Teens Who Break All The Rules. A Parents’ Guide To High Conflict Teens.
Conduct Disorder is a complex mental health issue. It is usually diagnosed during the teenage years in young people who have experienced behavioural problems in their tweens and sometimes earlier.
Young people diagnosed with Conduct Disorder may have had difficulties in school or educational settings, at home, in friendship groups and may have come to the attention of the police or legal systems. Conduct Disorder can be incredibly challenging to manage at home, with parents often feeling powerless as behaviours and incidents become more frequent and more worrying.
Interestingly, Conduct Disorder is usually present for approximately two years before parents and caregivers reach out to mental health professionals.
Early intervention is essential.
Studies indicate that 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. Children and teenagers with behavioural issues, such as Conduct Disorder and Oppositional Defiant Disorder, frequently challenge and break the rules, annoy others and rarely take responsibility for their actions. Parents often provide fresh starts, new educational settings and geographical locations until a pattern of sustained and persistent reports of behavioural and social problems occur across a range of settings.
What is Conduct Disorder?
Conduct Disorder, together with other disorders relating to disruptive behaviours and impulse control, is different from the typical ‘bumps in the road’ on the journey into adulthood.
It is a repetitive and persistent pattern of rule-breaking behaviours that conflict with usual, age-appropriate societal norms.
Conduct Disorder is diagnosed before the age of 18 and is defined in the American Psychological Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5):
Young people who present with at least three of the following 15 criteria (in the past 12 months) from any of the categories below, with at least one criterion met in the past six months:
Hostile behaviour conduct resulting in injury to others or animals
- Threatening, bullying or intimidating others
- Often initiates physical fights
- Has used a weapon that can cause serious physical harm to others (e.g. a bat, brick, broken bottle, knife, gun)
- Has been physically cruel to people
- Has been physically cruel to animals
- Has stolen while confronting a victim (e.g. mugging, purse snatching, extortion, armed robbery)
- Has forced someone into sexual activity
Destruction of Property
- Has deliberately engaged in fire setting intending to cause serious damage
- Has deliberately destroyed others’ property (other than fire setting)
Deceitfulness or Theft
- Has broken into someone else’s house, building or car
- Often lies to obtain goods or favours or to avoid obligations (i.e. cons others)
- Has stolen items of non-trivial value without confronting a victim (e.g. shoplifting, but without breaking or entering, forgery)
Serious Violations of Rules
- Often stays out at night despite parental rules (beginning before age 13 years)
- Has run away from home at least twice while living in the parental home, or once without returning for a lengthy period
- Often not attending school (beginning before age 13 years)
Teenagers who have severe and enduring behavioural problems can often have impaired functioning at home, school, and the workplace.
Conduct Disorder and Co-occurring Diagnosis
Children and teenagers diagnosed with Conduct Disorder are more likely than other children of the same age to be diagnosed with at least one other co-occurring mental health problem.
46% of boys and 36% of girls will have at least one other diagnosis.
Approximately 40% of those diagnosed with a further mental health condition will be diagnosed with ADHD.
Co-occurring mental health problems include:
- Mood disorders
- Anxiety disorders
- Personality disorders
- Substance use disorder
- ADHD (Attention Deficit Hyperactivity Disorder)
- PSTD or C-PTSD.
Children and teenagers may record a high ‘ACE’ score.
Who is at Risk of Developing Conduct Disorder?
Young people who have experienced childhood or developmental trauma are at increased risk of developing characteristics that can be later seen as reaching a level that is then diagnosed. Young people with significant lifetime traumatic events can appear disruptive, with poor impulse control and conduct disorders.
Young people who have experienced trauma in any setting may develop a lack of empathy, impulsivity, anger, sexual acting-out, self-harm, lack of trust of adults, and appear to be resistant to intervention or treatment.
Conduct Disorder is not caused by any one single event. Ongoing research suggests that genetics and environmental factors can play a part in its development.
Children who have other mental health problems, or have close relatives with mental health issues, may be at higher risk of developing Conduct Disorder.
Boys are diagnosed with Conduct Disorder more often than girls, across all age groups and socioeconomic groups.
Conduct Disorder and Childhood Trauma
Many treatment options appear punitive. Indeed, more traditional approaches to punishments and rewards can be further shaming for the child or teenager and may prompt an additional traumatic wound, early exit from therapy or education, and a host of fractured relationships.
A trauma-focused treatment perspective is not only more successful but also aims to help young people build resilience and strength, respect for themselves and others, whilst reducing the shame and inferiority often seen at the core of these young people.
Residential treatment options can assist in breaking the cycles that can frequently develop within the family system and allow reparative trauma-focused therapy to take place for the whole family.
Can Girls be Diagnosed with Conduct Disorder?
In the UK, the National Institute of Clinical Excellence reports that between the ages of 11–16 years, 6% of girls will meet the criteria for Conduct Disorder. In the USA, this figure is closer to 11%.
Girls who meet the criteria have usually been diagnosed with Oppositional Defiant Disorder.
Whilst there are some similarities in the developmental path of Conduct Disorder in boys and girls, there are some differences in the longer term.
Girls diagnosed with Conduct Disorder often go on to be diagnosed with Antisocial Personality Disorder following their 18th birthday.
A particular concern for this group of young people is the risk of unplanned pregnancies during the teenage years. There is also an increased risk in the number and frequency of sexually transmitted diseases, the number of sexual partners in mid-adolescence to early twenties, high-risk sexual encounters and an increase in the use of over-the-counter and street drugs.
Accidents requiring visits to A&E or the Emergency Room are also more likely for girls (and boys) who demonstrate behavioural issues, particularly those with a high risk-taking presentation.
What is Oppositional Defiant Disorder (ODD)?
Parents with teens who seem excessively angry, irritable, argumentative and defiant can often become concerned about the future. Parents are particularly concerned when they notice a persistent annoyance of others, which can be accompanied by vindictiveness or spiteful behaviours.
Children and teenagers who present with oppositional behaviours often run into difficulties at home and school, with temporary and permanent exclusions commonplace. Frequent arguments, challenging authority at home and school, refusing to comply with reasonable requests and perpetual blaming of others can create a hostile environment at home.
Young people who present with Oppositional Defiant Disorder may be at greater risk of developing other mental health concerns, including anxiety, depression and substance use disorder.
ODD is usually noticed in early childhood and during the teenage years. It is very unusual for it to appear for the first time in adulthood.
Whilst not all children and teenagers diagnosed with ODD will eventually meet the criteria of Conduct Disorder, a significant number do. Therefore, parental education and support –together with good therapeutic intervention and a structured, consistent approach to therapy, social skills, and education – are beneficial.
Is Oppositional Defiant Disorder the Same as Conduct Disorder?
Oppositional Defiant Disorder and Conduct Disorder are both related to conduct problems, which tend to cause conflict between the young person and the adults around them (teachers, peers, work colleagues, therapists, parents). The major difference is the extent and severity of the rule-breaking and socially unacceptable behaviours.
The behaviours noted in ODD tend to be less severe than those in CD. Most notably, in Conduct Disorder, there is usually aggression towards people and animals, destruction of property, and behaviours that could be seen as law-breaking, high risk and followed with criminal charges.
In contrast, Oppositional Defiant Disorder includes emotional dysregulation, which is not included in the criteria for diagnosis of Conduct Disorder.
Is Conduct Disorder the Same as Bullying?
Conduct Disorder is not the same as bullying. However, there is some overlap, as young people diagnosed with CD may have a history of bullying with aggression shown towards others at school, home or in other group settings.
Many children and teenagers have times where they can be rude or even disrespectful at home and school. Teenagers may also have times where they are less than thoughtful to others. Some children and teenagers may be seen to bully siblings or peers.
Is My Child a Bully? A Parents’ Perspective.
Parents often experience shame and disappointment when they are informed that their child is hurting or bullying others. These initial feelings are usually followed by fear and anger.
Parents may have experienced similar hurtful or cruel behaviours at home. Likewise, siblings may have experienced harsh, critical or hurtful behaviours.
Children and teenagers diagnosed with Conduct Disorder may have had explosive episodes in several environments.
Parents may have directly experienced violent conduct and often report explosive arguments, hostile reactions and violent outbursts.
It is essential that your child is able to look at the impact their actions have on others, including the broader impact on those that they harm. Parents are valuable in supporting children as they are invited to explore the consequences of their actions.
Conduct Disorder and Antisocial Personality Disorder (ASPD)
Conduct Disorders in childhood are associated with an increased risk of mental health issues in adulthood. Up to 50% of young people diagnosed with Conduct Disorder before the age of 18 will go on to be diagnosed with Antisocial Personality Disorder.
ASPD is the only personality disorder that cannot be diagnosed in young people under the age of 18.
Antisocial Personality Disorder is a diagnosis made by a psychiatrist and mental health team.
Treatment for Conduct Disorder
The family doctor or GP is often the first point of contact for young people and families concerned about behavioural issues. Typically 30% of general practitioners’ child consultations are for behavioural health problems. (NICE UK, 2017.)
Conduct Disorder can be very challenging to treat in an outpatient setting. The majority of young people who are diagnosed with CD find attending psychotherapy and outpatient appointments difficult. Many have a history of not completing treatment, dropping out or having services withdrawn.
CD often presents alongside other psychiatric diagnoses. Young people with co-occurring diagnoses may benefit from residential treatment in a trauma-focused program specifically designed to meet the needs of adolescents and young adults.
Young people require specialist treatment services that meet their needs and provide age-appropriate activities and interventions. In particular, young people diagnosed with Conduct Disorder or Oppositional Defiant Disorder, even when over 18 years, tend to do very poorly in treatment programs designed for an adult population.
Trauma-focused therapy fosters a connection between young people. Children and teenagers who have often been in conflict with adults can find the early days in treatment quite challenging. Building friendships, taking part in trust-building and team events, and learning to interact with others, are important aspects of any Conduct Disorder treatment program.
Mode Deactivation Therapy (MDT)
Mode Deactivation Therapy is an innovative, evidence-based psychotherapy conceptualised to create a bridge between traditional psychotherapists and the often difficult to reach adolescents with Conduct Disorders (and later Antisocial Personality Disorder).
MDT uses principles that, when combined, are effective in the treatment of adolescents with complex behavioural problems and equally hard-to-treat co-morbid diagnoses.
Research into the benefits of MDT for adolescents has shown that it consistently outperforms other interventions. As a recent addition to the treatment options offered in residential settings, there are currently only a handful of international treatment centres for adolescents that include MDT in their programs for behavioural problems.
The Wave Clinic in Kuala Lumpur offers programs for young people who have previously had unsuccessful or incomplete treatment episodes. Mode Deactivation Therapy is utilised as a preferred treatment intervention.
Medications for Conduct Disorder
Medication may be considered in the treatment of Conduct Disorder for some of the most distressing symptoms, including aggression, impulsivity, dysregulated mood and depression.
Medication can be used to successfully treat many co-occurring mental health issues, such as ADHD, mood disorders, anxiety disorders or similar.
Medication combined with group and individual therapy is considered to be more beneficial than medication alone.
Family Therapy and Conduct Disorder
Family therapy and positive parenting skills are essential in the treatment of conduct disorder. A family therapist will help parents to provide consistent boundaries and have a family plan in place to effectively manage the more difficult moments.
A family plan or contract will help all family members identify the family values and allow transparent and honest communication between them. Future planning enables families to operate from a place of nurturing structure and avoids harsh punishments or inflaming situations.
Young people with behavioural, emotional and self-control issues need the same safe, structured environment, access to education and treatment as others of the same age.
Residential treatment or therapeutic boarding schools can be a valuable resource for parents who wish to combine therapy with medical care and a superb start in education.
Essential Reading for Parents and Clinicians
The Defiant Child. A Parents Guide to Oppositional Defiant Disorder. Dr Douglas Riley (1997).
For Mental Health Professionals
The Role of Trauma in Conduct Disorder. Greenwald, R. (2002). Journal of Aggression, Maltreatment and Trauma, 6(1) 5–23.
Trauma Exposure, Posttraumatic Stress, and Psychiatric Comorbidity in Female Juvenile Offenders. Dixon, A., Pauline Howie., Jean Starling. J Am Acad Child and Adolescent Psychiatry. 2005 Aug; 44(8): 798–806.
Malek Yassin is the Treatment Director at The Wave Clinic in Kuala Lumpur, with over 16-years of experience in treating young people with behavioural difficulties, addiction and mental health concerns. Malek has a special interest in the treatment of Antisocial Personality Disorder and Substance Use Disorder in adolescents and young people. He 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 languages. He is a recognised expert in Family Therapy and accepts referrals from families and mental health professionals in Arabic and English. Malek is currently interested in Mode Deactivation Therapy (MDT) and Mentalisation-Based Therapy (MBT), which he is currently studying at The Anna Freud Centre in London. Malek has a private practice in Dubai and KL.