Conduct Disorder

Conduct disorder (CD) is a pediatric mental disorder characterized by a recurrent behavior in which patients do not comply with social norms and rules or the basic rights of others. Examples include violence, destruction, theft, lying, and serious breaking of rules present over ≥ 1 year. An important risk factor is parental rejection and neglect. Conduct disorder is difficult to treat and requires a multimodal approach that includes family therapy, behavior modification, and pharmacotherapy.

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Overview

Definition

Conduct disorder (CD) is a disruptive disorder that entails a high amount of problematic behaviors and antisocial activities. Children and adolescents with the condition show aggression toward others and willfully destroy property, steal, or lie.

Epidemiology

Estimated prevalence in the United States:

  • 2%–9% 
  • Highest in adolescent age group
  • Boys > girls

40% of children diagnosed with CD will develop antisocial personality disorder in adulthood.

Etiology

  • No definitive theory owing to multiple risk factors and comorbidities 
  • Risk factors: 
    • Personal:
      • Uncontrolled infant temperament
      • Lower-than-average intelligence, especially verbal IQ
    • Environmental: 
      • Parental neglect
      • Physical/sexual abuse
      • Parental criminality
      • Rejection by peers
      • Exposure to violence and/or substance misuse
    • Genetic and physiologic: higher risk in children with a biologic parent/sibling with other psychiatric comorbidities 

Clinical Presentation and Diagnosis

DSM-5 diagnostic criteria

  • A chronic pattern of maladaptive behavior in age-appropriate societal norms or infringing on the rights of others
  • Several subsets, depending on the age at onset 
Table: Diagnosis of conduct disorder
Categories Criteria
Aggression to people and animals
  • Bullies, threatens, or intimidates others
  • Initiates physical fights
  • Uses a dangerous weapon to cause harm
  • Physically cruel to people
  • Physically cruel to animals
  • Steals while confronting a victim
  • Forces someone into sexual activity
Destruction of property
  • Starts fire on purpose to cause damage
  • Destroys others’ property
Deceitfulness or theft
  • Breaks into someone else’s property
  • Often lies or deceives others for own benefit
  • Steals without confronting a victim
Serious violation of rules
  • Stays out at night despite parental prohibitions
  • Runs away from home overnight at least twice, or once without returning for a lengthy period
  • Truant or skips school (< age 13)

Further considerations

  • The behavior causes clinically significant impairment in social, academic, or occupational functioning.
  • If persistent after age 18, CD is reclassified as antisocial personality disorder.
  • The diagnostic evaluation should include collateral information from family and other caregivers as well as academic reports, if available.
  • Basic laboratory work, such as urine drug screening, can be valuable to rule out substance use disorders or other comorbid medical disorders.

Management

General approach

Multimodal approach:

  • Family therapy: increase communication skills, improve family interactions 
  • Behavioral therapy: anger management, improve social skills
  • Pharmacotherapy: directed at specific symptoms
Table: Pharmacotherapy for different target symptoms in CD
Target symptoms Pharmacologic options
Aggression, explosiveness Mood stabilizers (e.g., lithium)
Severe aggression
  • 2nd-generation antipsychotics (e.g., risperidone)
  • Selective serotonin reuptake inhibitors (SSRIs) (e.g., fluoxetine, citalopram)
Impulsivity, hyperactivity, inattention
  • Stimulants (e.g., methylphenidate)
  • Nonstimulant (e.g., guanfacine), if there is risk of stimulant abuse

Prognosis

  • Childhood-onset CD: higher risk of developing adult antisocial disorder and substance use disorders 
  • Adolescent-onset CD: better prognosis, may respond better to interventions

Differential Diagnosis

  • Oppositional defiant disorder (ODD): pediatric psychiatric disorder featuring a continuous pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness directed at adults or other authority figures. Symptoms must be present for ≥ 6 months. ODD patients do not show aggressive or violent behavior, and they do not impinge on other people’s rights as do those with CD. 
  • ADHD: neurodevelopmental disorder characterized by a pattern of inattention and/or hyperactivity/impulsivity that occurs in ≥ 2 different settings for > 6 months. Onset is usually before age 12 years. ADHD is a common comorbidity of CD; however, the hyperactivity and impulsive behavior of ADHD generally do not violate societal norms or the rights of others. 
  • Disruptive mood dysregulation disorder (DMDD): childhood mental disorder that involves chronic negative mood, irritability, and severe recurrent temperamental outbursts. Although the emotional outbursts are disproportionate to the developmental/maturity stage of the child, these episodes are not severe enough to be classified as CD, nor do they affect others’ rights as in CD. 
  • Intermittent explosive disorder: recurrent, severe, angry outbursts with normal mood between outbursts. Symptoms persist for > 3 months. Onset can be in late childhood or adolescence, but intermittent explosive disorder is usually diagnosed in young men (> age 18). Angry outbursts are not as severe or violent/damaging to others as behaviors seen in CD. These outbursts are also accompanied by regret, which is not commonly seen in CD.
Table: Features of conduct disorder in comparison to important differential diagnoses
Characteristics Oppositional defiant disorder (ODD) Disruptive mood dysregulation disorder (DMDD) Conduct disorder (CD)
Onset Preschool age Ages 6–10
  • Childhood-onset: < 10
  • Adolescent-onset: > 10
Mood Angry/irritable Angry/irritable No mood component
Impairment in interpersonal relationships Exhibits continued and frequent argumentative/defiant behaviors inconsistent with developmental level Exhibits outbursts of emotion inconsistent with developmental level
  • Initiates aggressive behavior
  • Reacts aggressively
Psychological features
  • Behavior secondary to threat to one’s autonomy
  • Patient considers behavior to be justified.
Extreme and disproportionately angry response to stimulus Lack of empathy, remorse, guilt
Behavioral features
  • Defies rules and authority figures
  • Not physically aggressive
  • Elevated mood without meeting criteria for bipolar disorders
  • Verbally or physically aggressive
  • Violates rules of society (thievery, vandalism)
  • Aggressive to people and animals
Exclusion diagnosis Not diagnosed if patient meets criteria for DMDD May co-occur with ADHD, CD, depressive disorders, and substance use disorders
  • May co-occur with ODD
  • Consider antisocial personality disorder if > 18 years old

References

  1. Mohan L, Yilanli M, Ray S. (2020). Conduct disorder. In: StatPearls Retrieved June 7, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK470238/
  2. Sadock BJ, Sadock VA, Ruiz P. (2014). Child psychiatry. Chapter 31 of Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, 11th ed. Philadelphia: Lippincott Williams and Wilkins, pp. 1247–1253..
  3. Barzman, D. (2017). Conduct disorder and Its Clinical Management. DeckerMed Medicine.

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