Specific Objectives

Content

Methodology

Time Allotment

Resources

Evaluation

1. Define Conduct Disorder

Conduct disorder involves a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated (APA, 2000). Physical aggression is common.

Essentials of Psychiatric Mental Health Nursing 5th ed. - M. Townsend (F. A. Davis, 2011) Essentials of Psychiatric Mental Health Nursing 5th ed. - M. Townsend (F. A. Davis, 2011)

2. Differentiate the

subtypes of Conduct Disorder

Childhood-Onset Type: This subtype is defined by the onset of at least one criterion characteristic of conduct disorder prior to age 10. Individuals with this subtype are usually boys, frequently display physical aggression, and have disturbed peer relationships. They may have had oppositional defiant disorder during early childhood, usually meet the full criteria for conduct disorder by puberty, and are likely to develop antisocial personality disorder in adulthood. Adolescent-Onset Type: This subtype is defined by the absence of any criteria characteristic of conduct disorder prior to age 10. They are less likely to display aggressive behaviors and tend to have more normal peer relationships than those with childhood onset type. They are also less likely to have persistent conduct disorder or develop antisocial personality disorder than those with childhood-onset type. The ratio of boys to girls is lower in adolescent-onset type than in childhood-onset type.

3. Recognize the Risk

Risk Factors of Conduct Disorder (CD)

Factors and Causes Various social factors that lead to lack of attachment to the parents or family unit of Conduct and eventually, to lack of regard for societal rules: Disorder - Early maternal rejection - Separation from parents, with no adequate alternative caregiver available

Lippincott Williams & Wilkins. Straight As in Psychiatric & Mental Health Nursing. 2006

Early institutionalization Family neglect, abuse, or violence Frequent verbal abuse from parents, teachers, or other authority figures Parental psychiatric illness, substance abuse, or marital discord Large family size, crowding, and poverty

Physical Factors and other conditions: Neurologic damage caused by low birth weight or birth complications Underarousal of the autonomic nervous system Learning impairments Insensitivity to physical pain and punishment Essentials of Psychiatric Mental Health Nursing 5th ed. - M. Townsend (F. A. Davis, 2011)

Causes of Conduct Disorder Biological Influences Genetics Studies with monozygotic and dizygotic twins as well as with non-twin siblings have revealed a significantly higher number of conduct disorders among those who have family members with the disorder (APA, 2000). Although genetic factors appear to be involved in the etiology of conduct disorders, little is yet known about the actual mechanisms involved in genetic transmission. One study found that regions on chromosomes 19 and 2 may contain genes conferring risk to conduct disorder (Dick et al, 2004). In this study, the same region on chromosome 2 was also linked to alcohol dependence. These researchers report that childhood conduct disorder is known to be associated with the susceptibility for future alcohol problems. They have concluded that these findings suggest that some of the genes contributing to alcohol dependence in adulthood may also contribute to conduct disorder in childhood.

Temperament The term temperament refers to personality traits that become evident very early in life and may be present at birth. Evidence suggests a genetic component in temperament and an association between temperament and behavioral problems later in life. Studies have shown that, without appropriate intervention, difficult temperament at age 3 has significant links to conduct disorder and movement into care or institutional life at age 17 (Bagley & Mallick, 2000). Biochemical Factors Researchers have investigated various chemicals as biological markers. Alterations in the neurotransmitters norepinephrine and serotonin have been suggested by some studies (Comings et al, 2000; Searight, Rottnek, & Abby, 2001). Some investigators have examined the possibility of testosterone association with violence. One study correlates higher levels of testosterone in pubertal boys with social dominance and association with deviant peers (Rowe et al, 2004). Psychosocial Influences Peer Relationships Social groups have a significant impact on a childs development. Peers play an essential role in the socialization of interpersonal competence, and skills acquired in this manner affect the childs long-term adjustment. Studies have shown that poor peer relations during childhood were consistently implicated in the etiology of later deviance (Ladd, 1999). Aggression was found to be the principal cause of peer rejection, thus contributing to a cycle of maladaptive behavior. .

Family Influences The following factors related to family dynamics have been implicated as contributors in the predisposition to this disorder (Foley et al, 2004; Sadock & Sadock, 2007; Ursano et al, 2008): Parental rejection Inconsistent management with harsh discipline Early institutional living Frequent shifting of parental figures Large family size Absent father Parents with antisocial personality disorder and/or alcohol dependence Marital conflict and divorce Inadequate communication patterns Parental permissiveness

4.

List down the Signs and Symptoms of Conduct Disorder

1. Aggression to people and animals a. Often bullies, threatens, or intimidates others. b. Often initiates physical fights. c. Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun) d. Has been physically cruel to people. e. Has been physically cruel to animals. f. Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery). g. Has forced someone into sexual activity. 2. Destruction of property a. Has deliberately engaged in fire setting with the intention of causing serious damage.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed.) Text revision. Washington, DC: American Psychiatric Publishing

b. Has deliberately destroyed others property (other than by fire setting). 3. Deceitfulness or theft a. Has broken into someone elses house, building, or car. b. Often lies to obtain goods or favors or to avoid obligations (i.e., cons others). c. Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery). 4. Serious violations of rules a. Often stays out at night despite parental prohibitions, beginning before age 13 years. b. Has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period). c. Is often truant from school, beginning before age 13 years. B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning. C. If the individual is age 18 years or older, criteria are not met for antisocial personality disorder.

5. Application of the

Nursing Process to Conduct Disorder

Background Assessment Data (Symptomatology) The classic characteristic of conduct disorder is the use of physical aggression in the violation of the rights of others. The behavior pattern manifests itself in virtually all areas of the childs life (home, school, with peers, and in the community). Stealing, lying, and truancy are common problems. The child lacks feelings of guilt or remorse.

The use of tobacco, liquor, or nonprescribed drugs, as well as the participation in sexual activities, occurs earlier than at the expected age for the peer group. Projection is a common defense mechanism. Low self-esteem is manifested by a tough guy image. Characteristics include poor frustration tolerance, irritability, and frequent temper outbursts. Symptoms of anxiety and depression are not uncommon. Level of academic achievement may be low in relation to age and IQ. Manifestations associated with ADHD (e.g., attention difficulties, impulsiveness, and hyperactivity) are very common in children with conduct disorder. Diagnosis/Outcome Identification Based on the data collected during the nursing assessment, possible nursing diagnoses for the client with conduct disorder include: Risk for other-directed violence related to characteristics of temperament, peer rejection, negative parental role models, and dysfunctional family dynamics. Impaired social interaction related to negative parental role models and impaired peer relations leading to inappropriate social behaviors. Defensive coping related to low self-esteem and dysfunctional family system. Low self-esteem related to lack of positive feedback and unsatisfactory parent/child relationship. Outcome Criteria Outcome criteria include short- and long-term goals. Timelines are individually determined. The following criteria may be used for measurement of outcomes in the care of the client with conduct disorder: The Client: Has not harmed self or others.

 Interacts with others in a socially appropriate manner. Accepts direction without becoming defensive. Demonstrates evidence of increased self-esteem by discontinuing exploitative and demanding behaviors toward others. Planning/Implementation On the next sheet provides a plan of care for the child with conduct disorder using nursing diagnoses common to the disorder, outcome criteria, and appropriate nursing interventions and rationales. Evaluation Following the planning and implementation of care, evaluation is made of the behavioral changes in the child with conduct disorder. This is accomplished by determining if the goals of therapy have been achieved. Reassessment, the next step in the nursing process, may be initiated by gathering information using the following questions. Have the nursing actions directed toward managing the clients aggressive behavior been effective? Have interventions prevented harm to others or others property? Is the client able to express anger in an appropriate manner? Has the client developed more adaptive coping strategies to deal with anger and feelings of aggression? Does the client demonstrate the ability to trust others? Is he or she able to interact with staff and peers in an appropriate manner? Is the client able to accept responsibility for his or her own behavior? Is there less blaming of others? Is the client able to accept feedback from others without becoming defensive? Is the client able to verbalize positive statements about self? Is the client able to interact with others withoutengaging in manipulation?

NURSING DIAGNOSIS: RELATED TO:

RISK FOR OTHER-DIRECTED VIOLENCE Characteristics of temperament, peer rejection, negative parental role models, dysfunctional family dynamics

Outcome COUTCOME CRITERIA Short-Term Goal Client will discuss feelings of anger with nurse or therapist.

NURSING INTEVENTIONS 1. Observe clients behavior frequently through routine activities and interactions. Become aware of behaviors that indicate a rise in agitation. 2. Redirect violent behavior with physical outlets for suppressed anger and frustration. Encourage client to express anger and act as a role model for appropriate expression of anger.

RATIONALE 1. Recognition of behaviors that precede the onset of aggression may provide the opportunity to intervene before violence occurs. 2. Excess energy is released through physical activities inducing a feeling of relaxation. Discussion of situations that create anger may lead to more effective ways of dealing with them. This conveys an evidence of control over the situation and provides physical security for staff. It is the clients right to expect the use of techniques that ensure safety of the client and others by the least restrictive means.

Long-Term Goal Client will not harm others or others property. 3.

3.

4. Ensure that a sufficient number of staff is available to indicate a show of strength if necessary. 5. Administer tranquilizing medication, if ordered, or use mechanical restraints or isolation room only if situation cannot be controlled with less restrictive means.

4.

5.

NURSING DIAGNOSIS: IMPAIRED SOCIAL INTERACTION RELATED TO: Negative parental role models; impaired peer relations leading to inappropriate social behavior NURSING INTEVENTIONS 1. Develop a trusting relationship with the client. Convey acceptance of the person separate from the unacceptable behavior. 2. Long-Term Goal Client will be able to interact with staff and peers using age-appropriate, acceptable behaviors. Discuss with client which behaviors are and are not acceptable. Describe in matter-of-fact manner the consequence of unacceptable behavior. Follow through. RATIONALE 1. Unconditional acceptance increases feeling of self-worth.

Outcome COUTCOME CRITERIA Short-Term Goal Client will interact in age-appropriate manner with nurse in one-to-one relationship within 1 week.

2.

Aversive reinforcement can alter or extinguish undesirable behaviors.

3. Provide group situations for client.

3. Appropriate social behavior is often learned from the positive and negative feedback of peers.

NURSING DIAGNOSIS: DEFENSIVE COPING RELATED TO: Low self-esteem and dysfunctional family system

OUTCOME CRITERIA Short-Term Goal Client will verbalize personal responsibility for difficulties experienced in interpersonal relationships within (time period reasonable for client). Long-Term Goal Client will accept responsibility for own behaviors and interact with others without becoming defensive.

NURSING INTEVENTIONS 1. Explain to client the correlation between feelings of inadequacy and the need for acceptance from others and how these feelings provoke defensive behaviors, such as blaming others for own behaviors. 2. Provide immediate, matter-of-fact, nonthreatening feedback for unacceptable behaviors.

RATIONALE 1. Recognition of the problem is the first step in the change process toward resolution.

2. Client may not realize how these behaviors are being perceived by others.

3. Help identify situations that provoke defensiveness and practice through role-play more appropriate responses. 4. Provide immediate positive feedback for acceptable behaviors.

3. Role-playing provides confidence to deal with difficult situations when they actually occur.

4. Positive feedback encourages repetition, and immediacy is significant for these children who respond to immediate gratification.

NURSING DIAGNOSIS: LOW SELF-ESTEEM RELATED TO: Lack of positive feedback and unsatisfactory parent/child relationship NURSING INTEVENTIONS 1. Ensure that goals are realistic. Short-Term Goal 2. Client will participate in own self-care and discuss with nurse aspects of self about which he or she feels good. 3. Long-Term Goal Client will demonstrate increased feelings of self-worth by verbalizing positive statements about self and exhibiting fewer manipulative behaviors. Plan activities that provide opportunities for success. Convey unconditional acceptance and positive regard. RATIONALE 1. Unrealistic goals set client up for failure, which diminishes self-esteem. 2. Success enhances self-esteem.

OUTCOME CRITERIA

3.

Communicating that client is a worthwhile human being may increase self-esteem.

4. Set limits on manipulative behavior. Take caution not to reinforce manipulative behaviors by providing desired attention. Identify the consequences of manipulation. Administer consequences matter-of-factly when manipulation occurs. 5. Help client understand that he or she uses this behavior in order to try to increase own self-esteem. Interventions should refl ect other actions to accomplish this goal.

4. Aversive consequences may work to decrease unacceptable behaviors.

5. When the client feels better about self, the need to manipulate others will diminish.