Excerpts from Your Adolescent on Conduct Disorders
By the time a person reaches adolescence, she likely knows what type of behavior is expected of her and which behaviors are unacceptable. Yet all teenagers misbehave from time to time, for a variety of reasons. Perhaps they feel that they need to assert their own autonomy. Maybe they wish to test the limits imposed on them. Teenagers sometimes misbehave because they are experiencing internal distress: anger, frustration, disappointment, anxiety, or hopelessness.
There are also teenagers whose behavior is consistently troubling to others. In these cases, the teen’s behavior is clearly outside the range of what is considered normal or acceptable. Perhaps most alarming is that many of these teenagers show little remorse, guilt, or understanding of the damage and the pain inflicted by their behavior.
Increasingly, we read stories in the newspapers of teenagers who routinely set fires, torture animals, or torment other people. We hear of teenagers who join gangs and cruise the streets, terrorizing others. In extreme cases, there are those who physically, sexually, or murderously assault people.
When their behavior is this disturbed, the temptation is to dismiss these adolescents as scary, lost, or bad to the core. Increasingly, there is a tendency to relegate them to the criminal or juvenile justice system. Yet, by doing so, we may overlook the fact that some of these youngsters have underlying psychiatric disorders that can help explain some of their behaviors. For some of these teens, psychiatric treatment is more effective than correctional incarceration.
Conduct disorders are among the most frequently diagnosed childhood disorders in outpatient and inpatient mental health facilities. It is estimated that 6 percent of all children have some form of conduct disorder. The condition is far more common in boys than in girls in early childhood, but adolescent girls are increasingly diagnosed with the disorder.
The earlier a child displays extremely disturbed behavior, the worse the prognosis. The teen with a conduct disorder has moved from being disobedient and disrespectful (behaviors characteristic of oppositional defiant disorder) to violating the rights of others with aggression or illegal activity. Some studies report that high levels of activity and unmanageable behaviors at the age of four presage behavioral problems in later school years. Behavioral problems at eight are reliable predictors of adolescent aggression. Some of the underlying causes of sever behavioral problems, including family violence and abuse, can be prevented or successfully managed.
Identifying the Signs
Teenagers who are diagnosed as having a conduct disorder are physically and verbally aggressive beyond what is seen among their peers. Their aggression typically is expressed toward people and animals, in the destruction of property, in deceitfulness and theft, and in serious violation of society’s rules.
In order to diagnose a conduct disorders, a clinician will evaluate the teen for the presence of a repetitive and persistent pattern of behavior that violates the basic rights of others. Usually, teenagers with serious conduct disorders engage in a umber of unacceptable activities. Almost invariably, they seem to have little or no remorse, awareness, or concern that what they are doing is wrong.
For example, teenagers with conducts disorders might bully, threaten, and intimidate others. Routinely, they initiate physical fights, sometimes using weapons such as bats, bricks, broken bottles, knives, and guns. They get involved in muggings, purse snatching, armed robbery, sexual assault, animal torture, and rape.
Teenagers with conduct disorders might break into other people’s homes, buildings, or cars. They might systematically lie to obtain goods or favors or to avoid obligations. They might con others, shoplift, or get involved in forgery. They repeatedly violate rules, break curfew, run away from home, or become truant. The severity of these negative or problem behaviors vary form youngster to youngster.
Clinicians distinguish between types of conduct disorder. Children younger than ten yours of age, especially those previously diagnosed with oppositional defiant disorder are said to have childhood-onset conduct disorder. When the symptoms and behaviors of conduct disorder are not evident until after the child has reached ten years of age, the diagnosis is adolescent-onset conduct disorder. Youngsters with childhood-onset CD are typically more aggressive; they are likely to have few or no friendships with their peers. They are also at greater risk of persistent conduct disorder or of developing antisocial personalities as adults. Few girls demonstrate childhood-onset conduct disorder; girls are at greater risk for adolescent-onset conduct disorder.
Causes and Consequences
The diagnosis of conduct disorder implies a multitude of potential criminal behaviors as well as numerous possible biological, psychiatric, and social problems. Teenagers who have not developed an adequate repertoire of behaviors and language skills to express their discomfort, misery, and confusion seem to be at highest risk for conduct disorders. Therefore, the same undesirable or antisocial behavior in different adolescents can indicate very different underlying problems.
It is likely that biochemical underpinnings and genetic vulnerabilities interact with environmental forces and individual characteristics to produce conduct disorders. When there are serious problems during pregnancy, delivery, and the postnatal period, for example, youngsters may demonstrate a variety of neurobiological problems during development. These include slowed development of gross motor coordination (required for throwing a ball or skipping), fine motor skills (handwriting, card playing), and impaired short-term memory, It is not uncommon for children with these kinds of problems to show poor judgment and to have trouble controlling their actions. They have difficulty modulating their behaviors, feelings and even their biological rhythms of sleep and appetite.
Many teenagers with conduct disorders have learning problems, especially in the area of verbal skills. Since many come from homes in which actions speak louder than words, however, lack of parental stimulation and modeling may account for these weaker verbal skills. Difficulties in reading and language contribute to academic difficulties, especially in the higher grades when understanding and using the written word is a crucial skill. Language deficits may also contribute to an inability to articulate feelings and attitudes, so a teenager might resort to physical expression out of frustration.
In many instances, unrecognized and untreated learning disabilities and cognitive deficiencies create deep frustration for a youngster. Thus, the entire school experience gets filtered through defeat and humiliation. An adolescent may then stop attending school or skip challenging classes. Teens which leave the structure of school, which should offer some opportunity to experience success, may then engage in delinquent behavior. For some, delinquent behavior, however unlawful or unacceptable, provides them with both the status among peers and the opportunity for some reinforcement that they are unable to find at school.
Antisocial behavior abounds in poor inner-city areas together with high rates of family instability, social disorganization, infant morbidity and mortality, and sever mental illness. These class and cultural conditions may well cause and perpetuate sever conduct disturbances in a youngster’s behavior.
More and more, child and adolescent psychiatrists and other professionals are recognizing the role played by prior physical, sexual, and emotional abuse in the genesis of certain kinds of aggressive and inappropriate sexual behaviors. Mental illnesses in parents – schizophrenia, sever depression, or manic-depressive disorders – can have a grave impact on the children in the family.
Recently, there seems to be a significant increase in such nonagressive aspects of conduct disorders as running away, truancy, and substance abuse. It is common for troubled teenagers to use drugs and alcohol. Drugs and alcohol may be used by the teenager in an attempt to self-medicate for symptoms of anxiety, depression, thought disorders, and hyperactivity. They may wish to blot out memories of abuse or treat insomnia. Some think they need drugs or alcohol just to be able to face another day in a violent, abusive household.
Some of the most violent youngsters are likely to be those who have been the most severely abused themselves. Their way of dealing with the abuse is to dissociate their feelings from action. They thus appear to be cold, detached, and lacking in empathy. Yet, because it is the most deeply disturbed teenagers who tenaciously maintain their bravado, boast of their offenses, and threaten others with further violence, they are often passed over to the justice system without effective psychiatric evaluation and intervention.
Conduct disorder can also occur along with psychiatric conditions such as ADHD, major depression, and bipolar disorder. Though depression is more often associated with withdrawal than aggression, its sysmptoms can include irritability and rage. Furthermore, episodic destructive behaviors or sporadic episodes of robbery and burglary may represent the manic phase of a bipolar disorder in the presence of a euphoric or expansive mood state. Suicidal behavior and self-mutilating behavior are not uncommon with teenagers who have conduct disorders. Rather than dismiss such attempts as manipulative behavior, adults must take them seriously, not only in terms of the immediate danger but as desperate expressions of frustration, pain, anger, and impulsiveness. Conduct disordered adolescents are usually not very articulate about their feelings and may demonstrate their pain with self-destructive behaviors.
How to Respond
No single treatment approach has been shown to be effective in addressing antisocial behavior. Because youngsters with conduct disorders may have a myriad of biological, psychological, and social vulnerabilities, a combination of treatment methods targeting each area is mot effective.
When a teenager with sever behavioral problems is brought to a child and adolescent psychiatrist or other professional, treatment usually begins with a comprehensive evaluation. This will likely include a detailed medical history, family profile, and psychological testing. A neurological examination sometimes accompanied by an EEG or MRI is often valuable in detecting any central nervous system dysfunction that could contribute to the youngster’s problems. A psychoeducational evaluation may uncover intellectual and learning problems that could cause academic and behavioral problems that, in turn, put the adolescent at risk for truancy and disruptive behaviors. The clinician will probably try to determine the degree to which the teenager as control over her aggressive acts and can anticipate a violent episode before it happens. An attempt is usually made to ascertain whether she feels any remorse or concern after such episodes and has the capacity for empathy.
It is often difficult to tap into the inner world of these disturbed youngsters. Turning off questions with a face of bravado or sullenness, many of these teenagers have become so unaccustomed to empathy or concern that they reject it when it is offered. They may brag of their brutality or denigrate their victims. Yet, sometimes, when left alone or in the company of an adult whom they trust, some may let down their defenses and share their agonies, talking about how distraught they really are.
Parent Management Training Many times, treatment for conduct disorders is family-focused. Parent management training has been used with considerable success with aggressive youngsters, especially when parents themselves are not significantly unstable or disorganized. The degree of alienation that the teenager has experienced in the family is an important variable in family-based treatment. When they can participate fully, this method helps parents recognize and encourage appropriate behaviors in their teenager and discipline the teen more effectively. In order to interact with their teenager in new ways, parents learn to use positive reinforcement. They learn to link misbehavior to appropriate consequences and develop better ways of negotiating with their teenager. Once the parent-child relationship improves, many youngsters are better able to navigate their social and academic worlds without getting as upset and disruptive. Often, however, teenagers are resistant to this kind of treatment and feel that adults are ganging up on them.
Family Therapy When teenagers are willing to work with their parents in therapy, this approach can help family members learn less defensive ways of communicating with each other. It can foster mutual support, positive reinforcement, direct communication, and more effective problem-solving and conflict resolution within the family.
Social Skills Training Skills training focuses on teenagers in an effort to enhance their problem-solving abilities. Through such programs, a youngster can learn to identify problems, recognize causes, appreciate consequences, learn to verbalize feelings, and consider alternate ways of handling difficult situations. Because most teenagers with conduct disorder feel alone and alienated from the adults in their lives, efforts are made to diminish mistrust of others, especially adults. This type of training helps the youngster seek and become receptive to support and encouragement.
School-Based Treatment Programs These are in wide use throughout the country, whether in special residential treatment environments, designated community-based schools, or specific programs in mainstream schools. These programs can reintegrate the student into regular classes as the youngster’s behavior allows. Successful school-based programs often assess the teenager’s strengths, interests, and potential and provide special programs to help the youth achieve skill in a particular area.
Cognitive-Behavioral Therapy Behavioral therapy may help adolescents control their aggression and modulate their social behavior. Teenagers are rewarded and encouraged for proper behaviors. Cognitive therapy can teach defiant teens self-control, self-guidance, and more thoughtful and efficient problem-solving strategies, especially as they pertain to relationships with their peers, parents, and other adults in authority.
Medication Since conduct problems tend to arise from a tangle of biological, emotional, and social stresses, there is no single class of medication that has been found especially useful. Even when another psychiatric problem has been defined (such as ADHD, depression, manic-depressive illness, or schizophrenia), medication is seldom sufficient to alter significantly the conduct disorder symptoms. If the teenager has underlying ADHD, the use of stimulants may help reduce negative behaviors and impulsiveness. Lithium, a mood stabilizer, has also been shown in some studies to reduce aggression. In some cases, anticonvulsant medications such as carbamazepine (Tegretol) have significantly curbed aggressive outbursts. Used judiciously to address specific clinical findings in each individual case, appropriate mediation can enhance the success of other treatment modalities.
Given the rather dramatic and disturbing quality of the conduct disorder symptoms, it is important to keep in mind that not all behaviorally disturbed teenagers go on to become antisocial or criminal adults. On the other hand, more often than not, ongoing, adequate medical, emotional, educational, and social supports are required fro many years if teenagers with severely disturbed behavior are to go on to live meaningful lives and become productive members of society.
Excerpts from Your Child on Conduct Disorders
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