Application of the Nursing Process: Conduct Disorder

APPLICATION OF THE NURSING PROCESS: CONDUCT DISORDER

Assessment

History

Children with conduct disorder have a history of disturbed relationships with peers, aggression toward people or animals, destruction of property, deceitfulness or theft, and serious violation of rules (e.g., truancy, running away from home, and staying out all night without permission). The behaviors and problems may be mild to severe.

General Appearance and Motor Behavior

Appearance, speech, and motor behavior are typically nor-mal for the age group but may be somewhat extreme (e.g., body piercings, tattoos, hairstyle, and clothing). These clients often slouch and are sullen and unwilling to be interviewed. They may use profanity, call the nurse or physician names, and make disparaging remarks about parents, teachers, police, and other authority figures.

Mood and Affect

Clients may be quiet and reluctant to talk or openly hostile and angry. Their attitude is likely to be disrespectful toward parents, the nurse, or anyone in a position of authority. Irritability, frustration, and temper outbursts are common. Clients may be unwilling to answer questions or to coop-erate with the interview; they believe they do not need help or treatment. If a client has legal problems, he or she may express superficial guilt or remorse, but it is unlikely that these emotions are sincere.

Thought Process and Content

Thought processes are usually intact—that is, clients are capable of logical rational thinking. Nevertheless, they perceive the world to be aggressive and threatening, and they respond in the same manner. Clients may be preoc-cupied with looking out for themselves and behave as though everyone is “out to get me.” Thoughts or fantasies about death or violence are common.

Sensorium and Intellectual Processes

Clients are alert and oriented with intact memory and no sensory-perceptual alterations. Intellectual capacity is not impaired, but typically these clients have poor grades because of academic underachievement, behavioral prob-lems in school, or failure to attend class and to complete assignments.

Judgment and Insight

Judgment and insight are limited for developmental stage. Clients consistently break rules with no regard for the conse-quences. Thrill-seeking or risky behavior is common, such as use of drugs or alcohol, reckless driving, sexual activity, and illegal activities such as theft. Clients lack insight and usually blame others or society for their problems; they rarely believe their behavior is the cause of difficulties.

Self-Concept

Although these clients generally try to appear tough, their self-esteem is low. They do not value themselves any more than they value others. Their identity is related to their behaviors such as being cool if they have had many sexual encounters or feeling important if they have stolen expen-sive merchandise or been expelled from school.

Roles and Relationships

Relationships with others, especially those in authority, are disruptive and may be violent. This includes parents, teachers, police, and most other adults. Verbal and physi-cal aggression is common. Siblings may be a target for ridi-cule or aggression. Relationships with peers are limited to others who display similar behaviors; these clients see peers who follow rules as dumb or afraid. Clients usually have poor grades, have been expelled, or have dropped out. It is unlikely that they have a job (if old enough) because they would prefer to steal. Their idea of fulfilling roles is being tough, breaking rules, and taking advantage of others. 

Physiologic and Self-Care Considerations

Clients are often at risk for unplanned pregnancy and sexually transmitted diseases because of their early and frequent sexual behavior. Use of drugs and alcohol is an additional risk to health. Clients with conduct disorders are involved in physical aggression and violence including weapons; this results in more injuries and deaths than compared with others of the same age.

Data Analysis and Planning

Nursing diagnoses commonly used for clients with con-duct disorders include the following:

·    Risk for Other-Directed Violence

·    Noncompliance

·    Ineffective Coping

·    Impaired Social Interaction

·    Chronic Low Self-Esteem

Outcome Identification

Treatment outcomes for clients with conduct disorders may include the following:

·    The client will not hurt others or damage property.

·    The client will participate in treatment.

The client will learn effective problem-solving and coping skills.

·    The client will use age-appropriate and acceptable behaviors when interacting with others.

·    The client will verbalize positive, age-appropriate state-ments about self.

Intervention

Decreasing Violence and Increasing Compliance with Treatment

The nurse must protect others from the manipulative or aggressive behaviors common with these clients. He or she must set limits on unacceptable behavior at the beginning of treatment. Limit setting involves three steps:

·    Inform clients of the rule or limit.

·    Explain the consequences if clients exceed the limit.

State expected behavior.

Providing consistent limit enforcement with no excep-tions by all members of the health team, including parents, is essential. For example, the nurse might say,

“It is unacceptable to hit another person. If you are angry, tell a staff person about your anger. If you hit someone, you will be restricted from recreation time for 24 hours.” 

For limit setting to be effective, the consequences must have meaning for clients—that is, they must value or desire recreation time (in this example). If a client wanted to be alone in his or her room, then this consequence would not be effective.

The nurse can negotiate with a client a behavioral contract outlining expected behaviors, limits, and rewards to increase treatment compliance. The client can refer to the written agreement to remember expectations, and staff can refer to the agreement if the client tries to change any terms. A contract can help staff to avoid power strug-gles over requests for special favors or attempts to alter treatment goals or behavioral expectations.

Whether there is a written contract or treatment plan, staff must be consistent with these clients. They will attempt to bend or break rules, blame others for noncompliance, or make excuses for behavior. Consistency in following the treatment plan is essential to decrease manipulation.

Time-out is retreat to a neutral place so clients can regain self-control. It is not a punishment. When a cli-ent’s behavior begins to escalate, such as when he or she yells at or threatens someone, a time-out may prevent aggression or acting out. Staff may need to institute a time-out for clients if they are unwilling or unable to do so. Eventually, the goal is for clients to recognize signs of increasing agitation and take a self-instituted time-out to control emotions and outbursts. After the time-out, the nurse should discuss the events with the client. Doing so can help clients to recognize situations that trigger emotional responses and to learn more effective ways of dealing with similar situations in the future. Providing positive feedback for successful efforts at avoiding aggres-sion helps to reinforce new behaviors for clients.

It helps for clients to have a schedule of daily activities, including hygiene, school, homework, and leisure time. Clients are more likely to establish positive habits if they have routine expectations about tasks and responsibilities. They are more likely to follow a daily routine if they have input concerning the schedule.

Improving Coping Skills and Self-Esteem

The nurse must show acceptance of clients as worthwhile persons even if their behavior is unacceptable. This means that the nurse must be matter-of-fact about setting limits and must not make judgmental statements about clients. He or she must focus only on the behavior. For example, if a client broke a chair during an angry outburst, the nurse would say, “John, breaking chairs is unacceptable be-havior. You need to let staff know you’re upset so you can talk about it instead of acting out.”

The nurse must avoid saying things like,

“What’s the matter with you? Don’t you know any better?”

Comments such as these are subjective and judgmental and do not focus on the specific behavior; they reinforce the client’s self-image as a “bad person.”

Clients with a conduct disorder often have a tough exterior and are unable or reluctant to discuss feelings and emotions. Keeping a diary may help them to identify and express their feelings. The nurse can discuss these feelings with clients and explore better, safer expressions than through aggression or acting out.

Clients also may need to learn how to solve problems effectively. Problem solving involves identifying the prob-lem, exploring all possible solutions, choosing and imple-menting one of the alternatives, and evaluating the results . The nurse can help clients to work on actual problems using this process. Problem-solving skills are likely to improve with practice.

Promoting Social Interaction

Clients with conduct disorder may not have age-appropri-ate social skills, so teaching social skills is important. The nurse can role model these skills and help clients to prac-tice appropriate social interaction. The nurse identifies what is not appropriate, such as profanity and name call-ing, and also what is appropriate. Clients may have little experience discussing the news, current events, sports, or other topics. As they begin to develop social skills, the nurse can include other peers in these discussions. Posi-tive feedback is essential to let clients know they are meet-ing expectations.

Providing Client and Family Education

Parents may also need help in learning social skills, solv-ing problems, and behaving appropriately. Often, parents have their own problems, and they have had difficulties with the client for a long time before treatment was insti-tuted. Parents need to replace old patterns such as yelling, hitting, or simply ignoring behavior with more effective strategies. The nurse can teach parents age-appropriate activities and expectations for clients such as reasonable curfews, household responsibilities, and acceptable behav-ior at home. The parents may need to learn effective limit setting with appropriate consequences. Parents often need to learn to communicate their feelings and expectations clearly and directly to these clients. Some parents may need to let clients experience the consequences of their behavior rather than rescuing them. For example, if a cli-ent gets a speeding ticket, the parents should not pay the fine for him or her. If a client causes a disturbance in school and receives detention, the parents can support the teacher’s actions instead of blaming the teacher or school.

Evaluation

Treatment is considered effective if the client stops behav-ing in an aggressive or illegal way, attends school, and fol-lows reasonable rules and expectations at home. The cli-ent will not become a model child in a short period; instead, he or she may make modest progress with some setbacks over time.