Excerpts from Your Child on Conduct Disorder
Children misbehave for a variety of different reasons. Perhaps they don't understand the rules, they feel they need to assert their own autonomy, or maybe they wish to test the limits imposed on them. However, some children misbehave because they are experiencing internal distress: anger, frustration, disappointment, anxiety, or sorrow. The younger a child is, the more likely he is to call attention to his distress through his behavior. As a child matures, however, there is an expectation that he will be increasingly able to resolve much of his distress on his own and will express his feelings through words rather than outwardly directed misbehavior.
There are also children, however, whose behavior is consistently troubling to others. In these cases, the children's behaviors are outside of the range of what is considered normal or acceptable for their level of development. Perhaps most alarming is that many of these children show little remorse, guilt, or understanding of the damage and the pain inflicted by their behavior.
Increasingly, we read stories in the newspapers of children who routinely set fires, torture animals, or torment other children. We hear of young children who join gangs and cruise the streets, terrorizing others. In extreme cases, there are those who physically, sexually, or murderously assault others.
When their behavior is extreme and highly disturbed, the temptation is to dismiss these children as scary, lost, or bad to the core. Increasingly, there is a tendency to relegate them to the criminal or juvenile justice system. Yet, by doing so, we may overlook the fact that some of these children have serious underlying emotional disorders.
Conduct disorder is the most frequently diagnosed childhood disorder in outpatient and inpatient mental health facilities. It is estimated that 6 percent of all children have some form of conduct disorder, which is far more common in boys then in girls.
The earlier a child displays extremely disturbed behavior, the worse the likely outcome. Some studies report that high levels of activity and unmanageable behaviors at the age of four anticipate behavioral problems in later school years. This is the best time to intervene. Behavioral problems at eight are reliable predictors of adolescent aggression. Many of the underlying causes of childhood behavioral problems, including family violence and abuse, can be prevented or successfully managed. It's important to look beyond obvious negative behaviors to identify underlying biological, emotional, or social vulnerabilities that might be present and treatable.
Identifying the Signs
Children who are physically and verbally aggressive much of the time should be evaluated to determine whether they have a conduct disorder. Their aggression typically is expressed toward people and animals, in the destruction of property, in lying and theft, and in serious violation of society's rules.
In order to diagnose conduct disorders, a clinician will look for a repetitive and persistent pattern of behavior which violates the basic rights of others. Usually, a child with a serious conduct disorder will engage in a number of unacceptable activities and seems to lack empathy and have little or no remorse, awareness, or concern that what he is doing is wrong.
For example, children with conduct disorders might bully, threaten, and intimidate others. Typically, they initiate physical fights, sometimes using weapons such as bats, bricks, broken bottles, knives, and guns. These are the children and, later, the adolescents and adults who get involved in muggings, purse snatching, armed robbery, sexual assault, animal torture, and rape. Some children deliberately set fires, vandalize, and destroy others' property.
Children with conduct disorders might shoplift or break into other people's homes, buildings, or cars. They might mislead people or systematically lie to obtain goods or favors or to avoid obligations. Examples of violating rules include repeatedly staying out of the home overnight, breaking curfew, running away from home, and truancy. The severity of these behaviors differs from child to child.
Clinicians distinguish between types of conduct disorder. Children younger than ten years of age, especially those previously diagnosed with oppositional defiant disorder, are said to have childhood onset conduct disorder. When the symptoms and behaviors of conduct disorder are not evident until after the child has reached ten years of age, the diagnosis is adolescent onset conduct disorder. Youngsters with childhood-onset CD are typically more aggressive; they are likely to have few or no friendships with their peers. They are also at greater risk of persistent conduct disorder or of developing antisocial personalities as adults. Few girls develop childhood onset conduct disorder; girls are more likely develop adolescent onset conduct disorder.
Causes and Consequences
The diagnosis of conduct disorder implies a multitude of potential criminal behaviors as well as numerous possible biological, psychological, and social problems. Because of its inclusive nature, the diagnosis of conduct disorder is common.
It is likely that biochemical underpinnings and genetic vulnerabilities interact with environmental forces and individual characteristics to cause conduct disorders. When there are serious problems during pregnancy, delivery and the postnatal period, for example, youngsters may demonstrate a variety of neurobiological problems as development proceeds. These include slowed development of gross and fine motor coordination (required for throwing a hall, skipping, or writing) and impaired short term, memory. It is not uncommon for children with these kinds of problems to show poor judgment, trouble regulating feelings, and difficulty controlling their actions as well. They have trouble modulating their behaviors, feelings, and even their biological rhythms of sleep and appetite.
Many conduct disordered children have learning problems, especially in the area of verbal skills. However, since many come from homes in which actions speak louder than words, lack of parental stimulation and modeling may account for these weaker verbal skills. Difficulties in reading and language contribute to academic difficulties, especially in the higher grades when so much depends on understanding and using the written word. Language deficits may also contribute to an inability to articulate feelings and attitudes, so that a child out of frustration might resort to physical expression.
In many instances, unrecognized and untreated learning disabilities and cognitive deficits create deep frustration for a child. Thus the entire school experience gets filtered through defeat and humiliation. A child may then stop attending school or skip challenging classes. Once he leaves the structure of school which might have been a major opportunity he had for experiencing positive success, he my engage in delinquent behavior. For some children, delinquent behavior, however unlawful or unacceptable, provides them with both the status among their peers and the opportunity for some reinforcement that they are unable to find at school.
Antisocial behavior abounds in poor inner-city areas, together with high rates of family instability, social disorganization, infant morbidity and mortality, and severe mental illness. These factors may well cause and perpetuate severe conduct disturbances in a child.
More and more, child psychiatrists and other mental health professionals are recognizing the role played by prior physical, sexual, and emotional abuse in the genesis of certain kinds of aggressive and inappropriate sexual behaviors. Substance abuse or mental illness in parents psychosis, severe depression, or manic depressive disorders can have a grave impact on the children in the family.
Substance abuse and conduct disorders commonly coexist in a child or teen. It is not unusual for deeply troubled children, some eleven or twelve or younger, to use drugs and alcohol. Children use drugs and alcohol for a number of reasons. They may try to self medicate for anxiety, depression, thought disorders, and hyperactivity. They may wish to blot out memories of abuse or treat insomnia. Some children think they need drugs or alcohol just to be able to face another day in a violent, abusive household.
The most violent children are likely to be those who have been the most severely abused. Their way of dealing with the abuse is to dissociate their feelings from action. They thus appear to be cold, detached, and lacking in empathy. Yet, because it is sometimes the most deeply disturbed children who tenaciously maintain their bravado, boast of their offenses, and threaten others with further violence, they are often passed over to the justice system. These are the children whose mental health needs are most often neglected and who are at highest risk for criminal and violent behavior in adolescence and adulthood.
Conduct disorder can also occur along with other disorders such as attention deficit/hyperactivity disorder. Though depression is more often associated with withdrawal than aggression, it can include irritability and rage. Furthermore, episodic destructive behaviors or sporadic episodes of robbery and burglary may represent the manic phase of a bipolar disorder. Especially violent children may demonstrate psychotic thinking. Suicidal behavior is not uncommon with children who have conduct disorders. Rather than dismiss such attempts as manipulative behavior, adults must take them seriously, not only in terms of the immediate danger, but as desperate expressions of frustration, pain, anger, and impulsiveness. Conduct disordered children are usually not very articulate about their feelings and may demonstrate their pain with self destructive behaviors.
How to Respond
No single treatment approach has been shown to be effective for conduct disorder. Because children with conduct disorders may suffer from myriad biological, psychological, and social vulnerabilities, a combination of treatment methods seems most effective. Frequently this combination of therapy will include liaison with community resources including juvenile court staff or probation officers.
When children with severe behavioral problems are brought to a child and adolescent psychiatrist or other mental health professional, treatment usually begins with a comprehensive evaluation. This will likely include a detailed medical history and psychological testing. A neurological examination is often valuable to determine if any central nervous system dysfunction contributes to the child's problems. A psychoeducational evaluation may uncover intellectual and learning problems that could cause academic and behavioral problems that will put a child at risk for truancy and disruptive behaviors.
The clinician will probably try to determine if the child has any control over his aggressive acts and if he can anticipate a violent episode before it happens An attempt is also made to ascertain whether the child feels any remorse or empathy toward victims after such episodes.
Parent Management Training Many times treatment for conduct disorders is family-focused. Parent management training has been used with considerable success with aggressive children, particularly when parents themselves can make changes. When parents can participate fully, this method helps parents to encourage appropriate behaviors in their children and to use discipline in more effective ways. In order to interact with their children in new ways, parents learn to use positive reinforcement, to link misbehavior to appropriate consequences, and to develop ways of negotiating with their children. Once the parent child relationship smoothes out, many children are better able to navigate their social and academic worlds in a more productive manner.
Family Therapy This approach can help families learn less defensive ways of communicating with each other. It can foster mutual support, positive reinforcement, direct communication, and more effective problem solving and conflict resolution within the family.
Social Skills Training Skills training focuses on children in order to enhance their problem solving abilities. Through such programs, a child can learn to identify problems, recognize causation, appreciate consequences and consider alternate ways of handling difficult situations. Efforts are made to diminish mistrust of others, especially adults, and to help the youngster open up more and seek support and encouragement. Most children with conduct disorder feel alone and alienated from the adults in their lives.
School based treatment programs are in wide use throughout the country, whether in special residential treatment environments, designated community based schools, or specific programs in mainstream schools. These programs can reintegrate the student back into regular classes as the child’s behavior allows.
Individual Psychotherapy A therapeutic relationship with a caring, consistent, older individual, when coupled with other treatments that help structure the child's behavior and with cognitive behavioral therapies, the youngster with conduct disorder symptoms may be helped in figuring out why he does what he does. As the child grows older, the clinician helps the child better understand his motions and actions and how to deal with both.
Medication Since conduct problems tend to arise from a tangle of biological, emotional, and social stresses, there is no single class of medication that has been found especially useful. Even when another psychiatric disorder has been clearly defined such as hyperactivity activity, depression, manic depressive illness, or schizophrenia medication is seldom sufficient on its own to alter conduct disorder symptoms. If the child has underlying ADHD, the use of stimulants may help reduce negative behaviors and impulsiveness. Lithium, a mood stabilizer, and anticonvulsants have also been shown to reduce impulsive aggression. Used judiciously to address specific clinical findings in each individual case, appropriate use of medication can enhance the success of other treatments.
Given the rather dramatic and disturbing quality of the conduct disorder symptoms it is important to keep in mind that not all behaviorally disturbed children progress to become seriously antisocial or criminal as adults.
On the other hand, more often than not, ongoing, adequate medical, emotional, educational, and social supports are required for many years sometimes well past the age of eighteen if children with severely disturbed behavior are to develop into adaptive adults, and go on to live meaningful lives and become productive members of society.
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See also:
Glossary of Symptoms and Illnesses - Conduct Disorder
Facts for Families No. 33 Conduct Disorder
AACAP Practice Parameter on Conduct Disorder*
Excerpts from Your Adolescent on Conduct Disorder
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