Teens Who Break All the Rules: a Parents’ Guide to High-Conflict Teens

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Conduct disorder is a complex mental health issue. It’s usually diagnosed in teenagers who have experienced behavioural problems during adolescence and sometimes earlier.

Young people diagnosed with conduct disorder may have difficulties at school, at home, or in friendship groups. They may also have come to the attention of the police or justice systems. Children and teenagers with conduct disorder tend to challenge and break rules, rarely taking responsibility for their actions.

For families affected by conduct disorder, life at home can become increasingly difficult to manage. Parents of a young person with conduct disorder often feel powerless as their child’s behaviours and incidents become more frequent and more worrying. They may try to offer their child fresh starts by moving to new places and different educational settings, only to see the same behavioural and social problems again. Parents of children who later meet the diagnostic criteria for conduct disorder may have moved their children’s schools and even the family home on several occasions.

Young people with conduct disorder are unlikely to change their behaviour by themselves. Conduct disorder is a mental health issue that requires long-term support and effective care that addresses the root causes of a young person’s behaviours. 

With professional support, young people can heal from the trauma that may underlie their interactions with others and begin to develop positive relationships with those around them. At the same time, parents can benefit from interventions that help them to provide consistent boundaries and manage difficult moments.

This parents’ guide offers some more information about what conduct disorder is, how it affects a young person’s life, and how to distinguish it from other conditions. It also explores different treatment options and introduces The Wave’s transformative approach to recovery.

Exploring Conduct Disorder

What is Conduct Disorder? 

Conduct disorders, along with other disorders relating to disruptive behaviours and impulse control, are not just normal ‘bumps on the road’ on an adolescent’s journey to adulthood. Conduct disorder is a repetitive and persistent pattern of rule-breaking behaviours which conflict with the usual, age-appropriate norms in society. Young people living with the disorder experience significant difficulties in their school, social, or work life.

Conduct disorder can look quite different from one young person to the next. They may engage in different kinds of behaviours or break rules in different settings. 

The fifth edition of the APA’s Diagnostic and Statistical Manual of Mental Disorders (DSM-V) outlines a set of criteria for a diagnosis of conduct disorder. To receive a diagnosis, young people have to have met at least three of a list of fifteen criteria in the past year, with one or more criteria met in the past six months.

The DSM-V criteria are divided into four categories. They include:

Aggression Towards People or Animals

  • threatening, bullying, or intimidating others
  • often initiating physical fights
  • using a weapon that can cause serious physical harm to others, such as a bat, brick, broken bottle, knife, or gun
  • being physically cruel to people
  • being physically cruel to animals
  • stealing something while confronting a victim, such as mugging, purse snatching, extortion, or armed robbery
  • forcing someone into sexual activity

Destruction of Property

  • deliberately setting a fire, intending to cause serious damage
  • deliberately destroying someone else’s property

Deceitfulness or Theft 

  • breaking into someone else’s house, building, or car
  • often lying to receive goods or favours, or to avoid obligations
  • stealing things of nontrivial value without confronting a victim

Serious Violations of Rules

  • often staying out at night despite parental rules, starting before age 13 years
  • running away from home at least twice, or once without returning for a long time
  • often not attending school, starting before age 13 years

Who Is at Risk of Developing Conduct Disorder?

Conduct disorder isn’t caused by any one single event. Researchers think that both genetic and environmental factors (things that affect a child as they grow up) play a role in the development of the condition. 

While there is no single pathway that leads to conduct disorder, there are certain risk factors that make developing the condition more likely. That said, many young people who experience these risk factors will not develop a conduct disorder, and its possible to develop the disorder without the presence of any factors.

Some risk factors for conduct disorder include:

Experiences of Trauma

Young people who have experienced childhood or developmental trauma are more likely to develop characteristics of a conduct disorder that later meet the criteria for a diagnosis. Teenagers who have experienced traumatic events as they grew up are also at an increased risk of having disruptive, impulse-control, and conduct disorders.

Trauma can have a big and lasting impact on the emotions and behaviours of a young person. It may affect the way that young people view others or understand themselves. It can also change the way a young person’s brain develops, affecting important functions like learning, emotional regulation, and memory.

Young people who have experienced trauma in any setting may develop a lack of empathy, impulsivity, anger, sexual acting out, self-harm, and a lack of trust in adults. They may also appear to be more resistant to intervention or treatment. This makes it especially important for young people to receive trauma-focused care that is sensitive to their experiences, feelings, and needs.

Other Mental Health Conditions

Children who have other mental health problems or have close relatives with mental health issues may be more at risk of developing conduct disorder. 

Gender

Boys are diagnosed with conduct disorder more often than girls, across all age groups and socioeconomic groups. 

Conduct Disorder & Childhood Trauma

When supporting young people with trauma, it’s important to approach treatment in a way that is sensitive to their experiences. Many traditional treatment options can seem punitive to a young person and ideas of punishment and reward often increase feelings of shame. This can leave children and teenagers with another traumatic wound, early exit from therapy or education, or a host of fractured relationships.

A trauma-focused treatment perspective takes a different, more successful approach. Trauma-focused treatment aims to help young people build resilience and strength and respect for themselves and others. It aims to reduce feelings of shame and inferiority that young people often hold at their core.

Healing from trauma requires a safe and supportive environment where young people can acknowledge and process their experiences. Residential treatment can help provide teenagers and adolescents with the stability and expert care they need, breaking the cycles that frequently develop within the family system and allowing reparative trauma-focused therapy to take place for the whole family. 

Can Girls Be Diagnosed with Conduct Disorder? 

While conduct disorders are less common in girls than boys, a significant proportion may still be diagnosed with the condition. According to the National Institute of Clinical Excellence, 5% of girls between the ages of 11 and 16 meet the criteria for conduct disorder. In the USA, the estimated lifetime prevalence for girls is around 7%.

Girls who meet the criteria for conduct disorder have usually had a previous diagnosis of oppositional defiant disorder and often go on to be diagnosed with antisocial personality disorder when they reach the age of 18.

Girls sometimes show different types of disruptive behaviours to boys. They’re less likely to be aggressive or engage in criminal behaviour, but more likely to show spitefulness and emotional bullying. They’re also more likely to engage in frequent unprotected sex, drug abuse, and run away from home.

Frequent unprotected sex can put girls with conduct disorder at risk of unplanned pregnancies during their teenage years. They’re also more likely to contract sexually transmitted diseases and engage in high-risk sexual encounters than girls without a conduct disorder.

Both girls and boys who demonstrate behavioural issues are more likely to be involved in accidents that require visits to accident and emergency, particularly if they often engage in risk-taking behaviours.  

Conduct Disorder and Co-occurring Diagnoses 

Children and teenagers diagnosed with conduct disorder are more likely than other young people of their age to be diagnosed with at least one other mental health problem. Research shows that 46% of boys and 36% of girls who live with conduct disorder have at least one co-occurring diagnosis. Attention-deficit hyperactivity disorder (ADHD) is particularly common, affecting around 40% of teenagers and young people with conduct disorder.

Some common co-occurring disorders include:

  • mood disorders 
  • anxiety disorders 
  • personality disorders 
  • substance use disorder 
  • ADHD (attention deficit hyperactivity disorder)
  • PTSD or C-PTSD

Young people with conduct disorder may need extra support and have additional needs in school. They’re more likely than other young people to record a high ‘ACE’ score, a scale that measures adverse experiences such as neglect and abuse. High ACE scores are associated with health problems later on in life and require interventions to help young people heal, recover, and have the chance to live a better future.

Conduct Disorder and Behavioural Problems at School

Children and teenagers with behavioural problems often find school very challenging. They may struggle to accept figures of authority, aggressively shouting or threatening teachers – or, in some cases, challenging their position in a more calm and instrumental way. They may resist engaging in work that they have been asked to do or find themselves frequently excluded from classes or school.

Research shows that conduct disorders are associated with poorer academic performance and weaker literacy skills. There is still debate as to whether behavioural problems cause young people to perform less well, or whether poor performance and feelings of frustration and failure exacerbate behavioural issues. Both pathways likely play a role.

When a child shows signs of conduct disorder in school, teachers and other staff members must recognise the child’s behaviours and needs. Young people with conduct disorder usually require considered interventions based on a comprehensive understanding of the causes of their behaviours and the most effective types of responses. 

In general, interventions at school should try to balance providing opportunities for positive, social behaviours (which should be praised) with setting consistent boundaries and limits. When schools focus on only one approach, interventions tend to be less successful.

If you have concerns about the way your child’s school is responding to their behaviours, you may like to speak with a teacher or member of staff about what strategies they have in place. It might help to seek the advice of a doctor or another mental health professional to support these conversations. 

In some cases, it may make sense to move to a school that emphasises emotions and behaviours rather than academic performance. However, changing school settings may have other consequences for a child, so it’s important to speak with school administrators and other adults close to your child (as well as the young person themselves) to decide on the best way forward.

Conduct Disorder and Bullying

Is Conduct Disorder the Same as Bullying? 

Conduct disorder is not the same as bullying. Conduct disorder is a mental health condition made up of a set of patterns of behaviours towards property, animals, and other people. Bullying is a certain type of unwanted, aggressive behaviour where a young person who is perceived to have more power purposefully abuses or intimidates another.

While conduct disorder and bullying are distinct concepts, there is some overlap. Young people diagnosed with conduct disorder often have a history of aggressive bullying of others at school, at home, or in other group settings.

Is My Child a Bully? A Parent’s Perspective 

Many children and teenagers have times when they are rude or even disrespectful at home or school. They may also go through periods when they are less thoughtful to others. 

In most cases, bullying involves more than a few instances of rude or disrespectful behaviour. When one person bullies another, they consistently or repeatedly make use of a real or perceived power imbalance to intimidate or abuse the other person. Bullying is a behaviour that can cause young people serious harm, significantly affecting their mental health and long-term well-being.

When parents are informed that their child is hurting or bullying others, their first feelings are often shame and disappointment. These initial emotions may be followed by anger and, in some cases, fear. 

Parents may also have recognised bullying-like behaviours that have taken place at home, towards themselves or other family members. Their child may have been cruel, hurtful, or critical towards their parents or their siblings. They may also have behaved violently or had explosive episodes at home. It’s normal for children and teenagers diagnosed with conduct disorder to have had escalating arguments or violent outbursts in several environments.

When parents first become aware of the extent of their child’s behaviours, it can be hard to know what to do. They may try out different disciplinary methods or move their child to a different school. However, patterns of behaviour like systematic bullying or hostile aggression rarely change with only a fresh start. Moreover, many of the techniques that parents may use to ‘discipline’ behaviours can make matters worse, only damaging a young person’s self-esteem.

In these situations, it’s a good idea for parents to seek external support. Parenting interventions, such as parent training, support caregivers to respond to their child’s behaviour in productive ways, helping them to set boundaries without feelings of guilt or shame. Parents can also talk to their GP or primary care doctor for advice.

Parents may be able to help their children by asking them to think about the impact of their actions on others, including the wider and lasting effects on those that they harm. Parents can play a valuable role in supporting their children as they invite them to explore the consequences of their actions.

Looking Deeper: Conduct Disorder and Related Conditions

What is Oppositional Defiant Disorder? 

Oppositional defiant disorder (ODD) is a type of behavioural disorder that is distinct from – but related to – conduct disorder. A significant number of young people with ODD are later diagnosed with conduct disorder.

Children and teenagers who show signs of oppositional defiant disorder often run into difficulties at home and school and may experience temporary or permanent exclusions. They may become involved in frequent arguments, challenge figures of authority, and refuse to comply with reasonable requests. Young people with ODD often blame others for situations where they hold responsibility, sometimes leading to a tense and difficult environment at home.

Children and teenagers with ODD may be more likely to develop other mental health concerns, including anxiety, depression, and substance use disorders. ODD is usually noticed in early childhood or during a young person’s teenage years: the appearance of the disorder during adulthood is exceptionally rare.

Parents of teens who show signs of ODD often feel worried about the future. They may be concerned about excessively angry, irritable, argumentative, and defiant behaviour that affects their child’s ability to form stable relationships with others and focus on school or other activities. Parents may be particularly concerned about a young person’s persistent annoyance of others, which can be accompanied by vindictiveness or spiteful behaviours.

For young people living with ODD, early intervention is important. While not all children diagnosed with ODD eventually meet the criteria of conduct disorder, without effective support, a significant proportion do.

Young people with ODD require long-term support involving education and therapeutic interventions that help them to work through past traumas and build better interpersonal relationships with others. At the same time, parent education supports caregivers to handle instances of misbehaviour productively and develop more stable relationships with less frequent conflict.

Is ODD the Same as Conduct Disorder? 

Conduct disorder and oppositional defiant disorder are both related to conduct problems that often cause conflict between the young person and adults (such as teachers, peers, work colleagues, therapists, and parents). The biggest difference between the disorders is the extent and severity of their rule-breaking and of their socially unacceptable behaviours.

The behaviours that characterise oppositional defiant disorder are usually less severe than those associated with conduct disorder. Most notably, conduct disorder usually involves behaviours that are law-breaking, high-risk, and sometimes followed with criminal charges. Conduct disorder behaviours also often involve a specific target or victim. Oppositional defiant disorder, on the other hand, focuses more on uncooperative, hostile, or defiant behaviours. It also includes emotional dysregulation, a symptom left out of the criteria for conduct disorder.

What Is Antisocial Personality Disorder?

Antisocial personality disorder (ASPD) is a serious mental health condition characterised by socially irresponsible, exploitative, and guiltless behaviour. It’s the only personality disorder that cannot be diagnosed in young people under the age of 18. People with ASPD often live with co-occurring conditions, substance use disorders, and medical co-morbidity.

Research shows that children and teenagers with conduct disorders are more likely to develop mental health issues as adults. Around 20% of girls and 40% of boys diagnosed with conduct disorder will later meet the criteria for antisocial personality disorder.

For young people with conduct disorder, effective intervention can support them to recover from the disorder and prevent it from developing into ASPD. The earlier interventions happen, the more successful they are, with younger children responding better to treatment than older teenagers or adolescents.

Moving Forward: Treatment and Recovery

Treatment for Conduct Disorder 

When a young person shows signs of conduct disorder, parents can find it hard to know what to do. Parents may experience many emotions – from disappointment to worry to anger. All of these feelings are normal, but they can make it harder to interact with the young person in a productive way.

For parents concerned about behavioural issues, it’s best to seek professional support. Expert advice and treatment can support both the young person and their family to develop more positive relationships while helping the young person process past traumas and change their behaviours towards others.

A family doctor or GP is often the first point of contact for young people and families who are concerned about behavioural issues. Usually, around 30% of GPs’ child consultations are for behavioural health problems. 

While outpatient treatment for conduct disorder is sometimes an option, it can present many challenges. The majority of young people who are diagnosed with conduct disorder find attending psychotherapy and outpatient appointments difficult. They may have a history of not completing treatment, dropping out, or having services withdrawn. 

Residential treatment offers an alternative to outpatient treatment that may be more suitable for young people who struggle to attend appointments, providing a safe and supportive environment where recovery can take place both in and out of therapy sessions. In residential settings, young people can develop relationships with other children and adolescents in the program. They’ll have the chance to build friendships, take part in trust-building and team activities, and learn to interact with others.

Residential programs can also gently introduce structure while breaking the cycles of behaviour and reaction that young people may experience at school or home. For young people with co-occurring diagnoses, residential treatment programs should address other mental health conditions alongside conduct disorder, promoting whole-person healing and lasting change. For many young people, trauma-focused programs that help young people to acknowledge – and heal from – their experiences in a safe environment are crucial to lasting recovery.

It’s important to recognise that children, teenagers, and adolescents have specific needs that require specialist treatment services with age-appropriate activities and interventions. Young people with conduct disorder or oppositional defiant disorder usually struggle to benefit from treatment programs that are designed for adults, even when they’re over the age of 18. The best recovery programs are dedicated to the needs of young people and sensitive to their individual experiences.

Treatment Options for Conduct Disorder

There are several different therapeutic approaches that can help young people to recover from conduct disorder. Most young people benefit from a combination of different techniques that address their multiple needs. 

Some types of therapy for conduct disorder include:

MDT or Mode Deactivation Therapy 

Mode deactivation therapy is a novel, evidence-based psychotherapy that was conceptualised to create a bridge between traditional psychotherapeutic approaches and often difficult-to-reach adolescents with conduct disorders and, later, antisocial personality disorder.

MDT is based on the idea that a young person’s core beliefs about past events can affect the way they respond to certain triggers, causing them to think and act in specific ways. Using the validation-clarification-redirection (VCR) change technique, MDT works with young people to validate their experiences while exploring different, positive alternatives and realigning their perceptions. 

While research has found that mode deactivation therapy consistently outperforms other interventions among young people with complex behavioural problems, only a handful of international treatment centres currently offer MDT for young people with behavioural issues. 

At The Wave Clinic, we offer MDT as a preferred treatment option for young people who come to our centre, including those who have had previously unsuccessful or incomplete treatment processes. Our therapy sessions are led by experts in mental health care for children, teenagers, and adolescents who understand how to build connections with young people, regardless of their presenting issues.

Family Therapy

Family therapy and positive parenting skills are an essential part of the treatment of conduct disorder. A family therapist can help parents to provide consistent boundaries and have a family plan in place to effectively manage the more difficult moments.

Therapists may work with families to form a family plan or contract that helps all members of the family to identify shared values and develop transparent and honest communication. Future planning supports families to build a nurturing structure at home and avoid harsh punishments or escalations.

For young people with behavioural, emotional, and self-control issues, living in a safe and structured environment is a crucial part of recovery. They also require access to education like other children their age. Residential treatment and therapeutic boarding skills can be a good option for parents who want to combine therapy with medical care and exceptional education.

Medications for Conduct Disorder 

Some young people may benefit from taking medication alongside group and individual therapy. Medication can help to treat some of the most distressing symptoms of conduct disorder, including aggression, impulsivity, dysregulated mood, and depression. It may also be prescribed for co-occurring mental health issues such as ADHD, mood disorders, and anxiety disorders.

The Wave Clinic: Transformative Treatment for Young People

The Wave Clinic offers transformative mental health programs for young people, helping them to plan and build fulfilling futures. Our trauma-focused approach combines exceptional clinical care with education, global citizenship, and a gap year experience, supporting young people to discover their dreams and develop the skills to follow them.

Our centre offers a safe haven for children and adolescents, providing them with the stability and support they need to work through sensitive issues and develop secure relationships with others. Our programs are specifically tailored to the unique needs of young people and draw on specialised expertise from around the world.

If you have any questions or would like to find out more about our treatment programs, contact us today. You can also reach us by phone at +60125227734 (immediate admissions), +60327271799 (Malaysia direct), and +60125227734 (Whatsapp chat).

From Our Library:

  • For families: The Defiant Child. A Parents Guide to Oppositional Defiant Disorder. Dr Douglas Riley
  • For mental health professionals: Defiant Teens, Second Edition: A Clinician’s Manual for Assessment and Family Intervention. Russell A Barkley. L Robin

References:

  1. Greenwald, R. (2002) The Role of Trauma in Conduct Disorder. Journal of aggression, maltreatment and trauma, 6 5-23. 
  2. Kovacs. M,  R S Krol, L Voti. (1994) Early onset psychopathology and the risk for teenage pregnancy among clinically referred girls. J Am Acd Child Adolescent. Psychiatry 106-13
  3. Dixon, A. (2005) Trauma Exposure, Post-traumatic stress disorder among female juvenile offenders. J Am Acad Child and Adolescent Psychiatry.

Malek Yassin is the Treatment Director at The Wave Clinic in Kuala Lumpur. Malek has over 16 years of experience in the treatment of young people with behavioural difficulties, addiction and mental health concerns. He has a special interest in the treatment of antisocial personality disorder and substance use disorder in adolescents and young people.

Malek is a certified child and adolescent trauma professional, an EMDR-trained trauma therapist (EMDRIA member), a fellow of ACCPH and a senior member of Addictions Professionals (UK). Malek is a bilingual accredited psychotherapist, conducting therapy in both Arabic and English.  Malek is also a recognised expert in family therapy and accepts referrals from families and mental health professionals in both languages.

Currently, Malek is interested in mode deactivation therapy (MBT) and mentalization-based therapy which he is studying further at The Anna Freud Centre in London. Malek has a private practice in Dubai and Kuala Lumpur.

Fiona - The Wave Clinic

Fiona Yassin is the founder and clinical director at The Wave Clinic. She is a U.K. and International registered Psychotherapist and Accredited Clinical Supervisor (U.K. and UNCG).

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