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2001 Third Web Report
M is nine years old(1). At this young age she has already beaten and tortured a 4 year old girl to death. She presents with absolutely no remorse about the incident. Any regret that she does exhibit is due to the fact that she understands that she is expected to feel apologetic about the incident, not because she intuitively feels remorse. D is ten years old (1). He has already killed a four year old girl because she "was annoying" him. He slapped her so hard that she fell to the ground and consequently died. While in the hospital, he was observed holding another patient's head under the water even after he was told not to do so. S is 10 years old and refuses to go to school. Instead, he runs across the street to play video games with his friend. When he is not over at his friend's house he sets fires for "fun". In addition, he often asked to carry drugs for his father with whom he has intermittent contact. He has been arrested for shop lifting from a local grocery(1). Dylan Klebold and Eric Harris walked into school on April 21, 1999 and killed 23 other people before finally taking their own lives(2). All of these people exhibit symptoms of conduct disorder.
Conduct disorder is an inability to follow rules and behave in a socially acceptable way. People with this disorder exhibit aggression towards people and animals, are destructive towards property, are deceitful and seriously violate rules set by authority figures(3). Moreover, there are usually problems in the home such as divorce, poverty, child abuse, neglect, or parents that carry their own psychiatric diagnoses. In addition, patients with the disorder often carry other diagnoses such as oppositional defiant disorder, mood disorders, anxiety, attention deficit/hyperactivity disorder, learning disabilities and thought disorders(4). There are two subtypes of the disorder: childhood-onset and adolescent-onset. Childhood-onset usually begins before the age or ten years and is associated with ongoing problems in adulthood(5). On the other hand, if the disorder begins in adolescence, there are more positive outcomes when treated. These individuals usually do not display anti-social personality traits in adulthood. In addition the male-female ratio is lower than the childhood type. Lastly, the people with adolescent onset type have more normal peer relationships(4).
One closely related disorder to conduct disorder is oppositional defiant disorder. This is a disorder usually seen in children younger than 10 years. It is characterized by a pattern of frequent uncooperative hostile behavior towards authority figures. It is manifested by frequent temper tantrums, excessive arguing, active defiance, deliberate attempts to annoy others, blaming others, frequent anger and resentment, mean and hateful talking, and revenge seeking(6). While these symptoms are part of normal development of two and three year olds they become part of a diagnosable disorder when they interfere with the normal development of the child. This disorder is often a precursor to conduct disorder especially the childhood-onset type(4).
While the picture may seem bleak for those children and adolescents diagnosed with conduct disorder, this is not necessarily the case. Less than 50% of cases are diagnosed with antisocial personality disorder later in life(4). In addition, as noted above, a later age of onset is associated with more positive outcome. Risk factors that are associated with a less positive outcome are age of onset, spread of symptoms across settings, frequency and intensity of symptoms, and family characteristics(4).
Where does this disorder come from? Current research cannot pinpoint one specific factor in the development of the disorder; however, it is suggested that it may be the result of an underlying neurological dysregulation(4). Perhaps they have lower levels of neurotransmitters that inhibit behavior. Another possible reason for neurological dysregulation is that these patients have lower intellectual capacity and thus less ability to analyze social cues properly. Still another reason could be that somehow these individuals do not have as much activation in their frontal lobes as other people and thus they do not interpret social situations in the same way. It has been shown that these children often misinterpret social cues in a negative way. They also consider fewer cues and facts when interpreting a social situation(4).
Still, another factor is the home environment. Children who witness marital discord and violence first hand are more likely to exhibit problems. It is important to note that the fact that the parents are divorced is not the factor but the severity and intensity of the marital conflict that influences the development of conduct disorder. The parent-child relationship is also extremely important. Parents that are violent, erratic and inconsistent in parenting practices are less likely to monitor behavior, punish pro-social behaviors and reinforce negative behaviors(4). Furthermore, parent psychological factors contribute to the development of conduct disorder. A mother that is depressed is more likely to be more critical of the child and be more inconsistent in parenting practices such as rules and discipline(4). These are characteristics of parenting practices most often observed in homes with children or adolescents with conduct disorder.
Another place that impacts the onset of conduct disorder is the school environment. As noted above, low academic achievement and low intellectual functioning is associated with conduct disorder. In addition, the characteristics of the school such as amount of teacher praise, emphasis on individual responsibility, emphasis on academic work, and teacher student ratio are also important(4). A teacher who does not praise a student who tries hard regardless of academic achievement is increasing the child's risk for behavior problems. If a student does not receive praise, he/she is not likely to work harder to achieve better grades. Conversely, a child who is praised for his/her efforts is more likely to work harder and take pride and enjoyment in his/her school work. He/she is also less likely to drop out of school later.
Lastly, major life stressors make conduct disorder more likely to develop. These stressors include poverty, unemployment, lack of supervision by adults, ill health, and overcrowding. All of these are characteristics of children in low income housing of large cities. All of these are characteristics of the children observed in the hospital mentioned above.
Several methods of treatment have been tried to combat the disorder. None is completely effective. In some cases, no treatment is ever effective even in conjunction with other treatments.
One method of treatment has focused on teaching these children social and problem solving skills(7). This method focuses on the idea that children and adolescents with this disorder cannot adequately interpret and solve problems in social situations. Patients are taught social and communication skills(4). Since this method of treatment has not been well studied, it is difficult to assess the effectiveness of treatment. Nevertheless, early studies suggest that this is a promising method. Short-term studies show that there are less aggressive behavior exhibited in a one year follow-up(7).
Another method of treatment often used in conjunction with social skills training is family therapy and parental skills training. In these therapies, the problems within the home are addressed. Parents are taught to reinforce pro-social behaviors with positive reinforcement, use mild punishment when well defined rules are broken and to enforce rules consistently(4,7). This form of treatment is most effective when the child is under the age of 9 years. This is because after this age, the maladaptive behaviors can become more entrenched when the child associates with deviant peers which usually starts around the age of 9 or 10(7).
Still another method of treatment is the use of psychiatric drugs. The effectiveness of drugs is debated among mental health professionals. Some claim that pharmacological therapy is completely ineffective(8). Others claim that use of different drugs can be helpful in initial control of deviant behavior. For example one study has shown the use of an atypical antipsychotic Risperidone to be useful(9). This drug and others like it target the aggression symptoms of conduct disorder. Other studies show drugs that increase attention, decrease hyperactivity, reduce anxiety, or reduce depression to be helpful in conjunction with psychotherapy(3).
Lastly, treatment programs also address the community environment of the child or adolescent. These treatment programs focus on encouraging the patient to join community groups(4). Other programs such as wilderness programs or group homes remove the patient from the community in which he exhibits symptoms of conduct disorder for a period of time. Nevertheless, wilderness programs and group homes are not well studied and cost a lot of money. Also, they may actually increase the likelihood and repertoire of deviant behavior by exposing the child or adolescent to other people with conduct disorder. In addition, behavioral gains do not generalize to other social settings. Thus, the gains made on wilderness trips or in group homes are not helpful in solving real world situations that the patient faces everyday(7). A more efficient and effective treatment that removes the child from the home is therapeutic fostercare. The therapeutic foster parents receive special training in coping with and managing the foster child's behavior. Moreover, they are more likely to be active participants in the child's individual therapy and skills training(7). Biological parents may be resistant to therapy and unwilling to continue with treatment(8).
So how can society prevent children from developing these terrible behaviors? Unfortunately, there is no clear way to prevent the development of conduct disorder. Clearly, one obvious way to help prevent the occurrence of such behaviors is to have better supervision of children. M was able to torture the little girl because she was not being watched by an adult. D also was not supervised when he knocked the little girl he killed to the ground. S does not have clear and consistent rules in his home. His mother does not follow through with punishments or if she does, they are often excessively harsh for minor infractions(1). Each of these children has only intermittent contact if that with their fathers and suffers from low income and overcrowding associated with low income neighborhoods of New York City.
Yet, Dylan Klebold and Eric Harris came from an upper middle class neighborhood where most students matriculate to college(2). Clearly, they have a different set of factors that fosters the development of violent behavior. Their symptoms are also different. School shooters such as these adolescents tend to announce to others their plans to peers. Moreover, they are more likely to strike in small towns, not big cities(10). Still, there are some commonalties. School shooters are often suffering from some diagnosable mental disease. Kiplan P. Kinkel shot his parents and 24 people at his school in Oregon in 1998(11). It was reported that he suffered from Schizophrenia. Almost 50% have been seen by a mental health professional(11)
A result of the rash of school shootings already observed is the closing of schools at the first threat of school violence. The accused adolescents and children are taken into custody and prosecuted. Moreover, students are being encouraged to take any violent statements by peers as serious threats. It is hoped that students can help prevent school shooting by telling authorities of any threats.
Still, there has not been such a response to children who exhibit other forms of conduct disorder such as M, S, and D. Services for these children are limited. Moreover, they often are handed over to the juvenile justice system (instead of mental health professionals) where they receive no psychiatric help with their problems. Consequently, they simply repeat their behavior patterns when released from juvenile detention. Since conduct disorder involves a resentment of authority and unresponsiveness to punishment, placing these individuals in juvenile detention hall is not a good way to prevent repeat offenses(7). By placing these patients in the mental health system, they can learn to modify their cognitions and behaviors to more socially accepted forms. As a society, we should give these children and adolescents the chance to learn ways to improve their behavior before committing them to prison terms.
In addition, continuity of care is a necessity. The behavioral gains made by a brief stay on a psychiatric ward cannot be maintained without constant follow-up by a therapist in the community(3). Moreover, since some patients and or parents may be averse to treatment, a court order should be issued to make sure that patients attend treatment sessions.
It seems that lately opening a newspaper on any day and one is likely to read about another child offender. If it is not a school shooting, it is a rape, theft, drug use/trafficking or murder in some other setting. The answer is not to write these children off but to try and help them through therapy and behavior modification. Juvenile hall can only serve to reinforce resentment of authority and ineffectiveness of punishment. Children and adolescents with conduct disorder can be helped through constant therapy. In addition, we must take seriously any threats that children make. Until mental health professionals learn how to discern the real threats from the people who are just stating violent fantasies we must protect our children. This means taking seriously any and all threats by treating the individual not simply placing him/her in juvenile hall.
1) These names were shortened to protect the confidentiality of these patients. All were observed while working on a child and adolescent psychiatry ward in New York City.
2) 2 Gunmen at Colorado School Reportedly Kill Up to 23 Before Dying in a Siege , On the New York Times website.
3) Conduct Disorder - AACAP Facts for Families #33, Part of the American Academy of Child & Adolescent Psychiatry website.
4) Conduct Disorder in Children and Adolescents, Part of the Behavioral Neurotherapy Clinic website.
5) Conduct Disorder , Part of the New York Presbyterian Hospital NOAH Website.
6) Oppositional Defiant Disorder - AACAP Fact For Families #72 , Part of the American Academy of Child & Adolescent Psychiatry website.
7) Effective Treatment of Conduct Disorder , Part of the University of Virginia Institute of Law, Psychiatry, & Public Policy website.
8) Counseling Children with Conduct Disorder , Part of the Counseling Today website.
9) A Double-Blind Study of Risperidone in the Treatment of Conduct Disorder, Published in the Journal of the American Academy of Child and Adolescent Psychiatry and found on the Find articles.com website.
10) How Youngest Killers Differ: Peer Support, On the New York Times website.
11) The Threaten, Seethe and Unhinge, Then Kill in Quantity , On the New York Times website.
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