All children and adolescents act out occasionally, but some consistently behave in very aggressive ways. Their behavior may defy reason. These children may have normal intelligence, but they tend to disrupt or skip classes and fall behind in school. Even worse, they may end up damaging property or physically harming others.
Let's look at what's behind these problems and a few ways to treat them.
Psychiatrists may call this behavior a conduct disorder. The child repeats a pattern of impulsive, aggressive and deceitful behavior early in life. He or she violates basic social rules and ignores the rights of others.
The child's behavior may include any of the following:
- Aggression toward people or animals that threatens or causes physical harm (bullying schoolmates, starting fights, using weapons, being cruel to animals)
- Burglary, vandalism and other behavior that causes property loss or damage (breaking car windows, destroying a peer's bicycle)
- Deceitfulness or theft (breaking into a house, shoplifting, “conning” people)
- Serious rule violations (truancy, staying out late at night, running away from home)
Conduct disorder is more common — or at least more frequently diagnosed — in boys. It is hard to say how many children fit into this category. Diagnosis is complicated because these children often have additional mental health conditions. For example, at least half have attention deficit hyperactivity disorder (ADHD). Also common are mood disorders, anxiety, post-traumatic stress disorder and learning problems.
The main feature of oppositional defiant disorder is repeated defiant, disobedient or hostile behavior directed at authority figures. Usually these are people the child has a relationship with. The symptoms are less severe than in conduct disorder. What stands out in oppositional defiant disorder is irritability or angry mood. By contrast, in conduct disorder, aggression and rules violations are most obvious — and are not aimed at a specific person.
A child's behavior may fit both disorders. There is also some evidence that a child who exhibits oppositional defiant disorder may have a greater risk of developing conduct disorder. Most of these children, however, do not.
The earlier a child shows conduct disorder symptoms, the more likely it is that problems will be severe and harder to treat. Family and peer relationships suffer. The chances increase that such a child will develop antisocial personality disorder in adulthood.
Youths diagnosed with conduct disorder after age 10 tend to be less aggressive than those who develop the disorder before that age. Their peer relationships are closer to normal. When they do act out, it is usually in the company of aggressive peers, such as gang members.
Children who grow up in dysfunctional families and in stressful environments are at greater risk. Many of those children carry extra vulnerability, because they are less likely to have access to good treatment and support.
Many children with these disorders are more likely to be irritable, impulsive or fearless from birth. These qualities are more severe if:
- The child is rejected or neglected
- There is physical or emotional abuse
- Discipline is brutal or erratic
- Caregivers constantly change
The child's behavior can get worse in response to these stresses. Parents, teachers and other children get angry, which just reinforces the child's problematic behavior.
Conduct problems are tough on anyone who interacts with the child — parents, peers and teachers.
Treatment works best when it involves and empowers parents. One popular approach is known as parent management training. It focuses on helping parents to better manage the child's behavior. Parents learn to:
- Give and enforce stable rules
- Negotiate compromises with older children
- Reward good behavior
- Substitute sensible discipline for inconsistent punishments
Therapists demonstrate the behavior for parents and they rehearse it with help from the therapists.
A related approach is behavioral family therapy. Therapists using this approach help parents learn how to modify a child's behavior. Parents also:
- Learn stress reduction techniques
- Understand how a child's temperament can affect behavior
- Begin to recognize how they view the child's behavior
An approach called multisystemic therapy may help children with the most severe problems. This includes teens who already have a significant track record of antisocial or delinquent behavior. It combines strategies from cognitive behavioral therapy, parent management training and various family therapies.
Multisystemic therapy is based on the assumption that antisocial behavior has different causes in different youths and must be managed and treated individually. Depending on the youth, the program may concentrate on behavior, family discipline, school performance, or gangs and other forms of peer pressure. As the name suggests, therapy usually includes people involved in key aspects of the child's life, usually at home and at school.
I wish there were simpler, less intensive solutions. But other treatments are not very effective.
Individual psychotherapy is of limited use, because children and adolescents with conduct disorder tend to resist it. They may be defensive because they have been forced to see a mental health professional. It can be difficult to penetrate their mask of insolence and bravado.
At other times, children with conduct disorder hide their difficulties. They would rather be considered bad than admit to weakness or suggest in any way that they need help. Asked to talk about themselves and their behavior, they may lie, deny and change the subject.
For all these reasons, individual therapy is likely to be insufficient as a single treatment, although it may help some youths benefit from other interventions.
As for medications, the American Academy of Child and Adolescent Psychiatry does not recommend them for a single diagnosis of conduct disorder. Medications may be helpful for co-occurring disorders, such as ADHD, anxiety or depression. For serious violence, mood swings and temper tantrums, clinicians sometimes recommend antipsychotic medications, anticonvulsants or mood stabilizers. But there is little evidence to support use of these drugs.
Boot camps are simply not helpful. The benefits of "tough love" are a fantasy. Long-term research suggests that forcing youths with conduct disorder to attend military-style boot camps or rugged wilderness camps is usually ineffective. And it may even aggravate their problems. Timid youths may admire and learn from those who are willingness to be aggressive, take chances, break rules and defy authority. Even when youths' behavior improves temporarily in a controlled and restrictive environment, the change doesn't necessarily hold when they have to face an unpredictable and indifferent outside world. Long-term data suggest that youths who attend boot camps have high arrest rates as adults.
People aren't very sympathetic to youth with aggressive misbehavior. And, without sympathy, it is very hard to gather the resources that might help such a child.
As a result, even though there is evidence that programs combining family and academic support can be effective, it can be extraordinarily difficult to find such a program in your area.
As a parent, know what types of programs are most effective. Then you can talk to your pediatrician, a school psychologist or other health care provider about programs that might be available in your area.
Here is a list of programs for you to check out:
Michael Craig Miller, M.D. is the former editor-in-chief of the Harvard Mental Health Letter and an assistant professor of psychiatry at Harvard Medical School. Dr. Miller has an active clinical practice and has been on staff at Beth Israel Deaconess Medical Center for more than 30 years.