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Typically there would
have been three or more of the following behaviours
in the past 12 months, with at least one in the
past 6 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 (e.g., 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 (e.g., mugging,
purse snatching, extortion, 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 (i.e., "cons" others)
3.has stolen items of nontrivial value without confronting
a victim (e.g., 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
Subtypes of Conduct Disorder
There are two subtypes of conduct disorder outlined
in DSM-IV, and their diagnosis differs primarily
according to the nature of the presenting problems
and the course of their development.
The first,
childhood-onset type, is defined by the onset of
one criterion characteristic of conduct disorder
before age 10. Children with childhood-onset conduct
disorder are usually male, and frequently display
physical aggression; they usually have disturbed
peer relationships, and may have had oppositional
defiant disorder during early childhood. These children
usually meet the full criteria for conduct disorder
before puberty, they are more likely to have persistent
conduct disorder, and are more likely to develop
adult antisocial personality disorder than those
with the adolescent-onset type (American Psychiatric
Association, 1994).
The second, the adolescent-onset type, is defined
by the absence of conduct disorder prior to age 10.
Compared to individuals with the childhood-onset
type, they are less likely to display aggressive
behaviours. 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. The ratio of males to females
is also lower than for the childhood-onset type (American
Psychiatric Association, 1994).
Severity of
symptoms
Conduct disorder is classified as "mild" if
there are few, if any, conduct problems in excess
of those required for diagnosis and if these cause
only minor harm to others (e.g., lying, truancy and
breaking parental rules). A classification of "moderate" is
applied when the number of conduct problems and effect
on others are intermediate between "mild" and "severe".
The "severe" classification is justified
when many conduct problems exist which are in excess
of those required for diagnosis, or the conduct problems
cause considerable harm to others or property (e.g.,
rape, assault, mugging, breaking and entering) (American
Psychiatric Association, 1994).
Co-morbidities and associated disorders
Children with conduct disorder are part of a population
within which there are higher incidences of a number
of disorders than in a normal population. The literature
abounds with studies indicating the comorbid relationships
between Attention Deficit Hyperactivity Disorder,
Conduct Disorder, Oppositional Defiant Disorder,
Learning Difficulties, Mood Disorders, Depressive
symptoms, Anxiety Disorders, Communication Disorders,
and Tourettes Disorder. (American Psychiatric Association,
1994; Biederman, Newcorn, & Sprich, 1991). A
high level of co-morbidity (almost 95%) was found
among 236 ADHD children (aged 6-16 yrs) with conduct
disorder, ODD and other related categories (Bird,
Gould, & Staghezza Jaramillo, 1994). In an 8
year follow-up study, Barklay and colleagues (1990)
found that 80% of the children with ADHD were still
hyperactive as adolescents and that 60% of them had
developed Oppositional Defiant or Conduct Disorder.
Prevalence of Conduct Disorder.
According to research cited in Phelps & McClintock
(1994), 6% of children in the United States may have
conduct disorder. The incidence of the disorder is
thought to vary demographically, with some areas
being worse than others. For example, in a New York
sample, 12% had moderate level conduct disorder and
4% had severe conduct disorder. Since prevalence
estimates are based primarily upon referral rates,
and since many children and adolescents are never
referred for mental health services, the actual incidences
may well be higher (Phelps & McClintock, 1994)
.
Course of Conduct Disorder
The onset of conduct disorder may occur as early
as age 5 or 6, but more usually occurs in late childhood
or early adolescence; onset after the age of 16 years
is rare (American Psychiatric Association, 1994).
The results of research into childhood aggression
have indicated that externalising problems are relatively
stable over time. Richman and colleagues for example,
found that 67% of children who displayed externalising
problems at age 3 were still aggressive at age 8
(Richman, Stevenson, & Graham, 1982). Other studies
have found stability rates of 50-70%. However, these
stability rates may be higher due to the belief that
the problems are episodic, situational, and likely
to change in character (Loeber, 1991).
Age of onset of ODD seems to be associated with the
development of severe problems later in life, including
aggressiveness and antisocial behaviour. However,
not all conduct disordered children have a poor prognosis.
Studies suggest that less than 50% of the most severe
cases become antisocial as adults. Nevertheless,
the fact that this disorder continues into adulthood
for many people conveys that it is a serious and
life-long dysfunction (Webster-Stratton & Dahl,
1995).
While not all ODD children develop conduct disorder,
and not all conduct disorder children become antisocial
adults there are certain risk factors that have been
shown to contribute to the continuation of the disorder.
The risk factors identified include; an early age
of onset (preschool years), the spread of antisocial
behaviours across settings, the frequency and intensity
of antisocial behaviours, the forms that the antisocial
behaviours take, having covert behaviours at an early
age and also particular parent and family characteristics.
However, these risk factors do not fully explain
the complex interaction of variables involved in
understanding the continuation of Conduct Disorder
in any one individual.
Causes of Conduct Disorder
There is evidence from research into causes of conduct
disorders that indicates that several biological
and environmental factors may contribute to the development
of the disorder.
Neurological Dysregulation
The high co-morbidity rate of Conduct Disorder with
ADHD, Tourettes syndrome and other disorders known
to be due to neurological dysregulation suggests
that Conduct Disorder may be a co-manifestation of
the same underlying dysregulation. Although there
are no studies to our knowledge, which have directly
investigated the neurological basis for conduct disorder,
there is ample clinical evidence indicating that
when treating ADHD with Neurotherapy, and Nutrient
supplementation, Conduct Disorder abates. It appears
that Neurotherapy may address the underlying dysregulation
and facilitate clinical treatment using cognitive
and behavioural interventions. More research is needed
in this area to determine whether Neurotherapy is
directly responsible for this abatement or whether
the resultant improvement in attention, and reduction
in hyperactivity promotes better self image which
in turn improves behaviour.
Child Biological Factors
Considerable research has been carried out into the
role of child temperament, the tendency to respond
in predictable ways to events, as a predictor of
conduct problems. Aspects of the personality such
as activity levels displayed by a child, emotional
responsiveness, quality of mood and social adaptability
are part of his or her temperament. Longitudinal
studies have found that although there is a relationship
between early patterns of temperament, and adjustment
during adulthood, the longer the time span the weaker
this relationship becomes.
A more important determinant of whether or not temperamental
qualities persist has been shown to be the manner
in which parents respond to their children. "Difficult" infants
have been shown to be especially likely to display
behaviour problems later in life if their parents
are impatient, inconsistent, and demanding. On the
other hand "difficult" infants, whose parents
give them time to adjust to new experiences, learn
to master new situations effectively. In a favourable
family context a "difficult" infant is
not at risk of displaying disruptive behaviour disorder
at 4 years old.
Cognitions may also influence the development of
conduct disorder. Children with conduct disorder
have been found to misinterpret or distort social
cues during interactions with peers. For example,
a neutral situation may be construed as having hostile
intent. Further, children who are aggressive have
been shown to seek fewer cues or facts when interpreting
the intent of others. Children with conduct disorder
experience deficits in social problem solving skills.
As a result they generate fewer alternate solutions
to social problems, seek less information, see problems
as having a hostile basis, and anticipate fewer consequences
than children who do not have a conduct disorder
(Webster-Stratton & Dahl, 1995).
School-Related Factors
A bidirectional relationship exists between academic
performance and conduct disorder. Frequently children
with conduct disorder exhibit low intellectual functioning
and low academic achievement from the outset of their
school years. In particular, reading disabilities
have been associated with this disorder, with one
study finding that children with conduct disorder
were at a reading level 28 months behind normal peers
(Rutter, Tizard, Yule, Graham, & Whitmore, 1976).
In addition, delinquency rates and academic performance
have been shown to be related to characteristics
of the school setting itself. Such factors as physical
attributes of the school, teacher availability, teacher
use of praise, the amount of emphasis placed on individual
responsibility, emphasis on academic work, and the
student teacher ratio have been implicated (Webster-Stratton & Dahl,
1995).
Parent Psychological Factors
It is known that a child's risk of developing conduct
disorder is increased in the event of parent psychopathology.
Maternal depression, paternal alcoholism and/or criminalism
and antisocial behaviour in either parent have been
specifically linked to the disorder.
There are two views as to why maternal depression
has this effect. The first considers that mothers
who are depressed misperceive their child's behaviour
as maladjusted or inappropriate. The second considers
the influence depression can have on the way a parent
reacts toward misbehaviour. Depressed mothers have
been shown to direct a higher number of commands
and criticisms towards their children, who in turn
respond with increased noncompliance and deviant
child behaviour. Webster-Stratton and Dahl suggested
that depressed and irritable mothers indirectly cause
behaviour problems in their children through inconsistent
limit setting, emotional unavailability, and reinforcement
of inappropriate behaviours through negative attention
(Webster-Stratton & Dahl, 1995).
Familial Contributions
Divorce, Marital Distress, and Violence
The inter-parental conflicts surrounding divorce
have been associated with the development of conduct
disorder. However, it has been noted that although
some single parents and their children become chronically
depressed and report increased stress levels after
separation, others do relatively well. Forgatch suggested
that for some single parents, the events surrounding
separation and divorce set off a period of increased
depression and irritability which leads to loss of
support and friendship, setting in place the risk
of more irritability, ineffective discipline, and
poor problem solving outcomes. The ineffective problem
solving can result in more depression, while the
increase in irritable behaviour may simultaneously
lead the child to become antisocial.
More detailed studies into the effects of parental
separation and divorce on child behaviour have revealed
that the intensity of conflict and discord between
the parents, rather than divorce itself, is the significant
factor. Children of divorced parents whose homes
are free from conflict have been found to be less
likely to have problems than children whose parents
remained together but engaged in a great deal of
conflict, or those who continued to have conflict
after divorce. Webster noted that half of all those
children referred to their clinic with conduct problems
were from families with a history of marital spouse
abuse and violence.
In addition to the effect of marital conflict on
the child, conflict can also influence parenting
behaviours. Marital conflict has been associated
with inconsistent parenting, higher levels of punishment
with a concurrent reduction in reasoning and rewards,
as well as with parents taking a negative perception
of their child's adjustment.
Family Adversity and Insularity
Life
stressors such as poverty, unemployment, overcrowding,
and ill health are known to have an adverse effect
on parenting and to be therefore related to the development
of conduct disorder. The presence of major life stressors
in the lives of families with conduct disordered
children has been found to be two to four times greater
than in other families.
Mothers' perception
of the availability of supportive and social contact
has also been implicated in child contact disorder.
Mothers who do not believe supportive social contact
is available are termed "insular" and have
been found to use more aversive consequences with
their children than non-insular mothers (Webster-Stratton & Dahl,
1995)
Parent Child Interactions
Research has suggested
that parents of children with conduct disorder frequently
lack several important parenting skills. Parents
have been reported to be more violent and critical
in their use of discipline, more inconsistent, erratic,
and permissive, less likely to monitor their children,
as well as more likely to punish pro-social behaviours
and to reinforce negative behaviours. A coercive
process is set in motion during which a child escapes
or avoids being criticised by his or her parents
through producing an increased number of negative
behaviours. These behaviours lead to increasingly
aversive parental reactions which serve to reinforce
the negative behaviours.
Differences in affect have also been noted in conduct
disordered children. In general their affect is less
positive, they appear to be depressed, and are less
reinforcing to their parents. These attributes can
set the scene for the cycle of aversive interactions
between parents and children.
Other Family Characteristics
Birth order and
size of the family have both been implicated in the
development of conduct disorder. Middle children
and male children from large families have been found
to be at an increased risk of delinquency and antisocial
behaviours.
Psychophysiological and Genetic Influences
Studies
have found that neurological abnormalities are inconsistently
correlated with conduct disorder (Kazdin, 1987).
While there has been interest in the implication
of the frontal lobe limbic system partnership in
the deficits of aggressive children, these problems
may be the consequence of the increased likelihood
for children with conduct disorder to experience
abuse and subsequent head injuries (Webster-Stratton & Dahl,
1995).
While twin studies have found greater concordance
of antisocial behaviour among monozygotic rather
than dizygotic twins, and adoption studies have shown
that criminality in the biological parent increases
the likelihood of antisocial behaviour in the child,
genetic factors alone do not account for the development
of the disorder.
Final Word on Aetiology
While the risk factors
outlined have been shown to be implicated in the
development of conduct disorder, it is important
to note that not all children exposed to these factors
develop a conduct disorder. Rather, the evidence
suggests that in those children who do develop conduct
disorders have an aetiology comprised of a combination
of these factors (Webster-Stratton & Dahl, 1995).
There is strong evidence that 75% of ADHD children
with hyperactivity develop behavioural problems including
50% conduct disorder and 21% antisocial behaviour
(Klein & Mannuzza, 1991).
Treatment
A number of interventions have been
identified which are useful in reducing the prevalence
and incidence of conduct disorder. Interventions
consist of prevention and treatment, although these
should not be considered as separate entities. Prevention
addresses the onset of the disorder, although the
child has not manifested the disorder, and treatment
addresses reduction of the severity of the disorder.
In mainstream Psychology, prevention and treatment
for Conduct Disorder primarily focuses on skill development,
not only for the child but for others involved with
the child, including the family and the school environments.
As previously discussed there may be clinical advantages
in applying nutritional supplementation and Neurotherapy
where appropriate with Conduct Disorder clients,
if the client appears to respond to this form of
neurological intervention, followed by cognitive
and behavioural intervention. The following paragraphs
considers three interventions, that assist in preventing
and treating conduct disorder; child training, family
training, and school and community interactions.
Child Training
Child training involves the
teaching of new skills to facilitate the child's
growth, development and adaptive functioning. Research
indicates that as a means of preventing child conduct
disorder there is a need for skill development in
the area of child competence. Competence refers to
the ability for the child to negotiate the course
of development including effective interactions with
others, successful completion of developmental tasks
and contacts with the environment, and use of approaches
that increase adaptive functioning (Kazdin, 1990).
It has been found that facilitating the development
of competence in children is useful as a preventative
measure for children prior to manifestation of the
disorder rather than as a treatment (Webster-Stratton & Dahl,
1995).
Additionally, treatment interventions have been developed
to focus on altering the child's cognitive processes.
This includes teaching the child problem solving
skills, self control facilitated by self statements
and developing prosocial rather than antisocial behaviours.
Prosocial skills are developed through the teaching
of appropriate play skills, development of friendships
and conversational skills. The social development
of children provides them with the necessary skills
to interact positively in their environment. A child's
development of cognitive skills provides a sound
basis from which to proceed. However, cognitive development
should not be considered in isolation, but as part
of a system, which highlights the need to include
the family in the training process.
Family Intervention
A child's family system,
has an important role in the prevention and treatment
of conduct disorder. The child needs to be considered
as a component of a system, rather than as a single
entity. Research supports the notion that parents
of conduct disordered children have underlying deficits
in certain fundamental parenting skills. The development
of effective parenting skills has been considered
as the primary mechanism for change in child conduct
disorder, through the reduction of the severity,
duration and manifestation of the disorder.
A number of parent training programs have been developed
to increase parenting skills. Research indicates
that the parent training programs have been positive,
indicating significant changes in parents' and children's
behaviour and parental perception of child adjustment.
Research suggests that parents who have participated
in parent training programs are successful in reducing
their child's level of aggression by 20 - 60 %.
Various training programs have been developed, which
focus on increasing parents' skills in managing their
child's behaviour and facilitating social skills
development. The skills focused on, include parents
learning to assist in administration of appropriate
reinforcement and disciplinary techniques, effective
communication with the child and problem solving
and negotiation strategies..
A further component of parental training incorporates
behavioural management. This involves providing the
family with simple and effective strategies including
behavioural contracting, contingency management,
and the ability to facilitate generalisation and
maintenance of their new skills, thus encouraging
parents' positive interaction with their child.
However, although these interventions assist parents
in developing effective parenting skills, a number
of families require additional support. There are
various characteristics within the family system
that can have an impact on parents' ability to cope.
This includes depression, life stress and marital
distress. Research suggests that family characteristics
are associated with fewer treatment gains in parent
training programs. As indicated by Webster-Stratton
and Dahl (1995), several programs have expanded upon
the standard parent training treatment. These programs
have incorporated parents' cognitive, psychological,
and marital or social adjustment. Through addressing
the parent's own issues it assists their ability
to manage and interact positively with the child.
School and Community Education
A child's' environment
plays an active role in the treatment of conduct
disorder and as a preventative measure. A number
of interventions have been developed for schools
and the community in relation to conduct disorder.
The various programs outlined in this paper have
a primary focus involving the skill development for
the child in the areas of problem solving, anger
management, social skills, and communication skills.
School
based programs
There are various preventative
programs devised which focus on specific cognitive
skill development of a child. A number of programs
developed focus on encouraging the child's development
in decision making and cognitive process. In addition
school based programs have involved teaching the
child interpersonal problem solving skills, strategies
for increasing physiological awareness, and learning
to use self talk and self control during problem
situations.
In addition to prevention programs, a number of treatment
interventions have been developed for children where
conduct disorder has manifested. The treatment programs
focus on further skill development, including anger
management and rewarding appropriate classroom behaviour,
skill development of the child including the understanding
of their feelings, problem solving, how to be friendly,
how to talk to friends, and how to succeed in school.
As Webster and colleagues describe, one school based
program has been designed to prevent further adjustment
problems, by rewarding appropriate classroom behaviour,
punctuality, and a reduction in the amount of disciplinary
action. In addition, the program provided parents
and teachers with the opportunity to focus on specific
problems of a child and for these to be addressed.
Community programs
Community based interventions
have also addressed both treatment and prevention.
A number of programs have been developed, and focus
on involving the youths in activity programs and
providing training for those activities. The children
are rewarded for attendance and participation in
the programs.
The treatments discussed are helpful in reducing
the prevalence and incidence of conduct disorder.
In their application it is important to provide an
integrated multidisciplinary approach to treatment
in multiple settings and by providing relevant nutritional
supplements, Neurotherapy and behaviour training
as appropriate.
Conclusion
Conduct disorder is very common
among children and adolescents in our society. This
disorder not only affects the individual, but his
or her family and surrounding environment. Conduct
disorder appears in various forms, and a combination
of factors appear to contribute to its development
and maintenance. A variety of interventions have
been put forward to reduce the prevalence and incidence
of conduct disorder. The optimum method appears to
be an integrated approach that considers both the
child and the family, within a variety of contexts
throughout the developmental stages of the child
and family's life.
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