Conduct Disorder Flashcards
Define
Characterised by a repetitive and persistent pattern of dissocial, aggressive or defiant conduct
Such behaviour should amount to major violations of age-appropriate social expectations
It should therefore be more severe than ordinary childish mischief or adolescent rebelliousness and should imply an enduring pattern of behaviour (≥ 6 months)
Epidemiology
Most common mental and behavioural problem in children and young people
More common in boys than girls
Aetiology
Cause is unknown, but likely involves the interplay of genetics and environmental factors
Oppositional defiant disorder: subtype and milder variation of conduct disorder seen in younger children aged up to 10 years
Risk factors
Individual:
- Males, lower average intelligence, learning or reading difficulties, or difficulty learning socially acceptable behaviours, coexisting mental health problems (ADHD), chronic illness, epilepsy
Risks within the family:
- Parent or sibling with conduct disorder, physical or sexual abuse, frequent changes of caregivers, or early institutional living experience, being rejected by parents or experiencing permissive, neglectful, harsh or inconsistent parenting, exposure to marital conflict and/or domestic violence, family poverty
Risks outside family:
- Low SES, inner city, Being bullied, physical or sexual abuse, in care system, involvement with other difficult young people, use of recreational drugs
Types
Types (<10yo = ODD; >10yo = unsocialised CD, socialised CD, CD confined to family context):
- Oppositional-Defiant Disorder (ODD; mild CD, characterised by angry, defiant behaviour to authority)
- Unsocialised CD (significant abnormality with relationships with other children)
- Socialised CD (generally well-integrated into a peer group)
CD confined to family context
Symptoms
Repetitive and persistent (>6 months) pattern of dissocial, aggressive, or defiant conduct, e.g.
- Excessive levels of fighting or bullying
- Cruelty to other people or animals
- Severe destructiveness of property
- Fire-setting
- More severe than ordinary childish mischief or adolescent rebelliousness
In the absence of features suggestive of another medical diagnosis (i.e. ADHD)
Investigations
Reports from parents, teachers, etc.
Strengths and Difficulties Questionnaire
Examination
Basic observations
- Usually diagnosed > 3 years old
- If it occurs < 10 years: early onset
- If it occurs > 10 years: adolescent onset
Management
(no medication is used in the UK):
Refer to CAMHS if they have any of the following complicated factors:
- Coexisting mental health problem
- Neurodevelopmental condition
- Learning disability or difficulty
- Substance misuse in young people
1st line = parent management training programmes (e.g. Webster-Stratton, Triple-P)
- Needs strong parental cooperation and motivation
- If weak outcome due to lack of parental engagement, move to 2nd line
2nd line = child individual or group interventions focussed on problem-solving and anger management
- Often, affected children do not have the motivation to engage with these well
Remedial educational teaching (for missed school)
Alternative peer activities
Multimodal intervention
- Offered to young people between 11-17 years
- Multisystemic therapy- provides intensive support to young person and their family
- Interventions provided to the young person, family, at school, at the criminal justice system and community
- Consist of 3-4 meetings each week for up to 5 months
In practice, there are FOUR arms of management carried out:
1. Family education- helping them understand conduct disorder and how they may have accidentally reinforced the behaviours
2. Psychological therapy- talk about feelings and thoughts about how these affect behaviour and wellbeing to a therapist
3. Parent management training
4. Family therapy- discuss current problems
Advise parents that medications like methylphenidate is not recommended unless child has co-existing ADHD
Educational support and remedial educational teaching for missed school
Anger management for the child if needed
Treat comorbid problems e.g. ADHD
Patient Information
Information leaflets from the Royal College of Psychiatrists
Complications / Prognosis
Complications
- May commit violent/ non-violent crimes
- Poorer school performance, unemployment, relationship problems
- Psychiatric problems
Prognosis
- 50% develop antisocial personality disorder
- Prognosis generally considered to be poor, but outcome varies
- Likely to become delinquents
- Adolescent onset (> 10 years) has better prognosis than early onset
- Worse prognosis associated with:
- Early expression of callous-unemotional behavioural traits
- Behaviours that are severe, frequent and varied
- Hyperactivity and attention problems
- Lower intelligence
- Parental criminality or alcohol misuse
Harsh inconsistent parenting with high criticism, low warmth, low involvement, low supervision
Low socioeconomic status
Ineffective schooling
