CONDUCT DISORDER
Conduct disorder is
a persistent antisocial behavior of children and adolescents that significantly
impairs their ability to function in the social, academic, or occupational
areas. Children and adolescents with this disorder have great difficulty
following rules and behaving in a socially acceptable way. They display
behavior that violates the basic rights of others or societal norms and rules.
Conduct
disorders are divided into three types which includes the following:
A. Group Type
-
Is when conduct problems occur
usually in the context of group activities with peers
B. Solitary Aggressive Type
-
Is predominantly aggressive behavior
towards peers and adults
C. Undifferentiated Type
-
Is for children or adolescents who
demonstrate mixed features of the conduct disorders
Persons with
conduct disorders have little empathy for others; they have low self-esteem,
poor frustration tolerance, and temper outbursts. Conduct disorder is often
associated with early onset of sexual behavior, drinking, smoking, use of
illegal substances, and other reckless or risky behaviors. These disorder
occurs three times more often in boys than girls, and as many as 30% to 50% of
these children are diagnosed with antisocial personality disorder as adults.
Diagnostic criteria for
312.8 Conduct Disorder
Conduct
disorder is a repetitive and persistent pattern of behavior in which the basic
rights of others or major age-appropriate societal norms or rules are violated,
as manifested by the presence of three (or more) of the following criteria in
the past 12 months, with at least one criterion present in the past 6
months:
A.
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., abat, 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
B.
Destruction of property
8.
has deliberately engaged in fire setting with the intention of
causing serious damage
9.
has deliberately destroyed others' property (other than by fire
setting)
C.
Deceitfulness or theft
10. has broken into
someone else's house, building, or car
11. often lies to
obtain goods or favors or to avoid obligations (i.e., "cons"
others)
12. has stolen items
of nontrivial value without confronting a victim (e.g., shoplifting, but
without breaking and entering; forgery)
D.
Serious violations of rules
13. often stays out
at night despite parental prohibitions, beginning before age 13 years
14. 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)
15. is often truant
from school, beginning before age 13 years
ONSET AND CLINICAL COURSE
Two
subtypes of conduct disorder are based on age of onset.
A. Childhood-Onset Type
It involves
symptoms that occur before age 10 years, including physical aggression toward
others and disturbed peer relationships. These children are more likely to have
persistent conduct disorder and to develop antisocial personality disorder as
adults.
B. Adolescent-Onset Type
It is defined by the absence of any conduct disorder
behaviors until after the age of 10 years. These adolescents are less likely to
be aggressive, and they have more normal peer relationships. They are less
likely to persistent conduct disorder or antisocial personality disorder as an
adult (DSM-IV-TR, 2000). Persons with the adolescent-onset type and few or
milder problems can achieve adequate social relationships and academic or
occupational success as adults.
Conduct disorder
clinical signs and symptoms can be classified according to degree of severity.
I. According to severity (DSM-IV-TR,
2000)
a. Mild
-
The person has a few conduct
problems that cause relatively minor harm to others, such as lying, truancy, or
staying out late without permission.
b. Moderate
-
The number of conduct problems
increases, as does the amount of harm to others, such as vandalism.
c. Severe
-
Many conduct problems are present,
and there is considerable harm to others, such as forced sex, cruelty to
animals, used of a weapon, burglary, or robbery.
The course of
conduct disorder is variable. Only about 40% of persons with conduct disorder
go on to develop antisocial personality disorder, but even those who do not may
lead troubled lives, difficulty with interpersonal relationships, unhealthy
lifestyles, and an inability to support themselves (Steiner, 2000).
ETIOLOGY
It
is generally accepted that genetic vulnerability, environmental adversity, and
factors such as poor coping interact to cause the disorder.
Risk Factors includes
·
Poor parenting
·
Low academic achievement
·
Poor peer relationships
·
Low self-esteem
Protective Factors include
·
Resilience
·
Family support
·
Positive peer relationships
·
Good health
There is a genetic
risk for conduct disorder, although no specific gene marker has been
identified. The disorder is more common in children who have a sibling with
conduct disorder or a parent with antisocial personality disorder, substance
abuse, mood disorders, schizophrenia, or ADHD.
A lack of reactivity of the autonomic nervous
system has been found in children with conduct disorder, similar to adults
with antisocial personality disorder. This abnormality may cause more
aggression in social relationships as a result of decrease in normal avoidance
or social inhibitions.
Poor
family functioning, marital discord, poor parenting and a family history of
substance abuse and psychiatric problems are all associated
with the development of conduct disorder. Child
abuse is an especially significant risk factor. The specific parenting patterns that are considered ineffective are
inconsistent responses by parents to the child’s demands, and giving in to
demands as the child’s behavior escalates. Exposure
to violence in the media and in the community is a contributing factor for
the child who is at risk in other areas. Socioeconomic
disadvantages such as inadequate housing, crowded conditions, and poverty
also increase the likelihood of conduct disorder in the at-risk child.
Academic
underachievement, learning disabilities, hyperactivity, and problems with
attention span are all associated with conduct
disorder. Children with conduct disorder have difficulty functioning in social
situations. They lack the abilities to respond appropriately to others or to
negotiate conflict, and they lose their ability to restrain themselves when
emotionally stressed. They are often accepted only by persons who have similar
problems.
TREATMENT
A wide
variety of treatments have been used for conduct disorder with only modest
effectiveness. Early is more effective, and prevention is more effective than
treatment. Dramatic interventions such
as “boot camp” or incarceration have
not proven effective and may even worsen the situation. Treatment must gear
toward the client’s developmental age; no one type of treatment is suitable for
all ages.
Preschool
programs such as Head Start result lower rates of
delinquent behavior and conduct disorder through use parental education about
normal growth and development, stimulation for the child, and support of
parents during crises.
School-age
children with conduct disorder
-
The child, the family, and school
environment are the focus of treatment.
-
Parenting education, social skills
training to improve peer relationships, and attempts to improve academic
performance and increase the child’s ability to comply with demands from authority
figures are included.
-
Family
Therapy is considered essential for children in this age
group.
-
Behavioral
Therapy and Psychotherapy are usually necessary to help
the child appropriately express and control anger.
Adolescents
-
Individual
Therapy is often used as a treatment for this age group
because they rely less on their parents and move on peers.
-
Many clients in this age group have
some involvement with the legal system as a result of criminal behavior, and
they may have restrictions on their freedom as a result.
-
The most promising treatment
approach includes keeping the client in his or her environment. Conflict
resolution, anger management, and teaching of social skills are frequently
included in the treatment plan.
Psychophamarcotherapy
·
Antipsychotic
-
If the client present a clear damage
to others.
·
Lithium
or other Mood Stabilizer
-
Carbamazepine (Tegretol) or Valproic
Acid (Depakote)
-
May be given to clients with labile
mood.
NURSING MANAGEMENT
Providing
interventions with a client diagnosed with conduct disorder can also be quite
challenging. The following nursing interventions incorporate the suggestions of
boys with the diagnosis of conduct disorder and living in reform school:
1.
Establish trust by being honest.
2.
Maintain control by setting limits for
manipulative, acting-out behavior.
3.
Be consistent with limit-setting.
4.
Respect’s the client’s age and
maintain and adult-child or adult-adult relationship, whichever is appropriate.
5.
Establish realistic observations.
Discuss such expectations with the client and encourage verbalization of
feelings.
Nursing
interventions for client with conduct disorder mainly focuses on maintaining
safety and helping the child or adolescent develop internal limits,
problem-solving skills, and self-responsibility for acts of antisocial
behavior, which may include violent physical harm, theft, fire setting,
assault, and callous or manipulative behavior.
Young client with
conduct disorder often have underlying medical problems; therefore nursing
interventions may include treatment for a medical condition such as epilepsy or
a closed head injury.
