Definition – repetitive persistent pattern of behavior in which the basic rights of others or societal norms or rules are violated; behavior is more serious than transient mischief of kids & teens.

Oppositional defiant d/o (ODD) – kids won’t do what their told; minor incidents

Attention deficit hyperactivity d/o (ADHD) – kids are impulsive & hyperactive; move around most of the time

Conduct d/o (CD) – juvenile delinquents; violating rules & regs, social norms or morals

–        Kids can progress from ODD to CD

–        ADHD can also develop into or w/CD

Symptoms of conduct d/o

–        Aggression to people & animals

o   Often bullies, threatens or intimidates others

o   Often initiates physical fights

o   Has used a weapon that can cause serious physical harm to others

o   Has been physically cruel to people and/or animals

o   Has stolen while confronting victim

o   Has forced someone into sexual activity

–        Destruction of property

o   Has deliberately engaged in fire setting w/intention to cause serious damage

o   Has deliberately destroyed others’ property

–        Deceitfulness or theft

o   Has broken into someone else’s house, building or car

o   Often lied to obtain goods or favors or to avoid obligations

§  If lying to avoid abuse, doesn’t count as symptom

o   Has stolen items w/o confronting victim

–        Serious violations of rules

o   Often stays out at night despite parental prohibitions

o   Has run away from home overnight at least twice

o   Is often truant from school

–        Duration

o   Pattern of behavior must last at least 6 mo

–        Severity

o   Mild – lying; truancy

o   Moderate – stealing w/o confrontation; vandalism

o   Severe – excessive symptoms; causing considerable harm to other people, such as physical aggression, cruelty, etc

Prevalence

–        Depends upon criteria used for diagnosis & source of data

–        30-33% of outpt referrals to clinics are for antisocial, often aggressive behaviors

–        Only a small percentage of arrested youths go on to become chronic offenders

Etiology – no single etiology for COs; consider intrinsic & extrinsic factors asso’d w/CO & interaction of them

–        Intrinsic factors

o   Genetic theories

§  XYY (‘super males’) – over-represented in prisons, but those individuals aren’t at any increased risk

§  Being male is biggest risk factor for developing violent behavior

§  Adoption studies

§  Twin studies

o   Biochemical abnormalities

§  Neurotransmitters (5-HT) & aggression

§  Testosterone levels – no direct link to aggression

o   Medical hxs & neurologic vulnerabilities

§  Normal finding & EEGs

o   Psychiatric vulnerabilities

§  Psychodynamic theory – concept of superego lacunae

  • Holes in superego that allows you to carry out antisocial behaviors

§  Long-standing hxs of maladaption – instability at home, school or in community

§  Comparison of incarcerated delinquents w/a matched sample of non-delinquents

§  Suicide – due to impulsivity & taking part in high-risk behaviors

§  Educational & intellectual factors – co-morbid w/ADHD

–        Extrinsic factors

o   Sociocultural factors

§  Socioeconomic factors – economically deprived environments

§  Family size – ­ family size, ­ risk for aggression

§  Lack of supervision

§  Prevalence of parental illness

§  Access to medical care

o   Racial minorities

§  Bias? – plays more of an important role in how kids are managed

o   Parental factors

§  Child-rearing practices – severe corporal punishment ® more aggressive behavior

§  Specific kinds of antisocial behaviors in succeeding generations

  • Substance abuse
  • Family hx of EtOH abuse
    • Parental & physical violence – exposure to violence

§  Identification w/aggressor

§  Physical abuse, EtOH abuse & brain injury

§  Parental discord (witness abuse) & physical violence

§  Media exposure

  • Effect on kids, predisposing them to violence/aggression
  • Caretaker plays key role in exposure’s effect
  • Toddlers (2-3) are especially sensitive to exposure to violence

Clinical features

–        Runs away

–        Stealing & lying

–        Trouble at home & community

–        Substance abuse

o   While not diagnostic, kids usu start younger (~10-11)

o   Exposure at home

–        Low self-esteem

o   Co-morbid w/depression

–        Sexual activity – at earlier ages

–        Impulsive behaviors

–        Complicated clinical picture

–        Average IQ/intelligence

Diagnosis & evaluation

–        Diagnosis – of exclusion

–        Prognosis

o   Variable

o   The younger the onset, the worst the prognosis

–        Differential considerations

o   Thought d/os

o   Mood d/os – manic, bipolar d/o

o   Organic impairment – endocrine imbalance

o   Intellectual deficits

o   Learning problems

–        Evaluation

o   Multiple vulnerabilities to risk factors – both intrinsic & extrinsic

o   Problem list

o   Multi-disciplinary – involve social worker, psychologist, etc

Tx

–        Multi-modal – not just one tx

–        Parenting – teach consistency

–        Problem solving – to manage aggression & impulsivity

–        Medications

o   No single medication is effective

o   Can be useful for certain target symptoms

–        Ongoing support

o   Parent surrogates

o   Emotional/physical support

o   Structure & consistency