An 11-year-old boy is brought to the psychiatrist by his mother for an evaluation as mandated by his school. The patient was recently suspended from school and will not be allowed back until he is evaluated by a psychiatrist. The mother is interviewed alone, and the patient is asked to wait in the waiting room. His mother reports that there has been a series of incidents at school where other children have accused her son of bullying them. The patient has had behavioral troubles in school since kindergarten where he would get up out of his seat and walk around class pinching other children. She reports that her son is a “very intelligent” boy who “refuses to apply himself” in his studies. He has always had difficulty completing assignments on time, remembering to turn in assignments, and has resisted doing homework. She reports that the patient is prone to violent outbursts where he screams at his mother and that he recently threatened her with a kitchen knife when she attempted to set boundaries. The last time mother cleaned his room she noticed that he had several pairs of sneakers that she did not purchase for him.
C) Conduct disorder
Conduct disorder is a behavioral disorder with a persistent pattern of violating rules and basic human rights. There must be at least three of the following behaviors: bullies/threatens/intimidates people, causes physical fights, has used a weapon to cause harm to a person, has been physically cruel to people/animals, steals or robs (with and without confronting the victim), rapes, destroyed property, has destroyed property by burning, has broken into personal property, runs away (must be twice), violates curfew before age 13, and truancy from school. These behaviors must have been present for at least twelve months with one of those behaviors occurring within the last six months. This constellation of behaviors must cause impairment in social functioning.
In this vignette, the boy’s behaviors have been present since kindergarten, and his last behavior is within the last six months. He shows a persistent pattern of aggression, dishonesty, theft, and violation of rules which has led to his suspension from school. He is bullying at school and home, he is physically cruel, he has threatened his mother with a knife, and he is stealing. In pediatrics populations, social functioning is measured by school performance, ability to make friends, and getting along with family.
Answer choice A: Antisocial personality disorder, is incorrect. Antisocial personality disorder cannot be diagnosed before the age of 18.
Answer choice B: Bipolar 2 disorder, is incorrect. Bipolar 2 disorder is a mood disorder characterized by depressive and hypomanic episodes. In childhood, bipolar can present primarily as irritability; however, there is no indication that the boy’s aggressive episodes are a connected to episodes of a mood disorder.
Answer choice D: Oppositional defiant disorder, is incorrect. Oppositional defiant disorder is a pattern of behavior which includes argumentative/defiant behavior and vindictiveness with or without an angry/irritable mood. Oppositional defiant disorder often precedes conduct disorder, and it is significantly less severe than conduct disorder. Oppositional defiant disorder does not include aggression towards people/animals, destruction of property, theft, and deceit.
Answer choice E: Intermittent explosive disorder, is incorrect. In this vignette, the patient does have impulsive aggressive outbursts; however, they are instrumental and used to manipulate.
Key Learning Point
Conduct disorder is a pattern of behavior which includes aggression, destruction of property, deceitfulness or theft, and/or serious violations of rules.
