Definition and Types of Conduct Disorder
Brian is 14 and has conduct disorder and depression. He lives with his Uncle and Aunt who have practically taken care of him since birth and who have adopted him. Occasionally his mom visits, but not regularly and she does not know who his father is. Brian’s uncle and aunt are the head of a “team” which cares for him, involving respite foster parents, Brian’s second Uncle and his grandparents or adoptive parents who have fixed weekends to have him stay with them. Currently, Brian is functioning, staying out of any major trouble and his grades have been improving. After his last sentencing, his adoptive parents were able to get better assistance from his probation officer and a more flexible probation agreement and in general Brian receives more supervision than his adopted parent’s four year old. Last year, he was hospitalized after he cut his wrist when he was caught drinking after breaking into someone’s house and has been found to have killed the neighbors’ cat or stray cats that wondered into his back yard and has stayed out at night until after three in the morning and found in a neighboring bad neighborhood. Brian is currently a member of a group at school who volunteer to help build houses for the poor and he generally does well except for when he broke into one of his teacher’s cars however, since Brian’s parents have included everyone in his life, including adults at school, they knew to watch out for such actions and were able to catch him. His punishment was to not play his video game for five days, which seems to be something he thoroughly enjoys. Brian’s parents go through his stuff in his room randomly while he is at school to make sure that there are no weapons in the house which they have managed to do for six weeks. Brian is aware of their searches as they informed him of such and he thinks that they are being unkind and unfair.
Based on the DSM-IV-TR conduct disorder is classified as a disorder usually first diagnosed in infancy, childhood or adolescence and consists of three criteria for diagnosis and can be code typed based on age at onset which include 312.81 Childhood-Onset Type where the onset of at least one criterion characteristic of the disorder was present prior to age 10 years, 312.82 Adolescent-Onset Type where the absence of any criteria characteristic of the disorder were present prior to age 10 years and 312.83 Unspecified Onset where the age at onset is unknown. The disorder can also be mild, moderate or severe.
The first feature of conduct disorder is that there is a repetitive and persistent pattern of behaviour where the basic rights of other individuals and primary societal norms and rules that are expected to be known and followed based on age, are violated. This feature is broken down into four criteria of which three or more must have been present within the last twelve months and at least one within the past six months. The first criterion includes aggression to people and animals such as bullying, being physically cruel to others and being physically cruel to animals such as when Brian killed his neighbours’ cats; destruction of property such as purposely part-taking in setting a fire with the intention of doing serious damage and deceitfulness or theft such as breaking into someone’s car and lying to obtain goods or avoid obligations such as when Brian broke into his teacher’s car to try to steal it and when he broke into someone’s house, was found drinking alcohol and cut his wrists which may have been an attempt to gain attention and pity, removing attention from his negative acts and the fourth which refers to serious violations of rules such as staying out late at night regardless of parental rules, beginning at age 13. The second feature of conduct disorder is that the disturbance in behaviour must cause clinically significant impairment in the individual’s social, academic and occupational functioning such as Brian’s previously declining grades and the final feature is that if the individual is eighteen years old or older, Antisocial Personality Disorder criteria have not been met (American Psychiatric Association, 2000). In the DSM-V no changes but additional instructions state that one should specify if the disorder is with limited pro-social emotions and to qualify the person must have shown at least two of the following characteristics within the last twelve months which include a lack of remorse or guilt, callous behaviour or a lack of empathy and must be unconcerned about their performance at school or in other important activities (American Psychiatric Association, 2013)
Causes of Conduct Disorder Many factors may contribute to a child developing conducting disorder and research has suggested that there are genetic influences, environmental, neurobiological, psychological and social. Much research has focused on Antisocial Personality Disorder and psychopaths which share many of the characteristics of Conduct Disorder or in terms of diagnosis were first considered Conduct Disorder until the child became older. Thus these findings can be seen as relevant to Conduct Disorder. In regards to genetic influences family, twin and adoption studies have found that adopted offspring of felons had significantly higher rates of arrests, convictions and antisocial personality than adopted offspring of normal mothers. It has also been found that many individuals with conduct disorder have a close family member with a mental illness such as a mood, anxiety, substance use or personality disorder which suggests that there may be a vulnerability to the disorder that can be inherited. However, it is believed that the environment also plays a part in this based on a study that focused on adopted children and how likely they were to develop conduct problems. If the children’s biological parents had an antisocial personality disorder and they faced much ongoing stress while with their adoptive parents, children were found to be more likely to develop conduct issues. Another study found that children of felons who became criminals spent more time in temporary orphanages than adopted children who didn’t become criminals and those of normal mothers. These two studies suggest a gene-environment-interaction. (Barlow, D. H. and Durand, V. M., 2009). Other environmental factors include childhood abuse, traumatic experiences, dysfunctional family life, parental deprivation and lack of affection, such as how Brian’s mother is and was hardly ever around, and parents being insufficiently strict and inconsistent with discipline (Barlow, D. H. and Durand, V. M., 2009; Ford-Martin, P., 2004). In terms of Neurobiological causes early theoretical work significantly focused on two hypotheses for those with antisocial personality disorder. The first being the under arousal hypothesis which identifies that unusually decreased levels of cortical arousal can be found in psychopaths and are identified as the main cause of antisocial behaviour and risk-taking behaviours as they seek stimulation to boost their arousal levels and often times the everyday activities that normal persons without antisocial personality or conduct disorder carry out for stimulation are not enough. The second hypothesis is the fearlessness hypothesis which identifies that psychopaths have higher threshold for experiencing fear than most people so things that generally frighten people do not frighten them such as when Brian stayed out late into the night in a bad neighbourhood which many people would be afraid to do (Barlow, D. H. and Durand, V. M., 2009).
As it relates to social causes, low economic status and not being accepted by peers have been linked to the development of conduct disorder and in terms of psychological influences, the disorder has been found to reflect problems with moral awareness, which speaks to their guilt and remorse, and deficits in cognitive processing. (Barlow, D. H. and Durand, V. M., 2009).
Psychodynamic/Psychoanalytic approach to explain the development of Conduct Disorder and
Symptomatology
According to Coomarsingh, K. (2012) psychodynamic theories stress that the behaviours associated with Conduct Disorder are not a reflection of the child’s personality but are more a representation of intrapsychic problems and results when the process by which the ego, ego ideal and superego develop, go astray.
From a psychoanalytic perspective according to Shore (1971), the major issue in conduct disorder is a defective or underdeveloped ego, which is responsible for dealing with reality and thus operates on the reality principle and ensures that the impulses of the id can be expressed in socially acceptable ways by developing a tolerance for frustration, ability to postpone gratification, feelings of guilt when necessary, and the development of self-esteem, and the superego which manages all our internalized moral standards and ideals providing guideline when making judgments. When the functions of the ego are not enforced the delinquent behaviours associated with conduct disorder, tend to occur. According to Bird (2001) the ego ideal refers to an image of the perfect self and the superego compares the actual self to the ideal self, acting as the individual’s conscience and punishes the ego when there is too much difference between the two. Jones (1926, cited in Bird, 2001) suggests that the psychic pain from such guilt or punishment motivates the person to punish themselves and avoid similar behaviour in the future however; children with conduct disorder do not experience such guilt over their wrongdoings because of their underdeveloped superegos. Without punishment from the superego, children with conduct disorder feel no need to alter their behaviour, explaining why their aggression and violation of social normal such as deliberate fire setting to cause damage, being truant from school and forcing someone into sexual activity, occurs repeatedly. Some of the previously mentioned causes of conduct disorder such as parental deprivation, lack of affection and erratic discipline have been suggested as reasons for a defective superego. The absence of one’s parents can often lead to an incomplete internalization or a defective superego due to the fact that the superego is an internalized image of parents. If parents are around but show little to no warmth and affection it is unlikely for the child to internalize their values or identify with them and if the child’s discipline is soft and inconsistent, the child’s superego will likely be too weak to control primal impulses that push to be expressed. It is also possible for the child’s superego to be well developed but the ego ideal is defective and thus the standard to which the superego compares the child’s behaviour is faulty and this can lead to conduct disorder (Schoenfeld, 1971). Conduct disorder can also occur with overly strict and condemning superegos, where the primitive childhood wishes or poorly resolved Oedipus complexes begin to manifest and greatly offend the superego and result in it provoking significant unconscious guilt thus causing the child to carry out crimes with the unconscious aim of being caught and punished such as being physically cruel to people and animals, breaking into someone’s house, building or car and running away from home overnight despite parental rules and regulations(Schoenfeld, 1971; Cameron, N. & Rychlak, J. F., 1985).
Cameron, N. and Rychlak, J. F. (1985) further argue that a phallic fixation is significant in persons with antisocial personality and they may attempt to manipulate and bully others to gain some enhancement of their weakened sense of self-esteem. Due to the fact that they did not internalize or identify with their parents which is how self-esteem develops they refer to such actions to acquire some personal mastery of life such as bullying or intimidating others.
Coping or Defense mechanisms used by persons with Conduct Disorder and the Costs and Benefits of using these Mechanisms
According to Ford-Martin, P. (n.d.) one analysis of antisocial behaviour is that it is a defense mechanism that helps children avoid painful feelings, or avoid the anxiety caused by lack of control over the environment. As mentioned previously a major part of the development of conduct disorder is a defective or underdeveloped ego. Due to this persons with conduct disorder have not developed a tolerance for frustration. This may result in the defense mechanism of acting out which refers to an inner conflict, oftentimes frustration, being translated into aggression. Since children with conduct disorder lack the ability to postpone gratification, much of their frustration may be due to having gratification delayed. Acting out further involves the individual behaving with little or no insight, reflection or regard for others in an attempt to gain attention and disturb other people. This may be linked back to Cameron, N. and Rychlak, J. F. (1985) suggestion that antisocial type individuals manipulate and bully others to bolster their inferior self esteem thus acting out may serve the purpose of making them feel more accomplished and better about themselves. A second defensive mechanism which is also related to frustrations is displacement. When the child with conduct disorder refuses to address the source of their frustration or pain for example, having a low self-esteem, they may pick a fight with someone weaker such as bullying someone at school or tormenting the cat rather than with parents for example which would result in more negative consequences to the individual.
Denial or repression is also used by children with conduct disorder, which refers to the inability to face reality or the ignoring of facts that filter out information that goes against one’s self image and believed notions of others and the world. Its purpose is to protect the ego from things that a person cannot deal with. This would take place to keep the primitive childhood wishes or Oedipus complexes that the child possesses before, according to Cameron, N. & Rychlak, J. F. (1985) they begin to manifest and punishment from the superego results in the child committing crimes with the unconscious hope of being disciplined and penalized by someone.
Intervention strategies considered most suitable for Conduct Disorder
As with many illnesses, before beginning treatment it is important to take into account factors such as the age of the child, severity of symptoms and how capable the child is as it relates to participating in certain therapy techniques. There is no definitive medication to treat conduct disorder but medications can be given to treat its distressing symptoms or other coexisting mental illnesses. According to Facts for families: Conduct disorder (2013) children with conduct disorder should receive an overall evaluation as many often have other co morbid conditions such as anxiety, PTSD, substance abuse, ADHD, learning problems, thought disorders or mood disorders such as major depression which was the case with Brian, which can also be treated.
One of the most common treatment strategies for children involves parent training (Barlow, D. H. and Durand, V. M., 2009; Bailey, V., 2001) and family therapy. According to Barlow and Durand (2009) in the case of parent training, they are taught how to identify behavioural issues early and use praise or reinforcement and privileges to lessen the negative behaviour and encourage the better. Studies show that these types of programs have led to improvement in antisocial behaviours of children. Research has found that youngsters with conduct disorder are likely to have ongoing problems if they and their families do not receive early comprehensive treatment. (Facts for families: Conduct disorder, 2013). In the case of abuse or neglect and so on, the child may need to be removed from their present home and placed in a less chaotic one (A.D.A.M., Inc., 2013) which caters more to them developing in a good way.
Another beneficial treatment is Cognitive-Behavioural Therapy which works best when part of a multi-modal approach and incorporates the school in addition to the parents. Teachers should be given advice on management and training in positive teaching methods should be provided (Bailey, V., 2001). This treatment aims at reshaping the way the child thinks to improve their moral reasoning, problem solving skills, anger management and ability to manage impulses. Problem solving issues can also be specifically targeted with a problem-solving skills training (PSST) programme which shares some characteristics as CBT. Focus is placed on emotional education, self-awareness and monitoring of feelings, self-talk and reinforcement and social problem solving. For example, The Think Aloud programme which was developed in 1985 which utilized a cartoon bear to teach a self-instructional approach to social problem-solving where the bear would model the stages in problem-solving by asking questions such as “What is the problem?”, “What can I do about it?”, “Is it working?” and “How did I do?” A study which looked at a PSST intervention for 9–13-year-olds with conduct disorder found that even one year post treatment there were clinically significant improvements and this was further enhanced by using parent training. (Bailey, V., 2001)

References
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