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Conduct Disorder

Conduct disorder (CD) is a pediatric mental disorder characterized by a recurrent behavior in which patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship 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 ≥ 1 year. An important risk factor is parental rejection and neglect Neglect Child Abuse. Conduct disorder is difficult to treat and requires a multimodal approach that includes family therapy Family therapy A form of group psychotherapy. It involves treatment of more than one member of the family simultaneously in the same session. Psychotherapy, behavior modification, and pharmacotherapy.

Last updated: Mar 1, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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 Aggression Behavior which may be manifested by destructive and attacking action which is verbal or physical, by covert attitudes of hostility or by obstructionism. Oppositional Defiant Disorder toward others and willfully destroy property, steal, or lie.

Epidemiology

Estimated prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency in the United States:

  • 2%–9% 
  • Highest in adolescent age group
  • Boys > girls
  • 40% of children diagnosed with CD will develop antisocial personality disorder Antisocial Personality Disorder A personality disorder whose essential feature is a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood. The individual must be at least age 18 and must have a history of some symptoms of conduct disorder before age 15. Cluster B Personality Disorders in adulthood.

Etiology

  • No definitive theory owing to multiple risk factors and comorbidities Comorbidities The presence of co-existing or additional diseases with reference to an initial diagnosis or with reference to the index condition that is the subject of study. Comorbidity may affect the ability of affected individuals to function and also their survival; it may be used as a prognostic indicator for length of hospital stay, cost factors, and outcome or survival. St. Louis Encephalitis Virus 
  • Risk factors: 
    • Personal:
      • Uncontrolled infant temperament
      • Lower-than-average intelligence, especially verbal IQ
    • Environmental: 
      • Parental neglect Neglect Child Abuse
      • Physical/ sexual abuse Sexual Abuse Sexual abuse and assault are major public health problems that affect many people from all walks of life, including people of all ages and genders, but it is more prevalent in women and girls, with reports of up to 1 in 3 experiencing sexual assault at some time in their life. Sexual Abuse
      • Parental criminality
      • Rejection by peers
      • Exposure Exposure ABCDE Assessment to violence and/or substance misuse
    • Genetic and physiologic: higher risk in children with a biologic parent/sibling with other psychiatric comorbidities Comorbidities The presence of co-existing or additional diseases with reference to an initial diagnosis or with reference to the index condition that is the subject of study. Comorbidity may affect the ability of affected individuals to function and also their survival; it may be used as a prognostic indicator for length of hospital stay, cost factors, and outcome or survival. St. Louis Encephalitis Virus 

Clinical Presentation and Diagnosis

Clinical 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 Aggression Behavior which may be manifested by destructive and attacking action which is verbal or physical, by covert attitudes of hostility or by obstructionism. Oppositional Defiant Disorder to people and animals Animals Unicellular or multicellular, heterotrophic organisms, that have sensation and the power of voluntary movement. Under the older five kingdom paradigm, animalia was one of the kingdoms. Under the modern three domain model, animalia represents one of the many groups in the domain eukaryota. Cell Types: Eukaryotic versus Prokaryotic
  • Bullies, threatens, or intimidates others
  • Initiates physical fights
  • Uses a dangerous weapon to cause harm
  • Physically cruel to people
  • Physically cruel to animals Animals Unicellular or multicellular, heterotrophic organisms, that have sensation and the power of voluntary movement. Under the older five kingdom paradigm, animalia was one of the kingdoms. Under the modern three domain model, animalia represents one of the many groups in the domain eukaryota. Cell Types: Eukaryotic versus Prokaryotic
  • 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 Antisocial Personality Disorder A personality disorder whose essential feature is a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood. The individual must be at least age 18 and must have a history of some symptoms of conduct disorder before age 15. Cluster B Personality Disorders.
  • 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 Urine Liquid by-product of excretion produced in the kidneys, temporarily stored in the bladder until discharge through the urethra. Bowen Disease and Erythroplasia of Queyrat drug screening Screening Preoperative Care, can be valuable to rule out substance use disorders or other comorbid medical disorders.

Management

General approach

Multimodal approach:

  • Family therapy Family therapy A form of group psychotherapy. It involves treatment of more than one member of the family simultaneously in the same session. Psychotherapy: increase communication Communication The exchange or transmission of ideas, attitudes, or beliefs between individuals or groups. Decision-making Capacity and Legal Competence skills, improve family interactions 
  • Behavioral therapy: anger management Anger management System of psychological and/or therapeutic techniques used to control and or reduce the triggers, degrees, and effects of anger. Oppositional Defiant Disorder, improve social skills
  • Pharmacotherapy: directed at specific symptoms
Table: Pharmacotherapy for different target symptoms in CD
Target symptoms Pharmacologic options
Aggression Aggression Behavior which may be manifested by destructive and attacking action which is verbal or physical, by covert attitudes of hostility or by obstructionism. Oppositional Defiant Disorder, explosiveness Mood stabilizers (e.g., lithium Lithium An element in the alkali metals family. It has the atomic symbol li, atomic number 3, and atomic weight [6. 938; 6. 997]. Salts of lithium are used in treating bipolar disorder. Ebstein’s Anomaly)
Severe aggression Aggression Behavior which may be manifested by destructive and attacking action which is verbal or physical, by covert attitudes of hostility or by obstructionism. Oppositional Defiant Disorder
Impulsivity Impulsivity Attention Deficit Hyperactivity Disorder, hyperactivity Hyperactivity Attention Deficit Hyperactivity Disorder, inattention Inattention Attention Deficit Hyperactivity Disorder
  • Stimulants Stimulants Stimulants are used by the general public to increase alertness and energy, decrease fatigue, and promote mental focus. Stimulants have medical uses for individuals with ADHD and sleep disorders, and are also used in combination with analgesics in pain management. Stimulants (e.g., methylphenidate Methylphenidate A central nervous system stimulant used most commonly in the treatment of attention deficit disorder in children and for narcolepsy. Its mechanisms appear to be similar to those of dextroamphetamine. Stimulants)
  • Nonstimulant (e.g., guanfacine), if there is risk of stimulant abuse

Prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas

  • Childhood-onset CD: higher risk of developing adult antisocial disorder and substance use disorders 
  • Adolescent-onset CD: better prognosis Prognosis A prediction of the probable outcome of a disease based on a individual’s condition and the usual course of the disease as seen in similar situations. Non-Hodgkin Lymphomas, may respond better to interventions

Differential Diagnosis

  • Oppositional defiant disorder Oppositional Defiant Disorder Oppositional defiant disorder is a pediatric psychiatric disorder characterized by a continuous pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness directed at adults or other authority figures. Symptoms must be present for at least 6 months to make a diagnosis of ODD. Oppositional Defiant Disorder (ODD): pediatric psychiatric disorder featuring a continuous pattern of angry/ irritable mood Irritable mood Abnormal or excessive excitability with easily triggered anger, annoyance, or impatience. Oppositional Defiant Disorder, argumentative/ defiant behavior Defiant behavior Oppositional Defiant Disorder, or vindictiveness Vindictiveness Oppositional Defiant Disorder directed at adults or other authority Authority Medical Ethics: Basic Principles figures. Symptoms must be present for ≥ 6 months. ODD patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship do not show aggressive or violent behavior, and they do not impinge on other people’s rights as do those with CD. 
  • ADHD ADHD Attention deficit hyperactivity disorder is a neurodevelopmental disorder characterized by a pattern of inattention and/or hyperactivity-impulsivity that occurs in at least 2 different settings for more than 6 months. Although the patient has normal intelligence, the disease causes functional decline. Attention Deficit Hyperactivity Disorder: neurodevelopmental disorder characterized by a pattern of inattention Inattention Attention Deficit Hyperactivity Disorder and/or hyperactivity Hyperactivity Attention Deficit Hyperactivity Disorder/ impulsivity Impulsivity Attention Deficit Hyperactivity Disorder that occurs in ≥ 2 different settings for > 6 months. Onset is usually before age 12 years. ADHD ADHD Attention deficit hyperactivity disorder is a neurodevelopmental disorder characterized by a pattern of inattention and/or hyperactivity-impulsivity that occurs in at least 2 different settings for more than 6 months. Although the patient has normal intelligence, the disease causes functional decline. Attention Deficit Hyperactivity Disorder is a common comorbidity of CD; however, the hyperactivity Hyperactivity Attention Deficit Hyperactivity Disorder and impulsive behavior of ADHD ADHD Attention deficit hyperactivity disorder is a neurodevelopmental disorder characterized by a pattern of inattention and/or hyperactivity-impulsivity that occurs in at least 2 different settings for more than 6 months. Although the patient has normal intelligence, the disease causes functional decline. Attention Deficit Hyperactivity Disorder generally do not violate societal norms or the rights of others. 
  • Disruptive mood dysregulation disorder Disruptive Mood Dysregulation Disorder Disruptive mood dysregulation disorder (DMDD) is a childhood mental disorder involving chronic negative mood, irritability, and severe, recurrent temperamental outbursts. Age of onset is prior to 10 years old and a typical feature is perpetual feelings of anger and irritability. Disruptive Mood Dysregulation Disorder ( DMDD DMDD Disruptive mood dysregulation disorder (DMDD) is a childhood mental disorder involving chronic negative mood, irritability, and severe, recurrent temperamental outbursts. Age of onset is prior to 10 years old and a typical feature is perpetual feelings of anger and irritability. Disruptive Mood Dysregulation Disorder): 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 Affect The feeling-tone accompaniment of an idea or mental representation. It is the most direct psychic derivative of instinct and the psychic representative of the various bodily changes by means of which instincts manifest themselves. Psychiatric Assessment others’ rights as in CD. 
  • Intermittent explosive disorder Intermittent Explosive Disorder Intermittent explosive disorder (IED) is an impulse-control disorder characterized by abrupt episodes of recurrent, severe, angry outbursts with normal mood maintained between the outbursts. 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 Intermittent Explosive Disorder Intermittent explosive disorder (IED) is an impulse-control disorder characterized by abrupt episodes of recurrent, severe, angry outbursts with normal mood maintained between the outbursts. 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 Oppositional Defiant Disorder Oppositional defiant disorder is a pediatric psychiatric disorder characterized by a continuous pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness directed at adults or other authority figures. Symptoms must be present for at least 6 months to make a diagnosis of ODD. Oppositional Defiant Disorder (ODD) Disruptive mood dysregulation disorder Disruptive Mood Dysregulation Disorder Disruptive mood dysregulation disorder (DMDD) is a childhood mental disorder involving chronic negative mood, irritability, and severe, recurrent temperamental outbursts. Age of onset is prior to 10 years old and a typical feature is perpetual feelings of anger and irritability. Disruptive Mood Dysregulation Disorder ( DMDD DMDD Disruptive mood dysregulation disorder (DMDD) is a childhood mental disorder involving chronic negative mood, irritability, and severe, recurrent temperamental outbursts. Age of onset is prior to 10 years old and a typical feature is perpetual feelings of anger and irritability. Disruptive Mood Dysregulation Disorder) 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 Extreme and disproportionately angry response to stimulus Lack of empathy Empathy An individual’s objective and insightful awareness of the feelings and behavior of another person. It should be distinguished from sympathy, which is usually nonobjective and noncritical. It includes caring, which is the demonstration of an awareness of and a concern for the good of others. Psychotherapy, remorse, guilt
Behavioral features
  • Violates rules of society (thievery, vandalism)
  • Aggressive to people and animals Animals Unicellular or multicellular, heterotrophic organisms, that have sensation and the power of voluntary movement. Under the older five kingdom paradigm, animalia was one of the kingdoms. Under the modern three domain model, animalia represents one of the many groups in the domain eukaryota. Cell Types: Eukaryotic versus Prokaryotic
Exclusion diagnosis Not diagnosed if patient meets criteria for DMDD DMDD Disruptive mood dysregulation disorder (DMDD) is a childhood mental disorder involving chronic negative mood, irritability, and severe, recurrent temperamental outbursts. Age of onset is prior to 10 years old and a typical feature is perpetual feelings of anger and irritability. Disruptive Mood Dysregulation Disorder May co-occur with ADHD ADHD Attention deficit hyperactivity disorder is a neurodevelopmental disorder characterized by a pattern of inattention and/or hyperactivity-impulsivity that occurs in at least 2 different settings for more than 6 months. Although the patient has normal intelligence, the disease causes functional decline. Attention Deficit Hyperactivity Disorder, CD, depressive disorders, and substance use disorders
  • May co-occur with ODD
  • Consider antisocial personality disorder Antisocial Personality Disorder A personality disorder whose essential feature is a pervasive pattern of disregard for, and violation of, the rights of others that begins in childhood or early adolescence and continues into adulthood. The individual must be at least age 18 and must have a history of some symptoms of conduct disorder before age 15. Cluster B Personality Disorders 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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