What is conduct disorder?

Introduction

Conduct disorder is a psychiatric disorder that is first diagnosed during childhood or adolescence. It is characterized by a continuing pattern of antisocial behaviors that violate the rights of other people. According to the Centers for Disease Control and Prevention in 2009, the prevalence of conduct disorder in the United States is believed to be around 3 to 10 percent of the child and adolescent population. It is four to five times more common in males than in females. Conduct disorder in adolescence is considered to have serious consequences for society, as it contributes to the high rate of criminal offenses found in that age category. Although many children and adolescents engage in antisocial acts, persons with conduct disorder engage in the behavior in a repetitious and persistent fashion.

Actions that are associated with conduct disorder include bullying, lying, fighting, temper tantrums, destruction of property, stealing, setting fires, cruelty to both animals and people, physical assaults, truancy, and sexual assault. Early signs of conduct disorder can involve excessive arguments with parents, stubbornness, refusing to cooperate with adults, substance abuse, and vandalism. The prognosis for conduct disorder is poor, as it may lead to adult criminal behavior and problems in occupational and marital roles. Many persons with conduct disorder become involved with illegal drugs and excessive alcohol use.

A key factor associated with long-term negative outcomes for the child is the level of aggression
shown by the individual. A particularly negative sign for long-term prognosis is the commission of sexual assaults. Highly aggressive children tend to remain aggressive over time and typically develop an antisocial personality in adulthood. About 25 to 40 percent of children with a conduct disorder that began before the age of ten have been found to develop an antisocial personality in adulthood. As adults, these individuals have a lack of remorse for hurting, mistreating, or stealing from other people. They do not conform to social norms nor do they care about other people. The adult with an antisocial personality acts in an impulsive fashion with disregard for the rights of others.

Another psychiatric disorder, oppositional defiant disorder, often precedes the development of conduct disorder. Oppositional defiant disorder is defined by a pattern of negativistic, defiant, disobedient, and hostile behavior toward authority figures. This disorder begins around six years of age, while conduct disorder typically does not begin until age nine. The specific signs of oppositional defiant disorder, according to the American Psychiatric Association, include often losing one’s temper, often arguing with adults, actively defying or refusing an adult’s requests, deliberately annoying people, blaming others for mistakes, being easily annoyed by others, being often angry and resentful, and being spiteful. The behaviors need to be present for at least six months to make the diagnosis. Almost all children with conduct disorder show the signs of oppositional defiant disorder. Neither of these psychiatric disorders should be confused with juvenile delinquency, which is a legal term referring to violations of the law by minors.

Diagnosis

According to the American Psychiatric Association, a diagnosis of conduct disorder is appropriate when a child shows a persistent and repetitive pattern of behavior in which the basic rights of others or societal norms and rules are violated. The pattern of behavior has to be shown in the following areas: aggression to people and animals, destruction of property, deceitfulness or theft, or serious violations of rules. Specific examples in these categories include intimidation of others, initiating physical fights, using weapons, stealing while confronting a victim, forcing someone into sexual activity, fire setting, deliberately destroying property, running away from home, and school truancy. The disturbances in behavior must cause significant impairment in social, academic, or occupational functioning. The pattern of misconduct must last for at least six months to warrant the diagnosis. Two types of conduct disorder are recognized. The childhood-onset type occurs when the disruptions take place before age ten. An adolescent-onset type is reserved for those persons who show the behavior after that age. Usually the early-onset type of conduct disorder is related to serious outcomes and long-term problems.

Causal Factors

The development of a conduct disorder appears to be the result of a combination of genetic and environmental factors. A genetic predisposition toward low verbal intelligence, mild psychoneurological problems, and a difficult temperament appears to set the stage for an early onset of conduct disorder in childhood. A self-perpetuating cycle emerges in the families of children with conduct disorder. The young child’s difficult temperament can lead to problems in parent-child bonding. The mild psychoneurological deficits may make it difficult for the child to attain self-control of impulsive behaviors. As the child interacts with the environment, a lack of parental bonding and difficulty in controlling impulses leads to poor social skills and rejection from others. By the time the child is school age, readiness has not been attained for that structured setting. Often, teachers cannot focus sufficient attention on the child to overcome the deficits in learning already experienced by the child. The cycle continues as disruptive behaviors grow in intensity in the new environments and further rejection takes place. Other children begin to exclude the aggressive and oppositional child with the conduct disorder, and this enhances the sense of isolation for that child. Soon the child is drawn to other children, typically older peers, who have already been isolated for their conduct problems. The child with conduct disorder may then seek companionship from peers who are antisocial. Associating with such individuals reinforces the disruptive behaviors. Rejection by parents, peers, and teachers leads these children toward continuing isolation and alienation. Antisocial acts against people and property escalate as the children with conduct disorders band together.

Researchers have noted that the family situation of children with conduct disorder is filled with conflict and disharmony. Family discord and hostility are commonly expressed between family members. Frequently, the parents have an unstable marital relationship and experience disturbed emotional expression. They do not provide the child with a consistent pattern of guidance, acceptance, or affection. The parents are ineffective in their parenting behavior and provide little effective supervision or discipline. Children in these households do not learn respect for authority, nor do they learn how to succeed academically. As the child grows older, the parents withdraw from the child as they become fearful of demanding anything from their son or daughter. Basically, the children in these home environments are trained by family members in an indirect fashion to have antisocial tendencies.

A negative home environment is a powerful factor in the development of children who become violent. Research has shown that the biological parents of children with conduct disorder have a high rate of antisocial tendencies and criminal records. Frustrating and unstructured home environments promote the development of an early-onset form of conduct disorder. Parents who are themselves antisocial provide inadequate models for healthy emotional growth. Children may find an environmental pull toward negative behaviors as they grow in a home environment that is frustrating and produces a sense of malaise. Negative environmental influences become greatest on the child with a genetic vulnerability and poor home situation.

Treatment Options

The focus for treatment is on the dysfunctional patterns of behavior found in the families of children with conduct disorder. One approach is called the cohesive family model of treatment. This method targets the ineffective parenting strategies found in these families. The child with conduct disorder has not been socialized to behave in socially accepted ways. Children learn to escape or avoid parental criticism by increasing their negative actions. When this happens, the parents show increasing amounts of anger, which serves as a model for the child to imitate. During treatment, cooperation from parents is needed to teach the most effective methods to control the child’s negative actions. Behavioral techniques based on learning principles are used to train parents in parenting skills. Parents are taught to consistently accept and reward only positive behaviors shown by their children. The parents must learn to stop focusing their attention on the negative actions. Specific skills are taught so that parents learn how to establish appropriate rules for the child and implement appropriate consequences for breaking rules.

Children can be taught to improve their verbal skills as a way to enhance their participation in groups and educational settings. Problem-solving skills are promoted in the child so that problem behaviors can be identified and alternatives can be selected. Family therapy permits a therapist to witness inappropriate interactions between family members and suggest ways to effectively interact with one another. Approaches a therapist may use are structural family therapy (SFT) or solution-focused family therapy (SFFT).

In some cases, the child with a conduct disorder is removed from the home environment. Foster homes or institutional settings may be recommended as the last resort to stop the detrimental effects of the home setting on the child. The goal then becomes to intervene with the parents to teach effective parenting skills and then return the child when progress has been made. A problem with this strategy is that the child often perceives the foster home as an additional rejection by both parents and society. The new setting must have a pronounced atmosphere of acceptance to counteract this possible sense of rejection.

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