Conduct Disorder

Conduct disorder (CD) is a behavioral and emotional disorder of childhood and adolescence. Children with conduct disorder act inappropriately, infringe on the rights of others, and violate the behavioral expectations of others.

Description

CD is present in approximately 9% of boys and 2–9% of girls under the age of 18. Children with conduct disorder act out aggressively and express anger inappropriately. They engage in a variety of antisocial and destructive acts, including violence towards people and animals, destruction of property, lying, stealing, truancy, and running away from home. They often begin using and abusing drugs and alcohol, and having sex at an early age. Irritability, temper tantrums, and low self-esteem are common personality traits of children with CD.

Causes and symptoms

There are two sub-types of CD, one beginning in childhood and the other in adolescence. There is no known cause. Researchers and physicians suggest that this disease may be caused by the following:

• poor parent-child relationships
• dysfunctional families
• drug abuse
• physical abuse
• poor relationships with other children
• cognitive problems leading to school failures
• brain damage
• biological defects

Difficulty in school is an early sign of potential conduct disorder problems. While the patient's IQ tends to be in the normal range, they can have trouble with verbal and abstract reasoning skills and may lag behind their classmates, and consequently, feel as if they don't "fit in." The frustration and loss of self-esteem resulting from this academic and social inadequacy can trigger the development of CD.

A dysfunctional home environment can be another major contributor to CD. An emotionally, physically, or sexually abusive home environment, a family history of antisocial personality disorder, or parental substance abuse can damage a child's perceptions of himself and put him on a path toward negative behavior. Other less obvious environmental factors can also play a part in the development of conduct disorder. Long-term studies have shown that maternal smoking during pregnancy may be linked to the development of CD in boys. Animal and human studies point out that nicotine can have undesirable effects on babies. These include altered structure and function of their nervous systems, learning deficits, and behavioral problems. In a study of 177 boys ages seven-12 years, those with mothers who smoked over one half a package of cigarettes daily while pregnant were more apt to have a CD than those with mothers who did not smoke.

Other conditions that may cause or co-exist with CD include head injury, substance abuse disorder, major depressive disorder, and attention deficit hyperactivity disorder (ADHD). Thirty to fifty percent of children diagnosed with ADHD, a disorder characterized by a persistent pattern of inattention and/or hyperactivity, also have CD.

CD is defined as a repetitive behavioral pattern of violating the rights of others or societal norms. Three of the following criteria, or symptoms, are required over the previous 12 months for a diagnosis of CD (one of the three must have occurred in the past six months):

• bullies, threatens, or intimidates others
• picks fights
• has used a dangerous weapon
• has been physically cruel to people
• has been physically cruel to animals
• has stolen while confronting a victim (for example, mugging or extortion)
• has forced someone into sexual activity
• has deliberately set a fire with the intention of causing damage
• has deliberately destroyed property of others
• has broken into someone else's house or car
• frequently lies to get something or to avoid obligations
• has stolen without confronting a victim or breaking and entering (e.g., shoplifting or forgery)
• stays out at night; breaks curfew (beginning before 13 years of age)
• has run away from home overnight at least twice (or once for a lengthy period)
• is often truant from school (beginning before 13 years of age).

Diagnosis

CD is diagnosed and treated by a number of social workers, school counselors, psychiatrists, and psychologists. Genuine diagnosis may require psychiatric expertise to rule out such conditions as bipolar disorder or ADHD. A comprehensive evaluation of the child should ideally include interviews with the child and parents, a full social and medical history, a cognitive evaluation, and a psychiatric exam. One or more clinical inventories or scales may be used to assess the child for conduct disorder—including the Youth Self-Report, the Overt Aggression Scale (OAS), Behavioral Assessment System for Children (BASC), Child Behavior Checklist (CBCL), and Diagnostic Interview Schedule for Children (DISC). The tests are verbal and/or written and are administered in both hospital and outpatient settings.

Treatment

Treating conduct disorder requires an approach that addresses both the child and his environment. Behavioral therapy and psychotherapy can help a child with CD to control his anger and develop new coping skills. Family group therapy may also be effective in some cases. Parents should be counseled on how to set appropriate limits with their child and be consistent and realistic when disciplining. If an abusive home life is at the root of the conduct problem, every effort should be made to move the child into a more supportive environment. Parent training programs are increasing in number.

For children with coexisting ADHD, substance abuse, depression, or learning disorders, treating these conditions first is preferred, and may result in a significant improvement to the CD condition. In all cases of CD, treatment should begin when symptoms first appear. Recent studies have shown Ritalin to be a useful drug for both ADHD and CD.

When aggressive behavior is severe, mood stabilizing medication, including lithium (Cibalith-S, Eskalith, Lithane, Lithobid, Lithonate, Lithotabs), carbamazepine (Tegretol, Atretol), and propranolol (Inderal), may be an appropriate option for treating the aggressive symptoms. However, placing the child into a structured setting or treatment program such as a psychiatric hospital may be just as beneficial for easing aggression as medication.

Prognosis

The prognosis for children with CD is not bright. Follow-up studies of conduct disordered children have shown a high incidence of antisocial personality disorder, affective illnesses, and chronic criminal behavior later in life. However, proper treatment of co-existing disorders, early identification and intervention, and long-term support may improve the outlook significantly.

Prevention

A supportive, nurturing, and structured home environment is believed to be the best defense against CD. Children with learning disabilities and/or difficulties in school should get immediate and appropriate academic assistance. Addressing these problems when they first appear helps to prevent the frustration and low self-esteem that may lead to CD later on.