Conduct Disorder

WHAT IS CONDUCT DISORDER?

Conduct Disorder is a psychiatric disorder of childhood and adolescence that is characterized by a persistent disregard for societal norms and rules, and includes behaviors such as aggression toward people or animals, destruction of property, theft or persistent lying, and other serious rule violations such as truancy and running away from home.

WHAT IS OPPOSITIONAL DEFIANT DISORDER?

Oppositional Defiant Disorder is a psychiatric disorder of childhood and adolescence that is characterized by a persistent pattern of negativist, hostile, or defiant behaviors. Hallmark behaviors of this disorder include frequent arguments with adults, disregard of rules, refusal to comply with the requests of adults, loss of temper, vindictive or spiteful acts, and displays of anger or resentment. Conduct Disorder encompasses a more serious disregard for societal norms than Oppositional Defiant Disorder. In both diagnoses, the behaviors must cause significant impairment in social, academic, or occupational functioning.

HOW COMMON ARE THESE DISORDERS?

Conduct disorder is one of the most frequently diagnosed disorders of childhood and adolescence.¹ Two to six percent, or from one to four million children and adolescents in the United States have Conduct Disorder. Conduct Disorder is as prevalent in preadolescent youths as in adolescent youths. Research has found Conduct Disorder in six to 16 percent of boys and two to nine percent of girls. The prevalence of Oppositional Defiant Disorder is two to 16 percent. After puberty, Oppositional Defiant Disorder is as prevalent in girls as in boys.

WHAT CAUSES THESE DISORDERS?

There is no single cause of Conduct Disorder or Oppositional Defiant Disorder. Research has found an association between Conduct Disorder and brain damage, genetic vulnerability, school failure, traumatic life experiences, and physical and sexual abuse during childhood. Family factors also appear to contribute to the development of Conduct Disorder and Oppositional Defiant Disorder. Research has shown a high correlation between these disorders and low socioeconomic status, poor parenting, parental alcoholism, and parental antisocial personality disorder.

Finally, research has found an association between conduct disorder and other psychiatric disorders. For example, young children with Attention Deficit Hyperactivity Disorder (ADHD; a psychiatric disorder characterized by poor impulse control, attention problems, and hyperactivity) are at greater risk than children without ADHD for developing Conduct Disorder during adolescence and adulthood.

HOW ARE THESE DISORDERS DIAGNOSED AND ASSESSED?

Diagnosis

The American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) describes Conduct Disorder as an ongoing pattern of behaviors that violate the rights of others, or disregard the accepted rules of home, school, or community. Some of these behaviors include:

1. Aggression to people and animals

· Bullying, threatening, or intimidating others

· Initiating physical fights

· Being physically cruel to people or animals

· Forcing someone into sexual activity

2. Destruction of property

· Deliberately engaging in fire setting with the intention of causing serious damage

· Deliberately destroying others' property (other than by fire setting)

3. Deceitfulness or theft

· Breaking into someone else's house, building, or car

· Lying to obtain goods or favors or to avoid obligations (i.e., "cons" others)

· Stealing items of nontrivial value without confronting a victim (e.g., shoplifting,

but without breaking and entering)

4. Serious violations of rules

· Staying out at night despite parental prohibitions, beginning before age 13 years

· Running away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy time period)

· Being truant from school, beginning before age 13 years

The age of onset for Conduct Disorder is usually older than for Oppositional Defiant Disorder. Many youths with Conduct Disorder have a history of Oppositional Defiant Disorder, but not all Oppositional Defiant Disorder cases will progress to Conduct Disorder. A child or adolescent with Oppositional Defiant Disorder often:

· Loses his or her temper

· Argues with adults

· Actively defies or refuses to comply with adults' requests or rules

· Deliberately annoys people

· Blames others for his or her mistakes or misbehavior

· Is touchy or easily annoyed by others

· Is angry and resentful

· Is spiteful or vindictive

Assessment

A comprehensive assessment of Conduct Disorder and Oppositional Defiant Disorder should include:

1. Clinical interviews and ratings of significant others, including parents, teachers, and therapists. It is important to gather information about the child's functioning from the child and other people in the child's life. Different people in the child's life have different perspectives. For example, some adults may view certain behaviors as aversive or problematic, while other adults may view the same behaviors as neutral. Rating scales such as the Child Behavior Checklist allow caregivers and people close to the child to report conduct problems.

2. Direct observation of the child's behavior in multiple settings -- for example, home, school, community -- collected at multiple points in time. Gathering information in this way works well for observing easily observed behaviors, such as arguing and fighting. On the other hand, discrete behaviors such as drug use or sexual promiscuity are not always easy to observe.

3. Institutional Records, including police records that document arrests and station adjustments, and school records that document grades, suspensions, and expulsions.

4. Self report measures can be effective ways to document behaviors that people close to the child might not know about, such as vandalism, theft, and drug use. The Child Behavior Checklist and scales of the Minnesota Multiphasic Personality Inventory Adolescent Version (MMPI-A) are frequently used self-report tools.

WHAT ARE THE TREATMENTS FOR THESE DISORDERS?

Early intervention for children exhibiting conduct problems is critical. Children with a history of childhood conduct problems are more likely than children without these problems to develop difficulties as adults that include alcohol abuse, psychiatric disorders, marital problems, poor work performance, and poor physical health.

Treating Conduct Disorder and Oppositional Defiant Disorder is complex and challenging. Children are frequently uncooperative and often harbor chronic feelings of fear and mistrust towards authority. Treatment usually involves a multi-modal intervention plan that includes a combination of psychosocial interventions and medication. Commonly used psychosocial treatments include parent training, family therapy, social skills training, and group therapy.

Psychosocial Interventions

Parent and Child Training

Many researchers believe that treatment of Conduct Disorder and Oppositional Defiant Disorder should include interventions directed at improving parenting. Treatments consisting of both child training and parent training are usually more effective than either treatment alone. A child's ability to sustain long-term benefits of treatment has been shown to depend on his or her caregiver's willingness to participate in treatment, so it is important to get caregivers involved in treatment.

Dyadic Skills Training

This treatment approach is based on the idea that children exhibit antisocial or conduct-disordered behaviors because they experience poor care-giving during infancy and early childhood. Dyadic skills training consists of 12 to 18 one hour-per-week sessions designed for pre-school age children and their parents. During treatment, the clinician teaches the parents about children's social, cognitive, and emotional development. Clinicians frequently give homework assignments and use role-playing and videotaping to help parents learn to set limits, problem-solve, and reframe a child's "negative behaviors." Dyadic skills training for youth combined with management training for parents can produce beneficial changes in youth and improve long-term parent and family functioning.

Family Therapy

Family-based interventions which focus on improving communication within the family have had some success in treating conduct problems. In family therapy, the primary goal is to change dysfunctional family systems, clarify family roles, and promote honest and open communication among family members. Family therapy is believed to be most effective with children who are in early to mid-adolescence and who have not exhibited the most serious conduct problems, such as running away, truancy, or theft).

Multisystemic therapy (MST)

A variation of traditional family therapy, MST appears to be an effective method for treating antisocial behaviors in mid to late adolescence. MST focuses on modifying the systems -- family, school, peer and community -- that maintain the child's conduct problems. The primary goal of MST is to provide parents or caregivers with the skills and resources necessary to independently address challenges presented by their children. In MST, the clinician assesses family strengths, helps the family clarify problems, and sets reasonable short- and long-term goals. In addition, the clinician may work with the child's school, or may assist the caregiver in finding transportation, childcare, food, or medical care.

MST has shown some success in reducing the rates of institutionalization for chronically delinquent children. MST has also been shown to improve school attendance and family functioning and to reduce externalizing behavior.

Group Therapy

Group therapies, including community-center groups and day-camp groups, attempt to promote change within group settings. Research has found that minimizing contact with deviant peers and maximizing contact with prosocial peers in supervised settings may decrease conduct-disordered behavior. Community Center group therapy, designed for school-age children, utilizes two basic group approaches: social learning and traditional. In social learning groups, clinicians apply principles of behavior modification such as reinforcement, modeling, and role-playing, to increase the frequency of desired behaviors. In traditional groups, the clinician emphasizes rules, norms and consequences rather than behavior modification principles. Social learning and traditional groups consist of 10 to 15 children who meet weekly for approximately three hours throughout the school year. Both kinds of groups have shown some success in treating children with Conduct Disorder.

Day Treatment

Day treatment programs have shown promise for treating youth who cannot be treated successfully on an outpatient basis. For example, one study found that youth diagnosed with Conduct Disorder or Oppositional Defiant Disorder who were involved in a multi-modal day treatment program utilizing a combination of medication, individual and group therapy, and family therapy maintained the benefits of treatment over a five-year period.A second study found that a partial hospitalization program that administered Methylphenidate in combination with behavior therapy, resulted in a decrease in oppositional behavior and an increase in positive social behavior.

Psychodynamic or Insight-Oriented Therapy

Psychodynamic or insight-oriented individual and group psychotherapy have not been found effective for treating Conduct Disorder or Oppositional Defiant Disorder.

Medication

Medication treatment alone appears to be an ineffective method of treating Conduct Disorder and Oppositional Defiant Disorder. Still, medication can be an effective means of treating some of the symptoms associated with conduct disorder or of treating comorbid disorders. For example, one study found that youth suffering from ADHD and Conduct Disorder or Oppositional Defiant Disorder showed a decrease in symptoms associated with each disorder over a three-month period when treated with Clonidine, Methylphenidate, or a combination of each medication.

WHERE TO GET HELP: RESOURCES

In seeking help, persons may be directed to psychiatrists, psychologists, licensed clinical social workers, community mental health agencies, the psychiatry department of hospitals or clinics, health maintenance organizations, university or medical school-affiliated programs, state hospital outpatient clinics, family service or social service agencies, private clinics, school counselors, or a local mental health association.

The National Institute of Mental Health provides information on the treatment of children with psychiatric disorders. The agency can be contacted at:

National Institute of Mental Health

Office of Communications and Public Liaison

Information Resources and Inquiries Branch

6001 Executive Boulevard, Rm. 8184, MSC 9663

Bethesda, MD 20892-9663

(301) 443-4513

www.nimh.gov

Current information about psychiatric disorders can also be obtained from:

American Academy of Child and Adolescent Psychiatry

3615 Wisconsin Avenue, N.W.

Washington, DC 20016

(202) 96607300

www.aacap.org

American Psychiatric Association

1400 K Street, N.W.

Washington, DC 20005

(202) 682-6000

www.psych.org

American Psychological Association

750 First Street, N.E.

Washington, DC 20002

(202) 336-5500

www.apa.org

National Alliance for the Mentally Ill

Colonial Place Three

2107 Wilson Blvd., Suite 300

Arlington, VA 22201-3042

(800) 950-NAMI (6264)

www.nami.org

National Mental Health Association

1021 Prince Street Alexandria, VA 22314

(800) 969-NMHA (-6642)