NCP Conduct Disorder

DSM-IV

312.XX Conduct disorder

312.81 Childhood-onset type

312.82 Adolescent-onset type

Conduct disorder is most distinguishable by the degree of repetitive and persistent violation of the basic rights of others. Common antisocial behaviors acted out in the home and school setting include physical aggression toward people and animals, destruction of property, lying, and theft. There is a total disregard for age-appropriate social norms as the child purposely engages in criminals acts, truancy from school, and breaking curfew. The DSM-IV criteria rates the level of severity as mild, moderate, to severe. The greater the level of delinquency and frequency in early childhood, the greater the risk for chronic offending into adulthood. Other prognostic factors leading to the continuation of the disorder include age of onset and the variation in problem behaviors displayed in multiple settings. Co-morbid diagnoses often associated with this condition are hyperactivity, depression, and chemical abuse and dependence.

ETIOLOGICAL THEORIES

Psychodynamics

According to psychoanalytical theory, these children are fixated in the separation-individuation phase of development. The mother figure projects her view of the child’s needs as an unrealistic demand on her. The child cannot solidify attachment with the maternal object and compensates for the mother’s narcissistic need for gratification by overidealizing the image of the mother. The child fails to build up identification and differentiation between self and others to support sufficient superego development. The id behavior is prominent.

Biological

Temperamental abnormalities have been observed in infants at birth in terms of excitability, attention span, and adaptability. Heredity influences such traits as the tendency to seek risks and obey authority. One possibility is the biological influence of heightened arousal in the CNS and abnormally high levels of testosterone, leading to aggression. Differences in the lack of sufficient serotonin transmission is evidenced.

Current research suggests that negative experiences in infancy cause biological and neurological damage to the brain tissue. When persistent stress results in an internal perception of a constant state of danger, the “fight-or-flight” hormones (adrenaline and cortisol) are released, reaching dangerously high levels that can cause neurological impairment. These damaged brain cells react in unusual ways to the stimuli, possibly resulting in epileptic seizures or depression.

Family Dynamics

Certain family patterns contribute to the disruptive behavior. A high correlation exists between chronic conflict and neglect in the parent–child relationship. Poor parental management skills, inconsistent or rigid and harsh discipline practices increase the risk for acting out by the child. Changes in caretakers, unstable spousal relationships, and parental rejection are all contributing/causal factors. These children lack strong emotional bonds or reliable role models to promote prosocial behavior. Socioeconomic conditions may also play a part, with poverty being a risk factor.

CLIENT ASSESSMENT DATA BASE

Ego Integrity

Feelings of rejection, powerlessness

Blames others for what happens to self

Displays maladaptive coping behaviors; uses manipulation to get needs met

Engages in unacceptable behaviors in response to stressors (e.g., staying out at night, running away)

May have had frequent/recurrent life changes, (e.g., multiple moves, change of schools, lifestyle changes, placement in foster homes)

Food/Fluid

Skips meals, eats excessive amounts of junk foods

Eats in response to external cues/stressors

Reports of nausea

May have excessive weight for height; recent weight gain may be noted

Hygiene

Poor hygiene/personal habits

Style of dress may reflect fashion trends or be atypical (antisocial/gang attire)

Neurosensory

Nervousness, worry, and jitteriness/excessive psychomotor activity

May be depressed, angry, or react with ambivalence or hostility; poor impulse control

Affect may be labile

Physical characteristics/development may not be normal for age range

Safety

Engages in risk-taking behavior (e.g., gang involvement, exposure to STDs, drug use)

Overt aggressive acts

Suicidal ideation; may have plan/means, previous suicide attempts

Sexuality

Early onset of sexual behavior, may have forced others into sexual activity

Social Interactions

Symptoms most often appear during prepubertal to pubertal period and may predispose the child to conduct or adjustment disorders in adolescence

Family disharmony/disruption, little contact with absent parent/separation from extended family may be reported

Individual may have history of poor school/work performance

Parents may report client isolates self, plays stereo loudly, does not participate in family activities; shows little empathy or concern for others

Displays hostility toward authority figures; intimidates others

Participation in social activities may be nonexistent or sporadic, or gang-related

Client may be involved with legal system/juvenile court, have record of antisocial behavior (e.g., fire-setting, cruelty to people/animals, stealing, use of a weapon)

Teaching/Learning

Onset usually between age 5 to early adolescence; rare after age 16

May be involved in drug use/abuse (e.g., alcohol, inhalants, cigarettes/chewing tobacco)

May have had previous psychiatric hospitalization for same or other problems

DIAGNOSTIC STUDIES

Drug Screen: To identify substance use/abuse.

NURSING PRIORITIES

1. Provide a safe environment and protect client from self-harm.

2. Promote development of strategies that regulate impulse control, regain sense of self-worth and security.

3. Facilitate learning of appropriate and satisfying methods of dealing with stressors/feelings.

4. Promote client’s ability to engage in satisfying relationships with family members and peer group.

5. Increase the client’s behavioral response repertoire.

DISCHARGE GOALS

1. Exhibits effective coping skills in dealing with problems.

2. Understands need and strategies for controlling negative impulses/acting-out behaviors.

3. Expresses anger in appropriate/nonviolent ways.

4. Family involved in group therapy; participating in treatment program.

5. Plan in place to meet needs after discharge.