Discussion Both patients meet the diagnostic criteria for conduct disorders in accordance with the current diagnostic classifications – the symptoms were present for longer than six months and significantly impaired their social and school functioning. The first patient’s medical history reveal edearly-onset conduct problems expressed through defiant, disobedient and hostile behaviour towards the social environment.
The results of one study indicated that physical aggression in kindergarten is the best and only predictor of later delinquency. The Australian Temperament Project identifies previous defiant behaviour, poor school adaptation and association with asocial peers as risk factors for antisocial behaviour at the age of thirteen to fourteen. These risk factors were assessed at the age range from childhood to adolescence. At the age of ten, the patient from the first case report meets the diagnostic criteria for childhood-onset conduct disorder.
The results of the studies indicate that early-onset conduct disorder is more commonly associated with severe family dysfunction, antisocial problems in parents, hereditary load, perinatal complications, neurocognitive deficit, lower intelligence, hyperactivity, neglect, impulsivity, difficulties at school and problems with peer relationships.
Some studies indicate that adverse psychosocial factors and early measures of temperament control in the first year of life are strongly related to the childhood-onset conduct disorder and a persistent course in both sexes, while neurodevelopmental deficits have no impact on it.
On the question of upbringing, in the first patient report, there was an inefficient parenting style reflected in strict, physical punishment by the father and anoverly permissive dimension of behavioural control by the mother.
Some of the risks for the development of conduct disorders, aggression and secondary forms of psychopathy, include ineffective parenting, broken home as well as educational styles characterized by emotional coldness on the dimension of affection, and excessive strictness or indulgence on the dimension of control. Parental conflicts and partner violence are also predictors of antisocial behaviourin children.
Conflicting partner relationships affect the child in three ways: parents who argue usually do not agree on the question of upbringing leading to inconsistent attitudes, offer the child a deviant model for solving problems, and become emotionally inaccessible to children due to everyday stress and dissatisfaction in the partner relationship.
The first patient’s family history revealed the existence of polytoxicomania and psychopathic patterns of behaviour of the father. Studies emphasize that parental history of antisocial behavior, alcoholism and substance abuse increase the risk of conduct disorders in children, through genetic or environmental influence (modeling, parenting).
The influence of the father’s criminal history as an independent predictor for the development of delinquency in the son is very significant. This transmission of antisocial behaviour across generations is explained by many factors: continual exposure to many risk factors such as poverty, poor living conditions, disrupted families, choosing a partner similar to oneself, poor children monitoring and inconsistency in the upbringing, genetic transmission mechanisms as well asstigmatization and labelling marking of families whose members are criminals.
Although at a younger age character dimensions are not finally formed and differentiated like inolder individuals, one particular characteristic of the patient from the first case report is the lack of guilt and remorse for the consequences of his actions as well lack of concern about the feelings of others. Some authors claim that key psychopathic features (such as dishonesty, lack of guilt and manipulation) can be encountered even in children.
Callous-unemotional traits in children are considered crucial in determining psychopathy. Despite the notion that the concept of child and adolescent psychopathy is accompanied by numerous controversies, one advantage of classifying young people with antisocial behavior patterns based on psychopathic traits is to identify risk groups for developing serious criminal careers and developing more effective preventive programs and treatments.
The results of studies in children, on both clinical and non-clinical samples, show that there is a psychopathic subtype of children with pronounced behaviour problems and callous-unemotional traits. In addition to the psychopathic group, there is also the impulsive group of children with pronounced behavioural problems, without unemotional traits.
The psychopathic subgroup of children showed a higher degree of disobedience, aggression and destructiveness, more contact with the police, and greater incidence of antisocial personality disorders in parents compared to the impulsive subgroup. The children from the psychopathic subtype had higher intelligence than the impulsive children. The subgroup with high psychopathic scores showed the highest rate of conduct disorders, hyperkinetic disorders, as well as oppositional defiant disorders.
The subgroup of children with psychopathic traits is similar to children with childhood-onset conduct disorders, as well as unsocialised conduct disorder, since this type includes some affective deficits similar to psychopathy (lack of empathy, difficulties in peer relationships and maintenance of friendships). Some studies show that a group of boys with an early onset of antisocial behavior have a significantly higher incidence of affective psychopathic traits (90%) compared to those with adolescence-onset antisocial behavioral (less than 50%).
The second patient’s medical history did not show any early and persistent behavioural problems, but the symptoms of conduct disorder developed in the later period of adolescence. The influence of a risk peer group is evident. Peer influence appears later in relation to individual and family factors.
It does not have to be the primary cause of conduct disorders but does represent a risk factor for children who already have high-risk individual and family factors. A larger number of studies find that adolescent subtypes of conduct disorders are influenced by an association with antisocial peers or seeking social status through delinquent behaviour, even in the absence of personality or family problems.
Because of the need for belonging to a peer group, such children are prepared to intensify maladaptive behaviour to the extent that they violate the rights and property of others in order to gain a ‘sense of belonging and acceptance.’ The frequency of their anti-social behaviour as well as the extent of violence and delinquency throughout teenage years may be even greater than in permanently antisocial individuals. Persisting problems in adulthood can be the result of antisocial behaviour in adolescence (criminal records, leaving school, and addiction to psychoactive substances).
The patient from the second report comes from a dysfunctional family burthened by the mother’s severe illness and father’s alcoholism. After the mother’s death, the father was denied custody due to the assessment that his involvement in child care ranged from indifference to neglect of the children’s needs.
A large meta-analysis of studies dealing with the correlation between parental behaviour (especially the emotional relationship of parents towards children) and the children’s externalizing behaviours indicates a significant correlation between parental rejection and externalizing problems in children. This correlation persisted in other studies examining different variables – the quality of parental relationships, single-parent families, parental education, employment and socioeconomic status, race and ethnicity, the subjects’ gender and age.
Parental acceptance or rejection, completely or partially, mediates the relationship between the aversive family structure variables and the behaviour problems of children. It was found that aversive family structure variables (the father’s absence, divorce, family size, parental unemployment, low socioeconomic status etc.) positively correlate with children’s conduct disorders. Parental rejection of the child has proved to be a significant mediator of this correlation.
Accoding to the treatment the first patient received a multicomponent treatment. This included an individual social skills training which typically comprises instruction, modeling, rehearsal, role playing with peers, feedback, and discussion as well as a Cognitive behavioural anger management training which helps an individual regulate intense emotions and modify cognitive distortions and promotes pro-social behaviours.
At the same time, family interventions were conducted through parental counseling, improvement of parent family management and communication skills, and parental training for the consistent monitoring of the child’s behavior. The father was required to continuously engage in the treatment of polytoxicomania at the Department of Addictive Disorders, Clinic for Mental Health Protection. Family interventions had some limitations due to the varying motivation of both the patient and the parents. In cooperation with the school, a mentoring system was introduced and the child’s behavior monitored at school.
A professional social service team started regular home visits to help improve family functioning. At the initial stage of the treatment, we used pharmacotherapy with small doses of atypical neuroleptic Risperidone. Most research indicates that Risperidone is a therapy of choice in the treatment of conduct disorders due to a better profile of adverse effects. Short-term use (up to 4 months) in low doses (up to 1-1.5 mg risperidone daily) is recommended but only in cases of extreme aggression followed by poor emotion control.
There has been little research of the program’s efficacy in children with conduct disorders and callous-unemotional traits. The research by a group of authors showed that young offenders with psychopathic traits improve their behavior with intensive treatment programs that use an award-oriented approach, target and modify value orientations and teach empathy.
Specifically, they reported that adolescent offenders who had received intensive treatment were less likely to recidivate in a 2-year follow-up period than offenders with these traits who underwent a standard treatment program in the same correctional facility.
Interventions that focus on encouraging personal identity development and increasing contact with prosocialally oriented young people through programs that provide structured after-school activities are beneficial for patients with adolescent-onset conduct disorders. The adolescent from the second case report was subjected to personal development interventions for anger management.
These interventions emphasize the need to address issues of motivation, self-esteem, and identity to enable adolescents to make effective use of techniques for self-control. Cooperation with the school counsellor/school psychologist was established to aid with studying. For irritability and depressive equivalents, lower doses of sertraline were included into the pharmacotherapy.
Although some theoretical approaches to depression do not explain depression in the antisocial population, empirical findings have unambiguously demonstrated a significantly higher incidence of co-morbidity of antisocial behavior and depression in the young in comparison to individual occurrence of these disorders.
Literature suggests that the basic conditions for depression in antisocial youth are unfavorable and insufficient affective relationships with the social environment (current and past, real or internalized), as well as ineffective adaptive mechanisms to overcome the situation.
In general, taking into account the data related to the patient from the first report, we can expect a worse prognosis related to the outcomes of antisocial behavior. However, the prognosis for adolescence-onset conduct disorders is not as good as it used to be believed.
They develop more internalizing problems and life stress and it is not clear whether their problems disappear during adulthood. According to some research, members of the adolescent subtype had higher rates of drug and property-related criminal offenses at the age of 26, and more symptoms of depression and anxiety on self-assess
