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Conduct Disorders In Children And Adolescents

Conduct disorder is the most prevalent psychopathologic condition of childhood. It is characterized by a persistent and repetitive pattern of aggressive, noncompliant, intrusive, and poorly self-controlled behaviors that violate either the rights of others or

These behaviors have a significant impact on the daily functioning of the

child or adolescent and on the ability of parents and them.

The specific behavioral criteria for the diagnosis of conduct disorder can be conceptualized as either aggressive or nonaggressive in type .

Examples of aggressive behaviors are physical fighting and bullying, assault,

vandalism, purse snatching, physical cruelty to persons or animals, breaking

and entering, and arson. More serious aggressive behaviors are armed robbery,

rape, and extortion.

TABLE 1. DSM IV R Diagnostic Criteria for Conduct Disorder


A disturbance of conduct lasting at

individual has done at least three of the following:

1. Stolen without confrontation of a victim on more than one occasion

(including forgery)

2. Run away from home overnight at least twice while living in parental or

parental surrogate home (or once without returning)

3. Often lied (other than to

4. Deliberately engaged in fire-setting

5. Often been truant from school (for older person,

6. Broken into someone else's house, building, or car

7. Deliberately destroyed others' property (other than by fire-setting)

8. Been physically cruel to animals

9. Forced someone into sexual activity with him or her

10. Used a weapon in more than one fight

11. Often initiated physical fights

12. Stolen with confrontation of a victim (eg, mugging, purse-snatching,

extortion, armed robbery)

13. Been physically cruel to people


Nonaggressive behaviors of conduct disorder include substance abuse,

persistent truancy, running away from

Children and adolescents with this type of conduct

disorder tend to be isolated socially and lacking in guilt or remorse for

their actions. They may expend little effort in concealing their

inappropriate activities.

The undifferentiated type is a residual group used to classify children

and adolescents who have clinical features that do not fit the previously

mentioned categories clearly. As such, it may be the most common form of

conduct disorder.

Conduct disorders may be characterized further as mild, moderate, or


Children and adolescents with conduct disorders have a higher rate of

affective, learning, and attentional problems than do children without conduct

disorders. The existence of these additional difficulties should be

acknowledged and reflected in the treatment plan.

Learning Problems

Children with conduct disorders frequently have problems in school.

Specific learning disabilities have been identified in this population, particularly dyslexia. Deficits in language development and problem-solving

skills have also been noted. Truancy, poor motivation for test-taking,

teacher bias, and lack of parental support for school work have been cited as

possible contributing factors. Poor school peormance, in turn, can lead to

low self-esteem and further truancy. The lack of academic achievement by

students with conduct disorders, however, cannot be explained on the basis of

intelligence quotient scores.


Attention Deficit-Hyperactivity Disorder

Some children with conduct disorders manifest the impulsivity,

inattention, and increased activity levels symptomatic of the attention

deficit-hyperactivity disorder. Motoric overactivity is reported in up to 75%

of children with conduct disorders. [4] Children with both conduct


A group of prepubertal children has been identified in whom the diagnosis



The goal of the evaluation phase is to gain a comprehensive perspective

of the overall functioning of the child or adolescent. This is a role for

which the pediatrician is well suited, given his or her likely rapport with

the family, school, and community. This rapport will facilitate data

collection and, thus, it is appropriate for the pediatrician to undertake this

aspect of the assessment, even if he or she intends eventually to refer the

family to a mental health professional for treatment.

Data will need to be collected from the child or adolescent, as well as

from sources within the family, school, and community. Care should be taken

to focus on the individual's strengths, talents, interests, and skills, in

addition to the obvious problem areas. Any identified competencies represent

important potential sources of self-esteem that can play a crucial role in the

treatment plan.

Information can be obtained through interviews, observation, and the use of questionnaires. Family members should be interviewed as a group and

individually. The advantage of the family interview is that it can be used to

address both a wide range of issues and particular problem areas. This

meeting provides an opportunity for members to express their views and hear

the perspectives of others, permitting intervention to begin during the


The pediatrician who has training in behavioral management and counseling

may elect to initiate treatment with certain families capable of implementing

behavioral advice, but referral to a mental health professional may be necessary in many cases. Referral is indicated if the behavior is extreme,

unremitting, or violent, if other psychopathology is present, or if the

child's or adolescent's daily functioning is impaired significantly. Referral

is also necessary in situations in which the family cannot manage the child's

behavior or is unable to participate in therapy.

The focus of treatment is a practical one of improving the child's or

adolescent's overall functioning. The specific goals include promoting compliance with age-appropriate rules and decreasing the frequency of

aggressive behavior. An effort should be made to identify areas of competence

that can be promoted as sources of gratification and self-esteem. An emphasis

on the inappropriate behaviors, which results in labeling and stigmatization,