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Treating Adolescent Conduct Disorder

The symptoms of conduct disorder seriously interfere with a teen's positive connection to home, school, or community. Effective interventions, however, are available.

The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) defines conduct disorder as a "persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated." The manual breaks the behavior patterns into four areas or criteria:    

  • aggression (such as physical fights, cruelty to animals, and forced sexual activity)
  • destruction of property (such as fire setting or inflicting other types of property damage)
  • deceitfulness or theft (such as breaking into someone else's home or stealing items without confronting   the owner)
  • serious violation of rules (such as truancy and running away from home)

Lastly, the DSM-IV-TR categorizes conduct disorder into two major subtypes: child-onset type and adolescent-onset type. These subtypes differ in regard to prognosis, age of onset, and severity of symptoms.

Childhood-onset type is characterized by the presence of one criterion characteristic of conduct disorder before age ten. The prognosis tends to be poor for this subtype, which appears to be genetic. At age of eighteen, the adolescent is more likely to be diagnosed with antisocial personality disorder as compared to those developing a later onset variety of conduct disorder.

It is common for the child-onset type to have non-normative peer relationships. Although they can be very charismatic, they tend to be loners. Adolph Hitler is an example of this type of presentation. History indicates he suffered from child-onset conduct disorder. In later life, he exhibited symptoms of bipolar disorder.

With childhood onset, the style of aggression may be predatory. Adolescents with this type "don’t get mad, they get even." These individuals may also experience symptoms that are strongly influenced by genetics. For example, reduced anxiety in the face of danger, lack of empathy, high degrees of stimulus seeking, high drive, and low-frustration tolerance are genetically influenced temperament traits and complicate the clinical presentation. This adolescent is going to be more interested in immediate gratification, as opposed to working hard for future gain such as going to college. Why work your way up the employment ladder when you can sell drugs or steal?

Adolescent-onset type is defined by the absence of any criterion characteristic of conduct disorder prior to age ten. These individuals tend to be less aggressive and have more normative peer relationships. Often, their aggressive tendencies come out while involved in a group action. The prognosis for an individual with adolescent-onset type is much better than for someone with the childhood-onset type.  Because these adolescents have shown the ability to bond to a group, the use of self-help and group therapies can be effective. The adolescent-onset type generally diminishes by adulthood.

Conduct disorder symptoms may emerge in someone as young as five or six years old. Generally, the disorder appears during late childhood or early adolescence. Less severe symptoms such as lying and stealing tend to emerge first. As the child grows older and sexually matures, more severe problems such as rape and burglary can appear. It must be remembered that each adolescent is different. It is also important to view the social and economic context of the behavior. Do the adolescents come from a war-ravaged nation or are they constantly exposed to violence and harm in their families and communities? Symptoms that fit a conduct disorder diagnosis might be perceived as survival skills in the above contexts.

Because individuals diagnosed with conduct disorder tend to tell lies, the use of "observers" is often necessary. An observer is any individual (employer, teacher, parent, and so on) who can provide independent and accurate information about the individual's behavior.

Middle School and High School Years
By middle school, it's common to observe noncompliance with commands, emotional overreaction, and a failure to take responsibility for one's own actions. Noncompliance with authority figures creates child-teacher and child-parent interaction problems that may result in less cognitive stimulation as the individual gets rejected both at home and at school.

Continued aggression makes the conduct-disordered preadolescent and adolescent unattractive to peers. This occurs during a development period where social and physical status is critically important. Aggressive and noncompliant actions in the classroom create an environment where teachers and other school staff reject the individual. Also, parents of the student with conduct disorder may have negative interactions with school staff due to the child's continuing disruptive behavior. An unfortunate result is that parents may lose interest in their child's activities and friends.

The above is a recipe for continuing and exaggerated problems. Because of school and parental lack of interest, the individual has more unstructured and unsupervised time, time which may be spent with those of similar mind and experience. The individual has been alienated from family culture, successful school orientation, and socially oriented peers. The individual with conduct disorder may now join a gang or hang out with others who have demonstrated failure in school and other social endeavors.

The affiliation with a deviant peer group provides a different type of education. Peer modeling of criminal and delinquent behavior, including substance abuse, is the norm. If the adolescent is arrested and incarcerated, experiences with other deviant peers in the juvenile justice setting create advanced learning opportunities in deviant behavior.

Promising Treatments
A number of different interventions have been used to treat youth with conduct disorder. Cognitive therapy, behavioral therapy, and combination cognitive-behavioral therapy are most frequently utilized.

The greatest difficulty arises from the fact that conduct disorders impacts not only the adolescent but also his or her family, school, and community. Family-based interventions have consistently demonstrated the ability to positively alter behavior. Two approaches to the treatment of conduct disorder that have gained empirical support are briefly discussed below.

Parent Management Training
Considerable evidence supports the use of parent training techniques based on social and behavioral learning theory for youth with conduct disorder. These interventions have been successfully implemented in the clinic and in the home using individual or group sessions. Parent management training is more effective in reducing behavior problems in younger children than in older adolescents.

Multisystemic Therapy
Multisystemic therapy conceptualizes behavior as being linked with the various aspects of the multiple systems in which the adolescent is embedded. This includes the family, peers, schools, and neighborhood. Interventions are designed for all levels to (1) promote disengagement from deviant peers, (2) build stronger bonds to the family and school, (3) enhance family skills such as monitoring and discipline, and (4) develop greater social and academic competence in the adolescent.

Conduct disorder is difficult to treat. Remember to never personalize the adolescent's behavior. In many ways the role of a parent is appropriate. Being fair (these are the rules), being consistent (you interpret the rules the same way every time), and being available (a positive role model) are the greatest and most needed gifts you can give these adolescents. For many, these gifts have never been experienced before.

Excerpted from Nuckols, C. N., Nuckols, and S. C. 2004. "Substance Use and Conduct Disorder." In the Adolescent Co-occurring Disorders Series. Center City, MN: Hazelden.

 
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