What is Conduct Disorder?

A friend was diagnosed with Conduct disorder. What does that mean?

First, it’s important to know that all children will have short periods of bad behavior. However, when things start to get out of hand, it may be evidence that there is more that needs attention. Children can get irritable and even hostile when they are tired, or they may argue with parents or disobey other authority figures to show their independence and are that they are growing up. Children may also lie to get out of trouble. Most of this behavior is fairly normal as children learn to navigate the world but when it becomes regular and persistent and starts getting them into trouble at home, at school, or with other kids, they may have what we call a disruptive behavior disorder.

Conduct Disorder can be diagnosed in a child or youth who has repeatedly and consistently shown a number of severely aggressive and anti-social behaviors that continue for 6 months or longer. It is diagnosed in childhood and adolescence, and is characterized by a pattern of antisocial behavior and defiance of rules where basic rights or age-appropriate norms are violated and has difficulty behaving in socially acceptable ways. Often these youth are viewed as simply being “bad” rather than diagnosed as having a mental health problem.

The child exceedingly misbehaves against people, animals or property and can be characterized as quarrelsome, destructive, threatening, physically cruel, deceitful, disobedient, or dishonest. This may include stealing, intentional injury, forced sexual activity, vandalism and/or lying. These behaviors are referred to as antisocial behaviors and are often seen as the precursor to Antisocial Personality Disorder.

Children displaying the disorder before the age of 10 (called childhood-onset type) are more likely to continue the behavior over time and are more likely to be boys. However if symptoms appear after age of 10 (adolescent-onset type) the disorder appears equally in girls as it does boys.

It is also argued that some children may not have conduct disorder, but are actually engaging in typical developmentally appropriate disruptive behavior. This is particularly true of teenagers that are testing out the world around them, trying to understand it, and where they fit into their environment. This is a natural time of emerging adulthood where a person learns independence and who they are as a person. Not surprisingly, a greater number of adolescent-onset conduct disorders are diagnosed than childhood-onset disorders, suggesting that there is an exaggeration of normal behaviors that are typical in adolescence, such as rebellion against authority figures and rejection of conventional values.

There appears to be a relationship among Oppositional defiant disorder, Conduct disorder and Antisocial personality disorder. Oppositional defiant disorder may precede conduct disorder as a weaker variation of the disorder. Additionally, most adults with antisocial personality disorder were previously diagnosed with conduct disorder. Although these relationships are common, these patterns do not occur in all people diagnosed with these disorders.

A child is diagnosed with oppositional defiant disorder when he or she shows signs of being hostile and defiant for at least 6 months and may start as early as the preschool years, while conduct disorder generally appears when children are older. However, Oppositional defiant disorder and conduct disorder do not occur together.

Conduct disorder appears in up to 10% of the population but, the prevalence of incarcerated youth with the disorder is between 23% and 87%. Also, for approximately 25-30% of boys and 50-55% of girls, having ADHD is the condition most commonly associated with conduct disorders.

 Furthermore, it seems that there is a relationship between substance use and conduct problems, such that aggressive behaviors increase substance use, and in turn, substance use tends to increases aggressive behavior. Children with conduct disorder generally begin substance use and abuse earlier than those without the disorder and tend to use multiple substances.  Almost all adolescents who have a substance use disorder have conduct disorder traits but about half of the adolescents lose their conduct disorder symptoms after successful treatment of the substance use.

Empathy is being able to recognize feelings of others. However a child diagnosed with conduct disorder often displays a lack of empathy because they are unable to place themselves in the other person’s shoes. Therefore they are unable to understand the consequences of their actions towards others.

Another factor of conduct disorder is a lower level of fear. If a child does not learn how to handle fear or distress the child will be more likely to lash out at other children. If the caregiver is able to teach children at risk better empathy skills, the child will have a lower incident level of conduct disorder.

Definition from the Diagnostic & Statistical Manual of Mental Disorders

(DSM IV – TR)

 A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past 6 months: 

Aggression to people and animals 

-           often bullies, threatens, or intimidates others 

-           often initiates physical fights 

-          has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun)

-           has been physically cruel to people 

-          has been physically cruel to animals 

-          has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery) 

-          has forced someone into sexual activity 

Destruction of property 

-          deliberately engaged in fire setting to cause serious damage

-          deliberately destroying others' property

Deceitfulness or theft 

-          has broken into someone else's house, building, or car 

-          often lies to obtain goods or favors or to avoid obligations (i.e., "cons" others) 

-          has stolen valuable items without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery) 

Serious violations of rules 

-          often stays out at night despite parental prohibitions, beginning before age 13 years 

-          has run away from home overnight at least twice while living in parental or parental surrogate

-          home (or once without returning for a lengthy period) 

-           is often truant from school, beginning before age 13 years 

·         The disturbance in behavior causes clinically significant impairment in social, academic or occupational functioning.

·         If the individual is age 18 years or older, criteria are not met for antisocial personality disorder.

Young people may be diagnosed with conduct disorder if they have displayed three or more of the following symptoms in the past 12 months, with at least one symptom also present in the past six months:

Children with conduct disorder or oppositional defiant disorder also may experience:

·         Higher rates of depression, suicidal thoughts, suicide attempts, and suicide

·         Academic difficulties

·          Poor relationships with peers or adults

·         Sexually transmitted diseases

·         Difficulty staying in adoptive, foster, or group homes; and

·         Higher rates of injuries, school expulsions, and problems with the law.

Other factors that may make a child more likely to develop conduct disorder include:

·         Early maternal rejection

·         Separation from parents, without an adequate alternative caregiver

·         Early institutionalization

·         Family neglect

·         Abuse or violence

·         Parental mental illness

·         Parental marital discord

·         Large family size

·         Crowding

·         Poverty.

What can be done to help?

Conduct Disorder is harder to treat than Oppositional Defiant Disorder and becomes worse as a child gets older. This makes early intervention extremely important.  Behaviors are hard to change after they have become learned so the earlier the conduct disorder is identified and treated, the better the chance for success. Most children or youth with conduct disorder are probably reacting to events and situations in their lives so it is important to look for the signs and try to understand the reasons why this may be happening to try and improve the situation. Getting help is a good way to start.

For children and youth:

·         Get to know about behavioral disorders by getting accurate information from your library, hotlines, community sources, or go online

·         See your family doctor

·         Talk with a mental health or social services professional, teacher, counselor, psychiatrist, or psychologist specializing in childhood and adolescent disorders.

·         Get training for the child in problem solving skills for the children

·         Get training for the child in social skill, and anger management

·         Monitor children's activities peer group influences nonschool hours promote curfews.

·         Encourage involvement in structured and supervised activities sports, like scouting, art, recreational programs at churches, schools or youth groups helps protect children from negative peer influences

·         Discuss and demonstrate clear and specific parental communication techniques.

·         Introduce rewards for desirable behavior.

·         Introduce realistic, clearly communicated consequences for noncompliance.

·         Establish a daily routine of child-parent activities.

It also extremely important to focus on other conditions the child may have. Children who have AD/HD, depression, anxiety and substance abuse to name a few, tend to lose symptoms of disruptive behavior when other problems are successfully treated

For parents:

Parents of children with conduct disorder are more likely to exhibit stress, anxiety, depression, substance abuse or antisocial personality traits. Various parental problems which may include mental disorders, high stress or marriage and financial problems can greatly influence a child's behavioral problems as well as inconsistent parenting, harsh discipline or lack of discipline, impaired parental attachment and minimal supervision can also greatly affect a child’s well being and behavior. Therefore it is just as important to address parent issues as well as the child’s issues because many of these things can be triggers for conduct problems in children.

o   Training in social skills, anger management

o   Training for parents on how to handle child and adolescent behavior

o   Training in problem solving skills for parents

o   Help with parental mental health issues and other personal coping skills

Changing parenting practices can help the child and benefit the family as a whole. If the parents, particularly the mothers, are unable to develop new ways of parenting, their children may go on to develop the more serious conditions.

What is Oppositional Defiant Disorder?

Oppositional Defiant Disorder? (O.D.D.)

All children are oppositional from time to time, particularly when tired, hungry, stressed or upset. They may argue, talk back, disobey, and defy parents, teachers, and other adults.  Oppositional behavior is often a normal part of development for two to three year olds and early adolescents. However, openly uncooperative and hostile behavior becomes a serious concern when it is so frequent and consistent that it stands out when compared with other children of the same age and developmental level and when it affects the child’s social, family and academic life.

Oppositional Defiant Disorder is a persistent pattern of angry and irritable mood along with vindictive behavior. DSM-V now includes three symptom clusters; an angry or irritable mood, touchy or easily annoyed by others, and resentful. It is characterized by a persistent pattern of negative, defiant, disobedient and hostile behavior towards authority figures that seriously interferes with the child’s day to day functioning. This behavior typically starts by age 8, but it may start as early as the preschool years. Up to 16 % of school-age children and adolescents are believed to have O.D.D. The disorder is more common in boys than in girls and is one of the most common reasons for referrals to mental health services for children and adolescents.

The exact cause of oppositional defiant disorder is not known however the term disorder may be misleading because it is thought that oppositional defiant disorder is a learned behavior or a combination of a child’s environment and their inherited characteristics which may include:

·         Ineffective, Inconsistent and/or harsh discipline

·         Lack of supervision, neglect or abuse

·         Developmental delays in the ability to process their thoughts and feelings

Signs and symptoms

The child must consistently exhibit signs and symptoms for at least six months, behaviors must be different from those of other children around the same age and developmental level and present at least 4 symptoms to meet the DSM-IV-TR diagnosis for oppositional defiant disorder. Common features of oppositional defiant disorder include:

·         Frequent temper tantrums or angry outbursts

·         Excessive arguing with adults

·         Often questioning rules

·         Active defiance and refusal to comply with adult requests and rules

·         Deliberate attempts to annoy or upset people

·         Blaming others for their mistakes or misbehavior

·         Often being touchy or easily annoyed by others

·         Mean and hateful talking when upset

·         Spiteful attitude and prefer taking revenge rather than calm resolutions

·         Excessive, often persistent anger and resentment

·         Disregard for authority

·         Parents often observe more rigid and irritable behaviors than in siblings.

·         Often have problems with school and friendships as a direct result of the behavior 

·         Behaviors cause considerable distress for the family

·         Put themselves in harmful situations

·         Interferes significantly with school or social activities.

The symptoms of oppositional defiant disorder may be difficult to distinguish from those of other behavioral or mental health problems. In addition, oppositional defiant disorder can be greatly amplified by other disorders and may be difficult to improve without treating the coexisting disorder. In children and adolescents, the following conditions can cause similar behavior problems:

·         Anxiety disorders

·         Attention-deficit /hyperactivity disorder (ADHD)

·         Bipolar disorder

·         Depression

·         Learning disorders

·         Substance abuse disorders

Successful treatment of the often-coexisting conditions will improve the effectiveness of treatment for oppositional defiant disorder. In some cases, the symptoms of oppositional defiant disorder disappear entirely. However if it is left untreated and becomes severe, with the child or adolescent showing a lack of empathy for the rights of others, oppositional defiant disorder can, and likely will, progress to more serious diagnosis of Conduct disorder, substance abuse, severe delinquency or Antisocial Personality Disorder in adult life, a severe disorder that is difficult to overcome and is associated with criminal behaviors and incarceration. A child diagnosed with oppositional defiant disorder is not automatically going to develop conduct disorder but it is important to seek treatment as early in the child's life as possible to treat the disorder before it progresses.

If the disorder does progress, the child will likely start violating more serious rules like running away from home or skipping school and progressing to more aggressive behavior toward people, property or animals. They may initiate bullying, fighting, or animal cruelty, or become disrespectful of others’ property by stealing, causing damage, vandalism and even arson.

What causes oppositional defiant disorder?

The cause of oppositional defiant disorder is not known however there are two main theories are used to explain the development of O.D.D. Developmental theory suggests children and adolescents who develop it may have had difficulty learning to separate and become independent from the parent or guardian that they were emotionally attached to. The bad behavior and emotional responses of oppositional defiant disorder are seen as normal developmental issues that were not resolved during the child’s early years. On the other hand Learning theory suggests that the negative features of O.D.D are learned attitudes reflecting the effects of reinforcing negative behaviors whether unintentionally or willingly used by parents or other authority figures.

No single factor causes oppositional defiant disorder but rather is a complex problem involving a many influences, circumstances and genetic components that can play a role in the development of oppositional defiant disorder such as:

·         The family's response to the child's personality style

·         The child's perception that he or she isn't getting enough of the parent's time and attention

·         Children of alcoholic parents or parents in trouble with the law have a higher chance of developing ODD (suggests the development of ODD may be influenced by the behavior of parents)

·         Having a parent with a mood or substance abuse disorder

·         Child being abused or neglected

·         Harsh or inconsistent discipline

·         Lack of supervision

·         Poor relationship with one or both parents

·         Family instability such as occurs with divorce, multiple moves, or changing schools or child care providers frequently

·         A family history of behavioral disorders which may include ADHD, oppositional defiant disorder or conduct problems

·         Financial problems in the family

·         Exposure to violence

·         Substance abuse in the child or adolescent

·         Having had an unusually hard time separating from parents when younger

·         Did not resolve their normal development issues leading to later behavioral problems

·         Developed unusually strong levels of negativity and pessimism because of excessive punishment or other forms of negative reinforcement

·         Acting out to obtain extra attention, time or sympathy and compassion from a parent/caregiver

·         A parent too often and too easily giving in to the child’s demands

·         The mother’s exposure to harmful agents while pregnant

·         Significant stress or a lack of predictable structure in the home or community environment

·         Biological causes relating to chemical imbalances or dysfunction in the particular parts of the brain.

·         A child’s temperament being particularly moody or displaying a dominant behavior

·         Environmental causes play a strong role, including dysfunctional family relationships or inappropriate parenting

·         Living in harsh surroundings or stresses such as poverty

Treatment

If your child is showing possible symptoms of ODD, it's important to seek professional help as soon as possible. The most effective way of treating disruptive behavior disorders is behavioral therapy which focuses on how to prevent problem thoughts or behaviors from being reinforced and to try new behaviors. Therapists may also work with parents to discontinue ways in which they are unintentionally reinforcing unwanted behaviors.

Researchers have found that the use of positive reinforcement and praise for appropriate behaviors are two key elements in effective interventions. If the majority of interactions with the child are focused around correcting their negative behaviors, a cycle of negative interactions is created, where the child expects attention after misbehaving. Positive reinforcement and praise builds the child's self-esteem and serves to strengthen the bond between a child and their caregiver.

Self-care for parents
Dealing with a child with oppositional defiant disorder can be overwhelming but here are some things to keep in mind:

·         Always build on the positives, give the child praise and positive reinforcement when he shows flexibility or cooperation.

·         Take a time-out or break if you are about to make the conflict with your child worse, not better.  This is good modeling for your child.  Support your child if he decides to take a time-out to prevent overreacting.

·         Recognize and praise your child's positive behaviors.

·         Model the behavior you want your child to have.

·         Pick your battles. Avoid power struggles.

·         Set limits and enforce consistent reasonable consequences.

·         Set up a routine. Develop a consistent daily schedule for your child.

·         Build in time together. Develop a consistent weekly schedule that involves parents and child being together.

·         Work with your spouse or others in your household to assure consistent and appropriate discipline procedures.

·         It is important to set your child up for success with tasks that are relatively easy to achieve and gradually blend in more important and challenging expectations.