Introduction
There is an age long axiom, which says that children are God’s gifts. This has made people to have large families that very often they could not maintain or control. Consequently, these children in turn become armed robbers, prostitution, cultists coupled with many other nefarious activities as they grow up
In the past, parents tried to have grips on their children no matter how large the family was the reverse is case nowadays with all the attendant blessing from the technological would whereby cell phones are being by children with all ignominy.
Misconduct or antisocial behaviour is a pattern of behaviour displayed by children goes contrary to approved or social acceptable conduct in the society. According to the National Mental Health Association NMHAS (2005), misconduct or conduct disorder is a pattern of behaviours that is repetitive and persistent in children and adolescents in which the right of others social rules are violated. The children or adolescent usually exhibits these behaviours patterns in a variety of settings, at home, school, and social situations cause serious impairment in his or her academic and family functioning.
The American Psychiatric Association (APA, 1994) sees conduct as one of the most difficult and intractable mental health problems in children and adolescents, antisocial activities such as lying, stealing, running away from the home, physical violence, sexual coercive behaviour, bullying etc.
Misconduct is marked by chronic conflicts with parents, teachers and peers resulting to damage to property, physical injury to self and others. These patterns of behaviours are consistent over time appearing in early middle childhood as oppositional deviant behaviour. Some conduct disordered children have also been noted to have emotional problems, hence the term ‘’mixed conduct and neurotic disorder’’ has often been used to describe these group. Boys with conduct disorder are more common than girls (NMHA, 2005).
Conceptual Framework
Appleby and Forshaw (1992) maintained that conduct disorder is characterized by a repetitive and persistent pattern of dissocial aggressive and deviant conduct, which at its most extreme, amounts to major violations of age — appropriate social expectations and is therefore more severe than ordinary childish mischief of adolescent rebelliousness. Pun and hall (1998) and Jacabson (2002) opined that disorder is characterized by severe and single group of psychiatric disorder in older children and adolescents.
Golder, Mayou and Geddes (2002) viewed conduct disorder as characterized by aggression, defiance, stealing, lying and destructive behaviour at home and school.They posited that conduct disorder is associated with persistent behaviour counter to rules of family and society involving such anti-social actions as lying, stealing, truancy, running away from home, sexual misconduct and aggressiveness.
The National Mental Health Association (NMHA) (2005) states that conduct disorder is a repetitive and persistent pattern of behaviour in children and adolescents in which the rights of other or basic social rules are violated.Murray, Hill and McGuffin (1997) maintained that conduct disorder is a child displaying anti-social aggressive or defiant behaviour that violates social expectation for a child of that age, present as an enduring pattern of behaviour, and is associated with impaired social functioning.
Irwin (1977) refers to conduct disorder as a pattern of behaviour giving rise to social disapproval. She continued that of conduct disorder is not defined too strictly then many children with problems of delinquent behaviour could be diagnosed as having conduct disorder. She however maintained that some conduct disordered children have also been noted to have emotional problems and the term “mixed conduct and neurotic studies revealed that those in the mixed conduct and neurotic disordered group have more in common with pure conduct disorder, than with pure neurotic disordered group.
Classification of conduct disorder
Murray et al.,(1997) classification fall into four categories:
- This include young children who are hostile, provocative, defiant, resentful, disobedient but does not violate right of others.
- Conduct disorder confounded to the family: Anti-social and aggressive behaviour which go beyond oppositional deferent behaviour and violation of the right of others which are only evident in the family, such as stealing from parents, destruction of family members clothing and household furniture.
- Socialized Conduct Disorder: resident anti social behaviour that includes both oppositional behaviour, violation of others right outside the home but is associated with good integration into a peer group and sustained friendship with children of similar age.
- Unsocialized Conduct Disorder: Anti-social behaviour which extends beyond family and is usually carried out in solitary basis, associated with pervasive abnormality of relationship with other children. This commonly includes unpopularity and rejection by them with a consequent lack of sustained peer relationship.
Nurcombe and Gallagher (1986) classified conduct disorder into two groups.
- Aggressive versus Non-aggressive
- Under Socialized versus Socialized
According to Gelder (1996) conduct disorder is classified into three groups.
- Socialized conduct disorder
- Unsocialized conduct disorder
- Over Inhibited Groups
Types of conduct disorder
The two major sub types of conduct disorder as childhood – on set and adolescent – on set types.
- Childhood – onset: This is defined by the presence of one criterion characteristic of conduct disorder before the age of 10 years. These individuals are typically boys displaying high levels of aggressive behaviour. They often meet criteria for attention deficit hyperactivity disorder (ADHD) poor peer and family relationships. These problems tend to persist through adolescence into adult years. They are more likely to develop anti-social personality disorder that individuals with the adolescent onset type.
- Adolescent – onset type: This is defined by the absence of any criterion characteristic of conduct disorder before an individual is aged 10 years. These disorders before an individual tend to be less aggressive and have more normative peer relationships. They often display their conduct behaviours in the company of a peer group engaged in these behaviours. Such as gang they are less likely to fit criteria for (ADHD). However the diagnosis of ADHD is still possible. They are farless likely to develop adult anti-social personality disorder. Boys are identified more often. But the estimated sex ratio of the type of conduct disorder approaches 50% for girls and boys in some communities. The prognosis for an individual with adolescent onset type is much better than for a person with the childhood – onset type in view of the onset and characteristics of conduct disorder. Sigmund Freud posited that human growth and development are tied personality of the person which is composed id (unconscious mind. Ego (conscious) mind and super ego (conscious mind or conscience). He believed that most behaviour of a person arise from forces located within the unconscious level. The id is egocentric have instruction drives demand. Instant gratification, pleasure seeking generated within the unconscious. The ego operates reality principles and consciously modifies the demand of id. The super ego is subconscious or conscience. It is restrictive, critical represents parental and society control and is the seat of moral disposition and conscience.
Infants are born with id but as they grow and begin to invest energy in people and things, they gradually develop ego and super ego. Freud believe that personality is determined by experiences of the first five years of life, especially the quality of parent child interactions that subsequent development is more or less an elaboration on the already laid born for with a fixed of institutional or sexual energy called Libido which isinvested on a part of a person behaviour at any time is determined by the position of the libidinal energy.
This libidinal energy becomes concentrated in different parts of the body at different ages thus giving rise to the different stages of development. Adverse experiences at any particular stage of development may lead to fixation. Fixation means being struck or blocked at any stage of development leading to individuals resorting to certain behavioural patterns of that stage later in adult life as a way of reducing tension.
The psycho – sexual stages of development
- Oral stage: 0-1 year
Libidinal energy is situated in the mouth and pleasure is derived from oral activities such as sucking, biting, spitting, fixation at this stage may lead to over possession, gullibility, nagging, argumentative behaviours excessive permissiveness, depression, alcoholism and excessive urges to eat and chew.
- Anal stage (1-3 years)
Libidinal energy is at the anal region, the child enjoys elimination and with holding of elimination. It is during this period that toilet training is introduced. However, care must be taken to avoid introducing it either to early or too later or being too strict about it as any of these can lead to fixation at this stage produces adult personalities characterized by obstinacy or stubbornness excessive indulgence to dirt or compulsive cleanliness.
Miserly people who indulge in collecting and storing things just for the sake of doing so are said to have experienced fixation at this stage. Too strict toilet training is assumed by freud to reduce natural exploratory tendencies in the child and result in causing the child shame. Moderate handling of such training result in orderliness and balanced consciousness or neatness and a high dedication to keeping things in their proper place.
- Phallic stage (3-6 years)
Psychic energy is concentrated around the genitals, the child enjoys touching the genital organs so that masturbation is common among children at this age range. Males libidinal urge is directed towards the mother and the father is seen as a powerful rival. The child would have wanted to eliminate the rivalry by killing his father, but he ends up being afraid that his father might castrate him called castration anxiety and the complex situation called Oedipus complex girls. Also experience this situation in the opposite direction called electra complex.
Gradually, this conflict is resolved by the child repressing his or her desire for the opposite sex parent and identifying with the same — sex parent. But an unsuccessful resolution of this conflict may lead to sexual pervasion, narcissism and boastfulness in adult life.
- Latency stage (6-11 years)
Infantile sexuality becomes dormant and the child engages in learning skills and the development of values. It is a period of consolidation and ego maturation.
- Genital stage (12-18 years)
This stage marks the reawakening of sexual urge and the development of mature hetero-sexual interest. Libidinal energy and interest is turned away from self and invested in other people freud believes that where the earlier stages are smooth, the genital stages will usher in normal heterosexual life but where previous stages experience tension, the child may not arrive at a true heterosexual adulthood. The genital stage culminates in marriage; sexual relationship with loved mate and child rearing.
Epidemiology of conduct disorders
When one sees the number of female children who roam the Street one is tempted to conclude that females with conduct disorder are more than boys but Irwin (1977) posited in the “Isle of Wight” studies of 34 boys and 9 girls with pure conduct disorder when screened in their last years at Primary school, another 22 boys and 5 girls with mixed conduct and neurotic disorder, giving at total of 56 boys and 14 girls having features of conduct disorder. In their last year in secondary school on the “Isle of Wight Study”. 39 boys and 9 girls i.e. 2.1 percent of the total age matched population) were found to have conduct disorder. 29 boys and 16 girls (1.9 percent of the total matched population) were found to have a mixed conduct and neurotic disorder an overall total of 68 boys and 25 girls.
Appleby and Forshaw (1992) Investigated the role of age status, race, location, and time in the onset of conduct disorder among children of Isle and Wight study and maintained that ages 10, 11 and 14 years accounted for 3 percent prevalence depending on social norms, location and time conduct disorder increased in lower class and 2 -3 times higher in urban areas, they found higher rates among west Indian youth and lower rates among Asian youths.
Academic problems of conduct disorders
Cognitive or academic deficits are the most widely reported educational correlates of conduct disorders, An association between achievement deficits and disruptive behaviour has been found as early as kindergating and is an important predictor of outcome during elementary and middle school. These findings extend to early adult life in longitudinal studies. In large epidemiological study, children aged 11 years with reading disorder were 3 times as likely to exhibit some acting – out behaviour problems. The relationship between academic problem and conduct problems is not clear. Research performed in the late 1960s indicated that delinquency progressed from academic failure to antisocial behaviour, the assumption was that academic failure led to loss of self-esteem, helplessness, decreased teacher and parent attention, and ultimately acting out to escape. Thus these individuals were not educated or trained to function successfully in the open unstructured society of the adult world. Conduct problems when present at the start of the school experience, interfere with learning.
Conduct disorder and poor achievement are function of dysfunctional out-side variables (e.g. low social economic status. An attention deficit disorder non supportive family environment). These variables inadvertently support the conduct difficulties and do not support social achievement. Despite a lack of clear of casual links academic problems are linked with conduct problems. A comprehensive treatment program is required to assess and address the academic difficulties inconjunction with the behaviour problems thus in developing a plan for children with conduct problems, the primary health care provider should request that the school should (a) evaluate the child for academic difficulties (b) provides appropriate educational services to address those needs and other behavioural needs. If the school is unwilling or unable to carry out needed educational assessments, the primary health care provider needs to assist the family to obtain those educational settings or private offices.
Recent outcome of research about conduct disorders
According to the National Mental Health Association Fact Sheets (2005), recent research on conduct disorder is very promising for example research has shown that most children and adolescents with conduct disorder do not grow up to have behavioural problem or problem with the law as adults, both socially and occupationally. Researchers are also gaining a better understanding of the causes of conduct disorder as well as aggressive behaviour more generally conduct disorder has both genetic and environmental components ‘that is ‘although the disorder is more common among the children of adults who themselves exhibited problems when they were young. There are many other factors which research believe contribute to the development of the disorder. For example, youth with conduct disorder appear to have deficits in processing social information or social cues, and some may have been rejected by peers as young children.
Despite early reports that treatment for this disorder is ineffective several recent reviews of the literature have identified promising approaches in treating children and adolescents with conduct disorder, the most successful approaches intervene as early as possible are structured and intensive, and address the multiple contexts in which children exhibit problem behaviour, including the family, school and community. Examples of effective treatment approaches include functional family therapy, multi-systemic therapy, and cognitive behavioural approaches which focus on building skills such as anger management. Pharmacological intervention alone is not sufficient for the treatment of conduct disorder.
Conduct disorder tends to co-occur with a number of other emotional and behavioural disorders of childhood, particularly attention deficit hyperactivity disorder (ADHD) and mood disorder (such as depression). Co-occurring conduct disorder and substance abuse problems must be treated in an integrated holistic fashion.
Educational options in the management of conduct disorders
- School should mount guidance and counselling programmes.
- Students should be told about the dangerous effect of deviant behaviours.
- Operant and classical conditioning should be used to build positive habits and exterminate negative habits. Audio-visual pictures and jingles can be used for this exercise.
- Teachers should endeavour to understand his students’ family background to be able to handle them effectively.
- Authorization and permissive methods should be discouraged while authoritative method should be advocated.
- Parents should be encouraged to maintain cordial relationship with their children. The school should include the good aspect of the societal value in the school rules,
- School curriculum should include skills and subjects that will make students useful independent and well adjusted.
- Parents should be encouraged to allow their children have enough resting period.
- In boarding house, lights out and siesta period should be observed strictly to ensure good heath and good personality development.
Interventions for conduct disorders
i). Medical treatment
Chamberlain and Mihalic (1998) were of the opinion that the multifaceted nature of conduct problems particularly related co-morbidities, that treatment should include medication, teaching parent skills, family therapy and consultation with the school because of the high degree of overlap between conduct disorder and ADHD, the clinician should perform an evaluation for ADHD symptoms, pharmacological treatment for ADHD is indicated if the child has the symptoms of that disorder. To make that diagnosis a thorough history, the presence of 6 of the 9 in attention or hyperactivity symptoms as specified in the DSM-IV and clear impairment of functioning in at least two settings (usually home and school) are necessary. In short term, stimulant medicine has proven effective in controlling the specific symptoms of in attention. Impulsivity and hyperactivity.
However by itself, stimulant medication usually does not result in improved parent child teacher, child or peer relationships. As with the approach to conduct disorder, a multidisciplinary and multi modal approach to ADHD is required. No medication has been consistently effective in treating persons with conduct disorder when ADHD is not present. Note that the substance abuse occurs in a high number of children with conduct disorder independent of whether they are treated with psycho active medication. Physicians should use caution when prescribing stimulants because they can be sold illegally.
Lithium am methyiphenidate reduce aggressiveness in one set of studies. However its subsequent follow research the effectiveness of lithium could not replicated. Carbamazepine also has been demonstrated to be effective in treating aggressive behaviour. Carbamazepine was effective in a pilot study however, multiple significant adverse effects occurred, thus the first choice of treatment is methuiphenidate.
Anticonvulsants are considered to be second group of medication to be used in non specific aggression, and lithium is the third choice. A fourth drug, clonidine has been explored in an open trial with 15 of 17 patients exhibiting significantly decreased aggressive behaviour, however this medication requires monitoring of blood pressure and cardiovascular parameters.
ii). Psychological treatment
Patterson and Forgatch (1995) maintained that of the psychological therapies, parent management training (PMT) is the method demonstrating the most impact on the child’s coercive pattern of behaviour. PT refers to procedure in which parents have been trained to alter their child’s behaviour in the home. PMT is based on research demonstrating that conduct problems inadvertently are development and sustained by maladaptive parent-child interactions while this conflicutural interaction often is triggered by the irritable temperament in the child, a major component of this pattern is ineffective parenting. This includes the pattern directly paying attention to disruptive and deviant behaviours but using unclear vague commands and directions and inconsistently applied harsh punishment. A pattern of failing to pay attention to appropriate behaviours, when they occur.
PMT education and the therapists teach the child’s parents to use specific procedures at home at alter interactions with their child. Parents are trained to carefully identify and observe behaviours and to reinforce desired behaviours. Training sessions provide opportunities to see how procedures work and to practice and refine their used of technique with group of pre-school children who has severe oppositional behaviour and aggressive behaviours, in which therapists adhered to a manual of techniques and in which it was documented that parents made changes in parenting skills. Research studies reflected gains that were evident 1-3 years after treatment. One study reflected gains 10 years later. Treatment effects have been stronger with younger children be also have co-varied with the severity of the problem. More recent research suggested that the severity of the problem rather than the age of the child is predictive of treatment failure. Severe conduct problem in adolescents are more resistant to this type of treatment than in younger children. However, with use of appropriate treatment programs, improvement has been documented.
Group treatment has had both benefits and drawbacks for children with conduct disorder. While some evidence exists that group social skills or problem-solving treatment has some benefits in children age 12years and younger, concern exist about group-treatment of adolescents diagnosed with conduct disorder with younger children combined treatment in which parents attend a PMT group while the children attend a social skills group consistently has exhibited good effect. However, research demonstrates that treatment of adolescents with conduct disorder, conducted in groups of individuals with conduct disorder tends to worsen the behaviours, particularly if the group participants engage in discussions of oppositional and illegal behaviours. Thus group treatment should be enacted with great care and consideration of group goals and possible negative adverse effects.
More drastic solutions (e.g. boot camps) consistently have demonstrated initial good come but worsening outcome in the long term, with higher rate of arrests and serious crimes found in boot camp gradates. Poor long-term outcome following this treatment is believed to be due, in part, to group mutual reinforcement and discussion of criminal activity and to the lack of family or community charge in many of these programs. Thus the adolescents are released back into the same environment, in which little support for the newly acquired skills and behaviours is present.
In general, individual psychotherapy as a single treatment has not proven effective for conduct problems. However, individual therapy sessions certainly can facilitate compliance with an overall program that emphasizes changes in the family. The school, and in social settings, thus individual counselling may help a child who is trying to adhere to a more comprehensive intervention program.
The multi-systemic treatment package is a comprehensive model of treatment of conduct disorder that includes behaviour PMT. Social skill training, academic support, pharmacology treatment of ADHD or depression symptoms, and individual counselling as needed. Initial outcome data for this type of comprehensive approach have been encouraging.
References
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