Conduct disorder

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Kiran Singh, M.D. [2], Haleigh Williams, B.S., Irfan Dotani

Synonyms and keywords: Conduct problems, disordered conduct, behavioral problems

Overview

Conduct disorder is a psychiatric disorder characterized by a pattern of repetitive behavior wherein social norms or the rights of others are routinely violated. Possible symptoms include excessively aggressive behavior, bullying, physical aggression, cruel behavior toward people and animals, destructive behavior, lying, truancy, vandalism, and stealing. After the age of 18, conduct disorder may develop into antisocial personality disorder.

Historical Perspective

• In 1880, the origins of conduct disorder lie within the social and legal problem of delinquency.
• In 1904, Stanley Hall published the book, "Adolescence". This marked the beginning of the recognition of adolescence as a distinct developmental period.
• From 1910 until 1968, there was increased research interest in conduct problems of children as researchers attempted to identify the causes of inappropriate behaviors.
• In 1968, a rapid accumulation in the knowledge around VI conduct disorders and an increasingly holistic perception of the cause and treatment of conduct disorders occurred.
• At the end of the 19th century, therefore, the "norm" shifted from children working as young adults to focusing on becoming a young adult.
• In 1968, conduct disorders were established as a valid medical diagnosis.
• At the end of the 19th century and the start of the 20th century, Phrenology laid the foundation for biological determinism.
• Biological determinism is a large contributing factor to children who are delinquents and commit a crime.
• 'Uri Bronfenbrenner's Ecological Systems Theory' has largely contributed to the development and maintenance of conduct disorders.
• Developmental psychopathology has helped to integrate how biological, cognitive, and environmental factors have accumulated to increases the risk of a pathological outcome, such as conduct disorders.

Classification

• Conduct disorder is classified in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).

• There are four categories that could present behavior similar to conduct disorder:
  • Aggression to people and animal
  • Destruction of property
  • Deceitfulness or theft
  • Serious violation of rules

• Early-onset (EO-CD) and adult-onset (AO-CD) conduct disorder are widely considered distinct diseases with divergent etiologies, though severe executive function is observed in both diseases.
  • Children with EO-CD are more likely to experience psychosis and to commit acts of violence.

Pathophysiology

• Patients with adult-onset conduct disorder (AO-CD) show increased cortical thinning in the paralimbic system, particularly in the precuneus/posterior cingulate cortex, as compared to healthy controls. This finding has not been reported in patients with early-onset conduct disorder (EO-CD).
• In children, the onset of conduct disorder (CD) seems to be associated with abnormalities in white matter pathways, particularly in the form of increased axial and radial diffusivity.
  • This effect seems to be especially prominent in girls with CD.

Commonly Comorbid Conditions

Conditions that are commonly comorbid with conduct disorder include:

• ADHD
• Substance abuse disorder
• Depression
• Oppositional defiant disorder (ODD)
• Disruptive behavior disorders

Differentiating conduct disorder from other diseases

Conduct disorder must be differentiated from diseases that share common symptoms, including:

• Adjustment disorders
• Attention-deficit/hyperactivity disorder
• Bipolar disorder
• Depressive disorder
• Intermittent explosive disorder
• Oppositional defiant disorder

Disease	Distinguishing features	Treatment
Conduct disorder	Persistent pattern of violating others' rights Aggression and illegal acts	Family therapy Behavior modification Pharmacotherapy
Oppositional defiant disorder	Chronic argumentativeness Refusal to comply with adult requests	Family therapy Behavior modification
ADHD	Hyperactivity Behavior disinhibition Inattention and distractibility	Pharmacotherapy (stimulants) Behavior modification
Substance abuse	Pattern of substance use associated with adverse social/personal consequences or physiologic tolerance or withdrawal	Specialized multimodal treatment, including group, individual and family therapies Medical detoxification and inpatient treatment
Major depression and dysthymic disorder	Dysphoric, irritable mood Sleep and appetite disturbance Anhedonia Suicidal ideation	Pharmacotherapy (SSRIs) Individual and family therapy
Bipolar mood disorder	Depressive symptoms coexist or alternate with periods of excess energy and/or thought racing Mania or hypomania may include hallucinations, delusions	Pharmacotherapy (lithium, selected anticonvulsants)
Intermittent explosive Disorder	Sudden, unpredictable physically/verbally aggressive outbursts	Pharmacotherapy (anticonvulsants, clonidine, lithium, SSRIs) Cognitive behavior therapy

Epidemiology and Demographics

Prevalence

• The one year prevalence of conduct disorder is 2,000 to >10,000 per 100,000 people (2% to >10%) within the overall population.
• Worldwide, estimates of the prevalence of ODD and CD range from 3-5%. A recent meta-analysis estimated the combined prevalence of ODD/CD to be 6.1%.

Age

• Among American children and adolescents aged 8 to 15 years, the prevalence of conduct disorder is approximately 2.1%.
• Children diagnosed with conduct disorder tend to be >10 years of age.
• In 2007, 4.6% of children between the ages of 3-17 years were diagnosed with conduct disorder.

Gender

• The lifetime prevalence of CD was 10.2% in an adult community sample, with men at 11.2% and women at 9.2%.

Race

• Currently, there are no population- or national-level data on the prevalence trends of ODD or CD among caucasion U.S. children.

Risk Factors

• The cause of conduct disorder is not fully understood. Family history plays a role that stems primarily from genetics, though common environmental circumstances also have an effect.
• While the male children of women who experience moderate or severe anxiety during the pre- and post-natal periods are more likely to experience conduct disorder than male children of women who do not, the same effect does not apply to female children.
• There exists evidence that a parenting style may have an outcome in CD:
  • Excessive controlling parenting/behavior
  • Substandard involvement with or supervision of children
  • Tendency to avoid expressing one's emotions may facilitate the development of conduct disorder in children
• Risk factors for the development of conduct disorder include:

• • Association with a delinquent peer group

• • Biological parents with:
    • Severe alcohol use disorder (alcholism)
    • Depressive and bipolar disorders
    • Schizophrenia
    • ADHD
    • Anxiety disorder
    • Conduct disorder
  • Childhood access to violent video games
  • Difficult under controlled infant temperament
  • Early institutionalization
  • Familial psychopathology
  • Frequent changes of caregivers
  • Harsh discipline
  • Inconsistent child-rearing practices
  • Lack of supervision
  • Large family size
  • Lower-than-average intelligence
  • Neighborhood exposure to violence
  • Parental criminality
  • Parental neglect or rejection
  • Physical or sexual abuse
    • The prevalence of a history of sexual abuse as a child is estimated to be 27% in individuals who suffer from conduct disorder.
    • Childhood abuse is more common among individuals with early-onset conduct disorder as compared to those with adult-onset conduct disorder.
• Social isolation
• Substance abuse

Natural History, Complications, and Prognosis

• Childhood conduct disorder is a known risk factor for the development of substance abuse disorder during a patient's youth.
  • Substance abuse may also intensify the symptoms of conduct disorder and negatively impact a patient's prognosis.
• Childhood conduct disorder may be a risk factor for the development of schizophrenia.
• Children who suffer from conduct disorder are more likely than their unaffected peers to become violent, an effect that may continue into adulthood.

Diagnosis

Diagnostic Criteria

DSM-V Diagnostic Criteria for Conduct Disorder

“

A. A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of at least three of the following 15 criteria in the past 12 months from any of the categories below, with at least one criterion present in the past 6 months: Aggression to people and animals. 1. Often bullies, threatens, or intimidates others. 2. Often initiates physical fights. 3. Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun). 4. Has been physically cruel to people. 5. Has been physically cruel to animals. 6. Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery). 7. Has forced someone into sexual activity. Destruction of Property 8. Has deliberately engaged in fire setting with the intention of causing serious damage. 9. Has deliberately destroyed others’ property (other than by fire setting). Deceitfulness or Theft 10. Has broken into someone else’s house, building, or car. 11. Often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others). 12. Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery). Serious Violations of Rules 13. Often stays out at night despite parental prohibitions, beginning before age 13 years. 14. Has run away from home overnight at least twice while living in the parental or parental surrogate's home, or once without returning for a lengthy period. 15. Is often truant from school, beginning before age 13 years. AND B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning. AND C. If the individual is age 18 years or older, criteria are not met for antisocial personality disorder. Specify whether: Childhood-onset type: Individuals show at least one symptom characteristic of conduct disorder prior to age 10 years. Adolescent-onset type: Individuals show no symptom characteristic of conduct disorder prior to age 10 years. Unspecified onset: Criteria for a diagnosis of conduct disorder are met, but there is not enough information available to determine whether the onset of the first symptom was before or after age 10 years. Specify if: With limited prosocial emotions: To qualify for this specifier, an individual must have displayed at least two of the following characteristics persistently over at least 12 months and in multiple relationships and settings. These characteristics reflect the individual’s typical pattern of interpersonal and emotional functioning over this period and not just occasional occurrences in some situations. Thus, to assess the criteria for the specifier, multiple information sources are necessary. In addition to the individual’s self-report, it is necessary to consider reports by others who have known the individual for extended periods of time (e.g., parents, teachers, co-workers, extended family members, peers). Lack of remorse or guilt: Does not feel bad or guilty when he or she does something wrong (exclude remorse when expressed only when caught and/or facing punishment). The individual shows a general lack of concern about the negative consequences of his or her actions. For example, the individual is not remorseful after hurting someone or does not care about the consequences of breaking rules. Callous—lack of empathy: Disregards and is unconcerned about the feelings of others. The individual is described as cold and uncaring. The person appears more concerned about the effects of his or her actions on himself or herself, rather than their effects on others, even when they result in substantial harm to others. Unconcerned about performance: Does not show concern about poor/problematic performance at school, at work, or in other important activities. The individual does not put forth the effort necessary to perform well, even when expectations are clear, and typically blames others for his or her poor performance. Shallow or deficient affect:Does not express feelings or show emotions to others, except in ways that seem shallow, insincere, or superficial (e.g., actions contradict the emotion displayed; can turn emotions “on” or “off" quickly) or when emotional expressions are used for gain (e.g., emotions displayed to manipulate or intimidate others). Specify current severity: Mild: Few if any conduct problems in excess of those required to make the diagnosis are present, and conduct problems cause relatively minor harm to others (e.g., lying, truancy, staying out after dark without permission, other rule-breaking). Moderate: The number of conduct problems and the effect on others are intermediate between those specified in “mild” and those in “severe” (e.g., stealing without confronting a victim, vandalism). Severe: Many conduct problems in excess of those required to make the diagnosis are present, or conduct problems cause considerable harm to others(e.g., forced sex, physical cruelty, use of a weapon, stealing while confronting a victim, breaking and entering).

”

History and Symptoms

Symptoms of conduct disorder include:

• Compromised executive function
• Violent behavior
• Disregard for the rights of others
• Cruelty toward people and animals

Psychiatric Examination

• A child with conduct disorder may display a pattern of disruptive and violent behavior and have problems following rules.

Laboratory Findings

• No laboratory test has been found to help diagnose this disorder.

Imaging Findings

• No recent imaging findings are available for this disorder.

Treatment

Medical Therapy

• Therapy is recommended mong all patients who develop conduct disorder.
• Three main therapies are used to treat conduct disorder:
  • Family therapy
  • Behavior modification
  • Pharmacotherapy

Criticism

• Some critics of psychiatry allege that individuals exhibiting symptoms of a "conduct disorder" (similar to oppositional defiant disorder) may be reacting to an abnormal circumstance.
• Patients may also be committing criminal and/or uncivil acts out of selfishness.
• Critics of the classification of this disorder also may state that the coming of age of an individual does not automatically signify a new disorder.
• It has also been noted that the criteria for diagnosis can often be subjective and that only exemplifying a few of the above behaviors may just indicate normal teenage rebellion.

See also

• Antisocial personality disorder
• Oppositional defiant disorder
• Psychopathy
• Bullying