Conduct Disorder

 

Conduct Disorder

Definition of “Conduct Disorder” (from the Diagnostic & Statistical Manual, DSM-5 of the American Psychiatric Association, AND the International Classification of Diseases – ICD 10): When the leader of the orchestra directs the musicians to play Beethoven’s 9^th symphony to the beat of Macarena using only piccolos and cowbells.  Oh wait… that’s Conductor Disorder!  (I hear that it’s being considered for inclusion in the 2050 12th editions of DSM and ICD.)

*If you’d like to know about the history of the DSM, the holy book of mental health professionals, view my rather irreverent video podcast on the topic.

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Conduct Disorder

Hello again, fellow B-Lister! Tell me: Does the delivery of this weekly newsletter seem like a cruel and callous act aimed directly at you?  If so, either I have a Conduct Disorder or you suffer from Paranoid Schizophrenia. Let’s assume the former.  (It’s not paranoia when they really ARE after you.)

Conduct Disorder (CD) is one the most pronounced, in-your-face, and intervention-resistant of the school-age diagnoses in the manual of mental illnesses.  It expresses itself in major violations of age-appropriate social expectations   I have a great deal of direct experience in self-contained classrooms chock-full of pre-teens & teenagers with this label.  (Although Conduct Disorder can appear as early as the pre-kindergarten years!)  Those days were memorable, and provide lots of stories for “I can beat that one.” story-telling competitions at conference’s end-of-day pubs.

In my early experience, I remember being anxiously alert even during CD’s inactive stage when the kids were on-task and cooperative.  Often I could sense an odd, undefined psychological undertone then made me feel tense and anxious… a harbinger of what was to come.  You see, many of my kids were like behavioral popcorn; you knew they were going to explode…

  You just didn’t know when. 

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It was akin to placing your ear to the train tracks…  

You know something’s coming, but you don’t know from which direction.

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Then you realize; the express train is coming!

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In its activated state, Conduct Disorder is one of the most frightening of disorders with which to be confronted… filled with terrible negative chi (energy).  Indeed, “confront” might be the operational word here.  When CD presents itself in its full-force, you better be on top of your professional game.

Fear not!   You can reach that point with the strategies found on my  BehaviorAdvisor.com and other fine sites. 

This posting will direct you to those essential resources.

First though, let’s wrap our brain around this psychological malstrom.  In an earlier B-list blast, we addressed ODD; Oppositional Defiant Disorder.  These youngsters exhibit a persistent pattern of disobedient, argumentative, defiant and hostile actions.

 

Like “Henry” in one of the videos found below, these youngsters are at great risk for transforming into someone with a more severe condition: Conduct Disorder.  Generally speaking, kids with the ODD diagnosis do not demonstrate the mean, cruel behavior found in the diagnostic criteria for Conduct Disorder. 

The CD diagnosis is made when the youngster presents a prolonged pattern of antisocial behaviour such as serious violation of laws, social norms and rules.  Our students with Conduct Disorder are the quick-tempered, non-empathetic, acting out kids who bully and threaten others,

   

solve their disputes with fearless violent physicality, destroy property, steal, lie, engage in drugs and alcohol, etc.

They break the rules, regulations and juvenile codes of society,  and violate the basic rights of others, sometimes in a callous and cruel manner, and disobey regulations in the home; staying out past curfew or running away (among other actions).   The condition is highly intervention-resistant.

The DSM-5 retained the critical points from its previous edition’s criteria (DSM-IVtr), and added a “specifier” regarding the Conduct Disorder diagnosis that is intended to differentiate between impulsive acts of rage due to emotional overload in the youngster, and those acts that are planned in a calculated manner before engaging in them.  The latter type are identified by DSM’s “Limited prosocial emotions” clause (see below).

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Diagnostic Criteria for Conduct Disorder

According to the , in order to diagnose Conduct Disorder, least four of the following traits must be present:

• Aggressive behavior toward others and animals.
• Frequent physical altercations with others.
• Use of a weapon to harm others.
• Deliberately physically cruel to other people.
• Deliberately physically cruel to animals.
• Involvement in confrontational economic order crime- e.g., mugging.
• Has perpetrated a forcible sex act on another.
• Property destruction by arson.
• Property destruction by other means.
• Has engaged in non-confrontational economic order crime- e.g., breaking and entering.
• Has engaged in non-confrontational retail theft, e.g., shoplifting.
• Disregarded parent’s curfew prior to age 13.
• Has run away from home at least two times.
• Has been truant before age 13.

The preceding criteria is accompanied by the following:

1. The behaviors cause significant impairment in functioning and

2. If the individual over age 18 the criteria for APD is not met.

           Further qualifiers are:

1. Child, Adolescent, or Unspecified onset.

2 Limited prosocial emotions, – lack of remorse or guilt, lack of empathy, callousness, unconcerned about performance, shallow or deficient affect.

3. With mild, moderate, or severe levels of severity (American Psychiatric Association, 2013).

For more information on associated factors, visit https://www.theravive.com/therapedia/conduct-disorder-dsm–5-312.81-(f91.1),-312.82-(f91.2),-and-312.89-(f91.9)

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It is hoped (by the American Psychiatric Association) that the “limited prosocial emotions” qualification will separate “cold blooded” versus “hot blooded” behavior; ruthlessness  versus rage; emotional versus evil.  McCauley Caulkin’s character in the film titled “The Good Son.” (Dr. Mac’s compilation of scenes) shows this latter behavioral motive at its cinematic extreme.  He is removed, unemotional, and callously cruel. 

For a less dramatic, more realistic depiction, take a look at these videos that were created by my wonderful graduate students in our behavior disorders teacher-training program at Hunter College (of the City University of New York… the 3rd largest university system in the United States). 

Here are the links to case study videos:

• Conduct Disorder – Henry, age 10-11 (DSM-IVtr criteria – part 1): https://www.youtube.com/watch?v=m-nzlDaJA5c  &  (part 2) https://www.youtube.com/watch?v=3aUsfiUyjMI  
• Conduct Disorder – Julian, age 8 (DSM5 criteria): https://www.youtube.com/watch?v=wMqbgTaJPSc

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Teachers talk about teaching kids with Conduct Disorder

1.  Dr. Mac is interviewed after being announced as a recipient of the MSLBD Janus Award (for significant contributions to the field of teaching students with mental health and behavior disorders): (part 1, 8 minutes) https://youtu.be/PTwVSrRcu7g  &  (part 2, 9 minutes) https://www.youtube.com/watch?v=tuBc-ldgIY0
2. Dr. Mac interviews Tony Mullen, the U.S National Teacher of the Year  (Audio) 

9-Part (80 minute) Interview with Anthony Mullen, National Teacher of the Year (USA). He is a teacher of urban students with severe emotional & behavioral disorders (EBD). (Tony is on the left in picture. Dr. Mac is on the right.)

#1 (8:15) Introduction and general overview

#2 (9:30) Building relationships with relationship-resistant youngsters

#3 (6:26) How he built strong trust bonds with one authority-aversive student

#4 (6:09) The use of humor & Helping students reach high standards

#5 (8:26) Forces that work against caring and competent teachers of EBD students

#6 (12:16) Models for reaching and teaching EBD students, Behavior management, Tips for new teachers, and reaching out to the homes of students with EBD

#7 (12:30) Teaching social skills & Use of cooperative groups with EBD students

#8 (9:52) Misbehavior as a test of the teacher & How to pass the tests our students give

#9 (9:09) Closure & Fond recollections of his teaching experience

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The ways that Conduct Disorder plays out on the urban poverty area streetcorner

Becoming streetsmart: Understanding and defusing the manipulative and aggressive tactics of urban streetcorner youth

Respecting and reaching streetwise kids

.How did they come to be this way? 

It is important to note that Conduct Disorder is rarely a conscious choice, at least initially.  While the jury is still out regarding the etiology and the extent to which nature and nurture intertwine, for the most part the source for this aberrant behavior, distorted value system, and negative character is believed to emanate from one primary source.  Typically, it is a lifestyle that develops due to the home/neighborhood environment in which these youngsters live.  As one example, a national office in the United Kingdom states that 40% of kids who were maltreated/abused by adults in their lives developed conduct disorder.  Others may be emulating the behavior they witnessed in their homes/neighborhoods.  In any case, one’s moral code and value system is maladapted to success in school and mainstream society.

Research shows that Conduct Disorder is frequently associated with the following factors; each of which increases risk for the aberrant behavior pattern:

• Smoking & alcohol use during pregnancy
• Abusive child-raising practices
• Inadequate supervision
• Inconsistent disciplinary measures
• Parental drug abuse and alcohol addiction
• Homes filled with familial conflict
• Single parent household
• Young age of mother
• Large family size
• Divorce in the family
• Living in areas of long-term, ingrained poverty

*! It is important to remember that the vast majority of kids who grow up in these circumstances do NOT develop Conduct Disorder.  However, these factors, especially in combination, do increase the risk of development.

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There might also be a biological component, as having Attention Deficit Hyperactivity Disorder (ADHD) increases the risk for developing CD, and an as-of-yet unidentified genetic component is also a possibility.  Indeed, one study found children adopted from parents with anti-social personality disorder (the adult version of Conduct Disorder) having a higher incidence of aggression than children adopted from parents who did not have anti-social personality characteristics.

It is common for kids with CD, especially those with early onset of the condition, to have impaired cognitive functions and intelligence.  This outcome may be the result of differences in brain anatomy and function, as youth with CD are more likely to have reduced responses in areas of the brain that are associated with interpersonal social actions and emotional responses (i.e., amygdala, insula, orbito-frontal cortex, and ventro-medial prefrontal cortex…. Whew!…That’s enough… My tongue gets dizzy just trying to say all those neuro-names).

How many kids have CD? 

It is difficult to assess the prevalence of the disorder because of the varied interpretations of the criteria for the diagnosis (e.g., “defiant”, “rule breaking”).  Additionally, the more international ICD manual uses a slightly different categorization system.   I guess that it’s akin to the difference between art and pornography; difficult to define, but you know it when you see it. (Some folks seem to see it more so than others.)

Consider the “epidemic” proportions of children with autism.  The latest estimates are 1 in 90 children up to 1 in 58.  Then consider the most common estimate for the number of kids with conduct disorder: 1 in 7! (Although estimates range from 1% to 10%, with a median guestimate of 4%.)  My intent is not to demean or downplay the need to address autism.  Rather, my intent is to show the unequal power of the parental/professional bases, and public perceptions of the two conditions.

 

ICD (International Classification of Diseases from the World Health Organization) has a section on mental health disorders that is an equivalent text to DSM.

 

 We also know that the diagnosis is more common among boys (estimated to be about 9% of young males), but girls (estimated at 2% of that gender) are certainly not immune.  The lesser estimate for females is sometimes attributed, in part, to the diagnostic criteria that tends to focus more on acting out behaviors which tend to be more common among males.

There are also racial disparities in diagnosis, with kids whose ancestry is from sub-Saharan Africa at greatest risk for diagnosis.  Kids of east-Asian ancestry appear to be at least risk. (Although, again, they are not immune.)

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INTERESTING (to me) FACT:  When the U.S. passed P.L. 94-142, The Education of All Handicapped Children Act (now Individuals with Disabilities Act), a committee was formed to define the educational disability label of “seriously emotionally disturbed” (now “emotionally disturbed).  It was led by Eli Bower.  Not surprisingly, the definition from a book he authored became the one that would be used in schools.  It contained five criteria “… a condition exhibiting one or more of the following characteristics over a long period of time and to a marked degree that adversely affects a child’s educational performance:

A. An inability to learn that cannot be explained by intellectual, sensory or health factors;

B. An inability to build or maintain satisfactory interpersonal relationships with peers and teachers;

C. Inappropriate types of behavior or feelings under normal circumstances;

D. A general pervasive mood of unhappiness or depression;

or E. A tendency to develop physical symptoms or fears associated with personal or school problems. The term includes schizophrenia. The term does not apply to children who are socially maladjusted, unless it is determined that they have an emotional disturbance (ED).“

That last sentence (in red) has caused confusion since that time.  First, there is no general agreement as to the definition of “socially maladjusted”.  What does this term encompass?  The most common definition is to equate it with DSM’s “Conduct Disorder”.  Second, why wouldn’t we wish to serve and reclaim these youth? Third, Eli Bower wrote an article in the mid 1990s stating that he had no idea where that final sentence came from!  When the definition left his committee, it was not part of the definition.  Yet when the regulations interpreting the new law were published, it was there.  It appears that some unknown bureaucrat slipped it into the definition when no one was looking.

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Let’s Reclaim These Kids! 

Here are some quick tips and approaches.  You’ll see some new ideas at the end of the lists, although most will be reiterations approaches and interventions for youngsters with ODD.  That’s to be expected though, as I used to be the director of the Department of Redundancy Department.  (Have I told that joke before?  If so, you now understand why… again.)

Educators

1. Don’t give directions.  Huh?! (That’s “Eh” for our Canadian readers.)  Yes, I realize that adults in authority see it as their duty, but with these kids you’re charging into the same valley as the 600.  Unlike the Light Brigade, ours IS to reason why, and if doomed to failure, decide on another course of action.

What then do we do?  Ask questions!  It hard to refuse a direction if it isn’t given!  Here are some examples:

“Atsa, where should your tush (Yiddish for “buttocks”) be?” (“In the chair.”) “Good thinking.”

“Kialani, when is the time for outside voices?” (“Recess.”) 

“Which voice level do we use during partner work?” (“Our six inch voice.”)  Teacher nods.

“Ebony, when is the time for learning centers?” (“Later.) “Thanks for returning to your seat.” (Pre-correction praise.)

“Wei, when the bell rings, where should students be?” (“In our seats.” as he then walks in that direction)

Note that the questions NEVER use “Why”.  That’s because that word can sound accusatory, setting off an angry and threatening self-defense strategy.

More information on how to entice students into cooperating can be found at – http://behavioradvisor.com/Webinar.html

2. Make use of strong, research-supported, positive interventions

2a. Differential reinforcement: It’s a twenty dollar term for a one dollar idea, but the different variations of the DR procedure are highly effective with intervention resistant kids

.2b. Self monitoring: Promote self-regulation of behaviour by having the student keep track of his/her behavior..

3. Pick up additional defiance-defusing tips.

4. Teach problem solving skills to devise alternative solutions to anger and rebellion.

5. Modify the character of the youngster using the Circle of Courage model of intervention.

6.  Determine the present level of readiness to change behaviour, and move the youngster toward greater levels of willingness to change his /her behavior for the better.

7a.  Use “The Behavior Survival Guide for Kids: How to make good choices and stay out of trouble”  in your social skills/anger management programs, or place it in the class library.

7b. Implement the FREE 100+ lesson plans that accompany The Behavior Survival Guide (or use them in isolation)

8. Engage the youngster in Multi-Systematic Training (MST: http://mstservices.com/index.php/what-is-mst)

9.  For girls who tend to me more responsive to peer-influence and empathy-based interventions than boys, provide this intervention focus.

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Parents

1. Develop a home-school behavior change program based on the monetary system.

2. Learn the principles of changing behaviour for the better, and effective strategies for helping your child make better behavior choices.

3.  Leave “The Behavior Survival Guide for Kids: How to make good choices and stay out of trouble”  out on the coffee table for your child to pick up.

4. Seek out family counseling.

5. If your child is engaging in drug abuse, seek out drug-exit programs.  One research study showed that 1/2 of drug users with conduct disorder no longer exhibited the disorder when free of illicit substances.

6. For girls who tend to be more responsive to peer-influence and empathy-based interventions than boys, adopt this intervention focus.

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NEXT WEEK (or maybe two): Childhood Depression (sometimes associated with CD)

 

 

Dr. Mac

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Tom McIntyre, Ph.D. (Dr. Mac)

Professor of Special Education and Coordinator of the Graduate Program in Behavior Disorders

Hunter College of the City University of New York

DoctorMac@BehaviorAdvisor.com

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