Conduct disorders are the most common psychiatric disorders in children and adolescents.
The background is multifactorial, and no one single factor explains the occurrence of a conduct disorder.
Conduct disorders are characterised by repetitive defiant, antisocial or aggressive conduct which violates age-appropriate social expectations.
Early intervention, which addresses both the risk factors and individual features of the conduct disorder, does improve the prognosis of these often difficult to treat disorders.
Conduct disorders are often associated with developmental problems, associated illnesses and psychosocial stress.
A comprehensive intervention usually warrants the use of a multiprofessional team with effective networking facilities.
If the symptoms go unchecked, those close to the child will start to see behavioural problems as part of the child's personality and not as treatable symptoms. This in turn may lead to pessimism as regards the possibility of treatment.
Classification of the disorders
Conduct disorder confined to the family context
Abnormal behaviour is confined to interactions with members of the nuclear family or household.
The prognosis is better than in the other forms of conduct disorder.
Unsocialised conduct disorder
The child has no positive relationships with others and poor empathy skills.
Socialised conduct disorder
The child has friendships with others of the same age and is able to feel empathy with them. The child's superego may deviate from the norms of society but meet those of the peer group (gang).
Oppositional defiant disorder
Characteristically seen only in children below the age of 10 years.
The child's conduct is typically disobedient without being seriously aggressive.
If left untreated, often develops into one of the above mentioned conduct disorders.
Diagnosis
Not all behavioural problems are conduct disorders. Diagnosis requires careful assessment and the fulfilment of the ICD-10 criteria. Moreover, these children are often lacking in conscience and have poor empathy skills.
The symptoms must include some of the following: often loses temper, argues, is disobedient, deliberately annoys people, blames others for own mistakes, is touchy or easily annoyed, is often angry, spiteful or vindictive, lies to obtain personal benefit, involved in physical fights, uses a weapon, stays out at night despite prohibitions (beginning before the age of 13 years), physical cruelty towards people or animals, destroys other people's property, deliberate fire setting, stealing, truancy from school, running away, crime while confronting a victim, forced sexual activity, bullying and intimidation, burglary.
A diagnosis may only be made if the child exhibits a repetitive and persistent pattern of conduct. Isolated antisocial or criminal acts are not in themselves grounds for the diagnosis.
Conduct disorders that have their onset in the childhood (before the age of 10 years) and those that start later in the adolescence may be considered as separate disorder types.
Once the diagnosis is set, also the severity grade of the disorder is determined: mild, moderate, severe.
To be separately taken into account are the characteristics that reflect limitations of the prosocial emotions, which often suggest a severe disorder (lack of remorse or guilt, weak empathic abilities, emotional shallowness, difficulty taking responsibility for one's actions, deceitfulness and manipulativeness).
Other disorders
Conduct disorders are often associated with other disorders, the most common of which are attention deficit/hyperactivity disorder (ADHD) and depressive symptoms in children and ADHD, depressive symptoms, anxiety disorder and substance use disorders in adolescents.In girls, post-traumatic stress disorder and borderline personality disorder are common as well. Some patients also have significant developmental problems at the same time (e.g. learning difficulties, particularly in the development of language and reading abilities).
Differential diagnosis
A conduct disorder cannot be diagnosed in the presence of, for example, severe developmental disorder, mania or antisocial personality disorder. These diagnoses take precedence over a conduct disorder diagnosis, and a conduct disorder should be regarded as an integral part of these disorders.
Differential diagnosis must also consider the possibility of neurological damage or illness (e.g. certain types of epilepsy), which may be associated with sudden bouts of aggressiveness.
Isolated behavioural problems are seen in many psychiatric disorders without meeting the criteria for a conduct disorder.
Regardless of the diagnosis, measures that offer help to a child with a conduct disorder (see below) will often also prove beneficial in other disorders that may include conduct problems.
Staging the treatment
Primary health care personnel have close links with the local community and are therefore in a key position to identify behavioural symptoms as well as risk factors that may contribute towards the emergence of conduct disorders.
Family related risk factors
The family life will often lack rules and regularity, and the pattern on childrearing is inconsistent. Discussion and problem solving skills are poor.
The risk of behavioural problems is particularly high in children whose family life involves violence, substance abuse or criminal activity.
Other risk factors
Genetic and other biological risk factors, risk factors associated with the family's interaction with outsiders, risk factors associated with the living conditions and environment as well as various social risk factors.
Primary health care personnel should assess the following
The child's developmental history, past symptoms, present state (interview, questionnaires, observation)
The home situation and the child's functioning in the social network
Physical and neurological examination, laboratory and other investigations if indicated (for example, blood glucose parameters, thyroid tests, chromosome testing or EEG).
If necessary, assessment by a speech therapist (dyslexia-related problems), occupational therapist, physiotherapist or psychologist.
Some cases of conduct disorder may be managed in the primary care in co-operation with the family and the close social network (day care facility, school, social services, child welfare, substance abuse clinics etc.).
The task allocation between the primary health care and specialist care is discretionary. However the consultation of a family guidance clinic, child/adolescent mental health services or a child/adolescent psychiatry clinic is always indicated when
it becomes apparent that the investigations required are beyond the scope of the primary health care
the patient has serious symptoms; self-destructive behaviour is always an indication for an immediate/urgent referral to specialist care.
the symptoms are milder but persist despite treatment and supportive measures
there is suspicion of a concurrent psychological condition, or a need for comprehensive differential diagnosis is identified.
If the situation requires emergency evaluation, the psychiatric condition of the child or adolescent as well as the risk of violent behavior are assessed, and the necessary treatment decisions are made accordingly.
Ordinary psychiatric examination (are there signs of a severe mental disorder?)
Assessment concerning the risk of violent behavior (e.g. violence-favouring attitudes, physical and mental ability to carry out a violent action, possible concrete plans or preparations to carry out such an action, the attitude of the persons near the child or the adolescent towards an expressed threat to use violence, motivation to adhere to the offered interventions)
The grounds for possible involuntary referral for monitoring at a hospital should be assessed, or some other action plan should be drawn.
Treatment is based on a care plan which is drawn up together with the family and all appropriate close contacts.
Treatment is multifaceted and must be adjusted individually for each case.
The treatment plan must also address risk factors and factors that maintain the current situation. All relevant facilities must work together to achieve this aim.
The parents should be helped to develop their parenting and childrearing skills. The parents may also need support to cope with their own problems (for example, mental health problems or substance abuse). If possible, consideration should be given to the family's living conditions, the situation at the day care centre/school as well as the leisure time pursuits of the child/adolescent (e.g. guided activities).
Guidance given to the day care facility personnel and teachers is important, as are various support measures regarding the child's schooling/day care.
Some children/adolescents with behavioural problems will also benefit from different individual or group psychotherapy methods as well as from other individual or group therapies.
If other disorders are recognized in the child or adolescent, these should be managed concomitantly as a part of comprehensive care.
Also these disorders (e.g. ADHD, learning difficulties etc.) must be taken into account when organising supportive actions by the early childhood education and care and by the school.