Conduct disorder

Conduct disorder (CD), which is informally perceived as juvenile delinquency,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.

Conduct disorder 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 toward people and animals, destroying property, lying, stealing, skipping school, 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 traitsof children with conduct disorder. A trademark of the disorder is the sufferer's refusal to take responsibility for his or her problematic behavior.

The Diagnostic and Statistical Manual of Mental Disorders fourth edition, (DSM-IV) describes two subtypes of conduct disorder, one beginningin childhood and the other in adolescence. There is no known cause. But researchers and physicians suggest a number of factors that may lead to conduct disorder.

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. Consequently, they 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 conduct disorder.

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 thedevelopment of conduct disorder. Long-term studies have shown that maternal smoking during pregnancy may be linked to the development of conduct disorderin boys. Animal and human studies suggest that nicotine can have undesirableeffects on babies. These include altered structure and function of their nervous systems, learning deficits, and behavioral problems. In a study of 177 boys ages 7-12 years, those with mothers who smoked over one half a package ofcigarettes daily while pregnant were more apt to have a conduct disorder thanthose with mothers who did not smoke.

Other conditions that may cause or co-exist with conduct disorder include head injury, substance abuse disorder, major depressive disorder, and attentiondeficit hyperactivity disorder (ADHD). Thirty to 50% of children diagnosed with ADHD, a disorder characterized by a persistent pattern of inattention or hyperactivity, also have conduct disorder.

DSM-IV defines conduct disorder as a repetitive behavioral pattern ofviolating 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 conduct disorder (one of the three must have occurred in the past 6 months): bullying, threatening, or intimidating others; picking fights; using a dangerous weapon; being physically cruel to people; being physically cruel to animals; stealing while confronting a victim (for example, mugging or extortion); forcing someone into sexual activity; deliberately setting a fire with theintention of causing damage; deliberately destroying the property of others;breaking into someone else's house or car; frequently lying to get somethingor to avoid obligations; stealing without confronting a victim or breaking and entering (e.g., shoplifting or forgery); staying out at night; breaking curfew (beginning before 13 years of age); running away from home overnight at least twice (or once for a lengthy period); frequently skipping school (beginning before 13 years of age).

Conduct disorder 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 (manic depression) or ADHD. A comprehensive evaluation of the child should ideallyinclude 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 or written and are administered in both hospital and outpatient settings.

In some cases, conduct disorder appears to be passed on from parent to child,especially in the case of sons of antisocial or alcoholic fathers. There doseem to be significant differences, however, in serotonin levels and EEG patterns in children diagnosed with conduct disorder and aggressive adults.

Treating conduct disorder requires an approach that addresses both the childand his environment. Behavioral therapy and psychotherapy can help a child with conduct disorder 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. Long-term data indicates that an intact family may be one of the most powerful factors in contributing to a positive outcome for children diagnosed with conductdisorder.

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 conduct disorder. In all cases of conduct disorder, treatment should begin when symptoms first appear. Recent studies have shown Ritalin to be a useful drug for both ADHD and CD.

Although children with conduct disorder are usually very aggressive, the waysthey exhibit their aggression may differ. Some sufferers exhibit uncontrolled outbursts, while outbursts in others may be triggered by individual eventsor related to some psychiatric disturbance such as a mood disorder. Still others may act in more predatory ways, with their behavior coming across as cold, callous, and premeditated. There is evidence that children who exhibit uncontrolled outbursts respond more favorably to pharmacological intervention than those who act in more predatory ways. 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.

Although there is no pharmacotherapy available to treat the core disorder, medication does appear to be helpful in treating conduct disorder when the disorder co-exists with another problem, such as depression, ADHD, post-traumaticstress, or anxiety. One study showed that children who were diagnosed with both conduct disorder and depression showed a pronounced reduction in both symptoms when they were treated with the tricyclic antidepressant imipramine. Similar findings have been reported for patients with both conduct disorder andADHD when treated with the stimulant methylphenidate (Ritalin). To treat agitation, aggression, and self-abuse, physicians often prescribe beta blockers(e.g., propranolol), clonidine, guanfacine, benzodiazepines (e.g., Valium, Klonopin), lithium, anticonvulsants (e.g., Tegretol, Valproate, Neurontin), naltrexone, or antipsychotics (e.g., Thorazine, Mellail, Zyprexa). When aggressive behavior is severe, the medications of choice are the mood-stabilizers, including lithium, carbamazepine, and propranolol.

The prognosis for children with conduct disorder is not bright. Studies showthat most children with conduct disorder will continue to have the disorder or experience aggressive behavior for a long time. 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 coexisting disorders, early identification and intervention, and long-term support may improve the outlook significantly.

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