El Modelo Cognitivo-Conductual

Hoy en da, el modelo conductual ha evolucionado hacia un modelo integrado en el que conducta
y cognicin han equiparado prcticamente su estatus y asumen su papel de agentes causales
recprocos entre s. Por tanto, los primeros modelos ms radicales (conductismo) en los que la
conducta manifiesta era el elemento principal de estudio han quedado relegados.
El enfoque cognitivo-conductual, en trminos generales puede conceptualizarse segn el
conocido esquema A-B-C. Donde "A" representa los acontecimientos de la vida que estn
relacionados con determinadas consecuencias emocionales o conductuales que definen un
problema o trastorno psicolgico representado por "C". Ahora bien, entre ambas, se sita "B",
elemento que integra las creencias, las imgenes, los pensamientos y que media entre las partes.
-Tal como sealan algunos autores, actualmente: " la Modificacin de Conducta se caracteriza
por ser una terapia breve, directiva, activa, centrada en el problema, orientada al presente,
que supone una relacin colaboradora y en la que el cliente puede ser un individuo, una
pareja, una familia, un grupo o una comunidad." (Marino Prez lvarez en "Caracterizacin
de la Intervencin Clnica en Modificacin de Conducta". Manual de Terapia de Conducta,
Volumen 1, Dykinson Psicologa).
-Por terapia breve se entienden aquellas que se sitan alrededor de las 15 sesiones. Sin
embargo, hay que matizar que hay ciertas terapias dentro del modelo conductual como las
terapias cognitivas de los trastornos de personalidad que suelen necesitar ms sesiones.
Las sesiones son de 1 hora por trmino medio a excepcin de las sesiones iniciales que pueden
prolongarse un poco ms (90').
Otras caractersticas:
1-Son activas en cuanto se supone que el paciente tiene que hacer algo respecto a la postura de
que algo ocurre en ellos.
2-Se centran en el problema como objetivo a resolver sin suponer la necesidad de otros cambios
"estructurales".
3-Sita el anlisis y solucin del problema en el aqu y ahora, es decir, en el presente, en
contraposicin a otras teoras que necesitan seguir el hilo evolutivo de ciertos signos y sntomas
en el pasado.
4-La relacin teraputica se construye desde una relacin colaboradora y de participacin activa
con el paciente. No es, por tanto, una relacin directiva en la que se produzca la imposicin de
un determinado camino.
5-Finalmente, el cliente de una terapia psicolgica puede ser un individuo, una pareja, una
familia o un grupo.

Adems de la gua, el NICE ha elaborado un Cuestionario de Capacidades y

Dificultades para su utilizacin durante la evaluacin inicial de un nio o joven con
sospecha de trastorno de conducta, as como una interesante herramienta online,
que acta a modo de rbol de decisin, para facilitar la tarea del profesional
sanitario a la hora de evaluar y manejar este problema (que puede consultarse en
el siguiente enlace: http://pathways.nice.org.uk/pathways/antisocial-behaviour-andconduct-disorders-in-children-and-young-people).

Offer multimodal interventions, for example, multisystemic therapy, to children and young
people aged between 11 and 17 years for the treatment of conduct disorder.
Multimodal interventions should involve the child or young person and their parents and carers
and should:

have an explicit and supportive family focus

be based on a social learning model with interventions provided at individual, family,

school, criminal justice and community levels

be provided by specially trained case managers

typically consist of 3 to 4 meetings per week over a 3- to 5-month period

adhere to a developer's manual1 and employ all of the necessary materials to ensure
consistent implementation of the programme.

The manual should have been positively evaluated in a randomised controlled trial.
Oppositional defiant disorder may be difficult to distinguish from conduct disorder. Key features
of oppositional defiant disorder include argumentativeness, noncompliance with rules and
negativism. While these features partially overlap with those of conduct disorder, there are
important distinctions. Children with oppositional defiant disorder, although argumentative, do
not display significant physical aggression and are less likely to have a history of problems with
the law. Parents of children with oppositional defiant disorder are more likely to have mood
disorders than the antisocial pattern common among parents of children who have conduct
disorder. Oppositional defiant disorder may, with time, develop into conduct disorder.
Significant acting out frequently occurs among children and adolescents with major depression
and dysthymic disorder. Patients with early-onset bipolar disorder may exhibit impulsive
violations of rules and aggression. However, mood disorders typically include disturbances of
sleep and appetite and pronounced affective symptoms, as well as significant alterations in
energy and activity levels not found among children with conduct disorder. The coexistence of
major depression with conduct disorder increases the risk of impulsive suicidal behavior.
Substance abuse may also overlap with the symptoms of conduct disorder. A key issue in
assessing substance use in adolescents is the distinction between experimentation and abuse or

dependence. The frequency and duration of substance use are helpful dimensions in this regard.
Early (i.e., at 10 to 13 years of age), repeated use of alcohol or illicit drugs is a red flag for the
development of other behaviors associated with conduct disorder. Additionally, substance use is
likely to further reduce impulse control and increase contact with deviant peers.16
Intermittent explosive disorder, featuring unprovoked, sudden aggressive outbursts, can only be
correctly diagnosed when the child's behavior does not meet the criteria for conduct disorder.
Patients with intermittent explosive disorder deny plans to harm anyone but report that they
snapped or popped and, without realizing it, assaulted another person. In children and
adolescents with intermittent explosive disorder, these episodes are the only signs of behavior
disturbance. Other than unplanned acts of aggression, patients with intermittent explosive
disorder do not engage in repeated violations of other rules or in illegal behavior such as theft or
running away from home.
Conduct disorder has varying degrees of severity. Parental abuse, onset of problem behavior in
early childhood, financial hardship and lack of supervision are all associated with more severe
conduct disorder.10,18 Additionally, a poorer prognosis is associated with an increase in the
number and severity of specific DSM-IV criteria.10 Risk also increases with comorbid ADHD
and substance abuse.10 These dimensions should guide treatment Subclinical conduct disorder
symptoms or those of recent onset may be amenable to physician-parent counseling. However,
more serious, longstanding behavior involving aggression, illegal acts, substance abuse or other
harmful acts should prompt referral to a mental health specialist. With comorbid substance
abuse, the focus of initial treatment should be cessation of drug use and may include medical
detoxification before rehabilitation.
Treatment interventions
Monitoring of children's activities and whereabouts by adult caregivers is critical. Compliance
with the evening curfew is essential. For working parents, telephoning to check on the child or
having another responsible adult ensure that the child is in an appropriate setting during
nonschool hours is important. Monitoring becomes particularly important during early
adolescence when peer group influences increase. Vulnerable youth are susceptible to peer
influences such as smoking, sexual risk-taking, and alcohol or other substance abuse. Organized,
supervised activities, such as sports, Scouting, the arts or recreational programs provided by
churches, schools or agency youth clubs often protect teenagers from negative peer influences.
Practical Interventions for Management of Patients with Conduct Disorder

Assess severity and refer for treatment with a subspecialist as needed.

Treat comorbid substance abuse first.
Describe the likely long-term prognosis without intervention to caregiver.
Structure children's activities and implement consistent behavior guidelines.

Emphasize parental monitoring of children's activities (where they are, who they are with).
Encourage the enforcement of curfews.
Encourage children's involvement in structured and supervised peer activities (e. organized
sports, Scouting).
Discuss and demonstrate clear and specific parental communication techniques.

TREATMENT
Research and practice consensusindicates thatsuccessful treatment must
address multiple domains in a coordinated manner over a period of time.
Outpatient treatment of CD usually involves the child/youth, family, school and
peer group. Some milder forms of CD, however, require minor intervention,
usually training for the child (social skills, problem solving) and training for the
parents (behaviour management, parenting skills) and consultation to schools.
Moderate and severe CD often involve comorbid disorders that require
treatment. Chronic CD, which is usually childhood-onset type, requires early
intervention, extensive treatment in multiple domains and long-term follow-up.
Pharmacotherapy alone is not sufficient to treat conduct disorder. Although
some psychiatric medications are used to treat CD youth with a comorbid
disorder (e.g., antidepressants for mood and anxiety disorders, stimulants for
ADHD), there is an absence of adequate efficacy studies in this area.
There is research evidence to support the effectiveness of Cognitive
Behavioural Therapy for treating youth with CD, especially Problem-Solving
Skills Training. These forms of therapy help to control antisocial behaviours
and strengthen pro social functioning. Although cognitive behavioural
interventions and skills training appear helpful in the short-term, especially for
older children and adolescents, their long-term efficacy has not been establish
ed. Family intervention is an essential component for treating conduct
disorder. For younger children, the family often is the primary target for
intervention and a useful support for adolescent treatment, if the family is
present and willing to participate. Before beginning interventions, children's
mental health professionals may need to collaborate with other systems
to ensure that there is a safe home environment, adequate housing and
resources to meet basic needs, and parents' psychiatric or substance ab
use issues are addressed. The overall approach for working with families is to
identify and build upon the parent(s) strengths through parent counselling,
parent education, family therapy, and parent management training
programs. There are numerous studies that demonstrate the effectiveness of
these programs for improving parenting skills and helping parents manage

child behaveiour effectively without the use of physical punishment. There

also is evidence that multi-systemic therapy is an effective intervention for CD
youth that may be delivered in family and community settings.
Children's Mental Health Ontario-3- May 31, 2001

Children and adolescents with conduct disorder usually show poor academic
achievement and may be disliked by their teachers an
d classmates. Faced with frustration and exclusion, the child or youth may
resortto bullying and antisocial behaviour and associate with other students
who are in a similar situation. Children with CD may be treated effectively in
day treatment programs, but good follow-up and transition planning is
necessary if treatment gains are to be maintained in regular classrooms. Two
common school-based treatment approaches for CD children thathave
research support are contingency management and the use of token
economies to reinforce positive behaviour and reduce negative behaviours.
During the last 10 years, a number of school-based programs have been
developed to address conduct problems, including anger management,
conflict resolution, social problem solving, and social skill training. Only a few
of these programs have empirical support for their ability to change problem
behaviours or to maintain changes after the program ends. Adolescent-onset
CD is often associated with membership in a group of antisocial youth. To
avoid conduct-disordered behavior, peer intervention may be necessary to
remove the youth from an antisocial group and help them to develop a new
peer group. Several evidence-based peer group intervention programs have
proven effective. There also has been research support for multi-systemic
therapy that treats conduct-disordered adolescents (including serious and
violent offenders) in their social settings while combining family and
community interventions.

Recommended family intervention includes:

Parent counselling that enhances parental strengths
Parent training to establish consistent behaviour management
Family therapy
6.5 Peer Intervention Since adolescents rely more on peers
than parents or teachers for values and direction, intervention
with adolescents should include a focus on peers as well as
family(Feldman & Weinberger, 1994).
Adolescent-onset CD is often associated with membership ina
group of antisocial youth.To avoid conduct-disordered

behavior,intervention may be necessary to remove the youth

from an antisocial group and help them to develop a new peer
group. Since CD youth often lack appropriate social skills, they
may need specific coaching on making and keeping friends,
learning new ways of using free time, and joining positive
activities and organizations in the community.
There has been research support for multi-systemic therapy
(MST) that treats conduct-disordered adolescents (including
serious and violent offenders) in their social settings while
combining family andcommunity interventions (Borduin and
others, 1995; Henggeler and others, 1998, 1990,1987a, 1987b),
but concerns have been raised that MSTmay miss psychiatric
problems and comorbid
Disorders (Fouras,1999). The Earlscourt Under 12 Outreach
Project (ORP) is an example of multifaceted intervention for
boys between 6 and 12 years of age who commit mild toserious
offenses. Several evaluative research studiesindicate that the
ORP is effective in reducing CD behaviours and police contact
among a group that is at risk of repeat offending (Day &
Hrynkiw-Augimeri, 1996; Hrynkiw-Augimeri and others, 1993).
The ORP consists of eight components, including an afterschool structured
group to teach self-control and problem-solving techniques, a
12-week parent training group to teach effective parenting skills,
family counselling, in-home academictutoring, school advocacy
and teacher consultation, victim restitution, individual
befriending to link the boys withstructured community-based
activities, and continuing groups. Earls court has recently
developed a multifaceted program for aggressive, antisocial
girls based on similar principles.
Other evidence-based peer group intervention programs include
Skillstreaming (Goldstein, Gershaw & Sprafkin, 1995) and
Aggression Replacement Training (Golds
tein & Glick,1994).

Recommended intervention with peers includes:

Peer intervention to replace deviant peer group with socially
appropriate group
Promote prosocial interactions with peers at school
GOALS

Long-term goals
Arrest of the development of adolescent antisocial behaviours and
drug experimentation.
Intermediate goals
Improvement of parent family management and communication
skills.
Evaluacion
effective in engaging students and their parents and in improving
parent-child relations
Cognitivo-conductual
GOALS

For parents:
Strengthened parental competencies
Involvement in childrens school experiences to promote
childrens academic and social competencies and reduce conduct
problems.
For children:
Strengthened social and academic competence
Reduced behaviour problems
Increased positive interactions with peers, teachers and parents
Enfocado familia
GOALS

Improved parenting skills

Acquisition of problemsolving skills
Improved family functioning
Development of supportive personal networks for logistical
assistance, information, support and encouragement

Increased awareness and utilization of local resources, e.g.

extracurricular programs for children during high risk unsupervised
periods