A child behaving in the socially unacceptable manner can be seen as rowdy and poorly brought up, but they can also be treated as a person with serious disorders which are included in the classification of diseases and mental disorders. Is there a difference between one (a conduct disorder) and the other (conduct disorders) and how to recognise it without doing any harm, but aiding? Conduct disorders (CD) constitute a complex set of emotional problems as well as problems concerning general conduct of children and youth. A child with CD has serious difficulties with mastering and perceiving moral rules as well as behaving in the socially acceptable manner. A child does not accepts the authority of adults, does not respect the basic rules of social life, shows aggressive behaviour which threatens physical health of other persons, often destroys objects which constitute his property as well as objects belonging to others, lies, steals, leaves home and does not come to school, it happens that a child runs away to the unknown place for the period longer than a few hours. A child is evaluated by others as rowdy, defiant and not ill or mentally disturbed, despite certainly in need of help. It is suspected that the reason of his disorders is the combination of genetic aberrations or environmental factors. Treatment procedures must include behavioural-cognitive and systemic therapy as well as pharmacotherapy.
Conduct disorders are diagnosed in case when the pattern of anti-social conduct, characteristic of a child, repeats on numerous occasions, indicates signs of permanency and constitutes a serious infringement of other people’s rights as well as breach of social-ethical rules. In addition, three or more specific types of conduct (from the following groups) are observed within a period of the last twelve months and at least one from the anti-social behaviours occurred within the last six months. Child conduct disorders negatively impact their functioning in many aspects of life, i.e. in interpersonal contacts with known and strange persons, school achievements and other types of activity.
Conduct disorders involve a few differentiated types. In DSM-IV classification there are conduct disorders differentiated due to age at which the problems occur and the level of symptom intensity.
Childhood type - this type of conduct disorders has its onset in childhood and includes disorders observed prior to 10 year of a child’s life. Children with this type of conduct disorder are mainly boys. They often manifest physical aggression, enter into conflicts with peers that end in fights. They are arrogant, disobedient, ignore adults’ instructions, fight with teachers and parents, offend them. They use course language. They often lose their temper, even due to a weak stimulus. On purpose, they perform actions which annoy and irritate others. Such children demonstrate a full set of symptoms of conduct disorder prior to the start of puberty period. It is highly probable that this behaviours will get worse in the next developmental periods, they can became the base of anti-social personality.
Adolescent type - this type of conduct disorders has its onset in the puberty period. It is a set of behaviours which are demonstrated as late as upon 10 year of child’s life. Such persons significantly less often show aggressive behaviours than in case of a childhood type of disorders. Usually, they have satisfactory relations with peers and the disorders mainly concern thefts, playing truant and violation of social rules. They occur in both sexes to the same extent.
Mild conduct disorders -they are diagnoses when a child’s or a young person’s conduct leads to minor law violation and does not result in serious threat for health and life of other persons. Nevertheless, it is bothersome, deviates from adopted norms and meets the diagnostic criteria included in DSM-IV.
Moderate conduct disorders - is a term used in reference to emotional and social disorders posing a significant threat to the environment and constituting a threat for a physical health of people and animals.
Severe conduct disorders - they are diagnoses when all diagnostic criteria included in DSM-IV are met and their occurrence is observed in a child’s or young person’s behaviour with especially high intensity and differentiation of symptoms included in particular groups.
Children with conduct disorders show many other, accompanying developmental disorders which can cause one of the CD causes. The most often listed disorders include syndrome of attention deficit hyperactivity disorder (ADHD). However, not all children with this syndrome manifest conduct disorders in the clinical meaning. As it was shown in the research conducted by Biederman et al. (1991), 80% of studied children with ADHD had still symptoms of psycho-motor hyperactivity manifested in the adolescence period and ca. 60% of them showed conduct disorders with different intensity. The research of Klein and Mannuzz (1991) revealed that 75% of children with ADHD have educational problems, out of which 50% are conduct disorders (CD) and 21% anti-social disorders.
Hypothesis of neurological dysregulation - high percentage of concurrence of conduct disorders with disorders conditioned with the neurological regulation disruption, such as ADHD or Tourette’s syndrome, suggests that the cause of behaviour problems can be the same in all aforementioned syndromes. There is a suspicion that the biochemical balance between neurotransmitters is disrupted at that time: dopamine, serotonin and noradrenaline responsible for self-control processes. The increased level of testosterone which has impact on insensitivity of aggressive behaviours can also suggest the participation of this factor in occurrence of problems of CD type. The clinical data include the information that ADHD pharmacotherapy results in weakening of insensitivity of concurrent conduct disorders. However, there is a need to conduct more precise studies which can help to explain the mechanism of discussed interdependencies. There is a question whether pharmacotherapy directly impacts weakening or even disappearance of conduct disorders that accompany ADHD or whether it leads to improvement or processes of attention and hyperactivity reduction, resulting in the self-esteem increase and, as a further consequence, also in positive change in conduct.
Biological factor hypothesis - it draws the attention to the role of congenital conditions, determining the manner of reacting in specified situations. This includes such cases caused by a change in the structure of the central nervous system as, e.g. level of balance between excitement and inhibition processes, their mobility and strength, type of neural system conditioning the type of temperament, their activity and reactivity remaining in the relationship with the need for stimulation. However, the research shows that the relationships between these factors and occurrence of conduct disorder get weaker as the studied population gets older. An important factor which can strengthen the analysed relationships is a social context, a so-called manner of parents’ reaction to child’s behaviours.
Psychophysiological hypothesis - it assumes the existence of relationships between disturbed functioning of frontal lobes and some structures of the limbic system (e.g. amygdala) responsible for correct course of emotional processes, their expression and selection as well as those regulating the control processes.
Genetic cause hypothesis - research on twins showed the presence of stronger correlation between anti-social behaviours in identical twins than in case of fraternal twins. On the other hand, the researchers highlight that despite the correlation between criminal actions of parents and increased probability of occurrence of conduct disorders in children - the role of genetic factors is minor in their development.
The concept of psychological and environmental causes is the most often proposal of explanation of CD conditions in the literature. Unsolved marriage problems, frequent and intense conflicts between parents, changes of child’s guardians, lack of stable life and economic situation, financial problems in a family are factors correlated with conduct disorders.
Specialist treatment in case of conduct disorders must include the entire system in which a child grows up, that is, the family, school and, of course, a person causing educational problems. The systemic approach in combination with elements of cognitive-behavioural therapy includes many types of intervention.
The therapy of a child with CD is directed at the development and shaping of basic psycho-social skills, self-control abilities as well as friendly manners of conducting communication. It aims to develop adaptive behaviours as well as mastering techniques of self-control of one’s emotions as well as skills of their identification and awareness of their sources.
The family intervention mainly consists in providing parents with support due to disorders in the functioning of the system in which a child with conduct disorders often constitutes the weakest link. Aid for parents in solving their personal problems is the one of the first therapeutical tasks on numerous occasions. In addition, in the scope of the behavioural therapy, they are equipped with knowledge and abilities of application of effective educational methods, effective communication with a child as well as negotiating strategies used in solving many problems.
The group of disorders characteristic of early onset (usually in the first five years of life), lack of consistency in performance of tasks requiring cognitive involvement, tendency to switching from one activity to another without completion any of them as well as disorganised, poorly controlled, hyperactivity. Other abnormalities can occur as well. Children with hyperkinetic disorders are often rash and impulsive, prone to accidents. They have discipline problems due to thoughtless violation of rules rather than due to deliberative disobedience. Their relationships with adults are often deprived of distance, they lack normal caution and reserve. They are not popular among other children and can be isolated. They often show weakened cognitive functions and specific delays both in the development of movements and speech. Secondary complications include anti-social behaviours as well as low self-esteem.
These disorders are characteristic of a persistent and repeating pattern of anti-social, aggressive and defiant behaviour. Such behaviour leads to serious violation of social expectations relevant to the age. Is must be something more than ordinary child malice and youth defiance as well as have relatively permanent nature (six months or longer). The characters of disordered conduct can also be the sign of other mental disorders, in such cases, the primary diagnosis is preferred. They often concur with emotional or hyperkinetic disorders.
Conduct disorder limited to family environment
This disorder manifests itself with anti-social and aggressive behaviours (a not only defiant and destructive behaviours) which are totally or almost totally limited to a family home and interactions with parents or siblings or the closes home-dwellers.
Conduct disorder with incorrect socialisation process
This disorder is characteristic of concurrence of fixed anti-social and aggressive behaviours and not exclusively oppositional, defiant and destructive behaviour, with concurrent, significantly incorrect, relationships with other children.
Conduct disorder with correct socialisation process
This disorder is characteristic of fixed anti-social or aggressive behaviours and not exclusively with oppositional, defiant or destructive behaviour. It occurs in children well-integrated with the peer group.
This disorder usually occurs in younger children and is mainly characteristic of increased defiant, disobedient, destructive behaviour which does not include criminal offences or more extreme forms of aggressive or anti-social behaviour.
Other conduct disorders
- behavioural disorders
Mixed disorders of conduct and emotions
The disorder is characteristic of concurrence of persistent, aggressive, anti-social or defiant behaviour with evident symptoms of depression, anxiety or other emotional disorders.
Depressive conduct disorders
This category is a combination of conduct disorders with persistent and clear low mood which manifests itself with that the patient feels extremely unhappy. In addition, the loss of interests and feeling pleasure from usual activities, self-blaming and sense of hopelessness as well as sleeping and appetite disorders are diagnosed.
Separation anxiety in childhood
It should be diagnosed only when the fear of separation is the main source of anxiety and when the anxiety occurs in the period of early childhood. It differs from a normal fear of separation with a significantly higher intensity as well as serious difficulties in social functioning.
Anxiety disorder in the form of phobia in childhood
They are fears which stand out with significant developmental specificity, intensity higher than normal and occur (to a certain extent) in the majority of children. It does not include:
Social anxiety in childhood
This disorder is characteristic of excessive caution towards present and anxiety towards new, unknown or socially threatening situations. This category should be applied only when the anxiety occurs in the early childhood and differs from the normal fear both in the level of intensity and concurring problems in social functioning. The disorder consisting in withdrawal, typical for the childhood period or adolescent age.
Disorder connected with rivalry in childhood
Certain emotional disorders occur in the majority of children just after birth of a younger brother or sister. The disorder connected with rivalry in childhood should be diagnosed only when both the level of intensity and permanence of disorders are abnormal and accompanied by abnormalities in the social interactions.
Other emotional disorders in childhood period
Disorders of social functioning with usual onset in childhood or adolescent age
A common feature of this heterogeneous group of disorders are disorders of social functions, starting in the development period, unlike in case of pervasive developmental disorders, there are lack of incapability of social interactions or lacks in the scope of all functioning zones caused by a change in the structure of the central nervous system. In many cases, the basis role in etiology is played by serious abnormalities and deficits in the child’s social environment.
It is characteristic of clear, emotionally determined selectivity of verbal communication, consisting in that the child talks freely in some situations and in the other (specified) ones - stops to talk. This disorder is usually accompanied by some personality traits, such as: timidity, excessive senility or stubbornness.
Reactive hindrance of establishing social relationships in childhood
It starts in the first five years of child’s life and is characteristic of persistent deviations from the norm in patterns of child’s social relationships. They include, e.g. timidity and excessive caution, poor social interactions with peers, self-aggression and aggression towards others. The patient sometimes feels extremely unhappy. In some cases, growth is also slowed down. These deviations depend on the changes in the child’s environment. This disorder probably occurs as the immediate result of negligence on the parents’ side and unskilful or poor child treatment.
Excessive ease in establishing social relationships in childhood
It s a particular pattern of incorrect social functioning which is created in the first five years of life. Children very easily get attached to all persons without selection and want to draw the attention to themselves as well as poorly modulate peer interactions. This disorder persistently maintains despite clear changes in the child’s social environment. Depending on circumstances, emotional and conduct disorders can occur.
The main symptom of this disorder is a form of tics. A tic is an involuntary, sudden, repetitive, not rhythmical movement (most often, including limited muscle groups) or expression of sounds or words which do not serve any visible purpose. Tics are felt as something that cannot be resisted, but most often can be held back to some extent and rather for a short period of time. Tics intensify in the period of stress and disappear during sleep. Frequent simple movement ticks include: blinking eyes, neck movements, shrugging shoulders and facial grimaces. Common simple vocal (sound) tics include: grunting, barking cough, sniffing and hissing. Complex movement tics include, for example, hitting oneself, jumping and skipping, and vocal - repeating singular socially unacceptable words, often obscene words.