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In consideration of facts relating behavioral disorders to juvenile delinquency, Conduct Disorder being one of the Disruptive Behavioral Disorder should not be ignored. Although the prevalence rate of this disorder may seem to be relatively low, the effects of such behaviors are significantly disruptive not only to the individual but also to all those people and properties he get along with.
This paper aims to gather and present facts and information from reliable sources relative to the nature, causes and treatment of Conduct Disorders. This paper used the DSM-IV Guidelines as major source in presenting the subject. Several studies have been used and journals and medical websites have been consulted in order for this paper to come up with a comprehensive study of the subject. The first three sections of this paper discusses the basic information that will describe to the reader the nature, categories, types and prevalence of Conduct Disorder. Next, the progression of the disorder has been thoroughly discussed in a separate section. Another section is set aside for the discussion of the risk factors that significantly contribute to the development of Conduct Disorder. To complete the paper, this paper also presented the common treatment methods currently being used by experts on their patients.
II. NATURE OF CONDUCT DISORDER
Conduct Disorder (CD) is just one of the behavioral disorders, specifically the Disruptive Behavioral Disorders. Such group includes the Oppositional Defiant Disorder (ODD) and attention deficit hyperactivity disorder (ADHD) (Better Health Channel). 1CD however is distinguished from other behavioral disorders such that it is characterized by a repetitive and persistent violation of the basic rights of others. 2Children and adolescents diagnosed with CD exhibit antisocial behaviors ranging from irresponsibility and delinquent behaviors to physical aggression towards others. Teens that have conduct disorder have trouble feeling and expressing empathy towards others and of reading social cues (Mental Health America). Children with conduct disorders often have the risk of taking drugs and of creating school problems.
This paper however prefers to use the definition made by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) for Conduct Disorder as having the essential characteristics of “a persistent pattern of behavior in which the basic rights of others or major age-appropriate social norms are violated.” DSM-IV requires that a behavioral disorder to be classified as Conduct Disorder when the subject exhibits three or more of the set criteria in the past twelve months or at least one criterion in the past six months (DMS-IV, Diagnostic Criteria for Conduct Disorder 312.8). Further, DMS-IV classifies a behavioral disorder if the disturbance in behavior causes clinically significant impairment in social, academic or occupational functioning (Criteria 312.8-B) and that the subject who is 18 years and older exhibits behaviors that do not meet the criteria for Antisocial Personality Disorder (Criteria 312.8-C).
III. CATEGORIES OF CONDUCT DISORDER
DMS-IV has set four criteria for Conduct Disorder:
A. Aggression to People and Animals-people with Conduct Disorder usually inflict physical hams to others, both to people and animals. They exhibit physical cruelty to persons and animals, bully and initiate fights. Threatening and intimidating others also characterized by this disorder including the use of weapon to inflict serious harm to others, stealing while confronting a victim and of forcing someone to engage in sexual activity.
B. Destruction of Property- one of the distinguishing behavior of people with CD is their deliberate intention of damaging properties the 3most common according to studies is fire setting.
C. Deceitfulness or Theft- According to American Academy of Child and Adolescent Psychiatry, teenagers with Conduct disorders also exhibit non-aggressive behaviors such as breaking into other people’s homes or buildings and destructing others’ cars including vandalism. They deceive others commonly by lying for the purpose of avoiding obligations or of obtaining favor from others. Forgery, shoplifting and conning are the most common deviant behaviors exhibited by people with Conduct Disorders.
D. Serious Rules Violations- disobedience is one common behavior of children with Conduct Disorder. They intentionally violate set rule at home, in school and even at work. Truancy and running away from home are commonly exhibited by them. DMS-IV says that these children often stay out at night which usually begins before the child reaches age thirteen. They intentionally disobey their parents and other authorities by intentionally and repeatedly violating rules set by them. They stay out without permission, miss out school and work in the absence of valid reasons (T. Radecki).
IV. TYPES OF CONDUCT DISORDER
There are basically two types of Conduct Disorder according to DMS-IV namely the Childhood-Onset Type and the Adolescent-Onset Type.
A. CHILDHOOD-ONSET TYPE (DMS-IV Code 312.81)
DMS-IV defines childhood-onset type of Conduct disorder as the onset of one criterion characteristic of conduct disorder before age 10. Studies say that these children are at greater risk of having peer and academic troubles (W.D. Tynan). The criterion characteristic of conduct disorder is usually being met fully by the child before the puberty stage and said to have a greater risk of developing personality disorder than those with adolescent-onset type of CD (American Psychiatric Association). At early childhood, individuals with this type of CD may also be diagnosed at the same time with Oppositional Defiant Disorder (ODD).
Childhood-onset Conduct Disorder may also be diagnosed as early as pre-school. At this stage, experts recommend that “appropriate intervention be provided to prevent ongoing behavioral and academic problems” (J. Kim-Cohen, et. al). In the Environmental Risk Longitudinal Twin Study conducted on twins in England and Wales, children ages 4.5 to five years revealed a 6.6% prevalence rate of moderate to severe conduct disorder and 2.5% severe conduct disorder (American Journal of Psychiatry, July 2005). The researchers tested 2,232 non-referred preschool children and at the same time interviewed their parents and teachers relative to the children’s conduct in the past six months. The same study also revealed that five-year-olds diagnosed with conduct disorder have greater likelihood of having behavioral and academic difficulties at age seven compared to other children at the same age who were not diagnosed with the disorder.
B. ADOLESCENT-ONSET TYPE
This is the Conduct Disorder which is characterized by the absence of conduct disorder prior to age 10 (DMS-IV, Code 312.82). Experts said that those diagnosed with Adolescent-Onset CD as less aggressive than those with childhood-onset CD. According to American Psychiatric Society, the percentage of females having this type of CD is higher than males. Further, experts also assess that “these individuals tend to have more normal peer relationships, and are less likely to have persistent conduct disorders or to develop adult antisocial personality disorder” (L. Phelps & McClintock, 1994).
V. PREVALENCE OF CONDUCT DISORDER
In the study made by Julia Kim-Cohen and her colleagues in 2005, an average of 6.6% of the tested children ages 4.5 and 5 years revealed to have moderate conduct disorder while 2.5% were diagnosed with severe conduct disorder. There also exists a different prevalence rate for males compared to females. Of the 6.6% total sample of children with moderate conduct disorder, 9.9% are boys while 3.5% are girls. Of children with severe conduct disorder, 4.2% are boys and 0.9% are girls (J.Kim-Cohen, et.al, 2005) The same study also concluded that boys ages five years have 3-5 times risk of having conduct disorder than girls of the same age. It has to be clear that the results were drawn from pre-school children in England and in Wales and more importantly, these children are classified as non-referrals, meaning that they have not been diagnosed by specialists with behavioral problems. The United States study had slightly different results as it revealed an estimate of 2%-9% prevalence rate (E.J. Costello, et. al, 2003). A separate study in the United States revealed that 6% of the American children have conduct disorder (Phelps & McClintock). But a higher prevalence result was revealed in the New York study having 12% and 4% of the sample were diagnosed with moderate and severe conduct disorders respectively. The difference of the studies in the UK and the United States is that the former used non-referral samples while the latter used referral samples. This difference in sample produced the hypothesis that prevalence rate of conduct disorders varies demographically. Further, because USA samples used referrals, experts estimate that there may be higher prevalence rate of conduct disorder when non-referrals are included in the study.
VI. SEVERITY OF CONDUCT DISORDER
DSM-IV Diagnostic Criterion 312.89 classified conduct disorder according to severity as Mild, Moderate and Severe. Conduct disorder is considered mild if it only causes minor harm to others and the conduct problems identified are only few. Such mild conducts include breaking parental rules and lying. Mild conduct disorder is diagnosed when conduct problems and its effects are moderate, such that they appear to be between mild and severe problems. Lastly, conduct disorder is classified as severe if conduct problems cause considerable harm to others. Such severe conduct problems include assault, breaking in and rape. It has to be clear that the conduct problems should be identified in excess of the requirement for diagnosis.
VII. PROGRESSION OF CONDUCT DISORDER
Conduct Disorder comes in progression, that is, symptoms or signs of the disorder are not revealed and exhibited by the child all the same time. There are basically three stages of the development of Conduct Disorder: Pre-school stage, elementary school stage and the middle and high school stage.
A. Pre-School Stage- children ages two may already exhibit signs of conduct disturbances that maybe diagnosed as ADHD or ODD. But severe cases of these disturbances are also indications of a child’s possibility of developing Conduct Disorder in later years. These early signs included temperamental difficulties which may come in forms of severe irritability, impulsiveness and non-compliance initially diagnosed as ODD and ADHD. In studies made by psychotherapies relative to the disorder they have found that children who belong to unstable families, who have experienced or experiencing economic stress and even legal and conduct problems have the greater risk of developing Conduct Disorder (Tylan, Section 4). At this stage, children with CD will have a more difficult time with their parents as they tend to be more resistant to corrections resulting to a negative parent-child interaction.
B. Elementary School Stage- children who have exhibited aggressive behavior at early age continue to live with them as they advance to elementary school age. Children with CD disregard rules and social cues and do not develop the skills needed for social interaction. Thus, they tend to be in a more difficult situation as they lack the skills that should enable them to solve social issues. What is of great concern here is that these children generally are irresponsible with their own actions. Children with CD usually blame others for inflicting harm with their peers.
C. Middle and High School Stage- at this stage, interaction problems are more prevalent. It is also at this point where children exhibit the three classes of behaviors that are considered as the core of conduct problems (G.R. Patterson & Forgatch, 1987). Such behaviors include non-compliance with commands, emotional overreaction and failure to take responsibility for one’s own action.
Since children with Conduct Disorders tend to have difficult interaction with parents and teachers, these children consequently will have low levels of cognitive stimulation leading to poor of academic performance. If a child with Conduct Disorder interacts with other high-risk children, conduct problems may intensify especially in communities where there is large percentage of distressed families. Children with CD also experience rejection as they tend to be more aggressive and thus, scary. Research said that middle school is the stage where relationships with other are critically developed and so must be paid attention to especially by parents. As these children continue to be rejected and be paid less attention to, they are likely to be less interested in interacting with others even their families. They too, lose the interest in academic activities.
Depression is also identified at the middle and high school stages of children with Conduct Disorder. This depression is developed after having social and academic failures (R.J. McMahon & Wells, 1998). At this stage, children with CD tend to prefer hanging out with gangs and other deviant peer groups rather than social groups such as sports clubs and church organizations.
There is also a clear link between substance abuse in teenagers including other criminal and deviant behaviors and Conduct Disorder developed at this stage. This stage according to experts is the critical stage where children with CD and develop juvenile delinquency (J. Randall et.al, 1999). It is because at this stage, children with CD have poor family bonding and so parental supervision is absent or at least at the lowest level. If they continue to be untreated, these children especially when associated with other deviant peers will likely to develop into a criminal offender.
VIII. CONTRIBUTING RISK FACTORS OF CONDUCT DISORDER
A. NEUROLOGICAL FACTORS
Neurological dysfunction has been one of the major considerations of experts in assessing the risk of conduct disorder. This is due to the high co-morbidity of other behavioral disorders such as ODD, ADHD and Tourettes Syndrome with conduct disorder. For all persons diagnosed with CD, co-occurrence with ADHD is at least 50% (Tynan, Section 5). In a cross-sectional study discussed by Tynan, children with conduct disorder revealed a32%-37% co-morbidity with other behavioral disorders.
B. BIOLOGICAL FACTORS
The child’s temperament has been linked with the development of conduct disorder. However there arguments that say that the child’s temperament only becomes a determinant of conduct disorder depending on the parents’ way of responding to them as early as the infancy stage. If parents are impatient, demanding and inconsistent, difficult infants are likely to develop conduct problems later (H.R Bird et. al, 1994).
Cognitions may also influence the development of conduct disorder (C. Webster-Stratton et.al, 1995). According to studies, children with conduct disorder have deficiency in social problem skills resulting to limited solutions to their problems. Also evident in children with conduct disorder is their tendency to misinterpret the actions or intent of others usually as with negative intent.
C. FAMILY-RELATED FACTORS
Family plays important role in the development of a child’s behavior and personality. Several researches have found the significant contributions of distressed families with the children’s deviant behaviors. Depression, alcoholism and criminal conducts displayed by parents or the elderly in the family have been linked to the development of conduct disorder. Family conflicts such as divorce, violence and marital distress are also included in the list of factors. The link to these family situations is clear to the fact that these situations create an unhealthy environment for the child as irritability, loss of love and friendly relationship are present within the home (M. Forgatch, 1989). Further, economic problems in the family such as poverty, overcrowding and unemployment also considered as contributors of the child’s risk of developing conduct disorder which, according to studies increase the risk by 2-4 times compared with normal family settings.
IX. TREATMENT FOR CONDUCT DISORDERS
A. MEDICAL TREATMENT
Stimulant medicines are the most common medical treatment prescribed by physicians. These stimulants are however proven effective only for short-term medication and only for controlling inattention, impulsivity and hyperactivity. There are four drugs that have already been used medically: lithium, carbamazepine, methylphenidate and clonidine. These drugs however were found to have been causing side effects especially the clonidine.
B. PSYCHOLOGICAL THERAPIES
Parent Management Training (PMT) has been found to have the most positive impact on the child’s coercive pattern of behavior (Tylan, Section 8). In this method, parents are trained to make ways of altering their children’s behavior at home. In here, parents are trained to pay attention with their children’s behavior and at the same time encourage the parents to become good parents by practicing socially acceptable behaviors and the employment of non-aversive punishments. Also in this process, the parent-child relationship is strengthened in order to produce a more effective learning environment for the child. Studies however made it clear that PMT as group therapy is effective only to children with conduct disorders while this may worsen the situation for adolescents. With these facts researchers recommend that PMT be conducted along with other treatment models such as social skills training, academic support, individual counseling and pharmacologic treatment for ADHD (T.J. Dishion, et. al).
Conduct Disorder has been proven to have been one of the prevalent behavioral disorders among children as evidenced by the results from different comprehensive studies. We have also found that Conduct Disorder has significant percentage of co-morbidity with ADHD and other behavioral disorders but is however distinguishable by conduct problems associated with the violation of the basic rights of others.
In this paper, we were able to link different factors that increase the risk of children developing Conduct Disorder. BY using the DSM-IV guidelines, we were able to identify the severity of the disorder, its progression, the types of the disorder and the common treatment methods used by experts to for conduct disorders. More importantly, we have learned that conduct disorder is greatly influenced by family and so it only the family, especially the parents who can make a better way of treating the disorder.
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TABLE OF CONTENTS
II. THE NATURE OF CONDUCT DISORDER
III. CATEGORIES OF CONDUCT DISORDER
IV. TYPES OF CONDUCT DISORDER
V. PREVALENCE OF CONDUCT DISORDER
VI. SEVERITY OF CONDUCT DISORDER
VII. PROGRESSION OF CONDUCT DISORDER
VIII. CONTRIBUTING RISK FACTORS OF CONDUCT DISORDER
IX. TREATMENT OF CONDUCT DISORDER