What is Conduct Disorder?

According to DSM-IV criteria, conduct disorder may be diagnosed when a child seriously misbehaves with aggressive or non-aggressive behaviours against people, animals or property that may be characterised as belligerent, destructive, threatening, physically cruel, deceitful, disobedient, or dishonest. This may include stealing, intentional injury, and forced sexual activity. Keep in mind that this behaviour disorder consists of a pattern of severe, repetitive acting-out behaviour and not of an isolated incident here and there.

As stated, conduct disorder is a repetitive and persistent pattern of behaviour in which the basic rights of others, or major rules and values of society are violated, as shown by the presence of three (or more) of the following behaviour patterns in the past 12 months, with at least one behaviour pattern present in the past six months:

Aggression to people and animals:

  1. Often bullies, threatens, or intimidates others.
  2. Often initiates physical fights.
  3. Has used a weapon that can cause serious physical harm to others (for example, a bat, brick, broken bottle, knife, gun).
  4. Has been physically cruel to people.
  5. Has been physically cruel to animals.
  6. Has stolen while confronting a victim (for example, mugging, purse snatching, extortion, or armed robbery.
  7. Has forced someone into sexual activity.

Destruction of property:

  1. Has deliberately engaged in fire setting with the intention of causing serious damage.
  2. Has deliberately destroyed others' property (other than by fire setting).

Deceitfulness or theft:

  1. Has broken into someone else's house, building, or car.
  2. Often lies to obtain goods or favours or to avoid obligations (in other words, "cons" others).
  3. Has stolen items of nontrivial value without confronting a victim (for example, shoplifting, but without breaking and entering; forgery).

Serious violations of rules:

  1. Often stays out at night despite parental prohibitions, beginning before age 13 years.
  2. 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).
  3. Is often truant from school, beginning before age 13 years.

According to DSM-IV, in order to diagnosis conduct disorder in a teen, the disturbance in behaviour must be causing significant problems in that person's life, including at school, with friends and family, and on the job. In other words, if a child gets into serious trouble one time, learns from the experience and never does it again, he or she probably does not have a conduct disorder.

Conduct disorder may be diagnosed in an individual 18 years or older if that individual displays some of the behaviours listed above but does not appear to have behaviours normally found in Antisocial Personality Disorder.

Childhood - Onset Type: Onset of at least one criterion characteristic of Conduct Disorder prior to age 10 years.

Adolescent Onset Type: Absence of any criteria characteristic of Conduct Disorder prior to age 10 years.

Mild: Few if any conduct problems in excess of those required to make the diagnosis, and conduct problems cause only minor harm to others.

Moderate: Number of conduct problems and effect on others intermediate between "mild" and "severe".

Severe: Many conduct problems in excess of those required to make the diagnosis, or conduct problems cause considerable harm to others.

Kids with conduct disorder often threaten suicide, and these threats should generally be taken seriously.

Boys with conduct disorder will be more inclined to fight, steal and participate in acts of vandalism, such as fire setting. Girls with conduct disorder are more likely to lie, run away and be involved in severe sexual acting-out behaviour, including prostitution. Both boys and girls with conduct disorder are at an extremely high risk of substance abuse along with severe difficulties getting along in school.

As you can see from the behaviours listed above, there is a large overlap between conduct disorder and oppositional defiant disorder, with similarities in both disorders that include defiance, rebellion against authority, school problems, disobedience, anger and resentment, and bullying of brothers and sisters. In order to differentiate between the two, one of the things a psychiatrist will generally look at is how a teen treats animals. Is he or she mean or cruel to the family pets or kind to them? Another area that is looked at is whether or not there have been problems with the law, what those problems were, and if they are recurring or one-time events. For example, many young teens experiment with shoplifting and end up getting caught, but this does not mean they have either a conduct disorder or ODD. However, if they keep doing it or their activities turn to more serious stealing behaviour, it is probably safe to assume that there is a more serious behaviour problem going on. Setting fires and stealing, such as breaking into cars and stealing stereos, are more serious offences that would generally tend to indicate a conduct disorder rather than oppositional defiant disorder.

To further complicate the process of making a diagnosis, some research is now beginning to show that conduct disorder may be a component of childhood bipolar disorder and there is a possibility that the behaviours attributed to conduct disorder or ODD are perhaps motivated by a mood disorder. Bipolar disorder, formerly known as manic-depressive illness, described in simplest terms is a chemical imbalance in the brain that causes major mood swings, from elation to severe depression, which often can be helped greatly with the right medication. According to the book, The Bipolar Child, teens with bipolar disorder can experience mood shifts from very elated to very depressed several times in a day, making it nearly impossible for these teens to concentrate and get anything done.

(Editors note: While there are similarities between CD and Bipolar Disorder, it is my belief that the two are distinctly separate disorders - this belief is supported by many leading psychiatric specialists). These mood shifts can cause symptoms that are similar to Attention Deficit Hyperactivity Disorder (ADHD), and therefore this is just one more diagnostic dilemma for the specialist. Other research shows that teens with ADHD can also present in a very similar way as those with either conduct disorder or ODD. The possibility that both conduct disorder and ODD may be a component of ADHD or bipolar disorder is currently being researched. Therefore, both bipolar disorder and ADHD as well as conduct disorder or ODD are processes that the psychiatrist must take into consideration when attempting to diagnose a teen who is displaying severe behaviour problems, such as those listed above. The psychiatrist may resolve the problem of overlapping behaviours and disorders by assigning more than one diagnosis to a child (dual diagnosis). And as many parents have discovered, because distinguishing among these disorders can be quite difficult, their child may receive one diagnosis from a psychologist and a different diagnosis from the psychiatrist. This only further adds to the concerns of the parents, leaving them to wonder if anybody at all knows what is really going on!)

According to Merck's Manual (The Merck Manual of Diagnosis and Therapy), more than half of teens with conduct disorder stop exhibiting these behaviours in early adulthood, but about one third of the cases persist, developing into antisocial personality disorder or other mood or anxiety disorders. Children with conduct disorder tend to have a higher than expected incidence of medical and psychiatric illness at follow-up.

Causes of Conduct Disorder

Research into causes of CD indicates that there are several causative factors, including:

Parental Factors - Unfortunately, parents often do play a role in children developing conduct disorders - Lack of parenting skills, inconsistent parenting or overly permissive parents can contribute. Maternal depression, paternal alcoholism and/or criminal behaviours and antisocial behaviours of either parent have been linked to CD. A lack of a good male role model is a major causative factor. Other parental factors include Divorce (in particular where there is severe conflict between the parents), Violence, poverty, long-term unemployment and on-going ill health of a parent (or indeed, any other close family member).

Place in Family - Middle children, and male children in large families, are more at risk of developing CD.

School Factors - Teachers attitudes to individual children can play a role in children developing CD, this along with factors such as poor reading ability (at least one study has shown that the average reading ability of CD children is up to 3 years behind their peers), teacher to pupil ratio, and even the sex of teachers (male teachers usually have firmer boundaries, and the ability to enforce those boundaries).

Genetic Influence

Treatment of Conduct Disorder

Treatment of all medical, neurological and psychiatric conditions (this includes comorbid conditions) by the appropriate caregivers can improve self-esteem and self-control. These kids will sometimes respond favourably to a very structured approach with clearly stated rules and immediate consequences for breaking rules. A home rules contract, which can be set up with the help of a support person and enforced uniformly by all caregivers, can clarify rules and consequences and provide structure for the teen. However, in some cases, only separation from the current environment, i.e. removing the child from the influence of his peers and/or a bad home environment, with external discipline and consistent behaviour management and modification offer hope for success.

What Medications are available?

Conduct Disorder is difficult to treat with medications, some specialists will try to treat CD with medications often used to treat Oppositional Defiance Disorder (ODD) - such as Risperidone or Tegretol, these have limited success.

Tightening Up Family Rules

Parenting a Conduct Disordered child is a FULL TIME parenting job, you will not cope if you are trying to hold down a job as well.

It is okay (in fact it is advisable) to ask for help from professionals, support people, or even Child Youth and Family Services.

Limits and rules are necessary to create order and productivity, the lack of which, create chaos and confusion. Rules provide the basis of understanding for what is expected, whether in the workplace, classroom, community or family. If a classroom had no rules, very little learning would occur. If a community operated without rules, it would cease to be a safe place to live. Likewise, if harmony is to be maintained within the family, there must be a proper set of family rules, understandings or expectations that are based on your family values.

If your teen is usually compliant and responsible, you will probably only need to have a few rules. However, if you are dealing with a difficult or defiant teen, you are already familiar with the need for a more defined structure.

Setting Core Rules

When setting rules, you want to identify some basic core rules and then support the core rules by establishing several small preventive rules. For example:

If you have a core rule of "Don't use drugs", then you will want to set some preventive rules such as WHO your teen may associate with, WHAT types of activities are allowed, WHERE your teen is allowed to go, and WHEN your teen may go as well as when he or she is expected to return. It would be foolish to think your teen could hang out at the wrong places or associate with drug-using friends and remain drug free.

When you create preventive rules along with your main core rules, it provides your teen with the greatest amount of protection. It also allows you to be involved so that you can be aware of problems early and resolve them before they become overwhelming.

Verifying Your Teen's Plans -

One way to keep tabs on your teen is to take the time to verify all of your teen's plans. If your teen says she is going to spend the night at her friend's house, then get the phone number and call the friend's parents to make sure that the friend's parents know about these arrangements and have okayed this plan. It is amazing how many kids walk out the door and say, "Bye, I'm spending the night at Mary's; see you in the morning", and then head off to a drug or alcohol party or a rave because their parents never bothered to double-check their arrangements.

In my experience, most parents who receive these types of calls from another parent are actually very happy to see that you are concerned enough about your child's welfare to verify his or her arrangements. This also gets the parents working together on their teens' behalf. Groups of parents who are united in maintaining the safety and welfare of their children can be a powerful force for a teen to reckon with.

One thing I should point out is that if you have any suspicions about whether or not you are really talking to a parent when you make your phone call (I have had situations where my teen's friends got on the line and pretended to be a parent), then either visit the house and talk to the parent directly or veto your teen's plans and make him/her stay home. If your teen knows that you will check every plan she makes, she will be a lot less likely to make plans you don't approve of or to end up in a place she should not be.

Maintaining Good Grades -

If you want your teen to maintain good grades, you may need to have some clear preventive rules in areas such as: school attendance, completing daily homework, and obtaining weekly progress reports. The key is that rather than waiting until the end of the term to see if your teen receives good grades, you set rules and create a structure that will help your teen along the way and maximize their chances for success.

Establishing Written Rules -

In order to clarify your rules and make sure that there is no misunderstanding or excuses regarding rules you set, consider writing up a Home Rules Contract with a teen, which clearly states each rule the teen is to follow. Many times, having the teen do the rough draft of a home contract for himself can provide structure for your teen that he will agree with since he helped to set it up.

Rules in a home contract should be clearly written, not too overbearing, and should be discussed thoroughly so that there is no question as to the meaning of the rule. If the contract is too punitive and restrictive, your teen may be overwhelmed by this new contract rather than helped by it.

Sometimes, a teen will want to put responsibility on you in a home contract. For example, a younger teen might ask for a stipulation in the contract that states that if he does all his chores for the week without a lot of fuss, in exchange you will drive him to the movies or to a friend's home on Friday night. As long as you are okay with your teen going to the movies and know that there is supervision at the friend's home and you also approve of the friends he might see at these places, this is generally a fair arrangement for a teen and parent to enter into.

Conclusion -

Conflict is inevitable with difficult or defiant teens. Consistently addressing and resolving conflicts over small issues, such as homework, dress, grooming and curfew, is your best preventive measure to avoid the large, devastating issues such as teen pregnancy, substance abuse and failing grades. "Take care of the small things, and the big things will take care of themselves", really applies when it comes to administering rules.