Conduct disorder is a childhood behavior disorder characterized by aggressive and destructive activities that cause disruptions in the child's natural environments such as home, school, church, or the neighborhood. The overriding feature of conduct disorder is the repetitive and persistent pattern of behaviors that violate societal norms and the rights of other people. It is one of the most prevalent categories of mental health problems of children in the United States, with rates estimated at 9% for males and 2% for females.
The specific behaviors used to produce a diagnosis of conduct disorder fall into four groups: aggressive conduct that causes or threatens physical harm to other people or animals, nonaggressive behavior that causes property loss or damage, deceitfulness or theft, and serious violations of rules. Two subtypes of conduct disorder can be delineated based on the age that symptoms first appear. Childhood-onset type is appropriate for children showing at least one of the behaviors in question before the age of 10. Adolescent onset type is defined by the absence of any conduct disorder criteria before the age of 10. Severity may be described as mild, moderate or severe, depending on the number of problems exhibited and their impact on other people.
Youngsters who show symptoms (most often aggression) before age 10 may also exhibit oppositional behavior and peer relationship problems. When they also show persistent conduct disorder and then develop adult antisocial personality disorder , they should be distinguished from individuals who had no symptoms of conduct disorder before age 10. The childhood type is more highly associated with heightened aggression, male gender, oppositional defiant disorder , and a family history of antisocial behavior.
The individual behaviors that can be observed when conduct disorder is diagnosed may be both common, problematic, and chronic. They tend to occur frequently and are distressingly consistent across time, settings, and families. Not surprisingly, these children function poorly in a variety of places. In fact, the behaviors clustered within the term "conduct disorder" account for a majority of clinical referrals, classroom detentions or other sanctions, being asked to stop participating in numerous activities, and can be extremely difficult (even impossible) for parents to manage.
The negative consequences of conduct disorder, particularly childhood onset, may include illicit drug use, dropping out of school, violent behavior, severe family conflict, and frequent delinquent acts. Such behaviors often result in the child's eventual placement out of the home, in special education and/or the juvenile justice system. There is evidence that the rates of disruptive behavior disorders may be as high as 50% in youth in public sectors of care such as juvenile justice, alcohol and drug
The financial costs of crime and correction for repeated juvenile offenses by youth with conduct disorder are extensive. The social costs include citizens' fear of such behavior, loss of a sense of safety, and disruptions in classrooms that interfere with other children's opportunity to learn. The costs to the child and his or her family are enormous in terms of the emotional and other resources needed to address the consequences of the constellation of symptoms that define conduct disorder.
Causes and symptoms
There is no known cause for conduct disorder. The frustrating behavior of youngsters with conduct disorder frequently leads to blaming, labeling, and other unproductive activities. Children who are "acting out" do not inspire sympathy or the benefit of the doubt. They are often ostracized by other children. Parents of such children are often blamed as poor disciplinarians or bad parents. As a result, parents of children with conduct disorder may be reluctant to engage with schools or other authorities. At the same time, there is a strong correlation between children diagnosed with conduct disorder and a significant level of family dysfunction, poor parenting practices, an overemphasis on coercion and hostile communication patterns, verbal and physical aggression and a history of maltreatment.
There is a suggestion of an, as yet, unidentified genetic component to what has generally been viewed as a behavioral disorder. One study with adopted children in the mid-1990s looked at the relationship between birth parents with antisocial personality disorder, and adverse adoptive home environments. When these two adverse conditions occurred, there was significantly increased aggressiveness and conduct disorder in the adopted children. That was not the case if there was no indication of antisocial personality disorder in the birth parents. This finding has important implications for prevention and intervention of conduct disorders and its associated conditions of substance abuse and aggressiveness.
The Diagnostic and Statistical Manual of Mental Disorders (also known as the DSM-IV-TR ) indicates that for conduct disorder to be diagnosed, the patient has repeatedly violated rules, age-appropriate social norms and the rights of others for a period of at least twelve months. This is shown by three or more of the following behaviors, with at least one having taken place in the previous six months: aggression to people or animals, property destruction, lying or theft, and serious rule violations.
Aggression to people or animals includes:
- engaging in frequent bullying or threatening
- often starting fights
- using a weapon that could cause serious injury (gun, knife, club, broken glass)
- showing physical cruelty to people
- showing physical cruelty to animals
- engaging in theft with confrontation (armed robbery, extortion, mugging, purse snatching)
- forcing sex upon someone
Property destruction includes:
- deliberately setting fires to cause serious damage
- deliberately destroying the property of others by means other than fire setting
Lying or theft includes:
- breaking into building, car, or house belonging to someone else
- frequently lying or breaking promises for gain or to avoid obligations (called "conning")
- stealing valuables without confrontation (burglary, forgery, shop lifting)
Serious rule violations include:
- beginning before age 13, frequently staying out at night against parents' wishes
- running away from parents overnight twice or more or once if for an extended period
- engaging in frequent truancy beginning before the age of 13
Mild severity would mean there are few problems with conduct beyond those needed to make a diagnosis AND all of the problems cause little harm to other people. Moderate severity means the number and effect of the conduct problems is between the extremes of mild and severe. Severe is indicated if there are many more conduct symptoms than are needed to make the diagnosis (more than three in the previous twelve months or more than one in the previous six months), or, the behaviors cause other people considerable harm.
Conduct disorder is generally diagnosed when somebody, often a child in school, comes to the attention of authorities (school, law enforcement, and others) most often because of behavior. The person might then be referred to a psychiatrist or psychologist for assessment and diagnosis . It is unlikely that any sort of specific test is given; rather, the individual would have to meet the criteria in the DSM-IV-TR. Usually there is a history of acting out in school, neighborhood, home, and other social settings. Court-ordered treatment would likely occur if the person comes to the attention of the police and if a crime is involved. A judge might order treatment as an alternative to jail, or before a sentence is served.
Earlier treatments of youth with conduct disorder relied on legal processes to declare a child in need of supervision or treatment and thus able to be placed in residential settings established for this purpose. While residential placements may still be used, recent treatment models have relied less on such restrictive procedures. The increased visibility and sophistication of the consumer movement, comprised of families of children and youth with mental health disorders, is bringing pressure to bear on treatment providers to stop blaming families, stop removing children from their families for services, focus instead on strengths and assets in both the child and his or her family, and to use community-based interventions in several domains in which the child and family live.
Community-based interventions are sometimes called wrap-around services to describe the intention that they will be brought to the child's natural environment in a comprehensive and flexible way. The idea is to target a range of child, parent, family and social system factors associated with a child's behavioral problems. This approach has been successful in modifying antisocial behavior, rates of restrictive placement, and in reducing the cost of services.
Another treatment that has been used with some success is the Child Cognitive Behavioral Treatment and Skills Training which trains children with conduct disorder in anger-coping, peer coping, and problem-solving skills.
Parent Management Training and family therapy are also used to treat conduct disorder. Parents learn to apply behavioral principles effectively, how to play with their children, and how to teach and coach the child to use new skills.
Medication is sometimes used and may be effective in controlling aggression. Generally, a variety of treatment modes are used to address such a complex disorder. Severe antisocial behavior on the part of the child and adverse parenting practices may suggest that the family will stop treatment before it can be effective, or before meaningful change can result.
Early identification and appropriate and innovative treatment will improve the course of conduct disorder and possibly prevent a host of negative outcomes that are often a consequence of the behaviors associated with it. Unfortunately, the stigma of treatment and the undiagnosed problems of many parents are still significant enough that families whose children could benefit from treatment never find their way to a treatment setting. Instead their children come into contact with the juvenile and criminal justice system.
Prognosis may best be improved by prevention of conduct disorder before it becomes so resistant to treatment. Research is being conducted on what early interventions hold the greatest promise. The research incorporates several components such as child tutoring, classroom intervention, peer training, social-cognitive skills training, parent training, and family problem-solving.
Other studies have included early parent or family interventions, school-based interventions and community interventions. Again, these include a variety of elements as suggested before, including parent training that includes education about normal child development, child problem-solving, and family communication skills training. Research is still needed to determine where and when to target specific preventive interventions.
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American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Ave. NW, Washington, DC 20016. <http://www.aacap.org> .
Federation of Families for Children's Mental Health. 1101 King St., Suite 420, Alexandria, VA 22314. <http://www.ffcmh.org> .
Judy Leaver, M.A.
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