Introductions to Child and Adolescent

Psychiatric Disorders

The practice of child psychiatry differs from that of adult in 4 important ways:

1. Children seldom initiate the consultation. Instead, they are brought by a parent or another
adult who thinks that some aspect the child’s behavior or development is abnormal
2. The child’s stage of development must be considered when deciding what is abnormal.
Some behavior s are normal at an early age but abnormal at a later one. For instance,
repeated bed wetting may be normal in 3 year old child but is abnormal in a child age 7
years. Also the child’s response to live events changes with age, thus, separation of the
parents is more likely to affect the younger child than an older child.
3. Children are generally less able to express themselves in words. For this reason, evidence
of disturbance often comes from observations of behavior made by parents, teachers, and
others. These informants often give differing accounts in part because the child’s
behavior often varies with his circumstances, and in part because the various informants
may have different criteria for abnormality. For this reason, informants should be asked
for specific examples of any problem they describe and asked about the circumstances in
which it has been observed.
4. Mediation is used less in the treatment for children than in the treatment of adults.
Instead, there is more emphasis on working with parents and the whole family, reassuring
and retaining children and coordinating the efforts of others who can help children
especially at school. Thus, multi-disciplinary working is even more important in child
than in adult psychiatry

CONDUCT DISORDER (CD)

Conduct disorder (CD) refers to age-inappropriate behaviors characterized by the violation of

family expectations, society’s norms, and the personal or property rights of others. It is
characterized by socially disapproved aggressive and destructive behavior and involves repeated
violations of the rights of others and society’s norms and laws. The Diagnostic and Statistical
manual of Mental Disorders (DSM-IV) characterized the disorder as “a repetitive and persistent
pattern of behavior in which the basic rights of others or major age-appropriate societal norms or
rules are violated”).

Children with conduct disorder exhibit a wide range of rule-violation behaviors, from lying,
cheating, stealing, running away from home, aggression, temper tantrums, truancy, non-
compliance, destructiveness and oppositional behavior. It has been found that many young
children engage in noncompliant, aggressive, and highly active behavior during the course of
normal development and that, at a certain moment of their development, they have demonstrated
aggressiveness, negativism and disobedience as a normal process of development

Conduct disorder is a common childhood psychiatric problem that has an increased incidence in
adolescence. The primary diagnostic features of conduct disorder include aggression, theft,
vandalism, violations of rules and/or lying. For a diagnosis, these behaviors must occur for at
least a six-month period. Conduct disorder is a psychiatric syndrome occurring in childhood and
adolescence, and is characterized by a longstanding pattern of violations of rules and antisocial
behavior. As listed in the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-
IV), symptoms typically include aggression, frequent lying, running away from home overnight
and destruction of property. Approximately 6 to 16 percent of boys and 2 to 9 percent of girls
meet the diagnostic criteria for conduct disorder. The incidence of conduct disorder increases
from childhood to adolescence.

Conduct disorder has a multi-factorial etiology that includes biologic, psychosocial and familial
factors. Conduct disorder (CD) is one of the most difficult and intractable mental health
problems in children and adolescents. CD involves a number of problematic behaviors, including
oppositional and defiant behaviors and antisocial activities (eg, lying, stealing, running away,
physical violence, sexually coercive behaviors).

AETIOLOGY OF CONDUCT DISORDERS

No single factor can account for children's antisocial behavior and conduct disorder, but several
factors may contribute to a child developing conduct disorder and all factors are not present in
each case. Conduct disorder appears to be the result of an interaction among a multitude of
factors:

a) Biological theories

Genetic factor

Indeed, biological children whose parents have conduct disorder have high rates of the
disorder even when they are adopted at birth and are raised by parents who don’t have the
disorder

Temperament

Temperament refers to the tendency of the newborn child and young infant to respond in
predictable ways to experiences Three different types of child temperament (“easy”,
“difficult” and “slow-to-warm- up”) were identified by Alexander Thomas and Stella
Chess in 1977 and another type (“shy”) was identified by Jerome Kagan and his
associates in 1991.

It has been found that the easy baby stays a relatively easy child, while the difficult one is
more likely to have behavioral problems (Berger & Thompson, 1998) [16]. As babies,
 children with conduct disorder were irritable, demanding, impulsive, seemed to have little
control over their behaviors, and responded to frustration with aggression.

b) Psychosocial theories

Cognitive Distortion

Cognitive theorists believe that behavior is influenced by cognitive processes and that
distorted modes of thought cause mental disorders (Baron, 2001) (5). They believe that
child’s cognitions may influence the development of conduct disorder since children with
the disorder have been found to misinterpret or distort social cues when interacting with
peers or when interpreting the intent of others.

Parental Factors

Parental psychopathology: The risk for a child to develop conduct disorder is increased in
the event of parent psychopathology such as maternal depression, substance abuse and
antisocial behavior in either parent. Indeed, it has been found that boys whose mothers
had smoked 10 cigarettes per day during pregnancy were four times more likely to
develop conduct disorder than boys whose mothers did not smoke.

Environmental factors

The behavioral theorists see the causes of conduct disorder as the learning of maladaptive
behavior. They suggest that behaviors included in conduct disorder are learned from the
environment through reward, punishment and imitation. Thus, harsh and continuous
physical punishment from parents encourages children to behave in aggressive ways, and
mothers who used aggressive child-rearing methods had children who were more
aggressive than those of mothers who used less aggressive methods.

Epidemiology

Conduct disorder is significantly more common among boys. The ratio ranges from 4 to 1
as much as 12 to 1. The disorder is also more common among children whose parents
have antisocial personality disorder and alcohol dependence than among the general
population. A significant risk for CD was found for boys and girls who were hyperactive
and unhelpful
 Co morbidity

Co morbidity refers to the tendency for disorders to occur together. It is very common
that conduct disorder occurs with one or two other disorders. Such disorders include
Attention- Deficit/Hyperactivity Disorder; Mood Disorders; Learning Disorder; Anxiety
Disorders, Communication Disorders, and Substance-Related Disorders

Prognosis

The prognosis of conduct disorder is variable. On the one hand, it was noted that about
half of children with conduct disorder engage in criminal behavior as adolescent; and as
adults, about 75 to 85% of them are chronically unemployed, have histories of unstable
personal relationships, frequently engage in impulsive physical aggression or abuse their
spouses. Also, aggressive and antisocial children are likely to have serious problems as
adults; and the more severe the antisocial behavior during childhood, the more likely it is
that the individual faces serious problems in adulthood

Clinical Features of Conduct Disorder

Four types of symptoms of conduct disorder are recognized:

(1) Aggression or serious threats of harm to people or animals;

(2) Deliberate property damage or destruction (e.g., fire setting, vandalism);

(3) Repeated violation of household or school rules, laws, or both; and

(4) Persistent lying to avoid consequences or to obtain tangible goods or privileges.

DSM-IV Diagnostic Criteria for Conduct Disorder

A repetitive and persistent pattern of behavior in which the basic rights of others or major age-
appropriate societal norms or rules are violated, as manifested by the presence of three (or more)
of the following criteria in the past 12 months, with at least one criterion present in the past six
months:

Aggression to people and/or animals

 Often bullies, threatens or intimidates others.

 Often initiates physical fights.

  Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick,
broken bottle, knife, gun).

 Has been physically cruel to people.

 Has been physically cruel to animals.

 Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed
robbery).

 Has forced someone into sexual activity.

Destruction of property
 Has deliberately engaged in fire setting with the intention of causing serious damage.

 Has deliberately destroyed others' property (other than by fire setting).

Deceitfulness or theft
 Has broken into someone else's house, building or car.

 Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others).

 Has stolen items of nontrivial value without confronting the victim (e.g., shoplifting, but
without breaking and entering; forgery).

Serious violations of rules

 Often stays out at night despite parental prohibitions, beginning before age 13 years.

 Has run away from home overnight at least twice while living in a parental or parental
surrogate home (or once without returning for a lengthy period).

 Is often truant from school, beginning before age 13 years.

Illustrative Cases

Patients with conduct disorder typically do not perceive their behavior as problematic. Similarly,
parents and teachers often do not consider longstanding conduct disorder when attributing causes
to children's behavior. Therefore, symptoms of conduct disorder are not usually a presenting
concern in the office. The following cases illustrate typical ways that con-dust disorder may
present in family practice.
Illustrative Case 1

Tim is a six-year-old boy brought to the family medicine clinic for an initial visit. On entering the
examination room, the physician observed Tim spinning in circles on the stool while his mother
pled, “If I have to tell you one more time to sit down…” Tim was not permitted to begin first
grade until his immunizations were updated. His mother explained that Tim had visited several
physicians for immunization but was so disruptive that the physicians and nurses always gave
up. She hoped that with a new physician, Tim might comply. The mother described a several-
year history of aggressive and destructive behavior, as well as four school suspensions during
kindergarten. He often becomes “uncontrollable” at home and has broken dishes and furniture.
Last year, Tim was playing with the gas stove and started a small fire. Tim frequently pulls the
family dog around by its tail. Tim's older sisters watched him in the past but have refused to do
so since he threw a can of soup at one of them. Tim's father is a long-haul truck driver who sees
Tim every three to four weeks.

Illustrative Case 2

Sharon, a 15-year-old girl, was brought to the office by her mother. Her mother explained that
Sharon was suspended from school for assaulting a teacher and needed a “doctor's evaluation”
before she could return to class. The history reveals that this is Sharon's 10 th school suspension
during the past three years. She has previously been suspended for fighting, carrying a knife to
school, smoking marijuana and stealing money from other students' lockers. When asked about
her behavior at home, Sharon reports that her mother frequently “gets on my nerves” and, at
those times, Sharon leaves the house for several days. The family history indicates that Sharon's
father was incarcerated for auto theft and assault. Sharon's mother frequently leaves Sharon and
her eight-year-old brother unsupervised overnight.

Illustrative Case 3: Family violence presenting as conduct disorder in a boy with ADHD

An 8-year-old boy was suspended from school for attacking his teacher with scissors after being
reprimanded for hitting some classmates. He had a history of disobedience and running away
from home, aggression to other children and stealing sweets and toys from shops. He was also
impulsive, overactive and had poor concentration; these symptoms were treated with
dexamphetamine by a paediatrician, with a resulting improvement in his concentration and
activity level.

During assessment a recurring theme was evident in his free play: a toy cow and her calf were
attacked and “eaten up” by a “wild lion”, a “wild racing car” crashed into a toy car and
“killed the mother and children”, and the doll’s house mother was “thrown around the room
down the stairs and out the window” by a “wild robber”.

This gave the clue, apprehensively confirmed by the mother, that she and her son were the
victims of domestic violence from her de facto partner. She had earlier separated from the boy’s
father because of his violence and drunkenness. After informing her of how to contact the local
family refuge, the mother elected to work on this problem with her partner in conjoint therapy. A
behavioral program for her son was also initiated at home and school using rewards (e.g.,
football cards) for an absence of aggressive behavior and a voluntary “time out” area if the boy
felt he needed to calm down. The boy rapidly lost his antisocial behaviour when the parental
relationship improved, although he continued to require stimulant medication.

TREATMENT

Psychotherapies

Behavior therapy

Behavior therapists assume that the task of therapist is to change the maladaptive behavior
through learning process which may be based on the association between a conditioned stimulus
and unconditioned stimulus, or on the consequences of the behavior (reinforcement or
punishment) or on observational learning. Thus, techniques of behavioral psychotherapy focus
directly on overt behaviors exhibited by the child with conduct disorder and include positive
reinforcement, negative reinforcement, punishment and social skills training

Cognitive therapy

Cognitive therapists emphasize on cognitive processes that are considered to lie behind
inappropriate behavior. Techniques used include problem-solving skills and self- statements.
Family therapy According to Kazdin (1985), “Family therapies focus on the family as the unit.
The emphasis is not on the identified patient’s problem but rather on the family structure,
processes, communications, interactions, and interrelationships from which the symptoms may
have emerged.”

Psychopharmacological treatment

It has been found that the addition of drugs to psychological techniques has enhanced the
treatment success rate of conduct disorder

Summary of Management

• Early intervention: parenting-skills training

• Creating opportunities for success in sport and recreation

• Success achievement in educational programs

• Behavior treatment (social skills)

• Family therapy for conflict and criticism