Introduction
Conduct disorder (CD) is a severe mental disorder in children and adolescents that is characterized by recurrent and persistent violation of the rights of others or social norms [1]. It is estimated that there are 51.1 million patients with CD in the world [2]. According to the epidemiological studies, the CD prevalence is 2-16% [1, 3, 4]. The non-suicidal self-injury (NSSI) is another common mental health problem among adolescents. According to previous studies, NSSI is a common comorbid problem with CD in adolescents [5-8]. The prevalence of NSSI behaviors among patients with CD is 15.5-62.5% [9], which increased during the COVID-19 pandemic [10]. The annual cost of CD and NSSI are substantial [11-13], and there is a crucial need for efficient and cost-effective interventions to treat them.
Multisystemic therapy (MST) was originally developed to treat juvenile offenders with severe conduct problems and their families [14]. During the past two decades, MST has been adapted and applied in various settings for treating adolescents with NSSI behaviors [15]. No study in Iran has investigated the effectiveness of MST in treating NSSI behaviors and CD simultaneously. Therefore, the present study aimed to examine the feasibility of applying MST-based intervention (MST-BI) as an unprecedented therapeutic intervention in treating CD symptoms associated with NSSI behaviors.

Methods

Case report
The case was a 17-year-old boy who met the criteria for CD and NSSI behaviors using the structured clinical interview for Diagnostic and Statistical Manual of Mental Disorders-4th ed. (DSM-IV) [19]. He was a tenth-grade student and the first child of a family with three children who was living with his single-parent mother at the time of the study. He had two younger sisters (aged 9 and 7 years), one had attention deficit/hyperactivity disorder (ADHD) and the other was diagnosed with autism. He was referred for treatment because of frequent aggressive behaviors at home and at school, school truancy, relationship with deviant peers. and persistent NSSI behaviors. His interactions with family members were highly conflictual –especially with his mother. Another major problem was that he often violated home curfew and his mother often did not know his whereabouts. His mother had married twice, and the case was her child from her first marriage that ended in divorce. His step-father had recently died of cardiac arrest. According to the case and his mother, the mother had authoritarian parenting style and constantly expected complete obedience from her son and even once had used physical punishment. The constant struggle between the mother and son had resulted in emotional distance between them. It should be noted that the mother had diabetes (type II) and suffered from major depressive disorder. However, the family had not received any kind of psychosocial interventions for their psychological problems. 

Measures

Achenbach System of Empirically Based Assessment (ASEBA)
This test battery consists of Child Behavior Checklist (CBCL), Youth Self-Report (YSR) and Teacher Report Form (TRF). Each subtest contains 113 items [20]. In the current study, we used two subscales of delinquent behaviors (or rule-breaking behaviors) and aggressive behaviors in the Persian version of ASEBA [20]. For the Persian version, internal consistency of ASEBA scales are from 0.63 to 0.95 [20].

Inventory of Statements About Self-injury (ISAS)
This inventory designed to assess NSSI behaviors in 13 functions of NSSI rated as 0 (not relevant), 1 (somewhat relevant) or 2 (very relevant) [21]. For the Persian version of ISAS, internal consistency of intrapersonal and interpersonal functions are from 0.52 to 0.79 and from 0.62 to 0.69, respectively [21].

Intervention
First, several meetings with key informants were held and semi structured interviews were conducted to complete fit factors (circles) of referral problems at the individual, family, peer, school and neighborhood levels to identify primary drivers that had significant role in sustaining CD and NSSI behaviors. Then, according to identified fit circles, the targets and goals of the intervention were determined through cooperation with the case, his mother and his school teacher. The case and his family received MST-BI for 20 weeks, 4 hours per week. At baseline (4 weeks), intervention (5 months) and follow-up (3 months) phases, the case and his mother as well as his teacher completed the YSR, CBCL and TRF, respectively [20]. Also, during these periods, the case completed the ISAS [21].

Results
According to the reports by the case and his mother and teacher, conduct problems (aggression and rule-breaking behaviors) decreased during the intervention and follow-up phases (Figures 1 and 2).






Also, according to the scores of ISAS, the NSSI behaviors decreased during the intervention and follow up phases (Figure 3).



Conclusion  
The current case report should be considered as the first attempt to examine the effectiveness of MST-BI in treating the co-occurrence of NSSI behaviors and CD symptoms. The findings showed that MST-BI was effective in treating CD and NSSI behaviors in adolescents. This intervention with a focus on the common factors for effective treatments of NSSI (including addressing the family problems, skills training, treatment intensity, and NSSI risk factors) [22] and using ecological validity caused a significant reduction in the frequency of NSSI behaviors. Also, aggression and rule-breaking behaviors decreased significantly at different phases of the study reported by the mother, the teacher, and the case himself. In fact, family intervention is the main component of MST and enhancement in family relations has considerable impact on youth’s antisocial behaviors [33]. 
The MST-BI has the potential to significantly reduce NSSI behaviors and CD symptoms in male adolescents. As a case report, the main limitation of the present study was the short follow-up duration. More studies with experimental design, large sample sizes, and longer follow up phases (12 months or longer) are recommended to examine the efficacy of MST-BI in individuals with comorbid NSSI and CD.

Ethical Considerations

Compliance with ethical guidelines
The study was approved by the Ethics Committee of Iran University of Medical Sciences (Code: IR.IUMS.REC.1395.9021521002). Before treatment, a written informed consent was obtained from the parent. 

Funding
The current study was extracted from the PhD thesis of the first author. This study was funded by Iran University of Medical Sciences.

Authors contributions
Conceptualization, methodology, validation, review & editing: All Authors; Investigation, resources, data Curation, writing original draft, visualization: Seyed Mohammad Bagher Hosseini Fayyaz; Formal analysis: Seyed Mohammad Bagher Hosseini Fayyaz and Ali-Asghar Asgharnejad Farid; Supervision, project administration, funding acquisition: Mohammad Kazem Atef Vahid; Funding: Iran University of Medical Sciences.

Conflicts of interest
The authors declare no conflict of interest.

Acknowledgments
The authors would like to thank the patient, his family, and his teacher for their cooperation in this study.



 

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