Conduct Disorder

8 Interesting Facts of Conduct Disorder 

1. Conduct disorder is a disruptive behavior disorder characterized by a repetitive and persistent pattern of aggressive, defiant, or antisocial behaviors that violates the basic rights of others or societal rules, leading to a significant impairment in social, academic, or occupational life
2. Emerges during childhood or adolescence and presents with variable (in number and severity) antisocial behaviors, such as aggressiveness causing physical harm to other people or to animals, destruction of property, theft, deceitfulness, and serious violations of parental or societal rules
   • Callous-unemotional traits (eg, absence of guilt or remorse, lack of emotional empathy, unconcern about performance, and a shallow manifestation of affect) are observed in a minority of children and adolescents, frequently in those affected by severe conduct disorder with onset during childhood
3. Diagnosis is based on DSM-5 criteria, which require 3 or more of the typical symptoms, observed during a period of 12 months, with at least 1 symptom present in the past 6 months 
4. Comorbid psychiatric conditions frequently associated with conduct disorder include oppositional defiant disorder, attention-deficit/hyperactivity disorder, and mood disorders such as depression and bipolar disorder
5. Treatment should address not only the child’s or adolescent’s problematic behavior but also any family, school, and wider social environment problems
6. Various psychosocial interventions are available for children, adolescents, and their families including parent management training, cognitive behavioral therapy, and social and emotional learning techniques; therapeutic foster care or pharmacologic therapy may be necessary in severe cases
7. Adverse outcomes of conduct disorder in childhood and/or adolescence may include school suspension/expulsion, alienation, physical injury from accidents or fights, and early onset of sexual behaviors with a higher incidence of sexually transmitted diseases and unplanned pregnancies
8. Development of antisocial personality disorder in adulthood occurs in up to 50% of affected patients and is associated with a poor prognosis, including difficulties in interpersonal relationships; employment problems; increased misuse of alcohol, tobacco, and drugs; contact with the criminal justice system because of illegal behaviors; and increased mental health issues

Pitfalls

• Few young children with conduct problems receive effective help, which results from a lack of both parental awareness of and accessibility to therapeutic interventions
• It is important to counsel patients about risks of their behavior, such as unprotected sex, membership in a gang, and violent confrontations

• Conduct disorder is a disruptive behavior disorder characterized by a repetitive and persistent pattern of aggressive, defiant, or antisocial behaviors that violate the basic rights of others or societal norms or rules
• To qualify as conduct disorder, the behaviors must:
  • Occur more frequently and persistently than what is typically observed in people of comparable age, sex, culture, and developmental level 
  • Lead to a significant impairment in a person’s social, academic, or occupational life 

Classification

• Classification based on age of onset
  • Onset during early childhood 
    • Child shows at least 1 characteristic symptom before age 10 years
    • Boys are affected more often than girls
  • Onset during adolescence
    • Child shows no characteristic symptoms before age 10 years
    • Boys and girls are affected equally
  • Unspecified onset
    • Diagnostic criteria are met, but there is insufficient information to determine whether symptoms first occurred before or after age 10 years
• Classification based on severity
  • Mild
    • Characterized by few, if any, conduct problems in excess of those required to make the diagnosis
    • Conduct problems cause relatively minor harm to others (eg, lying, truancy, staying out after curfew without permission, breaking other rules)
  • Moderate
    • Characterized by an intermediate number of conduct problems in excess of those required to make the diagnosis (between those of a mild and severe presentation)
    • Effects on others are also classified as intermediate (eg, stealing without confronting the victim, vandalism)
  • Severe
    • Characterized by many conduct issues in excess of those required to make the diagnosis 
    • Conduct problems cause considerable harm to others (eg, forced sex act, physical cruelty, use of a weapon, stealing with confrontation of the victim, breaking and entering) 
    • Includes a persistent and treatment-resistant subtype, characterized by distinct genetic, cognitive, emotional, biological, environmental, and personality features 
      • Patients exhibit elevated callous-unemotional traits (also defined as limited prosocial emotions by the DSM-5) in addition to serious conduct problems

Clinical Presentation of Conduct Disorder

History

• Most often, symptoms emerge between middle childhood and middle adolescence; however, some symptoms may begin as early as preschool years 
• Presentation is heterogeneous and includes a wide variety of antisocial behaviors (eg, violent acts against people and/or animals, property destruction, deceitfulness or theft, other serious rule violations), with at least 1 of the following common characteristics: 
  • Repetitive and persistent disregard for and violations of the basic rights of others
  • Excessive noncompliance with socially and culturally defined norms
  • Oppositional or inappropriately aggressive responses to situations
    • The aggressive patient frequently misperceives intentions of others as more hostile and threatening than they actually are and responds with aggression that they feel is reasonable and justified 
  • Antisocial behavior types include the following:
    • Aggressive antisocial behavior: a stable behavioral trait that emerges in early childhood and is associated with high levels of neuroticism
    • Nonaggressive antisocial behavior: more moderate level of stability; it is most frequent during adolescence and demonstrates association with impulsivity
• Presentation is usually gradual, with less serious symptoms emerging first (eg, lying, shoplifting), and more severe conduct problems manifesting last (eg, theft while confronting a victim) 
• Symptoms differ between boys and girls
  • Boys tend to exhibit both physical and relational aggression (ie, behavior that harms social relationships with peers) 
    • Frequently includes fighting, stealing, vandalism, breaking and entering, staying out late, and school discipline problems 
  • Girls tend to exhibit relatively more relational aggression (ie, covert-aggressive behavior) 
    • Behavior often includes nonconfrontational stealing, lying, truancy, running away, substance use, and prostitution 
• Minority of patients exhibit callous-unemotional traits (also referred to as limited prosocial emotions), which are a significant predictor of a more severe treatment-resistant type of conduct disorder. These traits include the following: 
  • Lack of remorse or guilt
  • Lack of concern about negative consequences of actions
  • Lack of emotional empathy (eg, callous, cold, uncaring)
  • Lack of concern about performance in important activities (eg, schoolwork)
  • Blames others for poor performance
  • Shallow or deficient affect (eg, does not express feelings or show emotions, or may seem insincere or manipulative)
• Co-occurring personality features may also include the following:
  • Negative emotional traits (eg, suspicion, anger, anxiety, hostility) 
  • Diminished responses to negative emotions in others (eg, signs of distress, fear in others) 
  • Poor self-control (eg, frustration intolerance, irritability, temper outbursts) 
  • Insensitive to punishment, especially when patient is motivated by reward, not punishment 
  • Fearless, thrill-seeking, reckless personality 

Physical examination

• Does not reveal any abnormal findings

What causes Conduct Disorder?

• Wide variety of reciprocal interacting biological, psychological, and social factors are believed to contribute to development and maintenance of conduct disorder, including: 
  • Perinatal exposures
  • Home environment
  • Parenting factors
  • Socioeconomic factors
  • Neurodevelopmental factors

Risk factors and/or associations

Age

• Overall prevalence in adolescents is 6.8%; rates increase to 9.6% among older adolescents (aged 17-18 years) 
  • Onset is rare after age 16 years 

Sex

• More common among boys than girls during childhood, but sex difference progressively narrows as age increases 
  • Childhood onset antisocial behaviors: 10:1 to 15:1 male to female ratio 
  • Adolescent onset of antisocial behaviors: 1.5:1 to 5:1 male to female ratio 

Genetics

• Genetic component has been hypothesized; family history is often reported in people with childhood-onset conduct disorder 

Ethnicity/race

• Prevalence is fairly consistent across different races and ethnic groups 

Other risk factors/associations

• Inherited characteristics (eg, low IQ, poor verbal skills, impaired executive functioning) 
• Adverse environmental circumstances
  • Living in poverty, living in disorganized neighborhoods, attending schools with reduced financial resources, associating with a delinquent peer group, and living in an institution when young 
  • Having parents who impose harsh discipline, provide inadequate or ineffective supervision, or have inconsistent child-rearing practices 
  • Family problems, including physical or sexual abuse, parental rejection and neglect (including perceived), frequent changes of caregivers, large family size, parental criminality, family breakdown, and parental psychopathology
• Substance use by biological parents 
  • Prenatal alcohol exposure (maternal equivalent of drinking 1 or more alcoholic drinks per day) during the first trimester significantly increases the likelihood of conduct disorder in adolescence 
  • Prenatal tobacco exposure (mother smoking a half pack of cigarettes or more per day) during the first trimester has been shown to marginally increase the risk of conduct disorder in adolescence 
• Biological parent history of depressive or bipolar disorders, schizophrenia, attention-deficit/hyperactivity disorder, or conduct disorder 
  • Estimated 31.3% of adolescents with conduct disorder have parents with multiple psychiatric illnesses 
  • Approximately 8.9% of adolescents with conduct disorder have parents who do not have a psychiatric disorder 
  • In boys, exposure to maternal pre- or postnatal depression and anxiety is associated with increased risk of developing conduct disorder by age 16 years 
• Poor theory of mind and social communication deficits (eg, those found in autism spectrum disorders) 
• Oppositional defiant disorder in childhood 
• Co-occurring attention-deficit/hyperactivity disorder and substance use have been shown to increase risk of conduct disorder; persistence is associated with childhood-onset conduct disorder 
• Subclinical bulimia has been shown to be a risk factor in middle-adolescent girls 
• Facial emotion recognition deficits 
• Certain childhood behaviors (eg, hyperactivity, fearlessness, unhelpfulness) are associated with a higher risk in boys than girls 
  • Boys have a significant risk for conduct disorder if they are hyperactive; hyperactive and unhelpful; or hyperactive, unhelpful, and fearless
  • Girls have a significant risk for conduct disorder only if they are both hyperactive and unhelpful
• Specific disruptive behaviors are different from normative in preschool-aged children, particularly when manifesting with high intensity, and are predictors of conduct disorder that persists into school-aged years: 
  • Argumentative/defiant behavior (high intensity)
  • Aggression toward people or animals (low and high intensity)
  • Destruction of property (high intensity)
  • Problems with peers (high intensity)
  • Deceitfulness/stealing (high intensity)
  • Vindictiveness
  • Inappropriate sexual behavior: 76% of children aged 6 to 12 years who show inappropriate sexual behaviors met the criteria for conduct disorder 
• Children with disruptive behavior that manifests by age 5 years have a 20-fold increased risk of conduct disorder diagnosis at age 7 years. These children have an increased risk for attention-deficit/hyperactivity disorder, aggression, delinquency, and emotional/educational impairments at age 10 years 

How is Conduct Disorder diagnosed?

Primary diagnostic tools

• Base diagnosis on a reliable clinical history obtained at diagnostic interview
  • Gather all possible useful information from a range of sources—family and caregivers, school, other agencies if available, as well as the children themselves—to obtain a full picture of the behavioral problems 
    • Use various sources, especially those who have known the child for extended periods, to estimate time of onset and possible environmental variation
  • Ask parents, teachers, and/or caregivers about child’s interpersonal skills and methods of conflict negotiation (eg, ask for a description of oppositional behavior they have experienced or witnessed)
  • Ask parents, teachers, and/or caregivers about peer interactions (eg, on the playground) and directly observe these interactions, if possible, to understand the child’s distorted social skills 
  • Obtain school reports that cover impact of the behavior in the classroom, child’s academic strengths and weaknesses, and presence or suspicion of specific learning difficulties 
  • Ask child for their perspective (self-report), which is crucial both for a complete account of the behavior and to understand family dynamics or other problems that may exacerbate the behavior 
  • Ask all involved parties for a detailed report about a specific recent episode of difficult behavior (ie, a blow-by-blow account); it is useful to help understand how difficult behaviors arise and what attempts are made to resolve them 
  • Ask parents, teachers, and/or caregivers about symptoms of possible comorbid conditions (eg, attention-deficit/hyperactivity disorder, anxiety, depression) 
  • Ask parents or caregivers about family history of psychiatric conditions, substance use, and contact with criminal justice system
  • Ask parents or caregivers about earlier medical history, in particular, prenatal history, and neurodevelopmental delays
  • Assess social and family risk factors for conduct disorder (eg, physical or sexual abuse)
• Assess family relationships and parenting styles
  • Observe parents and child when engaged in a joint task (eg, tidying up toys), if possible in a clinical setting
  • Pay particular attention to parental discord, especially in how parents respond to child’s behavior
    • It is important to elicit information about discord as it may not be obvious if only 1 parent attends
    • Ascertain whether parents and other caregivers have a consistent approach to child’s challenging behavior
  • Gain an overall view of the affective tone of family interactions
    • Look for evidence of warmth, approval, and sensitivity to child’s needs
    • Be vigilant for possible indicators of neglect and maltreatment
• Psychometric assessment is often helpful but not required
  • Various scales are used, including Child Behavior Checklist, Strengths and Difficulties Questionnaire, and Conduct Disorder Rating Scale 
    • Look for evidence of callous-unemotional traits using a variety of scales, including Inventory of Callous-Unemotional Traits 
• Diagnosis is made if patient meets criteria defined by the DSM-5, which includes the following: 
  • Presence of 3 or more of the following 15 criteria (from any of the 4 main behavioral groupings listed), observed during the past 12 months, with at least 1 criterion present in the past 6 months: 
    • Aggressive behavior that causes or threatens physical harm to other people or to animals
      • Often bullies, threatens, or intimidates others
      • Frequently initiates physical fights
      • Has used a weapon that can cause serious physical harm to others (eg, bat, brick, broken bottle, knife, gun)
      • Has been physically cruel to people
      • Has been physically cruel to animals
      • Has stolen while confronting the victim (eg, mugging, purse snatching, extortion, armed robbery)
      • Has forced someone into sexual activity
    • Nonaggressive behavior that causes destruction of property
      • Has deliberately destroyed other people’s property by setting fires or by other means (eg, smashing car windows, vandalizing school property)
    • Deceitfulness or theft
      • Has broken into someone else’s property (eg, house, shed, car)
      • Often lies for personal gain (ie, so-called conning behavior)
      • Has stolen items of nontrivial value without confronting the victim (eg, shoplifting, forgery, fraud)
    • Serious violation of rules
      • Often stays out at night despite parental prohibition (beginning before age 13 years) 
      • Has run away from home while living with parents or parental surrogates: overnight at least twice or once without returning for an extended period
      • Is often truant from school (beginning before age 13 years) 
  • The behavioral disturbances cause clinically significant impairment in social, academic, or occupational functioning 
  • If patient is aged 18 years or older, the criteria are not met for antisocial personality disorder 
  • Presence or absence of callous-unemotional traits/limited prosocial emotions (considered a specifier of diagnosis): 
    • To qualify, child or adolescent must have displayed at least 2 defining behaviors listed here, in multiple relationships and settings, and persistently over at least 12 months: 
      • Lack of remorse or guilt
        • Shows general lack of concern about negative consequences of their actions 
        • Does not feel bad or guilty when they do something wrong 
          • Does not include cases in which remorse is expressed only when the patient is caught and/or is facing punishment
      • Callousness (ie, lack of empathy)
        • Is cold and uncaring, disregarding of and unconcerned about the feelings of others, even when their actions result in substantial harm to others 
          • Appears more concerned about effects of one’s actions on oneself
      • Unconcern about performance
        • Does not show concern about poor or problematic performance at school, at work, or in other important activities 
        • Does not try to perform well, even when expectations are clear 
          • Typically blames others for poor performance
      • Shallow or deficient affect
        • Either does not express feelings or show emotions toward others or expresses them in ways that seem shallow, insincere, or superficial (eg, actions contradict emotion displayed; can turn emotions on and off quickly) 
          • Often expresses emotions for personal gain (eg, to manipulate or intimidate others)
• It is important to discriminate between excessive and age-inappropriate oppositional or antisocial behaviors and normal oppositional behaviors that emerge during children’s psychosocial development and that are an important part of their growing sense of individualization and autonomy 
  • Also important to identify context in which the behaviors have occurred (eg, in some settings, such as in threatening and crime-ridden areas or in war zones, patterns of disruptive behavior are viewed as near normative) 

Other diagnostic tools

• Child Behavior Checklist
  • Questionnaire for parents or teachers of patients aged 6 to 18 years
  • Consists of 118 questions that describe specific behavioral and emotional problems across a range of scales 
• Strengths and Difficulties Questionnaire
  • General psychosocial screening test appropriate for ages 3 to 17 years
  • Consists of 25 questions that may be completed by parent, teacher, or adolescent (aged 11-16 years)
• Eyberg Child Behavior Inventory
  • 36-item parent-report questionnaire appropriate for ages 2 to 16 years
  • Assesses disruptive behavior exhibited by young children
    • A variant and companion measure tool, the Sutter-Eyberg Student Behavior Inventory is a 38-item screening test for teachers to use to assess conduct problems in the classroom
• Conduct Disorder Rating Scale
  • 40-item questionnaire for parents, teachers, or siblings aged 5 to 22 years
  • Rates disruptive behavior symptoms
  • Able to assess the DSM-5 definition of conduct disorder
• National Institute of Mental Health Diagnostic Interview Schedule for Children Version IV 
  • Structured diagnostic interview that can be used to assess for a variety of behavioral, affective, and substance use disorders in patients aged 6 to 18 years
  • Branching tree questionnaire with parent and adolescent versions
• Antisocial Process Screening Device
  • Can be used to assess callous-unemotional traits in relatively young children (starting from age 6 years) but not in preschool-aged children 
  • 20-item behavior rating scale questionnaire ranging across 3 dimensions (ie, narcissism, impulsivity, callous-unemotional subscales); to evaluate presence of callous-unemotional traits, only the specific subscale is used 
  • For parents, teachers, or self-report 
• Inventory of Callous-Unemotional Traits
  • 24-item questionnaire to measure callous-unemotional traits; appropriate for ages 5 to 18 years
  • For parents or self-report 
  • Provides a more comprehensive assessment of callous-unemotional traits than the Antisocial Process Screening Device, from which it is derived 
• Youth Psychopathic Traits Inventory
  • Used in late childhood or adolescence (aged 12 years and older) to assess entire core traits of the psychopathic personality, including callous-unemotional traits
  • 50-item self-report questionnaire that evaluates 10 core personality traits while defining 3 high-order factors: callous-unemotional, grandiose-manipulative, and impulsive-irresponsible 
• Child Problematic Traits Inventory
  • Recently developed to assess psychopathic personality traits in children aged 3 to 12 years
  • 28-item teacher-rated instrument that evaluates affective, interpersonal, and behavioral dimensions in 3 interrelated factor scales: callous-unemotional, grandiose-deceitful, and impulsive–need for stimulation
    • Certain personality traits in each scale have been removed to adapt the test to younger children

Differential Diagnosis

Most common

• Oppositional defiant disorder
  • Type of disruptive behavior disorder occurring during childhood 
  • Similar to conduct disorder, has a heterogeneous presentation and is characterized by a pattern of defiant, disobedient, and/or hostile behavior toward adults and authority figures (eg, parents, teachers, work supervisors) 
  • Similar to conduct disorder, patients have difficulties in social learning (ie, how to adapt behaviors to a changing environment) 
  • Differentiating features include emotional dysregulation (eg, angry or irritated mood) and absence of aggression toward people or animals, absence of destruction of property, and absence of deceitfulness or theft 
    • Antisocial behaviors of oppositional defiant disorder are usually less severe than those of conduct disorder
    • Deficits in reward and punishment processing and social learning are not present to the same extent 
  • DSM-5 diagnostic criteria for oppositional defiant disorder include frequent occurrences of at least 4 of the following that persist for 6 months or longer: 
    • Angry/irritable mood
      • Frequent loss of temper
      • Frequent touchiness and annoyance
      • Frequent anger or resentment
    • Argumentative/defiant behavior
      • Frequent arguing with authority figures or adults
      • Active defiance or refusal to comply with requests or rules of adults
      • Deliberate will to annoy others
      • Frequent blaming of others for own mistakes or misbehavior
    • Vindictiveness
      • Presence of spiteful or vindictive behavior, at least twice within the past 6 months
    • Both diagnoses can be established when the criteria for both diagnoses are met; they can be comorbid 
• Intermittent explosive disorder
  • Characterized by recurrent behavioral outbursts due to failure to control aggressive impulses
  • High rates of aggression are characteristic of both disorders, as is the association with impaired occupational and/or interpersonal functioning
  • Differentiated by impulsive aggression that is not premeditated or committed to achieve some tangible objective (eg, money, power, intimidation)
    • Additionally, intermittent explosive disorder does not include the nonaggressive symptoms of conduct disorder: destruction of property, deceitfulness or theft, and violation of rules
  • DSM-5 diagnostic criteria for intermittent explosive disorder requires 1 of the following: 
    • Verbal aggression (eg, temper tantrums, tirades, arguments, verbal fights) or physical aggression toward property, animals, or people, not causing damage or physical harm, occurring on average twice a week for 3 months
    • 3 behavioral outbursts involving damage or destruction of property and/or physical assault against people or animals, causing physical injury, occurring within a 12-month period
      • The aggressive outbursts are not attributable to another mental disorder, a medical condition (eg, head trauma, Alzheimer disease), drug use, medication misuse, or an adjustment disorder in people aged 6 through 18 years
  • If criteria for both disorders are met, diagnosis of intermittent explosive disorder is given only when the recurrent impulsive aggressive outbursts warrant independent clinical attention
• Attention-deficit/hyperactivity disorder 
  • Neurodevelopmental disorder characterized by a persistent pattern of inattention, hyperactivity, and impulsivity that interferes with functioning and development 
  • Similar to conduct disorder, children often exhibit hyperactive and impulsive behavior that may be disruptive 
  • Differentiated by the fact that the disruptive behaviors do not violate societal norms or rights of others 
  • DSM-5 diagnostic criteria for attention-deficit/hyperactivity disorder requires the following:
    • 6 or more of the following symptoms indicate inattention:
      • Difficulty sustaining attention
      • Lack of attention to details
      • Difficulty with listening skills
      • Difficulty with task completion
      • Distractibility
      • Difficulty organizing tasks and activities
      • Avoidance of or reluctance to engage in tasks that require a sustained mental effort
      • Forgetfulness
      • Frequent loss of personal belongings
    • 6 or more of the following symptoms are typical of hyperactivity and impulsivity: 
      • Fidgeting or tapping with hands or feet, or squirming in seat
      • Inability to remain seated when required
      • Running around inappropriately
      • Inability to relax and remain still
      • Inability to play quietly or engage in leisure activities
      • Talking excessively
      • Answering before a question is completed
      • Difficulty waiting for their turn
      • Frequently interrupting others
    • Persistence of symptoms for at least 6 months to a degree that is inconsistent with developmental level; symptoms have a negative impact on social, academic, and occupational activities 
      • For older adolescents and adults (aged 17 years and older), presence of at least 5 symptoms is sufficient to confirm the diagnosis
    • Both diagnoses can be established when the criteria are met for both disorders; they can be comorbid 
• Mood disorders
  • Including disruptive mood dysregulation disorder, major depressive disorder, and bipolar disorder 
  • Similar to conduct disorder, irritability, aggression, and conduct problems can manifest 
  • Typically differentiated according to the course and pattern of conduct problems observed 
    • Significant levels of aggressive or nonaggressive conduct issues manifest, specifically during periods of mood disturbance
    • Behavioral problems are not premeditated
  • DSM-5 diagnostic criteria for disruptive mood dysregulation disorder are the following:
    • Severe recurrent temper outbursts manifested verbally or behaviorally (eg, verbal rages or physical aggression toward people or property) 
      • Outbursts are out of proportion in intensity or duration to the situation or provocation
      • Outbursts are inconsistent with developmental level
      • Outbursts occur, on average, 3 or more times per week for 12 or more months
      • Mood between outbursts is persistently irritable or angry most of day, nearly every day, and is observable by others
  • DSM-5 diagnostic criteria for bipolar disorder are as follows:
    • Presence of manic (lasting 1 week or longer) or hypomanic (lasting 4 consecutive days) symptoms confirm the diagnosis
    • Inflated self-esteem or feeling of grandiosity
    • Decreased need for sleep
    • Increased talkativeness
    • Subjective experience of racing thoughts
    • Distractibility
    • Increase in goal-directed activities or excessive involvement in activities that have a high potential for negative consequences, alternating with depressive episodes lasting 2 weeks
  • DSM-5 diagnostic criteria for major depressive disorder: 
    • Depressed mood
    • Feelings of worthlessness or guilt
    • Diminished interest or pleasure in most activities
    • Diminished ability to think or concentrate
    • Insomnia
    • Psychomotor agitation or retardation
    • Fatigue and loss of energy
    • Weight loss
    • Recurrent suicidal thoughts
    • 5 or more of these symptoms need to be reported/observed for at least 2 weeks and must represent a change from previous functioning
• Adjustment disorder
  • Presents as an intermediate condition between a normal response to stress and more severe emotional disorders such as anxiety and depression 
  • Disturbance of conduct, or a mixed disturbance of emotions and conduct, can be part of the common presentation; symptoms cause a significant impairment in social and occupational life, as well as in other important areas of functioning 
  • Differentiated by symptoms developing in clear association with the onset of a psychosocial stressor 
    • In adjustment disorders, the behavior is considered to be a response to an identifiable stressor; if the stressor is removed, the behavior should improve within 6 months
    • Patient had so-called normal behavior before exposure to the stressor
  • Differentiated according to DSM-5 criteria
    • Diagnosis is confirmed when:
      • Conduct/emotional problems do not meet the criteria for another specific disorder and are not an exacerbation of a preexisting mental disorder
      • Behavioral symptoms occur within 3 months from onset of an identifiable stressor and resolve within 6 months after termination of the stressor

How is Conduct Disorder treated?

• Address the full range of the child’s difficulties at home, in school, and in the wider community 

Disposition

Admission criteria

• Children and adolescents with severe symptoms, highly delinquent adolescents (eg, violent and chronic juvenile offenders, adolescent sex offenders), and/or adolescents with substance use problems must be admitted to a residential treatment center or group home to receive intensive care
• Placement in long-term foster care is required when reunification with family members is not an option and parental rights have been terminated by the state 
• Admission to a psychiatric hospital may be necessary for children and adolescents with psychiatric symptoms (eg, comorbid depression or bipolar disorders)

Recommendations for specialist referral

• A multidisciplinary team is involved in managing children and adolescents in therapeutic foster care programs (eg, trained foster parents, family therapist, individual therapist for the child/adolescent, program supervisor) 
• Refer children and adolescents who have comorbid psychiatric symptoms to a psychiatrist

Treatment Options

Various psychosocial intervention strategies are available to treat conduct disorder 

• Treatment consists of long-term interventions (owing to the chronic course of the disorder) that target the child or adolescent behavior as well as any underlying problems occurring within the family, school, and/or social environment 
• Treatment relies on a multidisciplinary approach and is tailored to individual symptom presentation and circumstances (eg, child’s intellectual and social assets, availability of family support, presence of comorbidity) 
• Concomitant treatment of comorbid psychiatric illnesses (eg, attention-deficit/hyperactivity disorder, mood disorder) by a psychiatrist is crucial 

Interventions for conduct disorder in childhood

• Parent management training
  • Directed at parents of children aged 3 to 12 years 
  • Goal is to teach parents how to interact differently with their children; training is based on the concept that conduct disorder is the result of an unintentional and maladaptive parent-child interaction 
  • Training is done individually or in groups, in an outpatient clinic or in a home setting 
  • Various approaches to parent management training have been implemented over the past few decades, and include the following: 
    • Parent-child interaction therapy
      • For parents of children aged 2 to 7 years; it has also been adapted for children aged 7 to 12 years who have a history of physical abuse 
      • Goal is to enhance the parent-child relationship through play therapy and repeated live coaching sessions, rather than using a didactic approach that trains parents separately from the child
      • Delivered in a group setting led by a teacher, usually in a community outpatient clinic, but it can be done in the home
      • Contraindicated as the first intervention under the following conditions: 
        • Severe untreated caregiver psychopathology
        • Severe marital discord
        • Children outside the target age range
        • Severe attention-deficit/hyperactivity disorder without medication consultation
        • Caregivers who are known perpetrators of sexual abuse
    • Triple P – Positive Parenting Program
      • For parents of children aged 0 to 12 years; used with families with different levels of dysfunction 
      • Goal is to reduce and prevent oppositional and aggressive behavior, as well as emotional and developmental problems, by enhancing parent skills and increasing their belief that they can overcome their problems managing the child
    • Helping the Noncompliant Child
      • For preschool-aged and early school-aged children (aged 3-8 years); typically directed at individual families rather than groups
      • Goal is to improve parenting skills by disrupting coercive parenting styles and replacing them with positive prosocial patterns of interactions; for the child, the program reduces conduct problems and increases prosocial behaviors
    • The Incredible Years training series
      • Offered as a parent-training program, a child-training program, and a teacher-training program; for children aged 2 to 8 years 
      • Goal is to visually teach positive strategies of reinforcement (eg, encouragement, praise, tangible reinforcement, monitoring) and methods to discourage problematic behaviors (eg, ignoring, limit setting, natural and logical consequences, calm down procedure, time-out)
  • Parent management training, including behavioral and cognitive-behavioral group-based parenting interventions 
    • Results in immediate and significant intervention effects with both short- and long-term beneficial results (especially in child-parent interaction at home)
    • Shown to improve symptoms in one-third to two-thirds of children 
• Cognitive problem-solving skills training for children are offered alongside parent-training programs 
  • Intervention designed to improve child’s understanding of interpersonal situations and extend their repertoire of effective responses, while gaining ability to cope with peers 
• Therapeutic foster care
  • Early intervention foster care: designed for preschool-aged children (aged 3-6 years); may be an option for severely affected children who cannot be maintained in their home and for whom other intensive home-based or out-of-home services have failed 
  • Multidimensional treatment foster care: serves severely affected children from elementary school–aged to adolescence who cannot be maintained in their home and for whom other intensive home-based or out-of-home services have failed
  • Programs are based on specific age-appropriate intervention techniques such as development of behavioral management plans and cognitive behavioral approaches (eg, problem-solving skills training) but with removal from the family setting and interventions undertaken by a trained foster caregiver

Interventions for conduct disorder in adolescence

• Multisystemic therapy
  • Most effective with adolescents younger than 15 years who have severe conditions 
  • Family-focused, multifaceted approach that recognizes multidimensional nature of serious antisocial behavior 
  • Provides parents with skills and resources needed to independently address the difficulty of raising adolescents while empowering the adolescent to cope with familial and extrafamilial problems 
  • Services are delivered in a community- or home-based setting 
  • Has been shown to effectively improve family relations, decrease both caregiver and child psychiatric symptoms, and decrease recidivism (eg, rearrests and incarceration) by more than 50% after a 14-year follow-up, and by 80% after a 9-year follow-up 
  • Reduces sex offender recidivism by 83% 
• Functional family therapy
  • Primarily targets highly conflictual family interactions; problems are viewed as a symptom of dysfunctional family relations 
  • Maintains a strong relational focus throughout treatment
    • Promotes adaptive family functioning with interventions aimed at establishing and maintaining new patterns of family interaction that replace dysfunctional ones
    • Uses both behavioral (eg, communication training) and cognitive behavioral (eg, assertiveness training, anger management) interventions
  • Services are delivered primarily in clinic and home settings, but also in schools, probation offices, or other community locations 
  • Effective treatment delivery requires considerable training and supervision; therefore, its use is limited 
  • Has shown a statistically significant reduction in felony (decreased by 35%) and violent crime (decreased by 30%) and a marginally significant reduction in misdemeanor (reduced by 21%) recidivisms 
• Multidimensional treatment foster care
  • Directed at serious chronic juvenile offenders who cannot be maintained in their home and for whom the other intensive home-based or out-of-home services have failed 
  • Serves children from elementary school–aged through adolescence
  • Provides a temporary community-based foster care alternative to state detention and group care facilities with the ultimate goal being to reunite children and adolescents with their biological or aftercare families 
  • If it fails and long-term foster care or adoption becomes the only alternative, the role of these programs is to stabilize the child’s or adolescent’s behavior to reduce disrupted foster placements or failed adoptions 
  • Programs are based on specific intervention techniques similar to those used in multisystemic therapy and functional family therapy, such as behavior therapy (eg, development of behavioral management plans) and cognitive behavioral approaches (eg, problem-solving skills training), but with removal from the family setting and interventions undertaken by a trained foster caregiver
    • Emphasizes the central and critical roles of foster parents, which consist of the following: 
      • Supervising and monitoring
      • Engaging child or adolescent in prosocial peer activities
      • Disengaging child or adolescent from deviant peers
      • Promoting positive performance at school
  • Has been shown to significantly reduce child and adolescent externalization of symptoms, depressive symptoms, and psychiatric distress after a 25-month follow-up 
    • Children and adolescents who received this type of intervention were 3 times less likely to experience placement disruptions than their counterparts who did not receive the intervention (13% versus 34%)

Pharmacologic therapy may be indicated to treat specific symptoms (eg, aggression, impulsivity) or to treat comorbid disorders

• Antipsychotics (eg, risperidone) can help improve conduct and lessen aggression in severe and refractory cases 
• Psychostimulant medications also have a role in reducing aggression in children and adolescents with conduct disorder, even in the absence of attention-deficit/hyperactivity disorder 
• Lithium plus antipsychotics or lithium alone also has been used to treat severe aggression in inpatients with conduct disorder; however, use of lithium has numerous adverse effects 

Drug therapy

• Antipsychotics
  • Risperidone
    • Risperidone Oral tablet; Children 5 to 12 years: 0.01 mg/kg/day PO for at least 2 days is a suggested initial weight-based dose. Then, may titrate to 0.02 mg/kg/day for 5 days, and subsequently adjust weekly as clinically indicated by 0.02 mg/kg/day. Max: 0.06 mg/kg/day PO. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions. In one study, body weight was used to determine dosage. Those weighing less than 50 kg received 0.25 mg/day PO initially; if weight 50 kg or more, 0.5 mg/day PO was given initially. Thereafter, the dose was increased gradually by 0.25 mg for patients less than 50 kg or 0.50 mg for those weighing 50 kg or more to a maximum daily dose of 0.75 mg/day PO for patients less than 50 kg or 1.5 mg/day PO for those 50 kg or more. The mean risperidone dosage was approximately 0.02 mg/kg/day. Doses have varied among studies. In a comprehensive review, the mean risperidone dose ranged from 0.98 to 1.5 mg/day at study end for all studies evaluated.
    • Risperidone Oral tablet; Adolescents: In one study, body weight was used to determine dosage. Those weighing less than 50 kg received 0.25 mg/day PO initially; if weight 50 kg or more, 0.5 mg/day PO was given initially. Thereafter, the dose was increased gradually by 0.25 mg for patients less than 50 kg or 0.50 mg for those weighing 50 kg or more to a maximum daily dose of 0.75 mg/day PO for patients less than 50 kg or 1.5 mg/day PO for those 50 kg or more. The mean risperidone dosage was approximately 0.02 mg/kg/day. Doses have varied among studies. In a comprehensive review, the mean risperidone dose ranged from 0.98 to 1.5 mg/day at study end for all studies evaluated. Coadministration of certain drugs may need to be avoided or dosage adjustments may be necessary; review drug interactions.
• Psychostimulants
  • Methylphenidate (immediate-release)
    • Methylphenidate Hydrochloride Oral tablet; Children 3 to 5 years†: Initially, 1.25 mg PO 3 times daily has been suggested. May increase gradually up to 10 mg PO 3 times daily. Use lowest effective dose. Max: 30 mg/day. Behavior training, parental training, and structured preschool are considered first line therapy in preschool-aged children.
    • Methylphenidate Hydrochloride Oral tablet; Children and Adolescents 6 years and older: 5 mg PO twice daily before breakfast and lunch. May increase by 5 to 10 mg/day at weekly intervals; some patients may require doses 3 times daily. Max: 60 mg/day per FDA-approved labeling; some experts use up to 100 mg/day in patients weighing more than 50 kg.
• Psychotropics
  • Lithium (immediate-release)
    • Lithium Carbonate Oral capsule; Children 6 years†: 15 to 20 mg/kg/day PO given in 3 to 4 divided doses initially; adjust as needed weekly to achieve target concentration. Range of dosing: 15 to 60 mg/kg/day PO given in 3 to 4 divided doses. An approximate dose range of 10 to 30 mg/kg/day PO, in divided doses, provides serum lithium levels of 0.6 to 1.1 mEq/L and is suggested in a consensus guideline, but the guideline does not differentiate between acute and maintenance therapy. Individualize dosage based on severity of disease, patient response, and serum lithium concentrations. Serum lithium concentrations above 1.5 mEq/L are generally associated with toxicity.
    • Lithium Carbonate Oral capsule; Children and Adolescents 7 years and older and weighing 20 kg to 30 kg: RECOMMENDED INITIAL DOSE: 300 mg PO 2 times per day. Obtain serum lithium concentrations after 3 days (12 hours after the last oral dose) and regularly until stabilization. Titrate dose by 300 mg weekly to desired effect. In patients at risk for lithium toxicity, consider a lower starting dose and titrate slowly; frequently assess serum lithium concentration and monitor for toxicity. TITRATION FOR ACUTE MANIA: Titrate to serum concentrations between 0.8 and 1.2 mEq/L. Usual dose range: 600 mg to 1,500 mg per day PO, given in divided doses. Monitor clinical status and serum lithium concentrations regularly until the patient is stabilized. MAINTENANCE THERAPY: Titrate to serum lithium concentrations between 0.8 and 1 mEq/L. Usual dose range: 600 mg to 1,200 mg per day PO, given in divided doses. Monitor clinical status and serum lithium concentrations; adjust patient’s dosage and therapeutic monitoring schedule accordingly. Max: Maximum dose has not been established for either acute mania or for maintenance therapy. Serum lithium concentrations above 1.5 mEq/L are generally associated with toxicity. An approximate pediatric weight-based dose range of 10 to 30 mg/kg/day PO, in divided doses, provides serum lithium concentrations of 0.6 to 1.1 mEq/L and has been suggested in a consensus guideline. Individualize dosage based upon the nature and severity of disease, patient response, and serum lithium concentrations.
    • Lithium Carbonate Oral capsule; Children and Adolescents 7 years and older and weighing more than 30 kg: RECOMMENDED INITIAL DOSE: 300 mg PO 3 times per day. Obtain serum lithium concentrations after 3 days (12 hours after the last oral dose) and regularly until stabilization. Titrate by 300 mg every 3 days to the desired effect. In patients at risk for lithium toxicity, consider a lower starting dose and titrate slowly; frequently assess serum lithium level and monitor for toxicity. TITRATION FOR ACUTE MANIA: Titrate to serum concentrations between 0.8 and 1.2 mEq/L. Usual dose range: 600 mg PO 2 or 3 times per day. Monitor clinical status and serum lithium concentrations regularly until stabilization. MAINTENANCE THERAPY: Titrate to serum lithium concentrations between 0.8 and 1 mEq/L. Usual dose range: 300 to 600 mg PO 2 or 3 times per day. Monitor lithium concentrations and clinical response; adjust the patient’s dosage and therapeutic monitoring schedule accordingly. Max: Maximum dose has not been established for either acute mania or for maintenance therapy. Individualize dosage regimen. Serum lithium concentrations above 1.5 mEq/L are generally associated with toxicity.

Comorbidities

• Conduct disorder is commonly comorbid with other psychiatric illnesses (eg, oppositional defiant disorder, attention-deficit/hyperactivity disorder, mood disorders) 
  • Presence of comorbidities complicates course of conduct disorder and has important prognostic value
  • Each comorbid psychiatric condition requires specific treatment, in addition to treatment of conduct disorder

Monitoring

• All parent management training programs begin with an assessment of symptoms and current functioning, and continue with symptom monitoring throughout treatment 
• Assessment of both child behavior and parenting skills throughout the training program is necessary to adjust the interventional plan and to monitor whether program is achieving desired goals
  • Assessment consists of the following:
    • Questionnaires for parents (parent-report) and/or teachers (teacher-report) to measure progress (eg, Child Behavior Checklist, Eyberg Child Behavior Inventory, Parenting Stress Index, Parent Daily Report) 
    • Direct observation, coupled with administration of questionnaires, to overcome reporter bias and recall that are inevitably associated with self-report and parent-report measures 
      • Parents and child are placed and observed in various situations that vary in degree to which parental control is required (ie, they range from free play to parent-directed activity)
      • Observation systems for assessing parent-child interaction in clinic setting or at home include Behavioral Coding System, Dyadic Parent-Child Interaction Coding System, Home Task Analogue/Clinic Task Analogue, and Compliance Test
  • Assessments may occur at every session, every other session, or according to some other regimen that allows the therapist to see patterns or trends over time 

Complications

• Adverse outcomes during childhood and/or adolescence
  • School suspension or expulsion 
  • Alienation from school or other social environments, as a result of punishment, misunderstanding, and eventual rejection by teachers and peers 
    • Results in child being unable to attend public schools and/or being unable to live in a parental or foster home 
  • Physical injury from accidents or fights 
  • Early onset of sexual behaviors, leading to the following: 
    • Early unplanned pregnancy 
    • Higher incidence of sexually transmitted diseases 
  • Severe and persistent delinquency 
• Adverse outcomes in adulthood
  • Development of (persistent as) antisocial personality disorder 
  • Difficulties in interpersonal relationships, both social and intimate (eg, unsupportive and volatile relationships) 
  • Problems with employment (eg, difficult work adjustment)
  • Increased alcohol, tobacco, and illegal substance use 
    • Estimated 86.7% of adolescents with conduct disorder (both sexes) use tobacco, alcohol, or marijuana 
  • Parenting difficulties with their own children 
  • Contact with criminal justice system for engaging in illegal behavior
    • Estimated that approximately 21% of adolescents already have had contact with police or juvenile justice system by ages 15 to 16 years 
  • Increased mental health difficulties, including the following:
    • Depression and other mood or anxiety disorders
    • Somatic symptom disorders
    • Impulse control disorders
    • Posttraumatic stress disorder
    • Psychotic disorders
  • Overall compromised physical health by midlife 
  • Higher-than-expected rate of suicidal ideation, suicide attempts, and completed suicide 

Prognosis

• Up to 50% of children and adolescents with conduct disorder are at risk of developing antisocial personality disorder as adults, and they have a poor prognosis 
  • People with childhood onset conduct disorder are more likely to have persistent conduct disorder into adulthood, with increased risk of criminal behavior and/or substance use–related problems 
    • Few children with conduct disorder receive the help they need because of parental lack of both awareness of and accessibility to evidence-based interventions 
  • Persistence is also more frequently observed in children and adolescents who present with limited prosocial emotions (callous-unemotional traits) and with comorbid psychiatric conditions 
    • Adolescents with elevated levels of callous-unemotional traits show especially poor response to treatment 
  • Patients with adolescent-onset conduct disorder have a better prognosis; disorder can remit by adulthood if person achieves adequate social and occupational adjustment as an adult 
    • Those with adolescent-onset type display less aggressive behaviors and tend to have more normative relationships with their peers, even if they still show conduct problems when in the company of others 
• Main intervention strategies for conduct disorder can produce significant short-term and long-term improvements in behavior, family relationships, and recidivism

Prevention

• Early identification and treatment of attention-deficit/hyperactivity disorder and oppositional defiant disorder may reduce risk of progression to conduct disorder 
• Several school-based programs (eg, fast track for conduct problems) have shown promising reductions in disruptive or antisocial behavior, school failure, and substance use in high-risk children and adolescents 

References

American Psychiatric Association: Disruptive, impulse-control, and conduct disorders. In: Diagnostic and Statistical Manual of Mental Disorders. 5th ed. American Psychiatric Association; 2013:461-80