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see also Attention Deficit Hyperactivity Disorder ADHD

CONDUCT DISORDER AND ASSOCIATED CHALLENGING BEHAVIOURS IN CHILDREN

Fact Sheets for Health Professionals

Definition ... case study

Conduct Disorder refers to a persistent pattern of behaviour in which the basic rights of others or major societal rules, given the particular age of the child, are violated. Conduct disorder is one of a triad of Disruptive Behaviour Disorders often referred to as challenging behaviours. It is the extreme end of the spectrum of difficult and challenging behaviour.

Many children present with persistent conduct problems but not all meet the criteria for Disruptive Behaviour Disorder (DSM-IV, Diagnostic and Statistical Manual of Mental Disorders from the American Psychiatric Association). At the primary care level it is more relevant to examine the group of challenging behaviours known as Disruptive Behaviour Disorders, which include:

  • Oppositional Defiant Disorder (ODD).
  • Conduct Disorder (CD).
  • Attention Deficit Hyperactivity Disorder (ADHD).

These three labels describe closely related and overlapping patterns of difficult behaviour, which retain some distinctive and unique features. All these disorders can have a significant impact on the development and long-term wellbeing of a child, therefore early detection and management in the primary school years is essential to improving the child's long-term outcomes.

Oppositional Defiant Disorder, or ODD describes a milder pattern of negative, hostile, defiant and disobedient behaviour.

It more commonly presents in school-age children, but may be tentatively diagnosed as early as three years old. Oppositional Defiant Disorder almost always precedes Conduct Disorder. Some of the children more difficult to manage are those who have a multiplicity of conditions.

Conduct Disorder, or CD is a more severe pattern of behaviour, which includes aggression to people and animals, destruction of property, deceitfulness or theft and severe violations of rules.

Attention Deficit Hyperactivity Disorder, or ADHD is generally noticed in younger children. Children with ADHD usually experience a triad of symptoms of inattention, poor impulse control and hyperactivity. ADHD and learning difficulties commonly accompany ODD and CD. These are children whose parents find them difficult, challenging, uncooperative and exhibiting a range of behaviours that are defiant or non-conforming. Difficulties with concentration, overactivity and poor task persistence distinguish ADHD from CD and ODD.

Diagnosis

  • Diagnosis of Disruptive Behaviour Disorder can only be made when:
  • The child displays persistent, non-transitory antisocial and aggressive behaviour for more than six to 12 months.
  • The clinical manifestations cause significant impairment in social, academic or occupational functioning for the child.

The diagnosis is generally made by a specialist service, which may include a paediatrician, psychologist, or child psychiatrist. The assessment includes a detailed interview with the child and family, including liaison with the school to ascertain the level of the child's functioning outside home. Behavioural checklists may be used. The DSM-1V provides the criteria for diagnosing disruptive behaviour disorders.

Co-Morbidities

ADHD and ODD or CD have considerable overlap in symptoms and both may be present in an individual child.

Learning disabilities are commonly associated with CD and ADHD.

Children with CD may also experience emotional problems such as depression. As these emotional symptoms are usually internalised, they are often overlooked for considerable periods.

Aetiology

While we do not know what causes these Disruptive Behaviour Disorders, the most significant risk factors for their development are:

Early behaviour displaying difficult temperament, inflexible, oppositional and aggressive behaviours.

Specific learning difficulties.

Family dysfunction, including parental psychopathology and poor parenting skills. (For example, harsh and inconsistent discipline, lack of structure and effective communication in child management, and failure to effectively monitor the whereabouts of their child). Other factors, such as stress and substance abuse, may further decrease the parent's skills.

Environmental factors in the family (such as, social disadvantage).

Prevalence of Disruptive Behaviour Disorders (DBD)

All three DBDs are more common in boys than girls.

The prevalence of ODD is about ten percent for children under 12 years, with a male to female ratio of 2:1.

In most studies the prevalence of CD is approximately five per cent in the 10-year-old population, with a male to female ratio of 4:1.

The prevalence of ADHD is between two per cent and five per cent of children and is three times more common in boys.

Clinical Manifestation

The average age of diagnosis of Conduct Disorder in boys is 10 to 12 years and in girls it is 14 to 16 years.

Oppositional Defiant Disorder usually develops at an early age and both disorders, ODD and CD, generally develop over a long period.

Children with ODD:

  • Often argue with adults and are angry, resentful and easily annoyed.
  • Actively defy rules and deliberately annoy others.
  • Are most difficult with people they know well.
  • Frequently have poor self-esteem, poor frustration tolerance, depressed mood and temper outbursts.
  • Blame others when things go wrong.

Children with CD may exhibit:

  • Overly aggressive behaviour towards their peers, including bullying, physical aggression or cruelty, including use of weapons and forcing others into sexual activity.
  • Lying, truancy from school, theft, vandalism and fire-setting.
  • Violation of family rules by staying out late at night or running away from home.
  • Suicidal gestures and acts.
  • Inappropriate sexual behaviour.
  • Early smoking, alcohol and drug use.
  • A lack of concern for others and a lack of remorse.

It is important to emphasise that a degree of oppositional behaviour is developmentally appropriate in children. For example, asserting one's own will and opposing that of others is regarded as crucial to normal development. Oppositional behaviour particularly occurs during the phases of normal toddlerhood and adolescence. A careful assessment is required to differentiate normal oppositional behaviours and ODD. This judgement involves assessing the intensity and duration of symptoms and the parents' and school's tolerance for, and ability to manage, the challenging behaviours.

The use of standardised behaviour check lists by a clinician allows the identification of a group of children who fall statistically outside the normal range of behaviour expected for their age.

Individual behaviours, such as causing injury to others, cruelty to animals, lack of remorse and the destruction of property, are outside the normal range and require individual attention.

Long Term Outcomes

The long-term outcomes of children with Oppositional Defiant Disorder are not well known. It has been reported some of these children will eventually develop Conduct Disorder, although the ODD symptoms may not increase but remain stable over time.

Children with CD are at higher risk of developing mental health problems (such as anti-social personality disorder) in the future. It is one of the strongest predictors of late adolescent and adult personality problems.

Aggression is one of the most persistent childhood traits. Marked aggression in preschool and early school years should be taken seriously and intervention offered promptly. The greater the number of symptoms and the earlier the onset, the worse the outcome for the child. Past studies were pessimistic about the prognosis for CD, however current trends suggest early, effective intervention may improve the prognosis.

Children with ADHD do not usually grow out of the condition, although many of their symptoms will improve with maturity. Those with ADHD and ODD or CD continue to experience the problems associated with these co-morbidities.

Management

There are a wide range of approaches. In general, the earlier the intervention, the better the chance or success.

On the whole, the outcome is less satisfactory than the other forms of emotional disturbance such as anxiety disorders. Treatment should consist of a management program determined by the needs of the child and family, which may include:

Parent skills and education. Parents may know about positive parenting skills, but have difficulty putting them into action when stressed. Others need education in parenting skills, which can be given during individual sessions or in a group where they can rehearse new strategies and receive encouragement from other parents. Some parents themselves may have had poor parenting as children and can benefit from programs that help them learn alternative ways of relating to their children and in managing negative emotions as they arise. Therapy for parents involves problem-solving, to develop effective ways of managing difficult children and to resolve conflict.

Cognitive Behavioural Therapy (CBT) may assist the child to manage impulsive behaviour. Behaviour therapy focuses on encouraging and rewarding appropriate behaviour and helps children learn what behaviour is expected of them. Social skills training for the child may be helpful. Children with conduct problems often need to be encouraged to develop alternative ways of relating to other children and adults.

A cognitive assessment performed by a psychologist to identify learning difficulties is desirable, followed by remediation through the program support structure within the Department of Education.

An educational assessment followed by remediation of learning difficulties through the program support structure of the Department of Education.

As discussed earlier, the risk factors need to be addressed in the individual management of the child to reduce the impact of these factors on the child and family.

Early Intervention

The vast majority of childhood behavioural problems fall within the normal range and are appropriately dealt with by primary care workers, such as maternal and child health nurses, general practitioners, community health workers, kindergarten teachers and child care workers. Difficult behaviour in preschool children can usually be controlled effectively with consistent behaviour management from all those involved with the child. Intervention with this age group allows professionals to work with a child who does not have an entrenched pattern of social and peer difficulties and school problems. A consistent approach across the range of agencies involving professionals and parents produces the best results.

School Experience

The management program should include all significant people in the child's life, including teachers and teacher aides, leisure and recreational leaders and other carers. Communication between teachers, carers and parents needs to be open and cooperative to work best for the child. These children are extremely difficult for any carers to manage and their behavioural problems may lead some to be suspended from school.

Role of Primary Health Care Professionals

It is important for primary health care professionals to:

  • Validate the parents' concerns.
  • Assess and refer for diagnosis and treatment.
  • Collaborate closely with the regional Child Mental Health Service to assist with a consistent approach.
  • Monitor and support the family.
  • Ensure programs are consistently conducted by all carers.
  • Assist with referral and coordination of other resources.

In Victoria, Child Mental Health Services can provide secondary consultations, diagnostic appraisal and work with primary care practitioners to ensure an age appropriate program is developed. All Child Mental Health Services have a telephone information service, which provides essential information for referral.

Primary Care Assessment - When to Refer?

These children may be uncooperative, provocative and difficult to interview. They may become angry with the interviewer, but persistence is often rewarded with compliance. The family and school are important sources of information. Families should be referred to specialist services if their child's behaviour is causing significant impairment in family or school functioning, and if the parents are having difficulty implementing the suggested management strategies.

References

DSM-IV. Diagnostic and Statistical Manual of Mental Disorders, American Psychiatrists Association.

Robins L.N. Conduct Disorder Journal of Child Psychology and Psychiatry January, 1991

Rutter M., and Hersov I. Child and Adolescent Psychiatry-Modern Approaches, Oxford: Blackwell Scientific 1985.

Written with expert opinion from Professor Robert Adler, Psychiatrist, and Ms Julie Barrington, Psychologist, Royal Children's Hospital, Melbourne.

Case Study - Conduct Disorder

This case study is provided to illustrate good practice in management of a child with conduct disorder.

Reason for Referral

Eight year old Dylan had recently been suspended from school for the fourth time for violent behaviour towards other children, often resulting in injuries. He had only been attending this current school for nine months.

Background

Dylan lives at home with his mother and only sees his father occasionally, during school holidays. His father had a history of anti-social behaviour, with a number of juvenile offences, and there was a family history of alcohol abuse. Dylan had been in child care since he was one. His mother reported a 'very normal' childhood. No records of his previous behaviour or development were available, as Dylan's family had moved from interstate.

His mother's job required her to be away from home for long periods and child care arrangements were ad hoc and poorly planned. The mother initially did not see Dylan's behaviour as problematic for her and blamed the school for his behavioural problems. In fact she was quite hostile to the school as a report had been made to the Department of Human Services' Protection and Care Branch, with concerns about his care. The Child Protection Service investigated this matter and concluded that the child was not at significant risk at this stage.

The school urgently referred Dylan to the Department of Education psychologist, who found it very difficult to gain a complete assessment as Dylan did not cooperate during the interview. Dylan was then referred to a Child Mental Health Service.

Assessment by the Child Mental Health Service

The clinician assessed Dylan's main problem behaviours to be:

  • Hitting, kicking, and bullying behaviour at school.
  • Lack of remorse about his behaviour.
  • Lack of understanding of how others felt.
  • Sexualised behaviour and language.

Risk Factors

The psychologist also noted that there were multiple risk factors:

  • Poor or non-existent family networks or support.
  • Inadequate supervision at home and in the neighbourhood.
  • Exposure to media violence due to lack of supervision during leisure time.
  • Lack of consistency in parenting styles due to frequent changes of primary care givers.
  • Family history of anti-social behaviour and substance abuse.

After a number of sessions with the family, a cognitive assessment was able to be conducted at the Child Mental Health Service. Results of the test showed that although Dylan's verbal skills were in the lower than average range, he performed very poorly in non-verbal tests and had severe difficulties in visual-spatial and sequencing relationships. Testing helped explain his very poor understanding of social cues and the consequences of this behaviour. Recommendations were provided to assist with his learning and behavioural problems.

Diagnosis

Conduct Disorder and Specific Learning Difficulties.

Management

In dealing with this child with multiple problems, priority setting was necessary. Gaining his mother's trust and developing her understanding of Dylan's problems and the risks he faced in the future were paramount. The aims of management were to decrease the risk factors in Dylan's life and manage the present concerns regarding behaviour and learning.

Aiming to provide consistent parenting addressed one of Dylan's risk factors. A management plan was developed for care givers when his mother was away or Dylan was being sent home from school due to misconduct. His mother reduced her absences wherever possible and prepared Dylan when she had to go away. More supervision at home was encouraged and guidelines for his mother developed. Suggested parenting strategies, both at home and school, included the consistent and appropriate use of limits (discipline), the importance of positive reinforcement, and encouragement of positive, non-aggressive behaviours.

In addition, a successful application was made for integration support for Dylan so he could return to school. The Program Support Group met on a fortnightly basis with his mother, integration aide (after appointment), Department of Education and Child Mental Health Service psychologists, school principal and vice-principal. One outcome of this process was the relationship between mother and the school staff improved markedly and a fully coordinated approach was able to be developed. Dylan recorded his behaviour at school in a record book and his mother had a positive behaviour book at home.

After three months an integration aide began working at the school with Dylan. The school staff were supported by the psychologist in planning consistent behavioural strategies for school and home and by monitoring his progress. Additional help was provided for his learning difficulties. His behaviour became more contained and his number of aggressive acts decreased.

After nine months the situation greatly improved for Dylan even though he had been suspended two further times (managed by removal from school for the rest of the day). The planned care arrangement supported him during this time of suspension. School holidays were still difficult for him and his behaviour tended to be more unsettled and impulsive on his return to school. In summary:

  • He now had constant attachment figures in the teacher aide, who was employed for the first three months full time, then slowly decreased in time depending on response, and regular carers arranged for home.
  • He was supervised during waking hours and his mother had reduced the number of work-related absences.
  • There had been a total reduction of Dylan's exposure to violence and aggression in daily life and in the media.
  • The full cognitive and educational assessment detailing his strengths and weaknesses guided recommendations for remediation.
  • The school was more confident in managing Dylan's behaviours. His violent behaviour had decreased with consistent handling of consequences.
  • His mother was attending meetings at the school on a regular basis and had acknowledged the school had developed some effective strategies resulting in a cooperative relationship.

After 12 months Dylan seemed somewhat depressed and his program was adapted to increase the amount of encouragement and rewards in his program. His aide put together a collection of special work and attributes, which Dylan displayed proudly. Teachers no longer blamed Dylan for all bullying occurring at the school.

After 18 months Dylan continued to struggle at school, but with ongoing assistance his behaviour continued to improve. He was no longer violent but was occasionally oppositional. He still mainly engaged in parallel play but slowly was becoming more acceptable to the other children. His problem-solving skills had started to improve and he was more able to understand others' feelings. He also joined a local basketball team as he was good at sport and it was felt that this would help his confidence.

In summary, the progress with Dylan to date has been due to:

  • Reduction of the risk factors listed previously.
  • A plan developed for consistent management of Dylan's violent and aggressive behaviour across school and home.
  • The trust established through regular meetings and open communication between his mother and his school. The program for Dylan was being continually responding to his changing needs.
  • The home/school coordination of behaviour management and firm limit-setting.
  • A focus on Dylan's positive achievements.
  • The cognitive assessment, which clarified gaps in development and enabled remedial strategies to be established.
  • An integration aide at school providing a secure attachment figure who modelled support, encouraged positive behaviour, and set firm limits and consequences for inappropriate behaviour.

North East Valley Division General Practice, Victoria, Australia, Disclaimer 
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