Conduct Disorder (CD)
Overview
Conduct Disorder (CD) is characterized as “a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated”, usually manifested within these four categories:
Aggression to people and animals
Destruction of property
Deceitfulness or theft
Serious violations of rules
Individuals must be under the age of 18 to meet the criteria for the disorder. These disturbances in behavior can cause clinically significant impairments in social, academic and/or occupational functioning.[1]
The prevalence of conduct disorder among school age children is around 3% worldwide.[2] This disorder is often classified as “externalizing” or “disruptive”, and is largely comorbid with other emotional and behavioral problems such as Oppositional Defiant Disorder (ODD) or Attention Deficit Hyperactivity Disorder (ADHD).[3-5]
Signs and symptoms
Conduct disorder is characterized by serious and continuous malicious behaviors, whether aggressive or non-aggressive, towards others. Children with CD display a pattern of behaviors which violate age-appropriate societal norms, rules and rights of others that check the boxes of either one of the four aforementioned diagnostic categories in the past 12 months.[6]
Additionally, children with CD often have difficulty understanding how others feel and think and misinterpret their intentions as malicious. Those with CD are often described as possessing callous-unemotional traits, and lack appropriate language or social skills that would prevent them from building necessary peer relationships, which can contribute to their isolation and frustration.[7-9]
However, it is important to understand that disobedient and disrespectful behavioral tendencies are common among children and adolescents. Therefore, the signs and symptoms of CD are ones that represent pervasive and extreme patterns of violations and aggressions.[10]
Causes and risk factors
Jami (2017) has identified some prominent psychosocial risk factors,[11] including:
Abuse:
Family influences
Parental separation, inter-parental violence
Low socio-economic status
Stressful living environment and family situation
Parental psychopathology
Drug addiction in family
Self-motivation
Enjoy wandering
Enjoy bullying, teasing others
Enjoy fighting
Enjoy stealing
No personal interest in home life
Peer influences
Peer pressure
Lack of closeness in relationships with friends, having no friends
Cognitive deficits
Deficits in social skills
Lack of risk perception
Media exposure
Violence on media
Additionally, the heritability (e.g., the likelihood of the disorder to aggregate among family members) for conduct disorder is substantial, estimated to be around 40%-50%. Genetic factors have also been found to be the main contributor to the stability of the disorder across ages.[12,13]
Diagnoses
Clinical Diagnoses
The diagnosis for conduct disorder is based on signs and symptoms stated within the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5. If symptoms are present, a medical professional will perform an evaluation with complete medical and psychiatric histories, along with physical exam and laboratory tests when appropriate if it is suspected that the symptoms may be caused by a physical illness. It is also important for doctors to rule out other comorbid disorders, such as ADHD and depression.[14-16]
The child can also be referred to a child and adolescent psychiatrist or other licensed mental health professionals who are qualified to diagnose and treat mental health problems in children and adolescents.[17]
Differential Diagnosis
Because conduct disorder is classified within the spectrum of disruptive behavior disorders in childhood, there are other disorders that also meet this criteria and are often comorbid with conduct disorder.[18-20]
There are mood disorders or psychotic disorders in which a sudden onset of engagement in negative and hostile behaviors are expected. It is important to rule out conduct disorder as a potential explanation in this case if the problems only occur in the context of during episodes of mood or psychotic disorders.[21]
Other commonly comorbid disorders are Oppositional Defiant Disorder (which is distinguished by chronic argumentativeness and refusal to comply) or ADHD (distinguished by hyperactivity, behavior disinhibition, inattention and distractibility).[22,23]
Treatment
Generally, treatment of conduct disorder should start with educating the child and their caretakers about the disorder, its prognosis and potential complications. It is also important to take into consideration the age of onset for the disorder. According to the ICD-11 (World Health Organization, 2019), it should be specified whether the child has the childhood-onset type, adolescent-onset type or unspecified onset type. This can help determine the likely direction of the disorder and possible effective interventions. Despite there being various interventions available that can treat early emerging conduct problems, their effectiveness decreases in older children. Treatment plans should also be individualized to the needs of the child due to the heterogeneity of the disorder and the diverse developmental processes that may contribute to the disorder.[24]
The most popular form of treatment for conduct disorder is nonpharmacological management, some of the treatment approaches that were found beneficial are:
Contingency Management Programs - including setting behavioral goals to shape child’s behavior in areas of interest, continuously monitoring the goals, and reinforcement to help children reach the desired goals.
Cognitive Behavioral Skill Training - wherein a therapist teaches child skills to decrease impulsivity and manage anger responses through problem-solving steps.
Parent Management Training - designed to teach parents necessary skills to manage the disorder at home to improve parent-child interactions, promote prosocial behavior in children, enhance parental supervision, and teach more effective discipline strategies.[25]
These approaches can, and are often used, along with each other. Treatment of conduct disorder with medication exists but is not sufficient on its own, and is mainly used to treat comorbid conditions (e.g., ADHD or aggressive/impulsive behaviors) but not the disorder as a whole.[26,27]
If you suspect that your child is demonstrating signs of conduct disorder, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.
Contributed by: Mai Tran
Editor: Jennifer (Ghahari) Smith, Ph.D.
References
1 American Psychiatric Association. (2013). In Diagnostic and statistical manual of mental disorders (5th ed.).
2 Fairchild, Graeme; Hawes, David J.; Frick, Paul J.; Copeland, William E.; Odgers, Candice L.; Franke, Barbara; Freitag, Christine M.; De Brito, Stephane A. (2019). Conduct disorder. Nature Reviews Disease Primers, 5(1), 43. doi:10.1038/s41572-019-0095-y
3 Angold A, Costello EJ, Erkanli A. Comorbidity. J Child Psychol Psychiatry. 1999 Jan;40(1):57-87. PMID: 10102726.
4 International Statistical Classification of Diseases and Related Health Problems (11th ed,; ICD-11; World Health Organization, 2019).
5 Sagar R, Patra BN, Patil V. Clinical Practice Guidelines for the management of conduct disorder. Indian J Psychiatry. 2019 Jan;61(Suppl 2):270-276. doi: 10.4103/psychiatry.IndianJPsychiatry_539_18. PMID: 30745702; PMCID: PMC6345126.
6 American Psychiatric Association (2013)
7 Conduct disorders. Nationwide Children’s . (n.d.). https://www.nationwidechildrens.org/conditions/conduct-disorders
8 Blair RJ, Leibenluft E, Pine DS. Conduct disorder and callous-unemotional traits in youth. N Engl J Med. 2014 Dec 4;371(23):2207-16. doi: 10.1056/NEJMra1315612. PMID: 25470696; PMCID: PMC6312699.
9 Christian, Rachel E.; Frick, Paul J.; Hill, Natalie L.; Tyler, Lori; Frazer, DanaR. (1997). Psychopathy and Conduct Problems in Children: II. Implications for Subtyping Children With Conduct Problems. Journal of the American Academy of Child & Adolescent Psychiatry, 36(2), 233–241. doi:10.1097/00004583-199702000-00014
10 Mohan L, Yilanli M, Ray S. Conduct Disorder. In: StatPearls. StatPearls Publishing, Treasure Island (FL); 2022. PMID: 29261891.
11 Jami, Humaira. "Psycho-Social Risk Factors of Conduct Disorder among Institutionalized Children." Journal of Gender and Social Issues, vol. 16, no. 1, 30 June 2017, p. 33. Gale Academic OneFile, link.gale.com/apps/doc/A541405629/AONE?u=anon~7fb311e2&sid=googleScholar&xid=7d38a8d5. Accessed 30 May 2023.
12 Wesseldijk, L. W. et al. Genetic and environmental influences on conduct and antisocial personality problems in childhood, adolescence, and adulthood. Eur. Child Adolesc. Psychiatry 27, 1123–1132 (2017).
13 Fairchild et al. (2019)
14 Searight HR, Rottnek F, Abby SL. Conduct disorder: diagnosis and treatment in primary care. Am Fam Physician. 2001 Apr 15;63(8):1579-88. PMID: 11327435.
15 Mohan et al. (2022)
16 WebMD. (2022, August 25). Mental Health and Conduct Disorder. WebMD. https://www.webmd.com/mental-health/mental-health-conduct-disorder
17 Ibid.
18 World Health Organization (2019)
19 Milich, R., Widiger, T. A., & Landau, S. (1987). Differential diagnosis of attention deficit and conduct disorders using conditional probabilities. Journal of Consulting and Clinical Psychology, 55(5), 762–767. https://doi.org/10.1037/0022-006X.55.5.762
20 Searight et al. (2001)
21 Mohan et al. (2022)
22 Searight et al. (2001)
23 Virtual Mentor. 2006;8(10):672-675. doi: 10.1001/virtualmentor.2006.8.10.cprl1-0610. - diff diagnosis
24 Sagar et al. (2019)
25 Ibid.
26 Ibid.
27 Juárez-Treviño, M., Esquivel, A. C., Leal Isida, L. M., Galarza Delgado, D. Á., de la O Cavazos, M. E., Garza Ocañas, L., & Sepúlveda Sepúlveda, R. (2019). Clozapine in the treatment of aggression in conduct disorder in children and adolescents: A randomized, double-blind, controlled trial. Clinical Psychopharmacology and Neuroscience, 17(1), 43–53. https://doi.org/10.9758/cpn.2019.17.1.43