Family problems associated with conduct disorder perceived by patients, families and professionals.

INTRODUCTION: Conduct disorder is among the most serious and complex complications in school-aged children. Considering severe problems in the families of children with conduct disorder, this article aimed to investigate such problems in this group. SUBJECTS AND METHODS: This qualitative research was conducted on 23 participants in Tehran, Iran. The study participants were selected by purposive sampling technique. Interviewees consisted of children with conduct disorder (8-12 years old), their parents, teachers, and relevant experts. This study is a qualitative research which is a content analysis. The research tools included a checklist of questions approved by experts. The content analysis method was used with the help of MAXQDA software to analyze the obtained data.
RESULTS: The findings comprised the studied families' issues in five categories. These classes included the parents' marital problems, helplessness, and inability of the family to improve conditions; inappropriate discipline approaches; the family's lack of interest in the treatment; and the family members' mental harms.
CONCLUSIONS: It is necessary to provide appropriate facilities and health-care centers for the families to reduce the burden of their problems. In addition, a specialist and experienced work team consisting of at least a child psychiatrist, a child psychologist, and a social worker is necessary to serving these families. Copyright:

Introduction

Typically, conduct disorder is a repetitive and persistent pattern of behavior in which others’ fundamental rights, as well as the major ethics and social norms commensurate with age or laws, are violated. The most significant example of such actions includes aggression against humans and animals; the affected child bullies and threatens others or starts physical fights. They might even use different weapon types and impose severe physical injury to others and show great brutality.[1] Behaviors, such as sexual abuse, deception, and theft, are highly prevalent in this group.[1] A child with conduct disorder destroys properties, attempts vandalistic behaviors, and majorly violates social regulations, for example, escape from school and staying out of school.[2] Conduct disorder is a complex issue, comprising biopsychosocial aspects. For instance, its biological dimension involves the effect of genetics. In addition, conduct disorder is correlated with psychological, familial, and social dimensions.[3] Conduct disorder is among the most acute conditions and one of the main causes of children's referral to health-care centers.[4] Studies suggested that the parents of children with conduct disorder are at risk for severe depression, aggression, and negative attitudes. Mothers with more severe depression reported higher extrinsic symptoms in their children. Specifically, attention problems, hyperactivity, disobedience, aggression, and crime are more frequent in this group. Maternal depression could impact child aggression; however, it has a dual effect on this condition. According to the literature, a child's difficult temperament increases the risk of maternal depression.[2] Furthermore, the child is rejected by others, leading to their reduced opportunities.[5] Identifying and exploring the type and severity of mental health issues in children could be beneficial in assessing the prevalence, etiology, and prognosis of mental health problems in them. Consequently, such measures could improve behaviors and future-related matters in children.[6] Statistics vary regarding the prevalence of conduct disorder in different groups; the prevalence of conduct disorder in the United States is estimated to be 3.5% (2.7%–4.7%) in the general population.[3] Najafi et al. estimated the prevalence rate of conduct disorder to be two times higher in the male population, compared to females. Different statistics exist on the prevalence rate of conduct disorder in Iran. In this respect, Najafi et al. documented the prevalence rate of conduct disorder equal to 4.99 in elementary school students; of whom, 5.11% were boys and 4.87% were girls.[7] Other studies indicated the same value to range from 2.6% to 3.29% among Iranian students.[89] Some studies have considered greater values for the true prevalence of this disorder. Salmanian et al. investigated the prevalence rate of conduct disorder in seven Middle-Eastern countries and reported various rates for it in different sociocultural settings.[10] Apparently, conduct disorder is more prevalent among children living in the most vulnerable and migrant areas of Tehran. According to available statistics, a significant number of families are directly or even indirectly involved in the associated problems of children with conduct disorder because conduct disorder is highly prevalent in children.[378910] There is no specific screening to identify and treat children in schools and educational support centers in Tehran. These children and their families struggle with numerous problems due to the lack of screening and paying special attention to them, as well as the lack of professionals, including social workers. Besides, the lack of appropriate intervention programs in this area has led to the serious neglect of assisting children and their families.[11] Disregarding these children and their families causes other damages and deviances, like a faulty loop. These children mainly exhibit inappropriate behaviors in the five categories of aggression, irresponsibility, deception, sabotage, and poor interpersonal relationships; thus, they impose numerous harm and problems on school, family, and the society.[12] The families of children with conduct disorder usually experience a faulty loop concerning their children, leading to increased issues in the children and their families and threatening the family's mental health. Educational and behavioral problems associated with conduct disorder negatively impact the relationships between these children and their teachers and school staff, which, in turn, leads to academic failure and decreased self-esteem in the affected children and adolescents.[13] Conduct disorder is correlated with harm in the society's health, especially the family; thus, special interventions are strongly required in this area. However, initially, the family issues of children with conduct disorder need to be properly addressed. The identification of these issues could facilitate planning and designing effective measures. It could also provide information to health researchers, therapists, and policymakers in the field of health. The present research aimed to identify the problems associated with conduct disorder in the families of affected children through in-depth interviews and qualitative content analysis. The obtained data could help address the existing gap in this respect, in order to improve the health in this population.

Subjects and Methods

In the current research, the participating individuals were selected through purposive sampling technique. Furthermore, this process continued until data saturation. The present study was conducted on a total of 23 participants using a triangulation sampling method. The study participants comprised children with conduct disorder aged 8–12 years (n = 5), their parents (n = 6), teachers (n = 5), as well as social workers and psychology experts (n = 7) in the field of children's psychiatric disorders in Tehran, Iran. The main inclusion criterion was having ≥6 years of work experience for the teachers and experts and at least 4 years’ academic education for teachers and 6 years for experts. Conduct disorder was diagnosed by a psychiatrist in the studied children. Moreover, they lived with their families in Tehran. Children with physical and mental retardation were excluded from the study. Age between 8 and 12 was necessary for children.

The current study was part of a qualitative research; the relevant data were acquired according to the directed content analysis method. As a result, in-depth interviews with flexible and open-ended questions were implemented. Initially, a pilot interview was performed in four samples. Then, some minor revisions were applied to the interview protocol. The current research was conducted in schools and counseling clinics from January 2019 to January 2020. Each interview lasted approximately between 45 and 80 min. All interviews were recorded applying a digital recorder. The study tool was a checklist approved by four experts in the field of children's psychiatric disorders. The interview consisted of some open-ended questions, as follows: please talk about the maladaptive behaviors observed in your child”, “what are other people's reactions to the child's maladaptive behaviors?”, “to provide care for your child, what services should be accessible to your family?”, and “what are the consequences of your child's maladaptive behaviors in your daily living?”. To maximize the theoretical sensitivity, constant comparison was performed by frequently referring to the collected information during the data analysis. All the study authors participated in the discussions throughout the data analysis process. All the transcripts of the interviews and the preliminary set of codes and categories were evaluated by two experts of the research team (peer review) and some of the study participants (member check).

The present study was approved by the Independent Ethics Committee of the University of Social Welfare and Rehabilitation Sciences, Tehran, Iran (code: IR.USWR.REC.1397.026). All the study participants provided an informed consent form. We also received verbal informed assent from the children who participated in the study. Moreover, written informed consent was obtained from their parents. The purpose of the study and the confidentiality of the acquired information were explained to the study participants. After conducting the interviews and obtaining the relevant transcripts, the compelling content was imported into the qualitative software program MAXQDA (version 12, which is manufactured by VERBI software in Germany Berlin) for analysis. Then, open text coding included examining each interview, dividing the transcript into different parts of meaning, and renaming them to identify the used categories and concepts. Next, concepts were reorganized to more abstract categories. These classifications were systematically sorted, compared, and contrasted. This process resumed with complex and inclusive themes, until data saturation. The nonlinear analysis was performed. Thus, the researchers frequently referred to the different steps of extracting and coding. Eventually, to ensure the exact equality of the transcribed texts and extracted themes, the outcome was compared with the originally recorded voices.

Results

The present study was conducted on 21 participants, including three children with conduct disorder, six parents, five teachers, and seven specialists [Table 1].

Table 1

The sociodemographic characteristics of the study participants

Variable	Children with conduct disorder	Parents	Teachers	Experts
Gender (number)
Male	3	2	3	3
Female	2	4	2	4
Total	5	6	5	7
Age (years)	9	39 36	40 49	38 37
	10	42 50	41 44	39 39
	10	37 34	55	46 32 41
Education (years)	3	16 12	18 18	18 18
	4	3 0	18 16	18 18
	4	18 12	18	22 22 22

The family-related issues are presented in Table 2. Five main categories were identified based on the parents’ marital problems, helplessness, and inability to improve conditions; inappropriate discipline approaches; the family's lack of interest in the treatment; and the family members’ mental harms.

Table 2

Family-related issues

Subcategory	Category
The incidence of couples’ marital conflict	Parents’ marital problems
Conflict with family members
Parents’ marital infidelity
Emotional divorce
Family burnout	The helplessness and inability of the family to improve the conditions
Parents’ unawareness about the support resources
Family disappointment with child’s recovery
Family concerns about the child’s condition
Entertainment inability
Family’s dual discipline behaviors	Inappropriate discipline approaches
Severe child punishment
Family’s reluctance to receive others’ support	Family’s lack of interest in the treatment
Family’s poor compliance with the therapists
Devoting inadequate time for the child
Parents’ alcohol and substance use	Psychosocial harms of the family members
Parents’ mental harms
Family system’s disorganization
Family’s poor resilience

Parents’ marital problems

The incidence of couples’ marital conflict, conflict with family members, parents’ marital infidelity, and emotional are grouped in this category.

According to the parents, all or at least a significant part of couples’ problems are derived from their child's matters. Our son's behaviors highly impact on our lives. We do not argue much, except for the child's behaviors. Indeed, our conflicts initiated right after our son started talking (parent 3). The reported conflicts are due to the presence of the child in the family.

These children have various conflicts with their family members. Besides, their families are highly involved in verbal and nonverbal conflicts with their child with conduct disorder. Moreover, these conflicts have been observed between the couples and other family members, as a result of the affected child's behaviors. There is a constant struggle between the father and child; this makes us angry, so we often punish our other kids although being innocent. We overreact, and I know it is not right, but our hands are tight, though (parent 1).

Marital infidelity (i.e., having extramarital relationships) was another marital problem in the families of children with conduct disorder. I have had boy/girl clients who ask me to tell their mom and dad to behave well or spend less time with their friends (their partners) (expert 6).

Emotional divorce was another prevalent problem in the studied couples. Emotional divorce results from couples’ conflicts and a lack of father's presence in the family, because of their long working hours” (expert 1) (In Iran, fathers have to be occupied with more than one job, due to financial problems.)

The helplessness and inability of the family to improve the conditions

This category includes five subcategories, as follows: family burnout, parents’ unawareness about the support resources, family disappointment with a child's recovery, family concerns about the child's condition, and entertainment inability.

The family's helplessness and inability to improve conditions were observed in various manners. Family burnout has been reported initially. It was like the family has become indifferent about the situation (expert 7). This statement indicates that the problems are so severe that families are unable to cope with them. It seems the family is so frustrated with the issues, and their resistance has reduced; they have become worn out and no longer felt like being initiative (expert 7).

Parents were unaware of the potential support sources in the community. You feel exhausted and unable to take care of this kid most of the time…I believe you would like to leave the child at someone you trust and have a few hours to yourself. There is no such place, and even if there is, I don't know about it (parent 3).

Families have a slight hope of improving their child's condition. I took him to several physicians and counselors, but it did not work at all; he does not seem to want to change (parent 2).

Families are concerned about their child's condition because they consider it as ambiguous. We will not live forever. I am not sure about this kid's future (parent 2). Such concern has been reported due to their children's malicious behaviors and poor obedience. The main problem is that he refuses to do what he is asked for, even if you repeat yourself many times; he looks into your eyes, and keeps going. This situation worries me a lot (parent 3).

Families are deprived of essential recreation because of the presence of a child with conduct disorder. I would like to travel; we have the opportunity to travel, though. However, we do not travel because of his special behaviors. He does not listen to us at all when getting ready to go out. It is so stressful that I would rather stay at home. My husband suggested to go on a trip several times, but I disagree (parent 5).

Inappropriate discipline approaches

Dual discipline approaches by the family, as well as severe and physical punishment of the child, comprise this category.

Dual discipline behaviors are among the inappropriate training methods of parents. We were at my brother's place. All the kids were playing with mobile phones. He turned to me and said, Mom! Please, give me the cellphone tonight. I said I would not give it to you because of your past misbehavior. His dad told the kid in front of everyone that he would have smashed the phone with a gooshtkoob [An Iranian tool that is used in kitchen which is look like a hammer] if he were him! Then, I was arguing with my husband about the reason I resisted to give him the phone and that he was spoiling my efforts. My husband said: When this kid asks you something in front of others, you got to give him. I think the kid should understand that a negative response won't change to insistence (parent 4).

The studied families reported severe conflicts and hitting the child. Moreover, there were all kinds of physical punishment, such as biting, where the child tried to hide. A mother has bitten her daughter's hand badly. This girl pulled her sleeves down and was hiding it's scar. When painting, I tried to observe her emotional state; then, her sleeve got pulled a little up and I realized the bite scar. She told me: This is not because of my mom! My friend did so! (expert 4).

The family's lack of interest in treatment

Families’ interest in treating their children was inadequate. This issue has been observed in three different forms, including family's reluctance to receive others’ support, family's poor compliance with the therapists, and devoting inadequate time for the child.

In many cases, families have shown no interest in receiving assistance from others. I do not like to talk about my kid or his problem or to ask for others’ help to take care of him (parent 1).

Families demonstrated poor cooperation with the therapists. In many cases, they discontinue treatment, or some family members refuse to cooperate with the therapist. One of our problems in referring these children to counseling centers is the lack of visiting a therapist or early treatment dropout. Most of the time, we miss fathers from the treatment team for various reasons; they are either super busy with work or have little faith in psychological services. (expert 4).

Inadequate time is dedicated to these children by their parents. This matter has been highlighted by experts and teachers in interviews. Too many children, about 5 or 6, are living in this family. Thus, parents devote limited time for each child, comprising training and discipline matters (teacher 2).

Psychosocial harms of the family members

Psychosocial damages reported in the families included parents’ alcohol and substance use, parents’ mental harms, family system's disorganization, and family's poor resilience.

Alcohol and substance use have been reported in these children's parents and their fathers, in particular. Alcohol and substance abuse and abusive language were highly prevalent in the families as well as the parents of these children; therefore, of course, the frequency of conduct disorder was also higher in them. His father and I sometimes drink alcohol too much. My husband referred to a substance dependence treatment camp twice. However, he is still dependent on substances (parent 1).

Psychological harms in parents were other significant issues in the families. The more the injures in the parents, the higher the frequency of maladaptive behaviors associated with conduct disorder in the children. With increased psychological injuries in parents, the children's conduct disorder associated misbehaviors (in the same context) has been more observed by us (expert 7).

Disorganization inside the family structure was a serious problem among these families. Children with conduct disorder have a problem inside their families’ context. The treatment room is delivered to individuals at home by handing over simple homework assignments. Nevertheless, it is impossible for this group, because the families of our clients have their problems, fathers, mothers, and children all have problems, and there are complications in their living environment (expert 4).

Lower tolerance than normal was another characteristic of these families. In fact, I have detected decreased resilience in these families. It might be either due to having limited resilience resources or because of the constant struggles created by the child (teacher 5).

Discussion

The present study was conducted by interviewing and triangulating 21 participants, including children with conduct disorder and their parents, teachers, and related specialists in Tehran. The present study investigated problems in the families of children with conduct disorder. The five generally explored categories included the following: parents’ marital problems, helplessness and the inability of the family to improve conditions, inappropriate discipline approaches, family's lack of interest in the treatment, and family members’ mental harms. These items were identified as the main problems affecting the families of children with conduct disorder. Children's maladaptive behaviors cause marital problems. Such behaviors might even lead to major conflicts in parents who experienced minor disagreements before the birth of their child. Couples seem to require negotiation to reach common discipline points because disagreement with the child's upbringing methods has exacerbated these problems. This result is consistent with that of other researchers.[11] Conflict with family members has been reported among the most common problems in these families. Besides, children with conduct disorder directly fight with their family members. Conflicts, however, are not finalized at this point, whereas it generates further issues between the family members. It seems that problems indirectly result from the child with conduct disorder, despite him/her not been directly involved in it. Conflicts between family members were also addressed in previous studies.[14] Marital infidelity is another frequent problem in these families. It seems that families with parents who have extramarital relationships are more susceptible to raising children with disorders. According to Batara, marital infidelity has a detrimental impact on children's behavior.[15] The presence of such children may also exacerbate such familial issues; therefore, further research is required to identify the exact impacting factors in this respect. The prevalence of children with conduct disorder is higher in families with a defective parenting system. Emotional divorce is another issue influencing these families. Emotionally divorced couples fail to spend much time to discuss and manage family-related conflicts. Naturally, children raised in these families observe no emotional and romantic relationships in their parents and are not emotionally saturated. In addition, their parents demonstrate no adequate collaboration with their child's referral to psychological care centers.[16] These families experience helplessness and incapability feelings and are desperate for change. According to the collected results, families report burnout and helplessness after a long-term experience of their child's problems and misbehaviors as well as failure to resolve these issues. This is because they are aware of having a major problem in the family system and suffer from it; however, they feel incapable of changing these conditions. They are unaware of the social resources available in the society. There are insufficient social support resources in the society for fragile groups.[17] We lack an adequate social support system for children and families in Iran. In other words, this population has not been addressed by governmental agencies and nongovernmental agenciess as a group with special needs. Thus, the involvement of support institutions is essential in this area. Besides, families are unaware of the few potential support sources available in the community. Treating conduct disorder is particularly complex, multidimensional, and time-consuming. There is no sustained improvement in these children's behavior, as their treatment, due to various reasons, is conducted on a short-term basis and temporarily. Therefore, their families have lost their faith and creativity in this regard. Families’ concern about the not-so-promising future of their child is another issue in them. Evidence suggests that given the relatively strong association of this disorder with adulthood behavioral problems, their parents’ concern is reasonable. One of the future problems of these children in case of the lack of treatment is developing antisocial personality disorder (APD); APD has been reported to be strongly associated with conduct disorder in childhood.[1] A significant number of prisoners consist of individuals with APD. Apart from such issues in adulthood, even in many cases in childhood and adolescence, children with conduct disorder are involved in crime; many of whom are sent to children's prisons or correctional centers.[1] The limitations of having a child with conduct disorder is highly stressful. As previously reported, the families of children with conduct disorder are unable to perform essential recreational activities, like traveling. Long-term leisure activities can profoundly affect interfamily (and couples') relationships. Prior research highlighted that leisure activity is crucial for families.[1819] Using inappropriate discipline methods has created numerous problems in these families. Unfortunately, their parenting patterns have been incongruent and in significant conflict with one another. Such training provides the child with an escape path, to avoid the necessities. This method is also associated with the dual disciplining of the child. The relationship between inappropriate behavior and the severity of punishment is irrational in these families, causing severe biopsychological harm to the child. A devastating effect of severe child punishment was documented in another study.[20] Furthermore, physical punishment was common in these families. Not only can it pose serious risks to the child's health, but it also creates a faulty loop of domestic violence and conflict. Families’ reluctance to receive treatment is another serious obstacle to the treatment of these children. The family system tends to be independent, and like all systems, is resistant to new inputs and changes.[21] The cultural issues have driven these families to silence and refuse to seek others’ assistance. This might be due to a sense of dependency and inefficiency in them. Typically, these families devote inadequate time to their children, especially children with disabilities. This is because families were involved in many issues, most notably financial problems. Moreover, multi-occupancy was common among the studied parents, especially fathers; it is difficult for these families to pay the heavy cost of living. As a result, the priority of families will be more basic biological needs of the Maslow Pyramid that each human primarily seeks. Psychosocial damages have affected these families. The negative effects of alcohol and drug use on the family system have been firmly established by various studies.[2223] Parents who abuse drugs and alcohol are more prone to abuse their children and spouse and expose the family to various harms. If families successfully and sustainably treat their substance and alcohol dependence, greater peace and stability in inter-family relationships would be achieved. However, this is a complicated matter that often fails.[24] Significant psychosocial harms were reported in the parents of children with conduct disorder. It seems that these injuries, like a faulty loop in the family system, lead to various parent–child conflicts. Other research studies indicated that the odds of having difficult children is higher in parents with mental disorders.[25] Disorganization within the family system reduces the cohesion and efficiency of these families. Disorganized and poly-problematic families fail to meet their children's necessities. Their treatment is also extremely difficult in such unhealthy context. These families are unable to follow many family-centered therapeutic assignments. The low resilience level in these families causes numerous harms. They react vigorously to the smallest problems, and their tolerance is seriously diminished. Therefore, this matter generates a constant struggle in these families and adds to the pressure within the family system.

Conclusions

In families with children with conduct disorder, problems are present in many ways. Those are marital problems, helplessness and inability of family to change situation, inappropriate upbringing methods, the family's lack of interest about treatment, and psychosocial damages of family members. Due to lack of attention or too little attention to the target groups’ problems by the support institutions of the community, there needs to be a cohesive team of experts in the field. It is important to say that, the least therapeutic team in this area is the presence of psychiatrists, child psychologists, and social workers. The availability of support centers and services to these families can play a key role in reducing the existing injuries. Finally, this study is done in Tehran. Hence, it should be done in other environments to know the exact prevalence and incidence of conduct disorder in other settings.

Limitation

Notwithstanding of so much try about data gathering, lack of time for teachers and other experts’ who are offices staffs was observed.

This study was done just in a specific society in Tehran. Hence, generalizability of the results to all of conduct disorders patients’ family was another limitation of the study.

The main disorder of children in this study was conduct disorder, however some other disorders have been observed.

This research is done by certificate code from the University of Social Welfare and Rehabilitation Sciences’ research ethics committee. Approval ID: IR.USWR.REC.1397.026.

Financial support and sponsorship

This study is supported by the Department of Social Work, University of Social Welfare and Rehabilitation Sciences.

Conflicts of interest

There are no conflicts of interest.