| In some ways, conduct disorder is just a worse version of ODD. However recent research suggests that there are some differences. Children with ODD seem to have worse social skills than those with CD. Children with ODD seem to do better in school. Conduct disorder is the most serious childhood psychiatric disorder. Approximately 6-10% of boys and 2-9% of girls have this disorder. Here is the Definition: A. A repetitive and persistent pattern of behavior in which the basic rights of others or major society rules are violated. At least three of the following criteria must be present in the last 12 months, and at least one criterion must have been present in the last 6 months. Aggression to people and animals-
Destruction of property-
Deceitfulness or theft-
Serious violations of rules-
B. The above problem causes significant impairment in social , academic, and occupational functioning. So how are ODD and CD related? Currently, the research shows that in many respects, CD is a more severe form of ODD. Severe ODD can lead to CD. Milder ODD usually does not. The common thread that separates CD and ODD is safety. If a child has CD there are safety concerns. Sometimes it is the personal safety of others in the school, family, or community. Sometimes it is the safety of the possessions of other people in the school, family or community. Often the safety of the child with CD is a great concern. Children with ODD are an annoyance, but not especially dangerous. If you have a child with CD disorder in your home, most likely you do not feel entirely safe. Or, you do not feel that your things are entirely safe. It is the hardest pediatric neuropsychiatric disorder to live with as a sibling, parent, or foster parent. Nothing else even comes close. It is worse than any medical disorder in pediatrics. Some parents have told me that at times it is worse than having your child die. Conduct Disorder and comorbidity It has been common in the past for people to think that conduct disorder is just the beginning of being a criminal. Up until the last few years, children with conduct disorder were often "written off". It is now clear that this is true only with a minority of cases. It is very easy to focus on the management of the CD child and forget to check the child out for other neuropsychiatric disorders. A careful examination of children with CD almost always reveals other neuro-psychiatric disorders. Some of the most exciting developments in this area of medicine involve understanding these phenomena. It is called comorbidty, that is the tendency for disorders to occur together. It is very common to see children with CD plus another one or two neuro-psychiatric diagnoses. By far the most common combination is CD plus ADHD. Between 30-50% of children with CD will also have ADHD. Another common combination is CD plus depression or anxiety. One quarter to one half of children with CD have either an anxiety disorder or depression. CD disorder plus substance abuse is also very common. Also common are associations with Learning Disorders, bipolar disorder and Tourettes Syndrome. It is exceptionally rare for a child to present for evaluation by a pediatric psychiatrist to have pure CD. Here are some examples of the comorbid presentations: Looking for comorbid disorders in every child with conduct disorder is absolutely essential. Many of the treatments of these children depend on what comorbid disorder is also present. CD plus substance abuse Sadly, this is very common. In my clinic, every child with CD is assumed to be abusing substances until proven otherwise. Compared with children who do not have CD, children who have CD are three times more likely to smoke cigarettes, 2.5 times more likely to drink, and five times more likely to smoke pot. As far as having a problem from drug use, children with CD a 5.5 times more likely to be addicted to cigarettes, six times more likely to be alcoholics, 7 times more likely to be addicted to pot. (16)This is certainly the most common comorbidity and often goes along with the one's below. Terry- When Terry was 9, he told his mom that he wanted to buy lunch instead of bring it. His mom at that point still believed that some of what Terry said was innocent of any other purpose, and so she let him. She did notice that he was very hungry when he came home from school. He said the lunches were small and for an extra 75 cents he could get seconds. She believed this. Two weeks later the principal called to report that Terry was caught with cigarettes on the playground. Terry's mom was amazed, as she did not smoke and neither did her husband. Not only that, but he had a whole pack. Well, it took a lot of "interrogation" to get the story out. The lunch money went to buy cigarettes from a boy in Jr. High. Terry then smoked a few of those and then sold the rest at a big profit. His parents remembered that two years later when he was found drunk in the locker room at Jr. High. Now his parents are lots wiser. Terry still thinks his parents are totally unreasonable. The rule is you get your allowance and phone privileges as long as those random urine drug screens are normal. If he does not cooperate, then they are assumed to be positive. So he ended up poor and lonely for a few weeks, but now that is under control. As far as cigarettes go, if he can buy them, he can smoke them outside. If he is caught drinking or around people who are drinking, good-bye allowance and phone. Terry hates it and can't wait until he moves out so he can finally do what he wants. ADHD plus CD When these two disorders are present, usually the ADHD symptoms are much more severe than when ADHD is present without CD. Stephen- Stephen is now 14. When his mother thinks back to his infancy, she could actually see it coming at age 18 months. At that age he got up in the middle of the night, put a chair up to the door, opened it and went walking outside. The Mounties found him a while later and brought him home. If only that had been his only contact with them! Stephen's mother hated school almost as much as Stephen did. Almost every day there were calls from the school about Stephen. In grade primary he tried to stab a child with scissors. He was swearing at his teachers by grade one. On Grade two it was stealing lunch money. Every time they seemed to get one problem under control, he was into something else. Everyone seemed at a loss about what to do except her brother, who took him Irish mossing every chance he could. It didn't matter what the weather was like, Stephen was out there. His uncle said that by the time he was ten, he could do the work of a grown man. There was no fear in Stephen. Cold weather, big swells, nothing bothered him. He refused to do any homework from fourth grade on. Up until that grade, his teachers let him go out for a walk around the building every hour or so, but when a set of keys went missing and were "discovered" by Stephen a few days later, the walks ended. Still, compared to the last few years, this was easy. Stephen was suspended from 7th grade after two weeks when he threw a match into a boy's locker. Why? The boy called him stupid. He was out for a week, then after only two more days, he was thrown out for making death threats against the teacher. His parents tried home school and they thought they were getting somewhere. Until they got a call from the bank. They were overdrawn. When it all came out Stephen had stolen the cash card and figured out the password and had taken out $500 dollars. They still don't know how he did it. Before they could even sort that out, Stephen was arrested for vandalizing the school. He would have only received probation, but after giving the judge the finger, he was sent to the Shelbourne Youth Centre. It was the staff there that finally figured it out. This guy could not sit still for anything, he said the first thing that came to his mouth, and was constantly getting in bigger trouble for it. He saw the doctor, ADHD was diagnosed, and he was given medication for this in the Youth Centre. But what will happen in two months when he gets out? His motherShe spends a lot of sleepless nights thinking about that. CD and depression Charlene- Charlene is 14, too. Her life didn't start out quite so difficult. In fact, her mom swears that until she was almost 10, there were no problems. That is hard for everyone to believe now. Her mom remembers thinking that Charlene was certainly starting the teen years early. At age 11 she was having a tantrum about not being able to go out with her boyfriend who was 15. You could hardly blame her. By the time Charlene was 11, she looked like she was 15 or 16. Unfortunately, she did not have the maturity of a 16 year old. She ran away from home at age 12 for a week before they could find her. She brought a bottle of rum to school and got drunk. But more than this, she was absolutely unbearable to live with. She had become super defiant, and would fight her parents or anyone else for no reason at all. She never seemed happy, just angry. Unless she was with her friends, which by age 13 or 14 were 18 or so. Her parents kept asking themselves, "what had happened to their old daughter?” She was failing in school mostly because she was never there. She was never where she told her parents she said she was. The first clue came when she came home high on something and told her parents she was going up stairs to bed. They heard a crash and came in the bathroom to find her trying to cut herself with a broken mirror. Charlene wanted to die. Her boyfriend of two months had left her. For a few weeks she just hung around the house and lay on her bed and listened to music. Her parents let her out one night to go to her girlfriend's house. They got a call later that night that Charlene had admitted to taking a half a bottle of Tylenol. It is not uncommon that a mood disorder along with CD gets missed. There are usually so many pressing problems to sort out and so many different stressors, that it isn't until suicide is tried or talked of that many families, physicians, and other health professionals consider comorbid depression. Recent studies of teenagers who have committed suicide have found that these children are about three times more likely to have CD and 15 times more likely to abuse substances.(15) Suicide is worth worrying about in CD. CD plus Tourettes, OCD, and ADHD Marc- Marc is now 12. He has seen more doctors, nurses, and psychologists than most people will see in a lifetime. His father worried that maybe his son could have Tourette's like him, but he never dreamed it could get like this. When he was 4 he was thrown out of pre-school for fighting. Because of his reputation, he was the first child where the school approached the parents about getting a teacher's aide in grade primary rather than the parents approaching the school. Lucky for Marc, he never seemed to have all of these problems at once. Usually he would have a tic, especially blinking, which would last a few weeks or so. Then he would have to touch things, and then that might go away, too. The tics and OCD were nothing compared to his behavior. His temper was incredible. The usual pattern was that the excitement of being around other kids would get him so wound up that he was literally bouncing around. This usually led to pushing, fighting, and punishment. He resisted this and usually ended up being sent home as they could not deal with him. He attacked him sister. He attacked his mother and broke her arm. That led to living with different relatives and now a foster home. No one seemed to be able to manage him. The new foster parents were actually being bothered the most by his poor sleep and a nearly constant vocal grunting tic. They brought him to yet another doctor to see if they could do anything about this. He was placed on some medicine for the tic and amazingly, he behavior improved quite a bit. For the first time his parents are hopeful that maybe he can come home again. Diagnosing Conduct Disorder Conduct disorder is diagnosed like all things in pediatric psychiatry. The child and the caregivers will be interviewed together and separately to go over the history and check out all other possible comorbid conditions. Usually there are school reports, too. The child is examined to look for signs of many disorders. This usually includes some school work, some parts of the physical exam, and getting the child's perspective on things. Occasionally, there are lab tests and x-rays to do. There is no lab test that shows these problems. Prognosis and Course of Conduct Disorder Perhaps about 30% of conduct disorder children continue with similar problems in adulthood. It is more common for males with CD to continue on into adult-hood with these types of problems than females. Females with CD more often end up having mood and anxiety disorders as adults. Substance abuse is very high. About 50-70% of ten year olds with conduct disorder will be abusing substances four years later. Cigarette smoking is also very high. A recent study of girls with conduct disorder showed that they have much worse physical health. Girls with conduct disorder were almost 6 times more likely to abuse drugs or alcohol, eight times more likely to smoke cigarettes daily, where almost twice as likely to have sexually transmitted diseases, had twice the number of sexual partners, and were three times as likely to become pregnant when compared to girls without conduct disorder (6). Looked at from the other direction, by the time they are adults, 70% of children no longer show signs of Conduct disorder. Are they well? Some are, but what often happens is that the comorbid problems remain or get worse. That is, a girl with CD and depression may end up as an adult with depression, but no conduct disorder. The same pattern can be true of CD plus bipolar disorder and other disorders. Here are some examples that illustrate this: Trisha- ADHD plus CD as a child which eventually disappears Age 4-12 Classic problems with aggressiveness towards others, hyperactivity, and impulsiveness along with running away and shoplifting Age 12-16 ADHD symptoms become less prominent. Continued fights with teachers, shoplifting, and lying. Age 16-24 Fighting decreases, returns to school and succeeds Age 25-35 No sign of psychiatric problems `````````` Reggie- ADHD plus Conduct Disorder leads to similar problems as an adult (the minority of cases) Age 3-7 Reggie shows lots of aggression and hyperactivity Ages 7-12 Besides being hyperactive, Reggie lies, cheats, steals, and eventually forces a child to take of their clothes Ages 13-18 In and out of trouble with the law, and more involved with alcohol, Reggie quits school at age 16 Age 18-24 Reggie has spent two years of the last six behind bars. He successfully stays off drugs and alcohol, but meets old friends, quits his job, and is back bootlegging again. `````````` Sarah- CD with more and more signs of mood disorder. Eventually CD disappears. Age 4-12 Sarah slowly gets into more and more trouble with everyone. She starts to get irritable. Age 12-18 Sarah continues to have troubles with gambling, shoplifting, and vandalism. Occasional thoughts of suicide. Age 18-24 Sarah is hospitalized twice for depression, eventually recovers and seems to settle down Age 24-50 A few more hospitalizations for post partum depression but no CD features `````````` Mitchell- Learning problems, CD, and drug abuse leads to schizophrenia Age 4-12 Trouble in School, zero social skills, and constant conflict with family and peers Age 13-18 Using drugs and occasionally hears voices and sees things. Goes away when he is clean. Age 18-30 Slowly but surely he gets the substance abuse under control. The hallucinations and unusual thoughts continue on and require medical treatment. `````````` Jeff- CD plus ADHD leads to mania Age 4-11 typical ADHD Age 12-14 Totally out of control. Assaults everyone, gets drunk, pulls fire alarms, attacks father, steals a car all in the space of a week. Diagnosed by a psychiatrist who visits the youth prison as manic. Age 14-20 At least 10 episodes of mania and or depression. Hyperactivity and CD not present except while manic. <== Back ==> Next Page |
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Conduct Disorder
