Conduct Disorder
The Largest Group of Childhood Mental Disorders
Predominantly Affects Boys
Serious and persistent patterns of disturbed conduct and antisocial behaviour predominantly
affect boys and comprise the largest group of childhood psychiatric disorders. Conduct
disturbance may begin early in childhood, manifesting as oppositional, aggressive and
defiant behaviour becoming established during the primary school years and amplifying after
puberty. The presence of other psychological disorders is common in these children, with
about 30% showing ADHD and learning problems. Clinical depression is also found in about
20% of young people with conduct disorder, and, although controversial, a prospective study
suggests that this emotional disturbance is secondary to the conduct disorder. This group of
childhood disorders requires vigorous early intervention, assessment and management
because, although about a third make a reasonable adjustment, there is evidence that at least
half of the young people with serious conduct disorder will continue to experience mental
health and psychosocial problems in adult life, such as personality disorder, criminality and
alcoholism, and about 5% develop schizophrenia.
Attention deficit hyperactivity disorder ( See ADHD )
Controversy exists regarding the prevalence of this condition, which is now being more
frequently diagnosed in Australia. Using international diagnostic criteria, the prevalence is
probably about 1%, being three times more common in boys than girls. There is usually a
history of difficult and uneven development from infancy. It is likely that the disorder has a
neurobiological basis that is complicated by family interactions and the progressive
consequences of associated learning problems.
More recent evidence indicates that the young person does not necessarily grow out of the
problem. Symptoms tend to persist, although adolescents usually become more
goal-directed and less impulsive, channelling activity into sport or work if the opportunity is
available. The outcome is less favourable for those who have an associated conduct disorder.
In these cases, there is a significantly increased risk of continuing to have mental health,
personality and social adjustment problems.
Principles of management
The key to effective management of childhood psychopathology is a comprehensive
assessment and diagnosis upon which to base the treatment plan. This process can of itself
provide families with an understanding of the problem and generate possible solutions. Even
if the child receives an individually focused treatment, involving the parents helps to improve
outcome and facilitates treatment compliance. Psychological treatments are the most
effective, with drugs having a limited role in childhood but an increasingly important role during
adolescence as more adult psychiatric conditions occur.
The first consideration is to ensure that the child is safe. In depressed young people, suicide
risk is assessed by determining a past history of suicide attempts and risk-taking behavior,
the experience of a sense of hopelessness, helplessness and having no future, and current
suicidal ideas, plan and means. Referral to specialist services is required when the young
person is suicidal.
Children and adolescents need to know that what they tell you in private is confidential, unless
they are a risk to themselves or others, or if they are being abused. Most children, provided
they were present when information was gathered from the parents, are relieved to consent to
the clinician sharing their concerns with parents. The young person usually wants to be
present when feedback is given to parents and this process is often therapeutic.
Psychological treatments
Cognitive-behavioral (Thoughts) therapy Each treatment program is modified
according to the symptoms, but involves: relaxation training, with progressive muscle
relaxation and breathing exercises which can then be used to cope with greater exposure to
anxiety-provoking or stressful situations modelling and reinforcement of confident behaviors to
help reduce anxiety and improve self-esteem formulating more positive thoughts (cognitions)
and self-attributions to alter maladaptive beliefs and self-appraisal, and to relieve anxiety,
depression and angry antisocial thoughts the experience of rewarding structured tasks, and
activities using operant conditioning to develop pro-social behaviour and improve social skills,
particularly in delinquent youths. The evidence for the effectiveness of cognitive-behavioural
treatment approaches is now so substantial that these should be used as the first option.
Play and psychodynamic psychotherapy
These approaches rely on using play, discussion and the relationship with the therapist to
help children develop insight into their problems and learn to understand and cope with their
emotional distress. There is growing evidence that these approaches do work, but they are
generally not as efficient and effective as cognitive-behavioural therapy.18 The more recent
structured approach referred to as "interpersonal psychotherapy" is providing results that are
more equivalent to cognitive-behavioural therapy when applied to the treatment of internalising
conditions.
Family therapy
There are a variety of different approaches to working with families, but most are based on
working with the family as a group, improving communication and problem-solving skills,
developing more effective methods of discipline of behavioural control and the expression of
emotion, and encouraging new patterns of interaction.20 Studies of family therapy often have
methodological problems, but, overall, it has been shown to be useful in treating a range of
child psychiatric problems including conduct disorder and delinquency, anxiety and
depression and bereavement.
Pharmacotherapy/Utilizing Medications as a Form of Therapy
Drugs have a limited role in managing psychopathology in children. Even in cases where they
have a clear therapeutic benefit, they should be used as an adjunct to a more broadly based
management plan which involves the parents and, when reasonable and available, the school.
Internalising disorders
The role of drug treatment for anxiety and depression in childhood has still to be firmly
established by controlled trials. There is limited evidence that imipramine may reduce
symptoms of anxiety in separation anxiety disorder and school refusal.21 Some case reports
indicate a positive response to tricyclic antidepressants in the treatment of depression in
children and adolescents, but systematic controlled studies have failed to demonstrate
significant efficacy compared with placebo (. A recent placebo-controlled outpatient study of
young people (aged 7-17 years) with non-psychotic major depression found significant
improvement in depression rating scale scores and clinical assessment in a group treated
with the selective serotonin reuptake inhibitor fluoxetine (20 mg morning dose for eight
weeks). This finding requires replication. The judicious use of antidepressants as a
secondary treatment is justified with regular review and monitoring for side effects and
compliance.
There is no evidence that benzodiazepines have any role in the treatment of anxiety or
depression in children, and they might even produce paradoxical responses.24 Due to
potentially serious side effects, neuroleptic drugs such as thioridazine should only be used in
consultation with a specialist.
Externalising disorders Conduct disorder: There is virtually no indication for the use of drugs
in the treatment of conduct disorder unless the child also suffers from ADHD or a depressive
disorder. Attention deficit hyperactivity disorder: There is a large body of evidence that, for
school-aged children with ADHD, psychostimulants such as dextroamphetamine and
methylphenidate reduce motor activity, enhance attention in cognitive performance and
improve social behavior. The effective daily dose of methylphenidate is usually 0.3-0.5 mg per
kg. Preschool children have a more unpredictable response and respond better to parent
training and behavioural management programs. Although psychostimulants are generally
safe, they can have a number of troublesome side effects, including anorexia and weight loss,
sleep disturbance, abdominal pains and headaches, irritability and depressed mood. Growth
can also be inhibited, but this is reversible on drug discontinuation. Drug dependence has not
been demonstrated.
Consulting teachers and providing structured educational programs that address specific
learning disabilities and facilitate and reward success are also an important adjunct to the
treatment of childhood emotional and behavioral disorders.
The Largest Group of Childhood Mental Disorders
Predominantly Affects Boys
Serious and persistent patterns of disturbed conduct and antisocial behaviour predominantly
affect boys and comprise the largest group of childhood psychiatric disorders. Conduct
disturbance may begin early in childhood, manifesting as oppositional, aggressive and
defiant behaviour becoming established during the primary school years and amplifying after
puberty. The presence of other psychological disorders is common in these children, with
about 30% showing ADHD and learning problems. Clinical depression is also found in about
20% of young people with conduct disorder, and, although controversial, a prospective study
suggests that this emotional disturbance is secondary to the conduct disorder. This group of
childhood disorders requires vigorous early intervention, assessment and management
because, although about a third make a reasonable adjustment, there is evidence that at least
half of the young people with serious conduct disorder will continue to experience mental
health and psychosocial problems in adult life, such as personality disorder, criminality and
alcoholism, and about 5% develop schizophrenia.
Attention deficit hyperactivity disorder ( See ADHD )
Controversy exists regarding the prevalence of this condition, which is now being more
frequently diagnosed in Australia. Using international diagnostic criteria, the prevalence is
probably about 1%, being three times more common in boys than girls. There is usually a
history of difficult and uneven development from infancy. It is likely that the disorder has a
neurobiological basis that is complicated by family interactions and the progressive
consequences of associated learning problems.
More recent evidence indicates that the young person does not necessarily grow out of the
problem. Symptoms tend to persist, although adolescents usually become more
goal-directed and less impulsive, channelling activity into sport or work if the opportunity is
available. The outcome is less favourable for those who have an associated conduct disorder.
In these cases, there is a significantly increased risk of continuing to have mental health,
personality and social adjustment problems.
Principles of management
The key to effective management of childhood psychopathology is a comprehensive
assessment and diagnosis upon which to base the treatment plan. This process can of itself
provide families with an understanding of the problem and generate possible solutions. Even
if the child receives an individually focused treatment, involving the parents helps to improve
outcome and facilitates treatment compliance. Psychological treatments are the most
effective, with drugs having a limited role in childhood but an increasingly important role during
adolescence as more adult psychiatric conditions occur.
The first consideration is to ensure that the child is safe. In depressed young people, suicide
risk is assessed by determining a past history of suicide attempts and risk-taking behavior,
the experience of a sense of hopelessness, helplessness and having no future, and current
suicidal ideas, plan and means. Referral to specialist services is required when the young
person is suicidal.
Children and adolescents need to know that what they tell you in private is confidential, unless
they are a risk to themselves or others, or if they are being abused. Most children, provided
they were present when information was gathered from the parents, are relieved to consent to
the clinician sharing their concerns with parents. The young person usually wants to be
present when feedback is given to parents and this process is often therapeutic.
Psychological treatments
Cognitive-behavioral (Thoughts) therapy Each treatment program is modified
according to the symptoms, but involves: relaxation training, with progressive muscle
relaxation and breathing exercises which can then be used to cope with greater exposure to
anxiety-provoking or stressful situations modelling and reinforcement of confident behaviors to
help reduce anxiety and improve self-esteem formulating more positive thoughts (cognitions)
and self-attributions to alter maladaptive beliefs and self-appraisal, and to relieve anxiety,
depression and angry antisocial thoughts the experience of rewarding structured tasks, and
activities using operant conditioning to develop pro-social behaviour and improve social skills,
particularly in delinquent youths. The evidence for the effectiveness of cognitive-behavioural
treatment approaches is now so substantial that these should be used as the first option.
Play and psychodynamic psychotherapy
These approaches rely on using play, discussion and the relationship with the therapist to
help children develop insight into their problems and learn to understand and cope with their
emotional distress. There is growing evidence that these approaches do work, but they are
generally not as efficient and effective as cognitive-behavioural therapy.18 The more recent
structured approach referred to as "interpersonal psychotherapy" is providing results that are
more equivalent to cognitive-behavioural therapy when applied to the treatment of internalising
conditions.
Family therapy
There are a variety of different approaches to working with families, but most are based on
working with the family as a group, improving communication and problem-solving skills,
developing more effective methods of discipline of behavioural control and the expression of
emotion, and encouraging new patterns of interaction.20 Studies of family therapy often have
methodological problems, but, overall, it has been shown to be useful in treating a range of
child psychiatric problems including conduct disorder and delinquency, anxiety and
depression and bereavement.
Pharmacotherapy/Utilizing Medications as a Form of Therapy
Drugs have a limited role in managing psychopathology in children. Even in cases where they
have a clear therapeutic benefit, they should be used as an adjunct to a more broadly based
management plan which involves the parents and, when reasonable and available, the school.
Internalising disorders
The role of drug treatment for anxiety and depression in childhood has still to be firmly
established by controlled trials. There is limited evidence that imipramine may reduce
symptoms of anxiety in separation anxiety disorder and school refusal.21 Some case reports
indicate a positive response to tricyclic antidepressants in the treatment of depression in
children and adolescents, but systematic controlled studies have failed to demonstrate
significant efficacy compared with placebo (. A recent placebo-controlled outpatient study of
young people (aged 7-17 years) with non-psychotic major depression found significant
improvement in depression rating scale scores and clinical assessment in a group treated
with the selective serotonin reuptake inhibitor fluoxetine (20 mg morning dose for eight
weeks). This finding requires replication. The judicious use of antidepressants as a
secondary treatment is justified with regular review and monitoring for side effects and
compliance.
There is no evidence that benzodiazepines have any role in the treatment of anxiety or
depression in children, and they might even produce paradoxical responses.24 Due to
potentially serious side effects, neuroleptic drugs such as thioridazine should only be used in
consultation with a specialist.
Externalising disorders Conduct disorder: There is virtually no indication for the use of drugs
in the treatment of conduct disorder unless the child also suffers from ADHD or a depressive
disorder. Attention deficit hyperactivity disorder: There is a large body of evidence that, for
school-aged children with ADHD, psychostimulants such as dextroamphetamine and
methylphenidate reduce motor activity, enhance attention in cognitive performance and
improve social behavior. The effective daily dose of methylphenidate is usually 0.3-0.5 mg per
kg. Preschool children have a more unpredictable response and respond better to parent
training and behavioural management programs. Although psychostimulants are generally
safe, they can have a number of troublesome side effects, including anorexia and weight loss,
sleep disturbance, abdominal pains and headaches, irritability and depressed mood. Growth
can also be inhibited, but this is reversible on drug discontinuation. Drug dependence has not
been demonstrated.
Consulting teachers and providing structured educational programs that address specific
learning disabilities and facilitate and reward success are also an important adjunct to the
treatment of childhood emotional and behavioral disorders.
| The information provided on these pages are intended as an educational public service vehicle only. New studies often change our understanding of how to diagnose and treat illnesses almost on an annual basis. In any case, it is always wise to seek the advise of an experienced mental health professional prior to diagnosing and/or treating any emotional or mental illness. |
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