This programme is a treatment manual written for mental health professionals. It assumes clinical training, experience of working with adolescents and their families, and a supervision framework. It replaces neither your clinical judgement, nor your professional responsibility, nor your legal obligations, in particular those concerning child protection and danger to others. Diagnostic criteria are reformulated in our own words and never reproduced: refer to the original manuals for the wording itself. It is written neither for the young people concerned nor for their parents. If a young person or someone around them is in immediate danger, call your country's emergency services.
1. The programme at a glance
Indication. Conduct disorder in preadolescents and adolescents aged 10 to 17: a lasting pattern of behaviour that violates the rights of others or the essential rules expected at that age — aggression, destruction, theft and deceit, running away and truancy —, that has lasted for at least a year and has an impact on the young person's life. The programme is addressed to the young person and to his parents, or to the adults who are bringing him up. A child aged 6 to 12 who presents with oppositional disorder, without violating the rights of others, falls under another manual: Treating oppositional defiant disorder in children: a therapist's manual.
Reference model. A multicomponent programme grounded in social learning: what an adolescent does depends on what follows his behaviour, at home, at school and in his group of friends, and it is in these three settings that you intervene. The programme combines four components, which take up the levels of intervention of the multimodal approaches recommended at this age — individual, family, school and community (National Institute for Health and Care Excellence, 2013): work with the parents adapted to adolescence, individual work with the young person, an organised link with the school, and work on the company he keeps. It borrows principles from multisystemic therapy and functional family therapy, without replacing them (section 15).
Format. Twenty sessions over three to four months, in three modules: eight sessions with the parents (P1 to P8) and eight with the young person alone (J1 to J8), of 50 minutes each, often on the same day; four joint sessions (F1 to F4), of 75 minutes, the first lasting 90 minutes, the third with the school. Three booster sessions follow, at one, three and six months after the last session. This format is lighter than that of the reference multimodal interventions, which involve three to four contacts a week for three to five months (section 14); section 44 says when it is not enough.
Mechanism targeted. Changing what follows the young person's behaviour in his three living environments, and what he tells himself before acting. On the adults' side: more warmth, less coercion, few rules that are held to, supervision that works through the relationship, a school that keeps the link. On the young person's side: reasons to change that are his own, anger spotted early, justifications examined, other ways of solving a problem, and less unstructured time with friends who transgress.
| Session |
Focus |
Session output |
| F1 |
Setting the frame |
Confidentiality in writing, safety checked |
| J1 |
The young person alone: his story and what he wants |
Risks assessed, the young person's measures taken |
| P1 |
The parents alone: the history and safety |
Maltreatment and violence looked for, record set up |
| P2 |
Regaining warmth |
One shared moment a week, three things noticed |
| J2 |
What I want, what it costs me |
Three goals written in his own hand |
| P3 |
Knowing where he is |
Written rule for going out |
| J3 |
The chain of an incident |
One incident broken down link by link |
| P4 |
Few rules, and negotiated ones |
Three to five rules and their privileges prepared |
| J4 |
Anger rising |
Thermometer and withdrawal plan |
| F2 |
The family agreement |
Agreement negotiated and signed |
| P5 |
Predictable consequences, without escalation |
Consequences grid and de-escalation plan |
| J5 |
What I tell myself to make it all right |
Two justifications identified and discussed |
| P6 |
Serious incidents |
Written plan for the six serious incidents |
| J6 |
Solving a problem differently |
Two real problems solved in five steps |
| F3 |
The meeting with the school |
Liaison sheet and designated adult in place |
| P7 |
Friends and free time |
One supervised activity chosen, the friends known |
| J7 |
Mates, and saying no |
Plan for three risky situations with peers |
| J8 |
My plan |
Prevention plan written by the young person |
| P8 |
The parents' plan |
Protocol for getting back on track written by the parents |
| F4 |
Review and next steps |
Measures repeated, boosters dated |
What the family takes away. Nine printable worksheets, listed in section 47: our week, what I want, my chain, my anger, solving it differently, our agreement, the parents' corner, the link with school, my plan for what comes next.
What distinguishes this programme from the other manuals on this site. First, a safety section returned to at every session, because this disorder has victims, and the young person may be one of them (section 11). Next, an equal place given to the parents and to the young person. And an explicit list of what is useless or makes things worse: very widespread interventions, such as frightening young people or disciplining them in military fashion, have shown no effect or unfavourable effects, and grouping together young people who transgress remains debated (section 46).
2. Before you begin
The four preliminary decisions
Is anyone in danger today? The young person, someone close to him, a classmate or a named person: this question opens every session, and section 11 is the only one that can suspend the programme.
Is the young person being subjected to violence? Maltreatment and exposure to domestic violence are among the known risk factors for the disorder (Lillig, 2018), and the British guidelines ask you also to look for exploitation by others (National Institute for Health and Care Excellence, 2013). You do not set up a programme of rules and consequences in a family where the child is being hit (section 11).
What is the legal frame of the treatment? Depending on whether the treatment has been requested by the family or ordered by a judge, what is passed on changes, and the young person must know this from the outset (section 12).
Is this programme enough? Serious and repeated violence, a life spent mostly out of the home, or an imminent placement call for a more intensive arrangement than twenty sessions in the consulting room (section 15).
What this programme does not treat
It does not treat oppositional disorder in children aged 6 to 12 without violation of the rights of others, which calls for the parent management training described in Treating oppositional defiant disorder in children: a therapist's manual.
It does not treat perpetrators of sexual offences, who fall under specialised programmes; the protection of victims comes first.
It does not treat a severe substance use disorder on its own; that disorder is treated in parallel, with the adolescent component of Cannabis use disorder: a therapist's manual (sections 34 and 35) or an addiction service.
It does not treat adults: from the age of 18, Antisocial personality: a therapist's manual takes over if the behaviour persists.
And it does not replace multisystemic therapy or functional family therapy when a trained team exists and the situation warrants it (section 15).
How to use it
Read the whole manual before the first session, in particular sections 5, 8, 11 and 12: what maintains the disorder, limited prosocial emotions, safety, justice and confidentiality. Every session follows the same framework: the aim, the steps, what you say, the common errors and the criterion for moving on. Sections 40 and 41 detail the techniques used in the sessions.
Three warnings specific to this indication.
The young person did not ask to come, and he expects one more lecture. The British guidelines point this out: many of these young people have had poor or punitive experiences of care, and they are wary of any offer of help (National Institute for Health and Care Excellence, 2013). The programme therefore starts from what he wants, not from what he is blamed for.
The parents feel accused. You need to state from the outset the purpose of the parent work, and respond to their fear of being blamed (National Institute for Health and Care Excellence, 2013).
And the therapist has reactions: fear in front of a young person who makes threats, anger at an account given without remorse, helplessness in front of an absent family. They lead you astray when you do not see them, and they are dealt with in supervision (section 48).
3. Four presentations not to be confused
The same complaint, "he steals, he lies, he stays out all night, he hits people", covers different situations.
1. The ordinary transgression of adolescence
What you observe. Occasional transgressions, often in a group: shoplifting, a night out, a fight. The young person is doing well otherwise, keeps friends who do not transgress, and feels embarrassed when he is caught.
What points the way. The isolated nature of the acts, the absence of a history in childhood, and the rest of his life holding together. Transgressive behaviour increases sharply in adolescence in the general population, and in the majority of young people it stops on entering adulthood (Moffitt, 1993).
What this implies. A twenty-session programme is not indicated. One or two consultations help the parents to react proportionately, without turning an isolated act into an identity.
2. Oppositional defiant disorder
What you observe. Temper outbursts, refusals, provocation and irritability, directed mainly at adults, without deliberate harm to people or property.
What points the way. The young person defies, but he does not steal, does not hit people to get something, and does not run away.
What this implies. Before the age of twelve, Treating oppositional defiant disorder in children: a therapist's manual applies. In adolescence, the parent and family components of this manual apply, stripped of what concerns violence and the justice system.
3. Conduct disorder
What you observe. Repeated violations of the rights of others or of the important rules for the age, across several domains, for at least a year, with consequences: exclusions, complaints, injuries, debts, placements being considered.
What points the way. The repetition, the diversity of the behaviours, and the fact that they cost other people.
What this implies. This is the programme described here, after section 11.
4. Behaviour that is a response to something else
What you observe. A pattern of behaviour that has set in as a response to a situation: violence suffered at home, bullying, exploitation by a network, substance use, a depressive episode, a trauma.
What points the way. An onset that is often recent and linked to a change, and clear suffering behind the behaviour. The running away of an adolescent girl who is fleeing a violent stepfather is not a symptom of conduct disorder.
What this implies. You protect, or you treat the cause, first (sections 9 and 11).
The three sorting questions
"Since when, and were there already difficulties before the age of ten?" It situates the onset, which changes the prognosis (section 4).
"What is going on for him at home, and is anyone hurting him?" It opens the question of maltreatment, which arises every time.
"Who suffers from it, and how much does it cost?" It measures the impact and identifies the victims.
4. The clinical picture
The four families of behaviour
Aggression towards people and animals. The young person frightens others, gets into fights, injures someone with a dangerous object, makes a person or an animal suffer, robs someone under threat, or forces a sexual act on someone. This is the family that weighs most heavily on safety.
Destruction. He damages what belongs to others, sometimes setting fires in order to destroy.
Deceit and theft. He lies to gain an advantage or to avoid what is expected of him, steals without people knowing, or breaks into their homes.
Serious violations of rules. He spends nights out despite his parents forbidding it, runs away, or misses school repeatedly; nights out and truancy only count if they began before the age of thirteen.
Note them separately. A young person who steals and lies but attacks no one has neither the same risk nor the same priorities as a young person who hits.
What the parents describe
They describe a family life organised around the young person: a hidden wallet, calls from the school, nights spent waiting, brothers and sisters who are afraid or who imitate, sanctions that have all failed, sometimes actions they regret, and, spoken with shame, fear of their own child.
What the young person describes
He rarely describes a disorder, more often unfair adults, teachers who "have it in for him", friends who are the only ones who respect him. He minimises, shifts the blame, says that "everybody does it": these sentences are part of the disorder and are worked on (session J5). When the alliance allows it, he also talks about boredom, failure at school, fear, a life he believes is already decided.
Age of onset
The DSM-5-TR, the text revision of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2022), distinguishes a childhood onset, when at least one of the behaviours of the disorder appeared before the age of ten, from an adolescent onset. The distinction matches Moffitt's taxonomy (1993): a small group of young people transgress at every age of life, with neuropsychological difficulties and an unfavourable environment adding up; a broader group transgresses only in adolescence.
Two nuances matter in practice. First, early onset has the darkest prognosis, but adolescent onset is not harmless: in the Dunedin cohort, people who had followed an adolescent-onset trajectory still had difficulties at 32, less marked than those of the persistent group (Odgers et al., 2008). Second, age of onset is a piece of prognostic information, not a verdict: it is not told to the young person as a label.
Limited prosocial emotions
In some of these young people, the behaviour is accompanied by little guilt and little empathy. The DSM-5-TR has made this a specifier, which changes how treatment is conducted (section 8).
Epidemiology
The disorder affects around 3% of school-age children, twice as often boys as girls, is frequently associated with attention deficit hyperactivity disorder (ADHD), and often leads to antisocial personality in adulthood (Fairchild et al., 2019).
5. What maintains the disorder
The origin of the disorder is multiple, made up of genetic and environmental factors and their interaction (Fairchild et al., 2019). Treatment does not target the origin: it targets what maintains the behaviour today. Six mechanisms maintain it, and all of them are accessible to treatment.
Coercion at home
This is the cycle described in younger children (see Treating oppositional defiant disorder in children: a therapist's manual, section 5): a request, a refusal, an escalation, and one of the two giving in. Each repeats what put an end to the tension. In adolescence, the cycle changes shape. The escalation goes faster and further, because the young person is stronger and can leave; the parents end up asking for nothing at all, to avoid confrontation; and home life is divided between periods of silent withdrawal and crises. Few pleasant moments remain, and it is this emptiness that the young person will go and fill outside.
Supervision lost
The parents no longer know where he is, with whom, or what he is doing. For a long time this lack was explained by a failure of monitoring. Research has shifted the question: in 14-year-old adolescents, what parents know comes mainly from what the young person tells them about himself, and it is this spontaneous disclosure that is most strongly linked to less transgression; control efforts, for their part, are linked to better adjustment only once the feeling of being controlled is removed, a feeling that is associated with poorer adjustment (Stattin and Kerr, 2000; Kerr and Stattin, 2000). These studies are correlational, but they ground the stance taken by this programme: supervision works first through the relationship.
The company he keeps and deviancy training
In adolescent friendships, exchanges in which one tells of a transgression and the other laughs, approves or goes one better function as reinforcement: this is what Dishion called deviancy training, and it predicts an increase in delinquency, substance use and violence (Dishion et al., 1999). This influence weighs more heavily on a young person who has been rejected by other children, and it is held in check by adult supervision, by positive parenting practices and by a structured setting (Dishion and Tipsord, 2011).
What the young person tells himself before acting
Two families of thoughts are well documented. The first concerns the interpretation of situations: a look, a jostle, a remark is read as hostile and intentional. This hostile attribution is solidly associated with aggressive behaviour (Orobio de Castro et al., 2002), and it fits into a broader model of social information processing, which breaks down the response to a situation into steps — noticing the cues, interpreting them, setting a goal, looking for possible responses, evaluating their consequences, acting (Crick and Dodge, 1994). The second concerns justification: thoughts that make transgression acceptable, by putting one's own needs at the centre, by blaming others, by minimising the harm done, or by assuming the worst of others. These self-serving distortions are clearly associated with externalising behaviour (Barriga and Gibbs, 1996; Helmond et al., 2015).
The school that excludes
Failure at school is one of the risk factors for antisocial behaviour, and the behaviour, in turn, compromises schooling. Exclusions add a mechanism of their own: they remove the young person from the most structured place in his day and give him free time without adults. In a longitudinal study of around 4,000 pupils aged 12 to 16 in Australia and the United States, a temporary exclusion increased the likelihood of antisocial behaviour twelve months later, with risk factors held equal, among them failure at school (Hemphill et al., 2006).
The immediate payoff
Finally, transgression pays, straight away: money, an object, respect, a thrill, the end of a humiliation. Its cost comes later, it is uncertain, and it is often experienced as an injustice rather than as a consequence. That is why a programme made only of sanctions has little chance of succeeding: other behaviours also need to pay, and early.
The complete circle
A young person who has few pleasant moments at home and a great deal of conflict spends his time outside; outside, he joins friends who value transgression; the parents, who no longer know anything, swing between threats and giving up; the school excludes; the young person tells himself that adults are against him and that only his friends respect him; and every transgression that pays reinforces the rest. It is this circle that you draw with the parents in session P2, and with the young person, in his own way, in session J3.