Watch your thoughts; they become words.  Watch your words; they become actions.  Watch your actions; they become habits.  Watch your habits; they become character.  Watch your character; it becomes your destiny.  ~Unknown

In Part One of this three part series on behavior disorders most often diagnosed in childhood or adolescence I discussed the impulse control disorder known as intermittent explosive disorder (IED).  In Part Two the reader was informed about oppositional defiant disorder (ODD).

To review Part One, intermittent explosive disorder is a disorder of behavior characterized by repeated episodes of extreme anger, oftentimes to the point of violence, way out of proportion to the actual situation.  Individuals with IED may attack others, as well as objects, causing significant bodily injury and property destruction.  These explosive episodes typically last from ten to twenty minutes, and may occur in clusters or can be separated by weeks, or even months, of well-controlled behavior.  Temper tantrums, road rage, domestic abuse and anger outbursts involving throwing and/or breaking things may well be signs of IED.  Following the violent outbursts many who suffer from IED feel deep regret, remorse and embarrassment.

To briefly recap last week’s column, oppositional defiant disorder is an ongoing and persistent pattern of anger guided disobedience, along with hostilely defiant behavior, toward authority figures which goes beyond the bounds of normal childhood behavior.  The signs and symptoms of oppositional defiant disorder most often begin before the age of eight, and almost always will have presented prior to becoming a teenager.  When ODD develops there is an enduring pattern of defiance, uncooperativeness and hostility which significantly interferes with the child’s day-to-day functioning.  Today’s discussion will focus on the behavior disorder known as conduct disorder (CD).

Conduct disorder is a psychiatric disorder of childhood and adolescence that involves chronic behavior problems including oppositional, defiant, and impulsive behaviors, conflict with parents, teachers and peers, property destruction, serious violations of rules, and persistent antisocial activities (chronic lying, stealing, physical violence, etc.).  Drug use and criminal activity are also commonly found.  Unfortunately, many of these children are all too often considered to be “bad” kids rather than mentally ill.

Conduct disorder typically presents in early or middle childhood with signs and symptoms of oppositional defiant disorder.  One of the more significant differences between CD and oppositional defiant disorder (ODD) is that conduct disorder tends to involve a much more deliberate motivation of their inappropriate and antisocial behaviors.  These kids often make no real effort to control or even hide their negative behaviors, and are often found to be with few if any friends as a result.  Sadly, nearly half of the children with early oppositional defiant behaviors will end up suffering from a mood disorder, conduct disorder, or both by the time the reach their adolescence.

Children with CD most often tend to be extremely difficult to control, impulsive, and are not at all concerned about the feelings, or impact of their behaviors upon, others.  The signs and symptoms of conduct disorder may include:

• Destruction or vandalization of property
• Intimidating, threatening our bullying others
• Persistent lying and deceit
• Physical cruelty to animals and/or people (may often initiate fights and use weapon to inflict serious physical harm)
• Truancy (failure to attend school) beginning before the age of 13
• Deliberately engaging in fire-setting behaviors with the intent of causing damage
• Persistent rules violations
• Extreme alcohol or illicit drug use
• Persistent runaway behavior
• Stealing, including breaking into homes, cars, or buildings

The vast bulk of research clearly suggests that conduct disorder is more common in boys, possibly on the order of three-to-four times more prevalent.   However, it is rather difficult to know just what the prevalence is in the U.S. population primarily because the criteria needed to make the diagnosis such as persistent rule violations, defiance, and lying are quite difficult to define.  Overall, in order to make the diagnosis, the negative behaviors need to be far more extreme than their normative peer group, and more than just adolescent rebellion.  In the U.S. it is estimated that the prevalence rate of conduct disorder is between 2% and 9% of teenagers.  However, these numbers are complicated by the high rates of co-occurrence with other mental health diagnoses such as Attention Deficit Hyperactivity Disorder (ADHD), greater than 50% in many studies, Oppositional Defiant Disorder (ODD), and a multitude of learning disabilities (approximately one-quarter of kids with conduct disorder have some type of learning disability).  Conduct disorder carries an increased risk for alcohol and other drug addiction, and has been associated with child abuse, family dysfunction and conflicts, alcoholism and drug addiction/abuse in parents, and possible genetic defects.

The American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders identifies two subtypes of conduct disorder; childhood-onset type and adolescent-onset type.  Childhood onset type refers to children under the age of 10, most often boys, who typically demonstrate extreme levels of aggression.  These same kids often present with signs and symptoms of Attention Deficit Hyperactivity Disorder (ADHD).  These youngsters are actually more likely than the later onset children to develop adult antisocial personality disorder.  The adolescent-onset type refers to those who present with CD signs and symptoms, but were absent of such prior to the age of 10.  Overall, the later onset conduct disorder individuals tend to demonstrate less aggression and are more apt to have more normal peer relationships.  In fact, their conduct disorder behaviors are most often demonstrated when involved with a group of peers (such as a gang) involved in similar negative behaviors.  Although these adolescent-onset individuals are still far more likely to develop adult antisocial personality disorder than the general population, they are much less likely than the childhood-onset type to do so.  Not surprisingly, the long term prognosis for those diagnosed with adolescent-onset is much better than those with childhood-onset type.

The two different subtypes of conduct disorder follow an unsurprising evolution.  Without effective treatment those who suffer from childhood onset go on to develop very high rates of alcohol and drug abuse, participate in high risk behaviors, and often end up being diagnosed antisocial personality disorder (the adult version of conduct disorder with almost total disregard of society’s rules).  In the case of adolescent onset the prognosis is better.  With the development of some necessary academic abilities and social skills a significant percentage of these adolescents move into a much more socially acceptable and productive pattern in early adulthood.

Although many factors have been shown to play a role in the development and continuation of conduct disorder family and social environment may be the most significant.  Studies have demonstrated that behaviors consistent with the diagnosis of conduct disorder have an association with single parent status, young age of mothers, large family size and parental divorce.  However, it is very challenging to ferret out these factors from other significant variables such as poverty.  Peer influences, in particular peer rejection during childhood, has also been shown to have a strong association with the occurrence of the disorder.  Parent-child interactions are also critical in the development of CD.  Low levels of parent involvement, erratic punishment routines, and inadequate and/or ineffective supervision all play a significant role.

As might be expected the treatment of conduct disorder can be rather challenging and complex.  Adding to this challenge is the predictable presence of an uncooperative attitude along with distrust of adults, particularly those in a position of authority.  As such, initial assessment and treatment planning would best be undertaken by a psychiatrist with experience in working with children and adolescents.  Effective treatment must not only include psychological and educational elements, but overall medical and family support as well.  It is absolutely imperative that the patient’s family be directly and regularly involved in order to learn intervention techniques to help manage their child’s behaviors, and that there be close and regular communication between the parents and school.  Of course, in cases of abuse, the child’s family involvement may actually have to be supervised, or in severe cases the child may need to be removed from the family altogether.  Treatment typically takes quite some time as developing new behavioral patterns and attitudes does not occur in a brief period of time.  Recent research indicates that it is the severity of the problematic behaviors, rather than the child’s age, which is most predictive of treatment success or failure.  Severe CD in adolescents is more resistant to treatment when compared to younger kids.  However, with appropriate and persistent treatment intervention some improvements have been demonstrated in all ages and in all levels of severity.

Of the many psychological therapeutic approaches available parent management training (PMT) has been shown to have the most positive impact in altering the negative behaviors of conduct disorder.  PMT trains parents how to effectively modify their child’s behaviors at home, and is based upon research showing that many of the problematic behaviors are actually developed and maintained by maladaptive parent-child interactions.  PMT assists parents to change their focus of attention on the negative and disruptive behaviors of their child, and instead identify, focus upon, and reinforce appropriate and positive behaviors.  It further helps improve parenting skills by teaching parents to use positive reinforcement techniques with clear and precise feedback in response to appropriate desired behaviors, and avoid aversive punishments whenever possible.  Treatment with medications can also be very helpful in addressing conditions often found in association with conduct disorder such as Attention Deficit Hyperactivity Disorder, depression, Post-traumatic Stress Disorder, anxiety and others.

A very good resource for better understanding how to more effectively parent the conduct disordered or otherwise behaviorally disordered child are the books Parent Management Training: Treatment for Oppositional, Aggressive, and Antisocial Behavior in Children and Adolescents and The Kazdin Method for Parenting the Defiant Child both by Alan E. Kazdin, Ph.D.  Dr. Kazdin is the John M. Musser Professor of Psychology, Child Psychiatry, and Institute of Social and Policy Studies at Yale University. He is also the director of the Yale Parenting Center and Child Conduct Clinic, an outpatient treatment service for children with aggressive and antisocial behavior.