by Elias Mpofu
Conduct disorder (CD) exists in children in all societies and carries a significant risk of developing into criminal
Practices in the diagnosis and treatment that were developed in Western Countries are better researched and more widely
known in the
international community that those in non-Western countries. A greater understanding of CD as a health condition affecting children
globally is likely to result from knowledge of practices in both Western and non-Western countries. This article presents a practitioner's
view on the diagnosis and treatment of CD in Zimbabwe and associated theories. Two case examples on practices with children with CD in
Zimbabwe are presented and discussed in relational to local and international practices with children with CD. Spiritual intervention
within a multisystemic and multidisciplinary framework is a resource for the diagnosis and treatment of CD in some Zimbabwean children.
Children with conduct disorder (CD) evidence a number of anti-social behaviors or behaviors that violate the basic rights of others and major societal norms and rules (American Psychiatric Association: APA, 1994). A diagnosis of CD is met when three of 15 anti-social behaviors are observed over a period of 12 months. The anti-social behaviors may involve overt behavioral disorders (e.g., defiance, temper tantrums, aggression and hostile acts against people or animals) or covert behavioral disorders (e.g., ignoring rules, non-confrontive theft, truancy, lying, running away) or a combination of overt and covert behavioral disorders. Failures in the diagnosis and treatment of CD operate at a very high cost to the family, significant others and society. For example, the family of a child with CD experiences significant emotional stress from containing behavioral excesses in a child with CD as well as from the fears that the family may eventually loose the child to the prison service. Family members may also be more involved in adversarial relations with neighbors, acquaintances and social agencies (e.g., schools, community centers), which adds to their level of stress as well as take away from productive use of time and other resources (Mpofu & Crystal, 2001). Conduct disorder has a significant risk factor of developing into serious psychological disturbance in adulthood, including criminal involvement (Rey, Morris-Yates, Singh, Andrews, & Stewart, 1995).
The research on CD in children and its treatments is more established in developed counties (North America and Western
Europe) than it is the developing countries. Traditions and practices in CD by Western countries are also widely distributed
and influential to mental health practices in other countries. By contrast, indigenous notions of CD and its treatment in
developing countries are not as well documented or disseminated, although they have the potential to reveal strengths and
limitations in Western models of CD as well as add to an understanding of the social construction of CD and associated
practices. Much of the research on CD in developed countries has also proceeded without an examination of how the findings
from the developed and developing countries may be complimentary or divergent. In this connection, Western conceptions of
nd treatments for CD serve as a useful baseline for a cross-cultural understanding of CD. Piaget (1974), spoke to the
significance of cross-cultural studies to understanding psychological phenomenon when he said "psychology elaborated in our
environment which is characterized by a certain culture and a certain language, remains essentially conjectural as long as
the necessary cross-cultural material has not been gathered as a control" (p. 309). Similarly, Fryers (1986) cautioned against
"giving too much weight to the wisdom of "the West" in mental health practices or generalizing from the Western experience as
the importation of Western practices to non-Western settings was "frequently inappropriate, wasteful and dangerous" (p. 29).
This article presents a practitioner's view on CD in Zimbabwe, treatment options and cultural efficacy in that setting. The presentation draws from my experience as a child psychologist in Zimbabwe over a 10-year period and in which I worked with children with emotional-behavioral and learning difficulties, their families and social agencies. Therefore, a primary goal of this article is to explore conceptions of CD in an African country and to examine how these views influence the treatment conceptualization, design, selection and perceived appropriateness. A secondary goal of this article is to offer an interpretation of conceptions of CD in an African setting from the context of implicit theories on CD and explicit theories developed in the international community. Meeting these goals would add to an understanding of CD as a mental health issue affecting children, and their families and communities internationally. It would also reveal the cross-cultural and within culture aspects of CD that are relevant to the design of culturally sensitive treatments.
The specific questions that are considered in this article are: (a) what are the indicators of CD in children in Zimbabwe? b) How are these indicators similar and different from those in the international community?; c) Who is responsible for identifying CD in children in Zimbabwe?; d) What are the theories on CD in Zimbabwe and how are these represented in case formulation and treatment design?; (e) How do theories on and practices with children with CD in Zimbabwe compare with those in the international community?; (f) What are the implications of the Zimbabwe experience on practices with children with CD in the international community?. In providing answers to these questions, I also present and discuss two case studies from my clinical practice that illustrate referral, diagnosis and treatment with cultural responsiveness.
The Context of Child Mental Health In Zimbabwe
Zimbabwe is a southern African country with a population of about 11 million people, and a total area of 150 873 square miles (390 759 km2). The country has ten administrative regions. Eighty percent of the population lives in rural areas and 20% in the cities. About 95% of the population are Blacks and five percent other ethnic groups. Eighty percent of the population are Shonas (a cultural-linguistic group), 15% are Ndebeles, and 5% Asians, Whites and others. Eighty percent of the population lives in rural areas and 20% in the cities. Agriculture is the leading economic activity in the country, although mining, tourism and manufacturing are also important to the national economy. Zimbabwe shares borders with five countries: Botswana, Mozambique, Namibia, South Africa and Zambia. Zimbabwe was a British colony until 1980.
The country has a multilayered system of mental health care: modern and traditional (Mpofu, 2001). The modern (formal) mental health care system is manned by medical doctors, psychologists, social workers and other rehabilitation professionals with training in Western methods of diagnosis and treatment. There are no national, official criteria for diagnosing CD in Zimbabwean children and rehabilitation professionals rely on those used in Western countries (e.g., the Diagnostic and Statistical Manual ÐVolume IV [DSM-IV]: APA: 1994). Nonetheless, there are regulations that govern expected behaviors of children in schools and other community settings. For example, the Zimbabwean Ministry of Education, Sport and Culture has a policy on student discipline that in many ways is designed to counteract significant infringements on the rights of other students and teachers. The Ministry of Labor, Manpower Planning and Social Welfare has primary responsibility for intervening in cases of gross violations of conduct by children in community settings and which pose a significant risk to the child and the community.
Traditional healers and prophets provide mental health services in the traditional (nonformal) sector. The World Health Organization (WHO) defines traditional healers as persons who use vegetable, animal, and mineral substances to treat a variety of acute or chronic conditions and are recognized by their communities as providers of health care. Traditional medicine is defined as "knowledge and practices, whether explicable or not, used in diagnosis, prevention and elimination of physical, mental or social disequilibrium and relying exclusively on practical experience and observation handed down from generation to generation, verbally or in writing" (p. 3). Traditional healers in Africa have a greater than chance success rate in the treatment of psychiatric illness (Asuni, 1990; Levers & Maki, 1995). Their ranks include spirit mediums who, in addition to practicing traditional medicine are also skilled at divination (Last & Chavhunduka, 1986).
Prophets are often leaders of indigenous Christian churches. The prophets and their followers believe in diagnosis and treatment through prayer. Prophets aspire to biblical standards of treatment (e.g., the mentally-ill achieve instantaneous recovery). Some prophets do not allow members of their congregations to visit hospitals or to take medicine.
There is typically no referral system for patients from experts in the formal health sector (e.g., doctors, psychologists) to those in the nonformal health sector (i.e., traditional healers; prophets) or vice-versa; - although traditional healers and prophets are likely to refer patients with intractable health problems to the hospitals. Often, the traditional healer is the first port of call and also the last resort for a majority of Black Zimbabweans. Middle to upper class Black and White Zimbabweans are also known to consult traditional healers, though to a lesser extent. A minute number of traditional healers are White. The lack of coordination between professionals in the formal and nonformal health care systems in the country is a source of confusion and anxiety for patients and their families.
Indicators of Conduct Disorder in Zimbabwean Children
For a majority of Zimbabweans, who are rural and Shona, children failing in culturally appropriate social competencies would be regarded as having CD. Socially competent Zimbabwean (and African) children are expected to be capable of many of the following:(a) appropriate extension of social greeting to peers and adults, (b) leadership with social responsibility, (c) a cheerful or friendly disposition; (d) age appropriate confiding of the family stories so as to protect the family name (Mpofu, 1996); (e) successfully carrying out errands; (f) being a parent-child (i.e., look after younger siblings) (Serpell, 1991); (g) sharing with and helping extended family (Mpofu, in press); (h) help with a variety of family chores (e.g., gardening, weeding, herding livestock) (Whyte, 1998); (i) identifying common illnesses in their community and the appropriate herbal treatments (Sternberg, Nokes, Geissler, Prince, Okatcha, Bundy, & Grigorenko, 2001; (j) deferring to older siblings; and (k) being quietly observant or deferring to adult talk (Bourdillon, 1987). Failures in one or more of these culturally defined social competencies would comprise CD. In addition, the behaviors that comprise significant violations of the rights of others and the community in Western countries (e.g., fighting, defiance, temper tantrums, destructiveness, negativeness, stealing, lying, ignoring rules, aggression and hostile acts against people or animals, truancy, running away) would also be indicative of CD in Zimbabwean children. Thus, CD in children in Zimbabwe (and other native communities of sub-Saharan Africa) has a presentation that is both similar and different from that for children in North America.
Chronicity, frequency and severity of behavioral indisposition are relevant to defining CD among Zimbabwean children. However, unlike the DSM-1V criteria for definition of CD which requires the display of a minimum number of behaviors from those regarded as indicative of CD (i.e., 3 of 15 behaviors) over a specified period (i.e., 12 months), there is no quantitative criteria for diagnosing CD with Zimbabwean children. Whether a child is regarded as having CD is by the informal or formal consensus of those who have had the opportunity to observe and work with the child in a variety of contexts and the cultural salience of the social competence in which a child is failing.
People Involved with Identifying Children with Conduct Disorder
The identification process is both a family and community effort. Immediate family, extended family, neighbors, the community and social agencies such as schools and churches are involved with the identification of CD in Zimbabwean children. For example, the school may inform the family about their child being truant from school, lying or getting involved in fights with other children. The family may also initiate the identification by alerting the school of negativeness or disregard of rules by a child. Peers and siblings may also initiate identification by reporting anti-social behaviors to their parents, and teachers. Members of the community or neighbors may express their concern about the child's behavior to the family.
Community members typically inform the immediate family of behavioral difficulties in their child. This is because in contributing to the identification of a child as having CD, the community members must save the face of the family of the child in question. The social etiquette of saving face requires that members of the community reporting on behavioral difficulties in a child must be sensitive to the social standing of families. Families regard each other as "vanyarikani" (Shona language: those who are held with reverence). For that reason, members of the community or neighbors are unlikely to report behavioral problems in a child unless the behaviors are quite conspicuous. Because of the cultural significance of the practice of saving face, a child with early onset CD is likely to be identified when he or she enters school.
Zimbabwean social agencies such as schools are more likely to identify CD than families and the community in general. This is partly because teachers accumulate a reliable and larger repertoire of experiences with child behavior through their day-to-day professional work than would be possible with families (Markowitz & Coccaro, 1995). Teachers may also be less emotionally involved with the child as to overlook troublesome behaviors. In addition, and as previously noted, Zimbabwean school regulations require that teachers work with the school administration in enforcing discipline among students. Schools are likely to work with parents to solicit the help of other social agencies (e.g., psychological services) in the diagnosis and treatment process. However, families may prefer to consult traditional healers and prophets for diagnosis and treatment. The identification process by family, community, and social agencies is done within a help-seeking or help-giving process. For example, when a family informs the school of negativism and general disobedience in a child, they are essentially asking the school to intervene in that context.
Theories of Conduct Disorder in Zimbabwe
An understanding of theories of CD germane to particular societies is important because such theories influence how persons with CD are identified, and the socio-cultural opportunities (e.g., education, treatment) available to them. A study of theories of CD in a society is also important because constructions of CD influence how members of a particular society think, imagine, talk, account and act towards those they regard as having CD disorder. In the case of Zimbabwe, modern and traditionalist influences on its citizens are such that some sections of Zimbabwean society would regard CD in children from a Western perspective and whereas others would view it from a traditionalist-indigenous perspective. There are also Zimbabweans who may prefer to view CD from both a Western and a traditionalist perspective. Many citizens of that country subscribe to an implicit theory of CD.
Implicit theories have been defined as "constructions by people Éthat reside in the minds of these individuals" and "are discovered rather than invented because they already exist Éin people's minds" (Sternberg, 1985, p. 608). These implicit theories are captured in the people's communications (e.g., language) pertaining to their notions about specific phenomena (Irvine, 1988; Sternberg, 1985). Implicit theories of native African communities have been documented by researchers on the psychology of human intelligence (e.g., Serpell, 1991; Sternberg 2001, Irvine, 1988, Mpofu, in press), disability and disease (Burch, 1989; Janzen, 1992).
The Shona terms musoro bhangu, (the one who bangs his or her head), musikahwa (one with distorted behavior), mambara (with cast away manners), and mwana anemamhepo (child with the winds) are descriptors for children with CD in that cultural community (Chimhundu, 2001). Musoro bhangu (one who bangs his head) suggests a view of CD as a failure in self-regulation associated with impulsive decision-making. Musikahwa (distorted behavior) is a term that is closely related to musoro bhangu in that children with musikahwa are regarded as having distorted thinking. A mambara child (or one with cast away manners) is so behaviorally maladjusted that he or she is appears to have lost all sense of culture or social propriety. The terms musoro bhangu, musikahwa, and mambara suggest that the Shonas have an implicit theory of CD and consider it as a failure in basic self-regulation due to poor cognitive processing.
The implicit theory by the Shonas that cognitive distortions cause CD in children is similar to explicit theories of conduct disorder that have been proposed by researchers in North America and Western Europe. Researchers on CD in North America have linked CD to distortions in the encoding of social cues, interpretation of social cues, clarification of goals, response access or construction, response decision, and behavioral enactment (e.g., Coie & Dodge, 1998; Dodge & Coie, 1987; Kazdin, 1996). As an example of a cognitive distortion, children with CD tend to interpret ambiguous interpersonal stimuli as hostile, and attend to fewer social cues before forming an interpretation. Such distortions predispose them to be hostile to others.
The notion that children with CD have "the winds" (ana mamhepo) is an implicit theory which is grounded in the belief by the Shona in a spirit world that influences the day to day activities of the living. The alleged "winds" causing child behavior problems are presumed to be spiritual visitations on the child from the dead or ancestors (Mpofu & Harley, 2002). For instance, a family may believe that CD in a child is the manifestation of a spirit of ill omen cast on the child by his or her family's enemies. The winds may also be the spirit of a departed person who was aggrieved by a family member of the child and is seeking appeasement. Conduct disorder in a child may also be caused by the spirit of a departed family member for whom culturally prescribed rituals were not performed. Thus, unfinished business with the departed or ancestors is regarded as a major source of human disturbance.
Typically, families holding the view that CD in their child is of spiritual causation would have consulted a traditional healer or prophet who may assert or confirm a spiritual causation for the CD. Children whose CD is ascribed to spiritual causation usually have more severe and chronic conduct problems or a conspicuous history of non-responsiveness to counseling by the family and social agencies.
A significant number of children with conduct problems who come to the attention of schools and social welfare agencies in Zimbabwe are children experiencing various types of abuse, neglect and / deprivation (M. Mutepfa, personal communication). Abuse, neglect and deprivation of children have been reported across social class. For instance, children of parents in the upper social classes (i.e., middle to upper levels professionals) are emotionally neglected by parents who are hardly at home because of their business interests and react with abusive aggression. Children in poverty may have CD because their parents cannot provide for their basic needs. Thus, they may steal and lie to get food and other essentials.
Social welfare officers and psychologists in Zimbabwe tend to work with children from the upper social classes more than with those from the lower social classes. This may be because parents with higher income are also more educated and aware of the services they can get for their children from social agencies. They can also afford consultation and other service fees.
Theories of Conduct Disorder in Zimbabwe: Influence on Treatment Options and Efficacy
Consultation behavior by Zimbabwean parents of children with disabilities spans both the formal and informal helping sectors. Piachaud (1994) observed the following about urban communities in Zimbabwe: "within workshops organized for parents and workers in Harare it was possible to combine biological and spiritual explanations as well as solutions; a behavioral approach was not seen as contradictory to caring, to taking medication or visiting a spiritual healer" (p. 385). Nonetheless, the fact that a traditional healer or a prophet was consulted may not be shared with health professionals in the formal sector because of the lack or a referral system between the formal and nonformal health services (Chidyausiku, 2000; Mpofu, 2001). In next section, I present two case examples from my clinical practice that illustrate the multilayered view of CD by Zimbabwean parents of children with CD, treatment options and perceived cultural efficacy.
Case Presentation and Discussion
Case Example 1.
Background information. Trevor (not real name) was a boy of 7 years 5 months of age and attending Second Grade at a school in the city of Harare. He was referred for assessment by his family through their physician on the grounds that he had encopresis and chronic behavioral problems. Encopresis is a condition of fecal soiling that often occurs during daytime. It is more common in boys than girls. Only about 1% of boys have encopresis after age 7.
At the time of referral Mr. and Mrs. Wilson said that Trevor had experienced encopresis for about 4 months. They also observed that the onset of the condition coincided with their recent change of residence. Mr. and Mrs. Wilson were both Zimbabweans of mixed race. Their first language was English.
Trevor was an only child of the Wilsons. Mr. Wilson was a retail merchant and Mrs. Wilson, an airhostess. Mr. and Mrs. Wilson said they normally left Trevor under the care of their housemaid if away or at work. They considered Trevor a very affectionate child.
Mr. and Mrs. Wilson reported that they had tried a variety of own management skills in an attempt to eliminate the problem of encopresis in Trevor but without success; - hence the referral. Mr. and Mrs. Wilson also noted that Trevor had experienced some school adjustment and behavioral difficulties since First grade and for which they sought help from the Zimbabwe Schools Psychological Services (SPS) some 2 years before. The SPS is a public agency for the assessment and educational placement of children with special needs. Upon request, the SPS forwarded to me copies of Trevor's test records but did not have a completed report on Trevor.
Mrs. Wilson said Trevor had problems working with one of his teachers and had threatened to kill the teacher and burn the school down. Mrs. Wilson further observed that at 3 years of age, Trevor had set fire to an apartment and from which he and other residents had emergency evacuation. Mr. and Mrs. Wilson reported that Trevor also had problems paying attention and was impulsive.
The family's implicit theory about the conduct disorder. Both Mr. and Mrs. Williams ascribed their child's conduct disorder to the fact that they were minimally involved in his life. They said they were both career persons and spent a considerable amount of time away from home. As a result, Trevor was looked after by a housemaid. In response to my enquiry, they said they did not recollect a history of conduct disorder in their childhood or families of origin.
Assessment findings. The results of formal assessment showed that Trevor had an overall cognitive ability within the low average range as compared to peers of a similar age. His scholastic attainment was very low for age and school grade placement. Trevor's story telling in response to a set of pictures (i.e., Children's Apperception Test) revealed that he had significant levels of fear and anxiety about his own emotions and those of others. The results of an analysis of an adaptive behavior inventory completed by Mrs. Wilson on Trevor showed that Trevor had significantly fewer skills in Cooperation, Assertion, Self-Control and Responsibility as compared to same age peers. He also showed significantly higher scores on acting out behaviors and hyperactivity. During the assessment, he had difficulties sustaining attention and with seatwork. He also soiled his pants during the assessment and tried to disguise it.
Clinical impressions and treatment recommendations. Trevor's behavioral history and assessment results indicate that he had Early-Onset (or Early Childhood Onset) Conduct Disorder (EOCD) with Attention Deficit Hyperactive Disorder (ADHD). The ADHD may have been the motor behind the CD since an inability to attend is likely to lead to inappropriate or impulsive behavior. His condition of Encopresis was an established fact, and could be linked to his sense of insecurity and consequent regression to an earlier stage of development. A behavioral management program was recommended for the disruptive behavior and the encopresis and with collaborative participation of his parents, and school.
The disruptive behavior treatment protocol. Mr. and Mrs. Wilson and school personnel worked collaboratively with school personnel to minimize Trevor's participation in activities that were likely to reward impulsive behavior, inattentiveness and non-task compliance. This inter alia entailed placing Trevor in a class with a lower teacher-pupil ratio where his behavior could be better treated and monitored. Training in self-regulation and task engagement involved:(a) breaking the requisite tasks into constituent components; (b) parent or teacher vocalizing to Trevor how to go perform a task, and with demonstration; (c) asking Trevor to verbalize while performing the task; (d) having Trevor perform the required task while whispering to himself; and finally, (e) performing a required task with internalized self-talk (i.e., quietly talking to self).
In learning this self-control procedure, Trevor was taught to self-question in sequence (e.g., What must I do? What do I need to accomplish the task? What should I do next? And After? Is there anything else I need to do? Am I finished? Would Mom or Dad think I am finished with this? Would my teacher think I am finished? Have I done what I started out to do?). I also recommended consideration of stimulant medication for the hyperactivity by the physician, and an initial review of treatment effectiveness with the Wilsons after three weeks.
The encopresis treatment protocol. Since the medical doctor's referral letter did not specify medical conditions that had already been investigated with regard to the encopresis, I recommended that the family physician rules out Hirschsprung's disease (a neurogenic megacolon that results from an absence of anglionic cells of the rectum or large intestine), and megacolon caused by obstructive lesions. In the absence of an established organic cause for the encopresis, the behavioral treatment regimen for the encopresis was premised on the assumption that it was of psychogenic origin. For that reason, Trevor was placed on scheduled or managed toileting retraining regimen as follows: (a) toileting at least 4 times a day including after each meal, and at bedtime; (b) remaining on the toilet seat until either a bowel movement occurred or five minutes have elapsed; (c) reward for achieving appropriate bowel movement or using the toilet appropriately (The selection of rewards was to take into account the activities, things and events that Trevor liked); (d) inappropriate bowel movement were to be ignored (Trevor was to be allowed required change of underpants though); (e) after being free from soiling for at least 2 weeks, supervised and scheduled toileting was to be followed by encouraging Trevor to take voluntary trips to the toilet whenever he sensed rectal fullness. Monitoring of voluntary trips was to last about eight weeks. The program was managed by Mr. and Mrs. Wilson and designated school personnel.
At initial review, the Wilsons reported remission of the encopresis, and notable improvements in impulse control. They also reported greater satisfaction with the amount of quality time they spent with the child as occasioned by the treatment regimen.
Discussion of Case Example 1.
The Wilsons exemplify consultation behavior by middle to upper class Zimbabweans. Middle to upper class Zimbabweans are more aware of health services in the formal sector and can access these directly or through their physician. They were also comfortable with a diagnosis stated in established nosology (e.g., DSM-IV), and introspective about the source of behavioral difficulty for their child. As previously mentioned, the Wilsons' implicit theory about conduct disorder in their child was that it originated from their lack of involvement with the child. Introspective views about the origin of mental health problem are associated with an individualistic worldview, and common to the health beliefs of people in Western societies (Landrine, 1992). The Wilsons were also amenable to cognitive-behavioral methods of treatment and with direct involvement in treatment design, implementation and evaluation. Thus, some Zimbabweans would accept and seek a diagnosis of conduct disorder as it is defined in the West, as well as associated treatment regimens. This worldview and approach to health problems in Zimbabweans is due to the country's British colonial heritage and modernization.
Case Example 2.
Background information. Mukuvisi Nyajena (not real name) was an eight-year-old boy who was referred for assessment by his school. He was in Third Grade and from a low-income, Shona cultural background. Mukuvisi lived with his father and stepmother in a small town in southeastern Zimbabwe. Mr. and Mrs. Nyajena (not actual name) were both of a Shona cultural background. They had less than Fifth grade schooling. Mr. Nyajena was a general hand (unskilled worker) with one of the companies in the town whereas Mrs. Nyajena was a full-time housewife. I established from Mr. Nyajena that Mukuvisi's biological mother has passed away five years before. Although the Nyajenas were currently residing in town, they also maintained a home in the rural areas and in a village mainly comprising members of the extended family. The practice of working in the city, while maintaining a rural home is common among Zimbabweans and many indigenous people of sub-Saharan Africa.
The referral letter from the school specified that Mukuvisi was highly disruptive of class. For example, the school reported that he often hopped from desk to desk during class time and at recess. He also performed unscheduled acrobatics on the school fence to the amusement of schoolmates and passer-bys, stole from classmates, physically assaulted other children, was verbally abusive, and had a record of truancy from school. His class performance was very poor.
Mukuvisi's niece was my initial contact person and informant from that family. She said that she had been asked by Mr Nyajena to accompany Mukuvisi to my clinic upon the request of the school. The niece also said that Mukuvisi was well liked by family, other children and neighbors. I requested the niece to be my "go between" (intermediary) with Mr. Nyajena and to respectfully ask him to come to visit me for an "exchange of ideas" on his son. This request was extended by word of mouth rather than in writing.
The cultural significance of word of mouth among the Shona (and most indigenous communities of sub-Saharan Africa) lies in that the oral tradition is an indelible part of African culture and much respected by traditionalist Africans. Furthermore, allowing the intermediary to couch the request in own words and a carefully selected or appropriate context maximizes the chances of acceptance of the message. A letter, even in the native language, would not have the same impact as word of mouth communication through a member of the extended family.
Assessment findings. On the day of visitation to my clinic I had Mukuvisi do a number of informal tests of attention, task orientation as well as an evaluation of perceptions of his acceptance by peers. For the peer status evaluation I asked him some open-ended questions in Shona, his native language. Some of the questions (and answers were (a) "What do you do if a classmate seems to be in trouble (Answer: I don't know; É Leave him alone); (b) What is the thing to do if a classmate does not do things the way you would (Answer: Tell him to do as I do?) (c) What do you do if you see someone first? (Answer: Look at the personÉGo to the person). (d) How do you get most children to do what you would like to get done (Tell them and say look; then do itÉ).
I then had Mukuvisi complete a curriculum-based assessment using the textbooks from his school. He had not mastered basic number and letter recognition. In addition, I asked Mukuvisi's teacher to do a baseline behavioural assessment using an observation checklist with time and activity sampling. The data would subsequently be useful in the design, implementation, and evaluation of school based treatment.
I asked a social worker to do a home situation analysis. The social worker's written report noted that Mukuvisi's neighbours said he had stolen quite a number of things from them (e.g. radio, watch, food). The social worker also reported that her interview with Mukuvisi's step- mother suggested that the family was critically short of basic commodities.
About a week later, Mr Nyajena honoured my request for a consultation meeting on his son. He shared the family's implicit theory about Mukuvisi's behavioural difficulties.
The family's implicit theory about the conduct disorder. Mr Nyajena acknowledged that his son had experienced significant behavioural difficulties in the previous two years. He said he was also aware of the problems that Mukuvisi was experiencing in school and had been to the school on several occasions upon invitation by the school head. Mr Nyajena also noted that Mukuvisi had stolen from neighbours previously and that as parent, he had amicably resolved issues with the concerned neighbours. Then, Mr Nyajena said that his son's behavioural difficulties were due to a protest by the spirit of Mukuvisi's mother who passed away five years before. Mr Nyajena said that although his wife had died that many years previously, he and extended family had not performed the necessary spiritual rituals to bring Mukuvisi's mother back into the family. For that reason, the spirit was causing adjustment problems in the boy as a way of calling attention to its neglect by the family and exclusion from family participation. Shona beliefs and customs hold that the spirit of a dead family member who has offspring stays in the wilds until a ritual is performed to invite it back into the family fold. Within the family, ancestral spirits are presumed to have both protective and benefactor functions (Mpofu & Harley, 2001).
Clinical impressions and treatment recommendations. Mukuvisi had behavioural problems consistent with Early Onset Conduct Disorder. Indicators consistent with this diagnosis include poor impulse control (e.g., steals, fights other children, climbs dangerous structures), being verbally abusive and truant over a period exceeding a year. The peer status interview showed he had a poor knowledge of age and culturally appropriate social skills. The fact that his family had significant difficulties meeting daily basic needs may have exacerbated behavioural difficulties (e.g. stealing of food from neighbours). I collaboratively designed a multi-component treatment regimen with the family and school: spiritual, special educational placement, and family support.
Spiritual intervention. Mr Nyajena, and family were to perform the requisite rituals to bring Mukuvisi's mother back into the family fold. The ritual was to be performed during the next school vacation to avoid loss of school time by Mukuvisi. In consultations with Mr Nyajena after the school vacation, I was informed that the spiritual ritual was subsequently performed.
The ancestral spirit reception among the Shona requires attendance by as many members of the immediate and extended family as possible. For that reason, most of these receptions are held during public holidays or weekends when family members who may be working in the cities are on leave. Staging a spirit reception can be quite involving. To begin with, the elders in the family with an identified patient should reach consensus that the presenting symptoms are likely to be of spiritual origin. A spirit medium is then consulted by a team of elders from the family, and /or related family (e.g., in the event of suspected spiritual causation by a departed mother). The spirit medium must confirm spiritual causation of the debilitating condition. He/she would also advise on proper procedures for the reception. Alternatively (or sequentially), a prophet may also be consulted.
The spirit reception itself typically involves the sharing of beer that is brewed by women who have reached menopause and no longer sexually active. Women who have reached menopause and abstaining from sex are considered chaste and respected by the ancestral spirits. The beer is brewed with stone ground African sorghum (a type of small grain). In addition to the home brewed beer, a goat is killed and its cooked meat eaten by participants. The meat is taken without salt. The relatives from the departed woman's family will perform the spirit invitation. The ceremony is held over a day or two. The identified patient is expected to attend the reception, even though he or she may not be directly involved with the practical aspects of the ceremony.
Acceptance of the call to rejoin the family is determined in various ways. One, an involuntary spasm by the goat to be slaughtered for the ceremony in response to cold water being poured on its shoulders by female grand children of the paternal family, and in turns. The individual who gets the goat to quiver is regarded as closest to the spirit of the departed, and may be called by the departed person's name henceforth. Two, the previously unwell family member should show a remission of symptoms or be cured. Three, a spirit medium is consulted and must testify that the reception was accepted and the spirit is question back with the family.
Special educational placement. I recommended educational placement for Mukuvisi in a resource unit for children with special needs at the school. Mr Nyajena accepted this placement on the grounds that it would help his son achieve better in school. I worked with the teachers to develop an individualized academic and behavioural programme for Mukuvisi. The behavioural problem treatment protocol used a problem solving approach with applied behavioural analysis as previously described. The resource unit teachers at the school had prior experience and training in the treatment of children with academic, emotional and behavioural difficulties.
Family support. Family support focused on enhancing parenting skills in Mr and Mrs Nyajena. It entailed monthly consultations on Mukuvisi's behavioural adjustment. In order to avoid the misperception that I was talking down to the family from the platform of an "expert", the Nyajena's and I referred to our consultations as "kupana mazano" (sharing of ideas). The Shonas have a proverb, which says "Mazano marairamwa" (As for plans, you best learn these by sharing with others). Within that cultural practice, deficiencies are implied rather than directly stated or apportioned to a parent. Extensive use is made of analogies and contrived stories involving people like the identified patient and other families that may be in similar circumstances. Attempts to get a parent to examine own parenting with a view to acknowledging areas of underperformance may be interpreted as a lack of trust in the family's parenting ability and could hamper cooperation. Nonetheless, homework specific to the client and family can be negotiated and assigned to the family. Asking the family to participate in the counselling of their child reinforces the perception that the counsellor trusts the family and therefore, can be trusted in turn.
Often, either Mrs. or Mr. Nyajena would come for consultation and rarely, both. This practice was consistent with consultation behavior among the Shona in which a consulting parent is regarded as standing in for the whole family (including extended family). The assumption is that consultation information will be accurately shared with all people involved. I also linked the family to Christian Care, a non-government organizations that supplied food and clothing to the poor.
Results of the treatment were positive for impulse control, abusive behavior and truancy at the end of the three-month period following intervention as attested to by teacher reports, family interview and home situation reports by the social worker. There was reason to be optimistic about the likely long-term effect of the treatment.
Discussion of Case Example 2
The case of Mukuvisi illustrates the belief among traditionalist Shonas that CD is of spiritual causation. It also shows that identification may be initiated by a social agency (in this case the school) because neighbours and members of the extended family may be unwilling to report conduct disorder in a child in order to the save the face of the child's family. Mukuvisi and family's neighbours did not notify any social agency of theft by Mukuvisi. They preferred to settle any issues with the family. Mukuvisi's niece would not admit to me that he had significant behavioural difficulties and deferred to Mr Nyajena (the father) to make that statement. Fortunately, Mr Nyajena found me a sufficiently credible counselor to share his implicit theory that the CD was due to spiritual causation. This break through was achieved, in part, because of the participation of a member of the extended family in brokering the meeting with Mr. Nyajena and respect of communication with him by word of mouth rather than in writing. Mr. Nyajena also admitted to behavioural difficulties in his son because they had become so conspicuous as to cause concern to neighbours and the school. The social welfare officer had also enquired on the boy's conduct, which may have added to the perception by Mr Nyajena that it was time to seek help for him from all possible sources.
Once a social agency was involved, traditionalist Shona families may cooperate with the treatment regimen (Piachaud, 1994). Families can reasonably be expected to participate in treatment design and activities consistent with their implicit theories about the conduct disorder. In the case of Mukuvisi, only the family could carry out the spiritual intervention.
It is possible that Mukuvisi's behavioural difficulties may have been a result of conflicts with his stepmother and/or father. However, with traditionalist Shonas, counselors should presume that a parent is competent unless proven otherwise by a competent group of elders or a formal court ruling. Possible problems with parenting were addressed within a kupana mazano (sharing of ideas) cultural practice.
The case of Mukuvisi demonstrates that success in identifying and treating conduct disorder in children from a traditionalist Shona background requires openness to spirituality as both a cause of ill health and a resource for treatment. Accommodation of a world-view that is centred in spirituality and saving face does not proscribe simultaneous use of traditional-spiritual interventions and modern, cognitive behavioural interventions. Use of treatments of CD that are respectful of both the traditional and modern views of CD was more appropriate than reliance on treatments premised on one world-view.
Implications for the Practices with Children with Conduct Disorder in the International Community
The data presented in this study show that people's implicit theories on CD are relevant to the diagnosis and treatment of CD in children. They are useful for understanding the socio-cultural ecology of the CD from the clients' perspective. Clients in this case are the children with CD and their families or significant others. People's implicit theories about CD also provide a window of opportunity for inviting the cooperation of family and significant others in treatment design and implementation. Since all people hold an implicit theory about most phenomenon (Sternberg, 1985), implicit theories on CD exist in all societies and are a resource for those who seek to work with children with CD and their families in culturally responsive ways. Children's implicit theories about their behavior have the potential to add to an understanding of CD and to treatment design.
Explicit theories on CD such as those developed in the West and associated practices can add
to an understanding of CD by enabling multiple perspective taking as well as suggesting resources
for successful practice with children with CD that may not be known to the client. For instance,
Rogler et al. (1987) acknowledged, "sometimes the objective of therapy is to change culturally
prescribed behavior" (p. 568) whereas Sue and Zane (1987) observed, "therapists should not simply
strive to match clients. At times, the client's belief systems may be inappropriate" (p. 41).
These views are consistent with the view that implicit and explicit theories of CD and associated
practices should be seen as complimentary rather than as exclusive and to be potentially applicable
to a majority of clients. In accommodating both implicit and explicit theories of CD in diagnosis
and treatment, the rehabilitation professional must "ultimately attend to the final objective of
relieving the client of psychological distress and of improving his or her level of effective
functioning in the society" (Rogler, Malgady, Constantino, & Blumental, 1987, p. 570).
The findings of this study support the view that effective treatments for CD are those that are multisystemic (Henggeler & Bordiun, 1990), and multidisciplinary in approach. Children with CD like those without the condition transverse a number of contexts each day. The contexts hold a variety of opportunities for addressing aspects of behavioural adjustment. Treatment is likely to be successful when it addresses the child's functioning in a number of contexts and from the viewpoint of people familiar with those contexts. A treatment team should comprise members with unique expertise and insight into the contexts in which the child will ultimately function (e.g., family, school, community). Professionals must be willing to work with people with experiences and expertise outside their customary comfort zones (e.g., spiritual leaders) but who may be significant to the client's world-view.
Summary and Conclusion
Conduct disorder involves significant and chronic behavioural violations of major societal norms by a minor. There is considerable variability in social criteria that may be relevant to defining conduct disorder both between and within societies. At the same time, there are basic human values that transcend societies and whose persistent infringement by children would constitute CD. The DSM-IV (APA, 1994) criteria for conduct disorder captures a majority of core norm violations by which children constitute CD, even in the international community. In African settings, additional criteria may apply and salience of the behavioural anomaly in relation to social competence norms is important to children's conduct status.
Zimbabwe has a dual system of mental healthcare services that are involved with children with conduct disorder: modern and traditional. The modern system has formally qualified practitioners where the traditional system is run by traditional healers and prophets. There is little coordination of services between these systems, although a majority of the citizens use both systems either sequentially or simultaneously. Mental health service utilization by children with CD and their families depends on social class and level of education with Zimbabweans with higher levels of formal education and in the upper classes utilizing the formal health services more that those in the lower social classes or with less formal education. This is despite the fact that children from lower income and less formally educated families are at an elevated risk for CD.
Child rehabilitation professionals in Zimbabwe rely on family members as informants. A majority of parents will approach professionals in the formal sector for diagnosis and treatment after a social agency or member of the community have raised concern about their child's conduct. There is considerable circumspection with acknowledging conduct disorder in a child by parents or significant others because of anxieties about loosing face in the community. As a result, CD among Zimbabwean children is likely to be underreported, and to remain untreated.
Zimbabweans hold implicit theories on CD that are both similar and different from those espoused by theoreticians in North America and the West. In particular, they regard CD as a manifestation of faulty or distorted thinking. In addition, some may also hold the view that CD is of spiritual origin and amenable to treatment by holding a spirit reception. Conduct disorder in Zimbabwean children is also due to child neglect and abuse by families and significant others. Case examples that are discussed in this article show that Zimbabweans have multilayered views of CD and depending of the background of the family, may use both formal and nonformal mental health services.
The findings of this study suggest that practices with children with CD in the international community should build on both the implicit theories unique to those societies while taking into account relevant aspects of explicit theories that were developed in the West. Specifically, the meanings attached to the behavioural-emotional difficulties that children experience are best understood from the social constructions of parents or caregivers. These social constructions reflect the parents or givers' theory of health and are important for the perceived credibility of diagnosis and treatment. Treatment compliance may also be significantly influenced by the perceptions by parents or caregivers of the extent to which their meanings were accommodated in diagnosis, treatment conceptualisation, implementation and evaluation.
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Assistant Professor, Pennsylvania State University
Elias Mpofu is an associate professor at the Pennsylvania State University. His research interests are in
developmental aspects of health and behavior in children and adolescents from a cultural and cross-cultural
perspective. He is a state licensed psychologist in Zimbabwe, and a certified rehabilitation counselor in the
USA. He taught at the University of Zimbabwe for 8 years before his current appointment, and is
a member of 6 national and international psychology, and rehabilitation associations across 4 continents.
Elias Mpofu, Ph.D., C.R.C., Department of Counselor Education,
Counseling Psychology and Rehabilitation Services,
The Pennsylvania State University,
29 CEDAR Bldg, University Park, PA 16802, USA
International Journal of Disability, Community &
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