Abstract and Summary

Conduct Disorder:
Definition, Statistics, Parental Role and Intervention
Introduction

When asked what developmental stage is diagnosed with conduct disorder the primary answer would be adolescent. However, based on research the greatest damage to society is the result of actions by delinquent adolescents but conduct disorder begins below the age of 7 (Scott, 2007). The researcher hypothesis suggests conduct disorder has a multi-factorial causation which includes biologic, psychosocial and numerous facets of the family unit. The research reveals a negative combination of these factors may predispose young children to exhibit symptoms of conduct disorder. The following questions will hopefully be answered: (1) What causes conduct disorder? (2) Can conduct disorder be prevented or predicted? (3) Does parenting style promote symptoms of conduct disorder? and (4) What are the interventions?

Definition

Conduct disorder is differentiated from other psychiatric disorders diagnosed in children by the following criteria: “persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated” American Psychiatric Association (as cited from Tehama, 2007). According to Sea right et al., (2001) conduct disorder is a psychiatric syndrome occurring in childhood and adolescence which characterized by a longstanding pattern of violations of rules and antisocial behaviors. They interpret conduct disorder as:

Conduct disorder is a common childhood psychiatric problem that has increased incidence in adolescence. The primary diagnostic features of conduct disorder include aggression, theft, vandalism, violation of rules and/or lying. For a diagnosis these behaviors must occur for a least a six-month period.

According to Evans (2003) conduct disorder is a steady pattern of harming others or their property, lying, stealing, or breaking societal rules of behavior. Remote instances of acute behavior, running away, or vandalism is not enough to merit a diagnosis of conduct disorder. Most children exhibit instances of poor judgment and bad behavior at least one time in their childhood. The distinction is children with conduct disorder break the rules over and over again, exhibit aggressive behavior, and show no regard for others. The behavior is not considered conduct disorder until the symptoms are displayed for one year or more. The disturbances in behavior result in significant clinical impairment with social skills, academics and occupational functioning (American Psychiatric Association, 1994).

Clinical Symptoms/Diagnosis

The clinical features of Conduct Disorder are:

· aggression or serious threats of harm to people or animals;

· deliberate property damage or destruction (i.e. fire setting);

· repeated violation of household or school rules, laws or both; and

· persistent lying to avoid consequences or to obtain tangible goods or privileges (Searight et al., 2001).

The American Psychiatric Association (1994) provides further symptoms which support the clinician in diagnosis of conduct disorder. The child will often bully, threaten or intimidate others. They may intentionally set fires with the objective of harming others. The violation of rules would include: (1) often staying out late at night regardless of parental prohibitions which can begin before the age of 13; (2) has run away from home more than two times; and (3) the child is often truant from school which usually begins before the age of 13.

Additional features of conduct disorder include an indifference to the welfare of others and little if any remorse about harming others. Adolescents often verbalize outward remorse to avoid punishment but do not exhibit any guilt. They do not require an objective basis to conclude others are a threat to them. Because of this demeanor they may lash out aggressively without being provoked (Searight et al., 2001).

During normal child development aggression and fighting is pertinent for defensive issues which do not escalate into anti-social behaviors; but, persistent anti-social behavior collectively handicaps during childhood and leads to deprived adjustment during adulthood. The child often endures negative responses by their peers and high levels of disapproval from their parents (Scott et al., 2001).

Worldview

Children who are diagnosed with conduct disorder judge the world as an antagonistic and intimidating place. They may tattle on friends or blame others for the harm they have caused. They have few if any friends because of their limited interpersonal skills. Peers and family members may view them as irritating because of their indifference to their actions. They often have low self-esteem internally but externally they appear tough, cocky or self-assured (Evans, 2003).

Statistics

Conduct disorder has become a major health and social problem; it is the most common psychiatric problem diagnosed among children. Around the world the prevalence of conduct disorder is 5% (Scott, 2007). A study conducted by Sujit et al., (2006) reveals 4.58% of boys and 4.5% of girls are diagnosed with conduct disorder worldwide. In their study of 240 students in four schools in Kanke childhood conduct disorder was found in 73% and in adolescent 27%. Mild conduct disorder was found in 36%, moderate in 64% and severe conduct disorder in none. Lying, bullying and cruelty to animals were the primary symptoms (Sujit, 2006).

Conduct disorder affects 1 to 4 percent of 9- to 17-year olds in the United States. The disorder is more predominate in boys than girls and more common in cities than in rural areas (U.S. Department of Health and Human Services, 1999). Between 6 to 16 percent of boys and 2 to 9 percent of girls meet the criteria to be diagnosed with conduct disorder. It is estimated 40 percent of these children will grow up to be adults with antisocial personality disorder (Searight, 2001).

Epidemiological studies state approximately 2% of girls and 9% of boys are afflicted with this disorder. Adolescents with more external signs and symptoms would amplify the percentage to one third or one half of all children and adolescent clinic referrals Kazdin et al., 1992 (as cited by McCabe et at., 2005).

Heredity, Prenatal Care & Other Aspects of Causation

The etiology of conduct disorder consists of the correlation of genetic, family and social factors. The child may inherit limited baseline autonomic nervous system activity, resulting in a need for greater stimulation to attain optimal arousal. This hereditary aspect may explain the high level of sensation-seeking activity associated with the disorder (Johnson et al., 2002). Several studies have revealed the role of autonomic under-arousal in conduct-disordered adolescents (Crowell et al., 2006). According to McBurnett & Lahey, 1994 & Scrapa & Raine, 1997 (as cited in Crowell et al., 2006) conduct disorder and antisocial behavior in adulthood are marked by autonomic under-arousal which included reduced electro-dermal responding (EDR) and heart rate. Beauchaine, 2003 & Beuchaine et al., 2001 (as cited in Crowell et al., 2006) revealed both elementary children and adolescents have reduced sympathetic and parasympathetic linked cardiac activity when diagnosed with conduct disorder.

The importance of this research is evident when considering the critical period of preschool when noradrenergic, serotonergic, and dopaminergic systems which administer behavioral control are susceptible to long-term changes in functioning Bremner & Vermetten, 2001 (as cited in Crowell et al., 2006). Parasympathetic nervous system (PNS)-linked cardiac activity has been associated with emotional regulation capabilities Porges, 1995 (as cited in Crowell et al., 2006) in contrast to deficiencies in sympathetic nervous system (SNS)-linked cardiac activity have been linked with reward inconsiderateness Beauchaine et al., 2001 (as cited in Crowell et al., 2006).

During gestation the brain is vulnerable to the effects of environmental stressors; this statement applies to both prenatal and postnatal development Dawson et al., 2000 & Hulzink et al., 2004 (as cited in Van Goozen et al., 2007). Environmental factors which can affect brain development are:

· Poor nutrition

· Maternal psychopathology

· Atypical child interaction from a depressed mother (Van Goozen et al., 2007)

Baumrind (as cited in Marsiglia et al., 2007) classified three parenting styles: authoritarian, authoritative, and permissive. For the purpose of this research authoritarian parenting styles will be discussed. The characteristics of an authoritarian parent are extremely restrictive and demanding rules. Parents who utilize this style tend to hamper children’s autonomy and force them to follow stringent rules by threatening harsh punishment (Marsiglia et al., 2007). This type of parenting may lead children to believe they are not responsible for their actions; by contrast, when actions are questions they assume it is not their fault. According to numerous psychological theories parent-child relationship can generate psychological disorders such as anxiety, identity confusion and conduct disorder (Dwairy, et al., 2006). Hoeve et al., (2008) concluded from their study a strong link between parenting styles and delinquency trajectories; therefore, they recommended future research include parenting styles in measuring serious behaviors which are classified as conduct disorders.

The link between exposure to violence in the home and community is a crucial risk factor for conduct disorder according to research by Elze et al., 1999; Fergusson & Horwood, 1998; Jouriles et al., 1989; Kaplan et al., 1998 (as cited in McCabe et al., 2005). Violence exposure can take place in many places within the child’s environment including: (1) victimization and witnessing child abuse; (2) community violence; (3) parental abuse (McCabe et al., 2005).

Culture and societal norms make up the macro-system which is seen as the most distant factors; the exo-system is seen as a midlevel factor; and the micro-system is seen as the most proximal position to the child. Lynch & Cicchetti, 1998 (as cited in McCabe, et al., 2005) stress risk factors which have the most impact are the factors which are more proximal to the child.

Family stresses: (1) substance abuse; (2) violence; and (3) social isolation etc increase a child’s risk of conduct disorder or other mental health disorders. Garrison et al., 1992 (as cited in Baker et al., 2007) reveals several studies have documented the relationship between childhood psychosocial issues and primary care visits. Pediatricians consistently under identify mental health problems in children. Behavioral problems have been linked to an increase in family stressors: (1) divorce; (2) relocation; and (3) financial issues Lavigne et al., 1998 (as cited in Baker et al., 2007). Pediatrician should be aware of these factors when addressing repetitive visits to the office or the emergency room for treatment (Baker et al., 2007).

Parental psychopathology and parenting behavior may be potentially important risk or protective factors in developmental outcomes for these children with concurrent conduct problems. Parental stress and maladaptive parenting may foster the development of conduct disorder Johnson & Mash, 2001 (as cited by Chronis et al., 2007).

The researchers propose maternal smoking is a significant factor in conduct disorder because nicotine may interrupt fetal brain development. Dr. Wakschalg stated, “Our study suggests that cigarette smoking may be one of the first prenatal risk factors for this very serious disorder” (University of Chicago Medical Center, 1997).

According to the ecological-transactional model child abuse has the greatest impact on child functioning. Kaplan et al., 1998 states several studies have correlated child maltreatment to an increase risk of conduct disorder (as cited in McCabe et al., 2005). A study at University of Chicago Medical Center (1997) reveals a link between smoking during pregnancy and the likelihood of having a son with conduct disorder. The researchers analyzed records of 177, 7-12 year-old boys who were referred for outpatient treatment for behavioral problems. The study indicated 24 percent of the mothers who reported smoking more than a half-pack of cigarettes per day during pregnancy, 80% of their sons had conduct disorder. This was in contrast to conduct disorder in 50% of the boys whose mothers did not smoke (University of Chicago Medical Center, 1997). Dr. Lauren Wakschlag stated “Our study indicates that regardless of other factors, smoking during pregnancy can have serious behavioral outcomes in children” (University of Chicago Medical Center, 1997).

The longitudinal and experimental studies on children who are raised in orphanages, children’s homes, and foster homes have established the adverse effects of long-term institutional care on children’s personality development according to the American Academy of Child and Adolescent Psychiatry, 2005 (as cited in Chronis et al., 2007). Consistent research has shown a correlation between institutional child rearing and hyperactivity and inattention. Both of these symptoms are precursors of conduct disorder Roy et al., 2000 (as cited in Chronis et al., 2007).

The research repeatedly exposes children who are diagnosed with ADHD and conduct disorder are predisposed for (1) risky sexual behavior; (2) substance abuse; (3) delinquency; and (4) driving risks Barkley et al., 1993 (as cited in Chronis et al., 2007). The most disturbing fact is children who are diagnosed with ADHD and conduct disorder are at a greater risk of chronic criminal offenses Lyman, 1998 (as cited in Chronis et al., 2007). Lynam 1996 (as cited in Chronis et al., 2007) identified children with conduct disorder at a greater jeopardy for continual offending and explained their perseverance by the correlation of their behavior, neuropsychological and physiological deficits are comparable to adult psychopaths.

Childhood conduct disorder is a major risk factor for adult disorders especially anti-social behavior. The key to diagnosing these children is to identify the origin of antisocial behavior which is found in (1) difficult temperament and (2) ineffective socialization (Van Goozen et al., 2007).

Conduct disorder in childhood which persists through adolescence is associated with co-morbidity, recurrence and resistance to treatment Moffit, 2005 (as cited in Jaffee et al., 2006). The study shows children and adolescence who struggle with signs and symptoms of conduct disorder continue to struggle throughout adulthood with psychosocial problems. The trajectories of antisocial behavior influence these children throughout adulthood and influence the childrearing environment (Jafee et al., 2006).

The influences of individual factors are multifaceted and confusion. Family dysfunction is repetitively identified as one of the crucial factor for conduct disorder in adolescence. Poor parental supervision is the preeminent predictor of violence and vandalism committed by boys. Psychosocial disturbances in children and adolescence bring together a comprehensive range of research to shed light on these young people who become parents of tomorrow; these parents who were diagnosed with conduct disorder predispose their child to the same disorder (Pearce, 1996).

The public debate concerning the relationship between family characteristics and children with conduct disorder continues to raise questions which researchers hope to answer. A longitudinal survey of children suggests ineffective parenting style is the strongest predictor of delinquent behavior in children between the ages of 8 and 11 years. In addition, aversion tactics, low socioeconomic status and the number of siblings in the home are associated with higher probability of children exhibiting conduct disorder (Stevenson, 1999). Somerstein (2007) reveals the common family dynamic in many individuals’ histories of male terrorist is authoritarian parents.

Intervention

There are several factors noted by the research which can help with children who are exhibiting signs and symptoms of conduct disorder. Parents need to monitor their child’s activities on a daily basis. Compliance with (1) curfew; (2) being a responsible parent; (3) monitoring your child’s activities; and (4) quality time with your child are important aspects of parenting (Searight et al., 2001). Most of the parents are diagnosed with some type of psychological disorder and do not have the skills to implement this tips.

A productive intervention for parents is learning good communication skills. Parents should be able to communicate clear, direct and specific rules, request or expectations. Parents should expect the child to react in a concise manner. There should be respect from each party and rules need to be enforceable. Parents of children with conduct disorder rely on inconsistent coercion which increases the negative climate of the home (Searight et al., 2001).

School based intervention has begun to be implemented because of the increase in children who are diagnosed with conduct disorder. Ray (2007) compared the impact of child-centered play therapy, teacher interaction only and a combination of teacher-child relationship. The results were statistically significant for each treatment group, the indication was school based play therapy intervention was more effective in facilitating a positive rapport between the teacher and child.

Hoagwood et al. (2007) reported school-based mental health interventions have a positive effect on academic and mental health progress for children. The interventions were more productive when received long-term and addressed multiple needs in the child’s lives. Community based agencies that provided services for children with conduct disorder in Great Britain were rated effective if they include:

· Socialization skills

· Improvement in family dynamics

· Role play

· Professionally trained personnel (National Institute for Health & Clinical Excellence, 2007).

Functional Family therapy is an empirically grounded, successful family intervention for kids with conduct order and other risk factors which hinder them from living a healthy life in society. The concept of FFT is to develop family member’s strengths which can improve the environment. The characteristics of the program give the family a foundation for change which includes direct support from the therapist. The family is included in each phase of treatment: (1) goals i.e. reduce negativity and improve communication; and (2) risk and protective factors i.e. blaming (risk) and alliance (protective) (FFT, 2007).

The effectiveness of the intervention is based on the following factors: (1) engagement with the child and the family; (2) motivation; (3) clear/concise/understandable assessment; (4) teaching the family skills to change behaviors; and (5) being available for individualized needs from each member of the family.

The program’s protocol suggests if the program is implemented successfully the child and family will show the following benefits:

1. noticeable changes in Conduct Disorder, Oppositional Defiant Disorder, Disruptive Behavior Disorder and substance abuse

2. reducing the need for other social service program which increase costs for the state and federal government

3. generate positive outcomes

4. preventive measures which are learned enhance the future outlook for the families

5. provide role models for the younger children in the family

6. prevent the adolescent offender from becoming an adult offender (Barton, 2007).

7. effective treatment touches beyond the family into the micro, macro, and other phases of the youths life.

According to the U.S. Department of Justice (U.S. Department of Justice, 2000):

Thirty years of clinical research indicate that FFT can prevent the onset of delinquency and reduce recidivism at a financial and human cost well below that exacted by the punitive approaches noted earlier.

If there is no change in the child’s behavior pharmacotherapy may be added to the treatment. There are no formally approved medications for conduct disorder there are medication which can help with specific symptoms. Stimulants i.e. Dexedrine, Ritalin, are the most promising medication for the treatment of conduct disorder. There is limited research for the long-term effects of these medications on conduct disorder.

There is some controversy when administering antidepressants to children with ADHD and conduct disorder. There have been reports of improvement by parents but more studies are needed. Lithium has shown to reduce aggression but lithium requires regular blood level monitoring for toxicity. The use of lithium and anticonvulsants provides limitations in treatment. Several studies have shown significant improvement with Clonidine but the side effects interrupt the child’s normal day i.e. drowsiness (Searight et al., 2001).

The parent may choose an outpatient mental health provider such as a community service board. The child would be assigned a case manager to assist with programs and concerns in the home and school. The case manager with the assistance of the parent would complete a treatment plan to notate long-term and short-term goals. Therapeutic interventions would include but not limited to: (1 psychological evaluation; (2) psycho-educational testing; (3) provide feedback to the parents and the teachers; (4) assist the parent and the child with establishing rule, boundaries and consequences; and (6) build a therapeutic rapport with the child (Jongsma et al., 1996).

Conclusion

Clearly the research reveals the correlation of diverse factors which promote conduct disorder. Parenting styles play a key role in promoting an environment which is conductive of this disorder. We (I) as new therapist need to education our clients, public, parents, families etc on the negative effects authoritarian parenting styles have on our children.

The research suggest children with conduct disorder become adults with anti-social behavior and others psychological problems. The disorder is more than a fussy child it is a serious issue which parents, teachers and the mental health profession needs to address.

The researcher has provided a brief look into the world of conduct disorder. Parents, caregivers, and clinicians need to be aware of the warning signs of conduct disorder. All three entity need to form a coalition to improve the environment these children endure everyday. Parents need to learn resources, interventions and build rapports with faculty at the schools.

Another aspect to consider is the link between nicotine and conduct disorder. Pregnant women need to be warned against smoking during and after pregnancy. There are significant risks with cigarette smoking during pregnancy but the research adds another aspect to the issue.

The statistics are staggering but the realization of what these children and their parents are enduring is more staggering. As a clinician at a community service board I witness daily these children who can not sit in a chair for five minutes. They need constant re-direction; as the research stated parents resort to coercion and threats instead of implementing good parental skills. Another aspect of the research is lack of communication; this is noticeable immediately.

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