Assessment

From the onset, assessment must be accurate, to explore other explanations for the behaviour and co-presenting conditions e.g. PTSD, Dissociative disorders, ADHD, early signs of personality disorder - BPD, etc.

The definition of Severe Conduct Disorder can be described as a marked life-long attitude of being self-centered, taking what one wants when one wants it without any regard for the feelings and rights of others. It is a DSM-IV diagnosis, which has various symptoms (15) that fall into 4 sets:

1. Aggression to people and animals
2. Destruction of property
3. Deceitfulness or theft
4. Serious violation of rules

Of these 15 symptoms, at least 3 have to have occurred in the past 12 months. Prevalence is said to be approximately 8% of boys and 3% of girls (Offord, 1991), although the ratio during early childhood of boys to girls is 3:1 by adolescence this disparity is viewed as abating rapidly.

It was emphasised that juveniles with SCD can in the latter stages of childhood commit many of the severe crimes seen in society which cause significant harm to others e.g. forced sex, physical cruelty, use of weapon. In early childhood it can present as the child being aggressive, disruptive, unloving, cruel, and defiant to caregivers, educators and others.

Due to these behavioural traits it can lead to peer rejection which can ultimately mean that they distance themselves from a broad based peer group and can set the stage for involvement with deviant peers (Lochman, 2001).

This can mean these young people begin to isolate themselves from pro-social peers and this environmental shift can predict delinquency, school dropout, internalising problems, adolescent pregnancy and drug and alcohol use.

A particular group of rejected children who over-estimate their social acceptance may be at particular risk for aggression. Aggression during early toddler years is common and the peak frequency for inflicting physical aggression upon others is at the age of two - which may be surprising to some (Tremblay, 1996).

Aggression is therefore common during the early stages of development and most children use some form of physical aggression, for instance at 18 months of age, 60% of boys and 30% of girls hit their peers. However, the frequency of this aggression steadily decreases from the age of 2 to 12years, but despite this gradual decline of aggressive behaviour over time a group of 5 - 10% of children (SCD) continue with serious levels of aggressive behaviour (Frick, 1998).

The most common co-occurring problems for youth with Conduct Disorder (CD) are substance abuse, ADHD, and depression. ADHD has been found in clinical samples diagnosed with CD to present with rates of 65% - 90% (Abikoff, 1992). When present with CD youth have more CD symptoms, early onset of SCD, more violent behaviour and early and greater substance abuse. It is often associated with alcohol and drug use and is this also resistant to treatment. Depression occurs in 15% - 31% of CD youth (Zoccolillo, 1992), which may be exasperated due to interpersonal conflicts with peers and family. Despite this it does not appear to alter the course of CD.

It is this sub group of chronic aggressive children are viewed as being of greatest risk of displaying the most physical violence, delinquency, substance abuse and having school difficulties during adolescence (Nagin, 1999).

The adult equivalent of this disorder is severe anti-social personality disorder. This sub group of adult offenders have psychopathic traits (egocentricity, shallow emotions and an absence of empathy, anxiety and guilty). However, it is still not clear if Psychopathy can be reliably assessed in the youth population, but a subgroup of conduct disorder youth exhibit callous unemotional (CU) traits.

The anti-social screening device (APSD), which has been adapted from Hare’s Psychopathy Checklist – revised has been used with adolescents to assess CU traits.

The features of Severe conduct disorder are:

• High rates of aggression
• Age of onset before 10 years old
• Persistent into adulthood
• High rates of co-morbidity
• More likely to be solitary or isolated (no intimate relationships, associates but not friends)

Detection of Conduct disorder therefore needs to assess core symptoms and behaviour in relation to age and attempt to gain information from a multiple of sources e.g. parent, teacher, and self-report. These assessments should use structured interviews with parents and youth (Diagnostic Interview Schedule for Children), but can also use behavioural checklists (Behavioural Assessment Scale for children) with age-based norms can be useful.

Word Of Caution

The assessment material presented above aims to assist clinicians and therapists to indentify and therefore provide support and the most appropriate interventions to children and young people. These indicators do not provide the relational insight into the origins of the individual child’s behaviours.

We must therefore understand what the trauma has done to a child during development and therefore to the adults they will become.

I always remind myself that parental rejection to the child produces children who feel untouchable, repellent or contaminated (Hopkins, 1991, p 197).

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