Running head: CONDUCT DISORDER
Conduct Disorder in Childhood and Adolescence
Jordyn A. Williams
Youngstown State University
CONDUCT DISORDER 2
Aggression is a natural human expression that frequently manifests in
young children. Through the guidance of parents and the community, these
children typically grow out of these aggressive tendencies, begin socializing
with others around them, and eventually inhibit their aggressive behaviors.
However, there are some children that never do grow out of these aggressive
manifestations of behavior; they do not learn to socialize with peers and
inhibit rule-breaking behavior. These are the children that may be eligible for
a diagnosis of Conduct Disorder.
According to Mental Health America (n.d.), children and adolescents
with Conduct Disorder can experience significant impairment in social,
academic, and family functioning. Many children and adolescents with
Conduct Disorder experience issues such as, empathetic expression, remorse,
and understanding social cues (Mental Health America, n.d.). It is common
for these children and adolescents to misinterpret the actions of others as
being hostile and to respond aggressively. According to the Children’s
Hospital of Wisconsin (2015), the prevalence of Conduct Disorder in children
varies, with ranges of approximately 6% to 16% for males and 2% to 9% for
females. Conduct Disorder is more common in males than females by a 4:1
ratio.
The most fundamental feature of Conduct Disorder is a “repetitive and
persistent pattern of behavior by a child or teenager in which the basic rights of
others or major age-appropriate societal norms or rules are violated” (Grohol, 2013,
p. 1). These behaviors are categorized into four domains: aggressive behavior that
CONDUCT DISORDER 3
results in or threatens physical harm to other individuals or animals, nonaggressive
behavior that results in property damage or loss, deceitfulness or theft, and
repetitious violations of rules. To be diagnosed, three or more of these behaviors
must manifest within the past 12 months, with at least one present within the past 6
months. The domain, aggression to people and animals, includes behaviors such as,
bullying and threatening others, initiating physical fights, and forcing someone into
sexual activity. The domain, destruction of property, includes deliberately engaging
in arson and deliberately destroying others’ property. The domain, deceitfulness or
theft, involves breaking and entering another’s home or car, lying for personal gain,
and theft. Finally, the domain, serious violations of rules, includes running away
from home at least twice while living at home and truancy from school (Grohol,
2013).
There are two subtypes of Conduct Disorder, according to Grohol (2013).
These subtypes are separated based on the age of symptom onset. They differ in
characteristics of presenting problems, developmental course, and gender
demographics. Childhood-Onset Type is defined by the presence of at least one
criterion prior to 10 years of age (Grohol (2013). These individuals are typically
male, frequently display physical aggression, may have had Oppositional Defiant
Behavior during early childhood, and are at higher risk for persistent Conduct
Disorder and Adult Antisocial Personality Disorder, than those with Adolescent-
Onset Type. Adolescent-Onset Type, according to Grohol (2013), is defined by the
absence of any criterion prior to 10 years of age. These individuals are less likely to
display aggressive behavior, compared to those with Childhood-Onset Type. These
CONDUCT DISORDER 4
individuals are more likely to have normative peer relationships, but often display
inappropriate behavior in the presence of others). These individuals are at a lower
risk for the development of persistent Conduct Disorder or adult Antisocial
Personality Disorder. The ratio of males to females with diagnosed Adolescent-
Onset Type Conduct Disorder is lower than diagnosed Childhood-Onset Type
Conduct Disorder (Grohol, 2013).
According to Scott (2008), childhood conduct disorders have predictive value
for numerous issues later in adulthood such as, serious difficulties in work,
education, and finances, abuse, homelessness, substance abuse and dependence,
poor physical health, compromised immune functioning, dental and respiratory
problems, and suicidal behavior (Moffitt et al., 2002 as cited in Scott, 2008).
However, with treatment and effective intervention, reasonable work and social
adjustment can be made by adulthood (UCLA, 2008).
Development
According to Bernstein (2014), signs of disturbances of conduct can be found
as early as the age of two years. An early predictor of aggression in early childhood
is the presence of diversity of antisocial behavior (UCLA, 2008). Early symptoms
typically involve inattentive and impulsive behavior, irritable temperament, poor
attachment, hyperactivity, and poor compliance. Development of Conduct Disorder
in childhood has an increased chance of occurrence with the presence of negative
environmental factors such as, parental rejection and neglect, inconsistent and
harsh discipline, physical or sexual child abuse, lack of supervision, and frequent
changes of caregivers (UCLA, 2008). In some cases of Conduct Disorder
CONDUCT DISORDER 5
development, a genetic and environmental factor is involved with parent(s) who
have a history of psychopathology and conduct problems. In many cases,
symptomology of Conduct Disorder is perpetuated by ineffective parenting styles of
parents and caregivers. These styles involve parenting behavior that is inconsistent,
punitive, and impatient. As a result of stressful environmental conditions, such as
financial problems, marital issues, lack of parenting skills, and issues with child
temperament, parents may struggle to effectively and consistently set limits and
emotionally support their child (Bernstein, 2014). From this behavior, a negative
cycle can begin in which the child’s temperamental difficulties can increase. This can
result in noncompliance with requests, increased punitive action from the parents
attempting to increase compliance, and eventual relinquishment of control from the
parents. If this happens, the child’s defiant behaviors are reinforced. Consequently,
parents oftentimes become isolated from external support and, following increased
negative interaction with their child, may spend less and less time with him or her.
This behavior, as a result, provides the child with decreased support and inadequate
opportunity to learn accurate identification of his or her emotions and self-control
skills (Bernstein, 2014).
According to Bernstein (2014), advancement to elementary school age for a
child with Conduct Disorder can yield increased behavioral aggression with others.
Children, in their elementary school years, who have Conduct Disorder typically
display behaviors such as hostility, inattention to social cues, misinterpretation of
others’ intentions, and an inability to solve complex social situations (Bernstein,
2014). Children with Conduct Disorder are also likely to exhibit impulsivity and
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poor self-control. As children with Conduct Disorder progress to early adolescence,
their hostility may develop into episodes of intense anger and aggressive action. As
this behavior begins to occur, these children typically blame others for their
aggressive actions, rarely taking personal responsibility (Bernstein, 2014).
According to Patterson and Forgatch (1987; as cited in Bernstein, 2014),
three clusters of behavior begin to emerge as children with Conduct Disorder reach
middle-school age. These behaviors consist of: noncompliance to commands,
emotional overreaction, and failure to take responsibility for personal actions. As
aforementioned, in many cases, parents spend less time with their children, which
may result diminished cognitive stimulation and, consequently, decreased
achievement in academic areas. Diminished cognitive stimulation can also be the
result of poor teacher-child relationships from repeated instances of noncompliance
and hostility towards adults. An intensification of behavioral problems can also
result in poor peer relationships and complete rejection from peer groups. This
defiant behavior can also result in rejection by teachers and even parents. According
to Bernstein (2014), this rejection not only leads to emotional damage but also to
increased unsupervised and unstructured time. As a result, children with Conduct
Disorder, often times, will loss all motivation to excel academically, develop a
negative self-image, and associate with peers who exhibit negative influence and
share similar deficits in socialization, empathy, and self-regulation (Bernstein,
2014).
By early high school, adolescents with Conduct Disorder, if left untreated,
typically display signs of depression as a result of continuous academic and social
CONDUCT DISORDER 7
failures (Bernstein, 2014). These adolescents are at high risk of joining deviant peer
groups, such as gangs. If no interventions are put in place, these adolescents will
likely become completely isolated from family systems, positive school orientation,
and all other pro-social groups. According to Bernstein (2014), continuous
association with deviant peer groups is likely to result in criminal and delinquent
actions. As adolescents with Conducted Disorder are poorly bonded to family, peers,
school, or general social norms, they may come to the attention of the juvenile
justice system. If incarcerated, it is likely that their delinquent behaviors and
attitudes will be left to further intensify (Bernstein, 2014).
Described above is one scenario of a student with Conduct Disorder who
escaped the eye of those who were in the position to intervene. While it is estimated
that 5 out of every 100 teenagers in the United States suffer from Conduct Disorder
(Bernstein, 2014), it is possible to prevent the above scenario for each one through
the implementation of researched-based prevention and intervention techniques.
Medical Diagnostic Considerations
Conduct Disorder is defined by the Diagnostic and Statistical Manual of
Mental Disorders– 5th Edition (DSM – V) as “ a repetitive and persistent pattern of
behavior in which the basic rights of others or major age-appropriate societal norms
or rules are violated” (Bernstein, 2014; American Psychiatric Association, 2013). In
order to be diagnosed with Conduct Disorder, the client must display a
manifestation of at least 3 of 15 criteria in the past 12 months, with at least one
criterion manifesting within the past six months. These criteria are organized into
four clusters: aggression to people and animals, destruction of property,
CONDUCT DISORDER 8
deceitfulness or theft, and serious violations of rules. In order to be diagnosed with
conduct disorder, the individual must experience significant impairment in social,
academic, or occupational functioning, as a direct result of symptomology
(American Psychiatric Association, 2013).
Impact on Academics
According to Bernstein (2014), deficits in cognitive functioning and academic
performance are widely reported as educational correlates of Conduct Disorder.
Research on the topic has resulted in inconclusive data as to the definitive link
between poor academic performance and Conduct Disorder. However, researches
have theorized that delinquency could be the result of progression from academic
failure to antisocial behavior. This theory postulates that academic failure can result
in decreased self-esteem and helplessness, and, escape from academics via acting
out or dropping out of school (Bernstein, 2014). Another theory, described by
Bernstein (2014), hypothesized that Conduct Disorder and poor academic
achievement are a result of dysfunctional external variables; i.e., socioeconomic
status, familial support, environment. These external variables serve as supports for
conduct problems and inhibitors of academic achievement. In a third theory, it is
believed that some individuals with Conduct Disorder and poor academic
achievement have a comorbid disorder of cognitive processing known as, Hebb
Repetition Effect. This involves selective impairment in cognitive tasks of serial
order processing (Bernstein, 2014).
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Special Education Eligibility Considerations
Conduct Disorder itself is not a category for special education eligibility
under the Individuals with Disabilities Education Act (IDEA) (2004). However,
Conduct Disorder is frequently comorbid with learning disabilities or Attention
Deficit Hyperactivity Disorder (ADHD). As a result, students with Conduct Disorder
may be eligible for special education services under the categories of Other Health
Impairment, Specific Learning Disability, or Emotional Disturbance.
IDEA (2004) defines the category of Other Health Impairment (OHI) as,
“Having limited strength, vitality, or alertness, including a heightened
alertness to environmental stimuli, that results in limited alertness with
respect to the educational environment, that: (i) is due to chronic or acute
health problems such as asthma, attention deficit disorder or attention deficit
hyperactivity disorder, diabetes, epilepsy, a heart condition, hemophilia, lead
poisoning, leukemia, nephritis, rheumatic fever, sickle cell anemia, and
Tourette syndrome; and (ii) Adversely affects a child’s educational
performance.”
IDEA (2004) defines the category of Specific Learning Disability as,
“A disorder in one or more of the basic psychological processes involved in
understanding or in using language, spoken or written, that, may manifest
itself in the imperfect ability to listen, think, speak, read, write, spell, or to do
mathematical calculations, including conditions such as perceptual
disabilities, brain injury, minimal brain dysfunction, dyslexia, and
developmental aphasia. SLD does not include learning problems that are
CONDUCT DISORDER 10
primarily the result of visual, hearing, or motor disabilities, or mental
retardation, of emotional disturbance, or of environmental, cultural, or
economic disadvantage.”
IDEA (2004) defines the category of Emotional Disturbance as,
“A condition exhibiting one or more of the following characteristics
over a long period of time and to a marked degree that adversely
affects a child’s educational performance: (A) An inability to learn that
cannot be explained by intellectual, sensory or health factors. (B) An
inability to build or maintain satisfactory interpersonal relationships
with peers and teachers. (C) Inappropriate types of behavior or
feelings under normal circumstances. (D) A general pervasive mood of
unhappiness or depression. (E) A tendency to develop physical
symptoms or fears associated with personal or school problems. The
term includes schizophrenia. The term does not apply to children who
are socially maladjusted, unless it is determined that they have an
emotional disturbance. “
Assessment Techniques
Conduct Disorder is diagnosable by a qualified mental health professional
through the collaboration and review of detailed records of the child’s behavior
from parents, caregivers, and teachers, observations, and psychological assessment.
There is a variety of scales and rating systems that can be utilized in the assessment
of students with Conduct Disorder.
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According to the Massachusetts General Hospital division of School
Psychiatry (2010), self-rating scales include the Conduct Disorder Scale (CDS) and
the Reynolds Adolescent Adjustment Screening Inventory (RAASI). The CDS is a
checklist that includes 40 items and requires approximately 5 to 10 minutes for
administration. The age range for this assessment is 5-22 years and it assesses
aggressive and non-aggressive behavior, deceitfulness, theft, and norm violations.
The RAASI is a screening measure of psychological adjustment that includes 32
items. It requires approximately 5 minutes for administration and is for student’s
ages 12 to 19 years. This assessment measures antisocial behavior, anger control,
emotional distress, and self-esteem and social inhibition.
According to the Massachusetts General Hospital division of School
Psychiatry (2010), there are also a number of scales and rating systems for teachers
and parents of the student. These include the Adjustment Scales for Children and
Adolescents (ASCA) and the Social Skills Rating System (SSRS). The ASCA is an
assessment for student’s ages 5-17 years that includes 156 items. It measures
positive and problem behaviors in situations involving peers, smaller or weaker
youths, authority, recreation, confrontation, and learning. It requires approximately
10 to 20 minutes to complete and should be administered to a teacher who knows
the student well. The SSRS is a questionnaire that can be used to screen and classify
students suspected of having a social behavioral problem. It evaluates teacher-
student relationships, academic performance, and peer acceptance. The SSRS
requires about 10 to 25 minutes to complete. It includes a student self-report
CONDUCT DISORDER 12
measure for students 8 to 18 years of age, a measure to be completed by a parent of
the student, and a measure to be completed by a teacher of the student.
Implications on the Family System
Conduct Disorder is one of the most difficult behavioral disorders to treat
and can have significant impact on the family of the child affected. According to
UCLA (2008), children and adolescents with Conduct Disorder and their families
often benefit from services that include, family therapy, parental training on how to
handle child or adolescent behavior, problem solving skills training, and
community-based services that focus on the child or adolescent within the context
of their family. Parents and caregivers of children with Conduct Disorder may
experience a range of conflicting emotions such as, anger, fear, grief, anxiety, love,
and depression. Feelings such as these are not unusual; parents and caregivers have
reported emotional support from family, friends, and support groups to be
significantly helpful in coping with these emotions (UCLA, 2008). Research has
found individual, couple, and family therapy to be helpful in providing guidance and
emotional support for the family of children with Conduct Disorder (UCLA, 2008).
Instructional Prevention and Intervention
According to Scott (2008), effective academic interventions include
programs that promote self-management and self-reinforcement training. The goal
of this training is to increase the child’s time spent on a task and to encourage him
or her to complete assignment quickly and accurately. Many of these programs were
created with the idea that students with antisocial and conduct concerns who are
struggling academically are likely to have parents who are not involved with their
CONDUCT DISORDER 13
education (Scott, 2008). Approaches utilized by these programs include the
encouragement of home-school cooperation by improving the parent-teacher
relationship, involvement of parents in their child’s academics, and the use of
effective methods to reduce these children’s academic difficulties (Scott, 2008).
According to Levendoski & Cartledge (2000) as cited by Scott (2008), research into
the effectiveness of these programs has found moderate to large effects.
Medical Intervention
According to Scott (2008), it is highly likely that children with conduct
disorder will require clinical intervention to assist in the prevention and burden of
poor health and social maladjustment in adulthood.
Some pharmacological approaches for Conduct Disorder target reactive
aggression and overarousal (Scott, 2008). Treatments for these conditions often
include mood stabilizers (i.e., lithium and carbamazepine) and medications that
target affect dysregulation (i.e., buspirone and clonidine) (Scott, 2008). Research
into pharmaceutical treatments for Conduct Disorder have found methylphenidate,
and in one case, lithium, to be effective in reducing aggressiveness. Research has
also found lithium to be effective in reducing drug and alcohol cravings in
adolescents with Conduct Disorder (Swartout and White, 2010 as cited by
Bernstein, 2014). According to Bernstein (2014), studies have also shown
carbamazepine and guanfacine to be effective in the reduction of aggressive
behavior.
The first choice in pharmaceutical treatment, however, is stimulant
medication, which has been shown to be much safer. According to Bernstein (2014),
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stimulant medication has been shown to be effective in controlling symptoms of
inattention, impulsivity, and hyperactivity. According to Scott (2008), the use of
psychostimulants (i.e., methylphenidate and dexamfetamine) is amongst the best-
studied pharmacological interventions for children and adolescents with Conduct
Disorder, comorbid with Attention Deficit Hyperactivity Disorder (ADHD). Research
has found evidence that supports the claim that psychostimulants reduce
hyperactivity, impulsivity, and conduct problems; however, insufficient evidence
has been found to assert that stimulants reduce aggression when there is an absence
of ADHD (Scott, 2008).
Behavioral Prevention and Intervention
According to Scott (2008), conduct disorders can result in considerable
distress for children, families, and schools. Conduct problems, often times, result in
social and educational impairment (Lahey et al., 1997 as cited in Scott, 2008). School
personnel have a tendency to view punishment as the only response when dealing
with a student with chronic problems of conduct (UCLA, 2008). Oftentimes, in an
effort to control the aggressive student, school personnel see only punishments such
as, doing something the student does not want done (i.e., removal a privilege or
engagement in an undesirable activity), suspension, and expulsion as effective
responses (UCLA, 2008). With no treatment or interventions effectively
implemented, long-term negative outcomes such as criminal and violent offending,
incarceration, and development of antisocial personality disorder may occur (Scott,
2008).
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Methods for prevention of behavioral issues include the expansion of social
programs and improvement of school environments. According to UCLA (2008),
prevention techniques for social programs expansion include an increase in
economic opportunities for adolescents from low-income families, augmentation of
health and safety maintenance, and extension of quality day care and early
education. Prevention techniques for school improvement include the
personalization of classroom instruction to accommodate diversity in motivational
and developmental levels, increased utilization of “status” opportunities for
students with social difficulties (i.e., special jobs in the classroom), and early
identification and intervention of children with skill deficits (UCLA, 2008).
Immediately following acts of misbehavior, the function of the behavior should be
identified in order to prevent future occurrences.
According to Bernstein (2014), Parent Management Training has been shown
to be a highly effective treatment for coercive behavioral patterns in children. This
treatment involves training parents to effectively alter their child’s behavior in-
home. According to Scott (2008), Parent Management Training was designed to
improve the behavior management skills of parents and to promote a positive, high
quality relationship between the parent and child. As research has shown that a
major trigger for the escalation of childhood defiance is ineffective, inconsistent
parenting practices, this treatment aims to educate the child’s parents in the use of
specific procedures to alter negative interactions with the child, encourage pro-
social behavior, and to reinforce desirable behaviors. Key target skills promoted by
this intervention include: promotion of play, use of praise and rewards to encourage
CONDUCT DISORDER 16
desirable social behavior, use of clear rules and directions, use of consistent and
calmly executed consequences for undesirable behavior, and reorganization of the
child’s routine to prevent issue (Scott, 2008). Recent research has suggested that the
severity of the child’s behavior is predictive of the treatments success or failure. To
promote success of this method, according to Rehberg, Fürstenau, & Rhiner (2011)
as cited in Bernstein (2014), treatment should be highly structured and use specific
goals and established behavioral techniques.
Cognitive Behavioral Therapy, utilized in either individual or group therapy
sessions, has been demonstrated as an effective intervention for preschool and
school-aged individuals with Conduct Disorder (Scott, 2008). The most common
skills targeted for child therapy interventions are the promotion of prosocial
interaction (i.e., participation in group activities, starting conversation, sharing,
listening, negotiating, and cooperating), the reduction of aggressive behavior (i.e.,
shouting and pushing), improvement of emotional regulation and self-control
problems (to reduce the occurrence of impulsivity, explosiveness, and emotional
lability), and correction of cognitive deficiencies, distortions, and incorrect self-
evaluation (Scott, 2008). One program that utilizes this intervention is Problem-
Solving Skills Training (PSST-P) (Kazdin, 1996; as cited by Scott, 2008). This
training program was designed for children ages 7 and over and involves individual
training in interpersonal cognitive problem-solving techniques. This training
focuses on identifying problem situations and learning how to apply problem-
solving steps. Children are reinforced using a token system and therapeutic
strategies include games, modeling, and role-play. According to Scott (2008), PSST-P
CONDUCT DISORDER 17
has been shown to significantly decrease deviant behavior and increase prosocial
behavior in children involved.
Anger Control Training is an evidence-based cognitive-behavioral
intervention that has been shown to be effective with elementary school aged
children with conduct problems (Eyberg, Nelson, & Boggs, 2008). This intervention
requires students to meet once per week during the school day for 40 to 50 minutes.
Students are split into separate groups of approximately 6 children. During group
sessions, students are involved in activities such as, creating specific goals,
discussing vignettes of social encounters with peers, social cues and possible
motives of individuals in the vignettes. Other sessions involve activities such as,
teaching problem solving strategies for anger-provoking social situations, practicing
appropriate social responses, practicing self-statements in response to different
problem situations, and awareness of feelings. Later in training, the group involves
the students engaging in anger-inducing role-play and providing support for their
use of taught anger control strategies (Eyberg, et al. 2008). Studies on effectiveness
of this intervention found it to be superior to no-treatment control groups in
reducing disruptive behavior (Eyberg, et al. 2008).
According to Scott (2008), the most effective classroom behavioral
interventions focus on promoting positive behaviors (i.e., compliance and following
established classroom rules), preventing problem behaviors (i.e., talking
inappropriately and fighting), teaching social and emotional skills (i.e., problem
solving and conflict resolution), and preventing the escalation of aggressive
behavior and acting out. Students should be aware of the consequences for acts of
CONDUCT DISORDER 18
misconduct. These consequences should be perceived by students as logical, fair,
and reasonable and should be used with consistence (UCLA, 2008). In order for
students with Conduct Disorder to perceive consequences as logical and socially
agreed upon and not as personal attacks or acts of power, steps must be taken to
increase an understanding of behavioral norms. Steps must be taken to teach these
students right from wrong, to teach them to respect the rights of others, and to
accept responsibility for their actions (UCLA, 2008).
Minimally intrusive intervention techniques that can be utilized in the
classroom include, signal interference, interest boosting, support from routine, and
self-management. Signal interference is an intervention that involves the use of cues
and signals to remind students that their behavior is inappropriate and disruptive.
These cues can be things such as, clearing of the throat, snapping of the fingers,
ringing a bell, or placing a warning sign on the board (UCLA, 2008). These nonverbal
cues can be used to minimize student embarrassment and can be decided on in
private by the student and teacher. According to UCLA (2008), interest boosting is
an intervention that involves maintaining the interest of the student by relating the
classroom activities to the student’s areas of interest. This can be accomplished by
obtaining interesting facts that relate to the lesson and the student’s interests, using
activity sheets related to the area of interest, and using educational games that
relate to the area of interest. Support from routine simply involves providing
students who have conduct problems with well-defined routines. For students with
Conduct Disorder, being in a predictable and structured environment, under the
supervision of a caring teacher, is very important (UCLA, 2008). One of the more
CONDUCT DISORDER 19
obvious deficits of students with Conduct Disorder is in productive self-
management (UCLA, 2008). The self-management intervention should only be used
following the successful use of interventions such as the ones listed above. After the
student’s behavior improves to a more pro-social level, self-control techniques
should gradually be introduced. This training involves, self-selected behaviors to
change, self-determined reinforcements, self-administered reinforcements, and self-
monitored progress. According to UCLA (2008), students have a tendency to
respond well to programs when given control of their own development.
Conclusion and Summary
According to Buitelaar, Smeets, Herpers, Scheepers, Gellon , & Rommelse
(2013), compared to other childhood on-set psychiatric disorder, Conduct Disorder
has been student relatively less. It results in the significant impairment of social,
academic, and family functioning and is of serious concern due to the significant
impact on the child and their family. If left untreated, it can result in altercations
with the law, association with deviant peers, substance abuse, and academic failure.
The most fundamental feature of Conduct Disorder is a “repetitive and persistent
pattern of behavior by a child or teenager in which the basic rights of others or
major age-appropriate societal norms or rules are violated” (Grohol, 2013, p. 1).
While IDEA (2004) does not include special education eligibility for Conduct
Disorder, students frequently experience comorbid psychiatric disabilities and may
qualify for services under the categories of Other Health Impairment, Specific
Learning Disability, or Emotional Disturbance. Conduct Disorder is an impairment
that can have devastating effects on a child and family. However, through the use of
CONDUCT DISORDER 20
prevention and early identification behavioral, academic, and medical interventions
can be implemented to help the student succeed academically, behaviorally, and
socially.
CONDUCT DISORDER 21
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(2013). Conduct disorders. European Child and Adolescent Psychiatry, 22,
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