventional wisdom that nothing much helps, who will? In the 19th and early 20th centuries psychiatry was active in trying to understand and help individuals with a range of conditions previously attributed to moral deficit, including epilepsy and schizophrenia. It is important that we do not abandon that important tradition.
This authoritative text on Conduct Disorder (in childhood and adolescence) that draws together current knowledge of a difficult clinical and social problem is warmly welcomed. This volume joins a growing series of excellent monographs from Cambridge University Press on important conditions of childhood and adolescence including hyperactivity disorders, depressive disorders, schizophrenia, anxiety and autism. The present volume includes contributions from centres of excellence in the UK, Italy, USA and Canada. The major contribution, made by two New Zealand longitudinal studies, to our understanding of the developmental trajectory of conduct problems is frequently acknowledged throughout the text, but sadly is not represented in the authorship. This is not a ‘how to’ manual, and clinicians looking for a set of guiding principles for the assessment and management of Conduct Disorder will be disappointed. There is no discussion of approaches to assessment, and only one chapter devoted to management. This chapter focuses on four psychosocial treatments for which there is evidence of efficacy (which is reasonable) but glosses over other treatments where evidence may still be emerging. Material about pharmacotherapy is superficial, with no discussion of the role of the β-blockers or clonidine for aggression, or discussion of the role of the atypical antipsychotics.
Slavish adherence in the text to either DSM or ICD diagnostic criteria is appropriately avoided, on the grounds that the criteria are imperfect and limited in their usefulness. Costello and Angold state in their introductory chapter that a visitor from Mars could be excused for thinking that the DSM criteria for Conduct Disorder were written for lawyers rather than clinicians. The ‘symptoms’ of Conduct Disorder only make sense if taken in their social context, since fighting, killing animals, and the destruction of property may all be considered adaptive behaviours under certain circumstances.
There is a very strong contribution from the discipline of psychology to the text, with chapters on neuropsychological deficits, the reinforcement model, perceptual and attributional processes, friendship networks, developmental trajectories, and psychosocial treatments. Inevitably in a text of this nature there is some repetition. For example, the contribution of disturbed attachment to the development of conduct problems is described in at least four of the chapters. A chapter on the economic evaluation of conduct problems was well placed in this volume, given the public health significance of the disorder. In addition to describing a pilot study that estimates the costs of Conduct Disorder to be about A $40 000 per year per patient, the author provides an excellent overview of approaches to economic analysis.
In conclusion, this is a text for the serious student of the biological, neurocognitive and sociocultual aspects of Conduct Disorder. Readers seeking advice on approaches to assessment and management would be better looking to the review articles and practice parameters published in key child and adolescent psychiatric journals. However, the present volume does provide an excellent compendium of contemporary thought about the nature of conduct problems.