Conduct Disorder: An Overview

Tara, a four year old, was yelling & screaming and interrupting everyone at dinner table. As her mother scolded her, she picked up the serving spoon and threw it at her mother with all force and hit her- Everyone was terrified to see this rage in a 4 year old.

10 year old Golu, loves sports, does well in studies but is not like any other kid. He burnt his pet dog’s tail with a matchstick, pushed his sister down stairs, stole money from his grandfather’s wallet, hit his friend with a bat.

Most of us have seen Tara and Golu, somewhere around us, and mostly have had two kind of responses. Either it is considered some childish behaviour and is deemed to get better with growing age or it is dealt with punishing the child hard.

Although, children’s behavioural problems have drawn attention since long and have been considered as early warning of juvenile delinquency and adult criminality, it has yet not been overcame. Rather substantial numbers of youth display antisocial and violent behaviour, sometimes explicitly open and many hidden from public.

“Many types of adolescent conduct problems have increased substantially over the past 25 years, a change that has affected males and females, all social classes, and all family types (Collishaw,Maughan, Goodman, & Pickles, 2004)”

Higher rates of antisocial behaviour and increasing involvement of females rises the concern and immediate need for understanding and assistance.

What is conduct disorder?

Conduct disorder is a major health and social problem. It is the most common psychiatric disorder in childhood, with a prevalence of around 5% across the world, which is rising. It usually emerges in childhood or adolescence and is characterized by severe antisocial and aggressive behaviour. CD affects ~ 3% of school-aged children and is twice as prevalent in males as in females. Conduct disorder describes a wide range of age-inappropriate actions, violation of family expectations, societal norms and the personal or property rights of others (McMohan, Wells, & Kotler, 2006).

Like the children in given examples, children display a vast range of behaviours, ranging from minor annoying behaviours as whining, swearing and temper to much serious forms as theft, assault and vandalism. Displaying stubborn, hostile and defiant behaviour is early sign of “Oppositional Defiant Disorder” that may progress to Conduct Disorder. ODD usually appears by age 8 and is more common to males. Due to the diversity in behaviour, repetitive and persistent patterns are required to be observed and understood singularly.

According to the DSM-5, Conduct Disorder can appear as early as the preschool years with Oppositional Defiant Disorder. Middle childhood to middle adolescence is the time period when Conduct Disorder symptoms are most likely shown. DSM-5 has also defined a new specifier for the CD diagnosis named “with limited prosocial emotions” (LPE); According to DSM-5, CU traits should be present “persistently over at least 12 months and in more than one relationship or setting”. Therefore, it is important to verify whether these features are present as a constant pattern of expression or behaviour or are just specific responses to certain situations.
Conduct Disorder is categorized into two subtypes on the basis of age of onset of the disorder-

• Childhood Onset Type

• Adolescent Onset Type

In each subtype, the symptoms can be mild, moderate or severe. There is a third category, Unspecified Onset, which means that the time when the Conduct Disorder began is unknown. Children with untreated CD are at increased risk of developing vivid problems during their adult years including substance use, personality disorders and mental illnesses.

Symptoms:

Conduct disorder is visible through various symptoms among children in growing age.

Some of them are:

• Indulging in fights – Children getting involved in fight and violence frequently. Being cruel with other people or animals, initiating fights, using weapons to harm others( e.g. bat, hockey, knife, gun)

• Bullying – It is one of the common symptom where the child regularly hurt others by teasing, violence or threatening them. Often being intimidating, indulging in verbal abuse and inconsiderate.

• Destruction of property and goods – Children suffering from conduct disorder are prone to destruction and other similar activities where they tend to dismantle things physically. They may even try to set fire to cause damage.

• Involving in sexual activities at young age – It has been observed that getting involved in sexual activities is very common in children who suffer from conduct disorder. Forcing someone into sexual activity is also seen.
Pic: children taking alcohol, smoking

• Use of alcohol and drugs – Increase in consumption of alcohol and drugs is very common issue among the victims of conduct disorder.

• Deceitfulness or theft- Shoplifting, stealing items, lying to obtain goods or favours, forgery or breaking into someone’s car or house. They might also get involved in mugging, purse snatching, extortion and armed robbery.

• Serious violation of rules :Usually begins before age 13, involves being out at night despite prohibition, often truant from school, running away from home for long period and being defiant.

Those with a diagnosis of conduct disorder may also have co-occurring diagnoses, including attention-deficit hyperactivity disorder (ADHD), substance abuse, post-traumatic stress disorder (PTSD), anxiety disorders, depression, or bipolar disorder. They may also have learning difficulties.

Causes:

No single or specific cause can be determined to be responsible for Conduct Disorder. Initially, conduct problems were viewed as result of inborn characteristics or acquired through poor socialization. Several proposed causes of Conduct disorder are:

Genetic factor: Adoption and twin studies indicate that 50% or more of the variance in anti-social behaviour is attributed to heredity (Baker et al., 2007). Genetic factors may be related to difficult temperament, impulsive behaviour, tendency to seek rewards or insensitivity to punishment, insecure attachment, childhood-onset of symptoms, social avoidance and withdrawal, lower verbal intelligence and increased likelihood to exposure to environmental risk factors.

Prenatal and Neurobiological factors: Several pregnancy and birth factors are also found related to development of CD. Malnutrition, mother’s use of nicotine, marijuana and other substances like alcohol during pregnancy are also associate with later development of CD.

Also low levels of cortical arousal and low autonomic reactivity seem to play central role in antisocial behaviours, particularly in early onset problems.

Family & Parenting: Many family factors have been attributed as possible causes for children’s antisocial behaviour, including antisocial family values, parental criminal behaviour, poor disciplinary practices, parental substance abuse, single parenthood, family isolation and violence in family. Low socioeconomic status of family, low education of mother, carelessness, unavailability of parents and effect of marital conflict of parents on children may also contribute to personality of children.

School environment and peers: Poor school practices leading to low school motivation and weak bonding are also to be blamed partially. Poor academic performance, low educational aspiration occurs due to poor guidance and supervision. Rejection or bullying by peers, or being in contact with deviant siblings and mates encourages the will to indulge in antisocial acts.

Sociocultural: Portrayal of violence and glorification as heroism, cultural attitudes toward violence, exposure of children to aggression in real lives frequently in forms of play, cultural activities, and socialization and as a medium of expression in everyday lives provides the modelling for adapting similar behaviour.

Treatment and prevention:

Many types of treatment we can see around. Right from punishing the child at home and school expulsion to typical, court- mandated treatments as psychotherapy, punishment, group therapy, tutoring, and boot camps, we can find it all. These ways somehow fails to understand the root of problem and address it rightfully, turning out less effective.

Most people understand that family dysfunction, abuse, association with drug-using peers, residence in high crime area and minimum parental supervision contribute to serious conduct problem (Henggeler, 1996)

According to Frick, 2000, two- pronged approach to treatment is needed:

• Early Intervention/prevention, for young children just starting to display problem behaviours

• Ongoing interventions to help older youths and their families cope with many associated social, emotional and academic problems.

The recognition only is not helpful, but rather a sincere action plan, sensitive treatment and approaches are required to be taken. Effective treatments designed to treat and change child’s behaviour with some proven success are:

Parent Management Training (PMT): It teaches parents to change their child’s behaviour at home and in other settings (Brinkmeyer& Eyberg, 2003; McMahon& Forehand, 2003). The assumption that maladaptive parent-child relation are up to some extent responsible and changing the way parents interact with their children will improve the behaviour, is central to this treatment. Parents learn procedures to change parent- child interactions, promote positive child behaviour, and observe child’s problem and ways to identify them. Sessions cover how to use commands, how to set rules, use of praise and mild punishments. Progress in treatment is carefully monitored and required adjustments are made.

Problem solving skills training: PSST focuses on cognitive problem solving. It is used both alone and in combination with PMT. Self-statements are used to direct attention to aspects of problem that lead to effective solutions. Treatment combines modelling, role-playing, behavioural contracts, reinforcement by using structured tasks as games and activities.

Multisystemic Treatment: MST is intensive family and community based approach for adolescents with severe conduct problems that place them at risk for out-of-home placements (Henggeler, Sheidow & Lee, 2007). Treatment is carried out with all family members, school personals, peers, juvenile justice staff, and other individuals in child’s life. Also it provides specialized interventions such as special education, substance abuse treatment and legal services.

Success of failure in treating antisocial behaviour depends on type and severity of problem but it requires to be acknowledged first rather than avoiding in the name of ‘it would get better with time’.