What is conduct disorder

Conduct disorder is an overarching term used in psychiatric classification that refers to a persistent pattern of antisocial behavior in which the individual repeatedly breaks social rules and carries out aggressive acts that upset other people ¹. Conduct disorder is a common serious mental health disorder that is characterized callous disregard for and acting aggressively toward people and animals (such as bullying, physical fights, use of a weapon) and destroying other people’s property on purpose, lying or stealing, or violating important rules (such as running away overnight or often skipping school before age 13). Children with conduct disorder exhibit cruelty, from early pushing, hitting and biting to, later, more than normal teasing and bullying, hurting animals, picking fights, theft, vandalism, and arson ². Since childhood and adolescent conduct disorder often develops into the adult antisocial personality disorder, it should be addressed with treatment as early as possible; the earlier treatment starts, the better the outlook.

Conduct disorder is much more prevalent in boys than girls. The rate of conduct disorder in boys is between 6% and 16% while girls ranged from 2% to 9% ³.

Conduct disorder is a more serious disorder than oppositional defiant disorder involving ongoing behavior that breaks social rules ⁴. The behavior causes significant problems in school or social activities. People with conduct disorder may deny or downplay their behaviors. Conduct disorder is only diagnosed in children and youth up to 18 years of age ⁴. Adults with similar symptoms may be diagnosed with antisocial personality disorder ⁴. Early treatment can help prevent problems from continuing into adulthood.

One difference between conduct disorders and many other mental health conditions is that with conduct disorders, a person’s distress is focused outward and directly affects other people ⁴. With most other mental health conditions, such as depression and anxiety, a person’s distress is generally directed inward toward themselves.

Conduct disorders tend to begin in childhood or adolescence and are more common in males than females ⁴. Several factors make it more likely a person will have a conduct disorder, including harsh parenting, physical or sexual abuse, or parents with a history of addiction or problems with law enforcement ⁵.

Globally, conduct disorders are the most common mental health disorders of childhood and adolescence, and they are the most common reason for referral to child and adolescent mental health services in Western countries ¹. A high proportion of children and young people with conduct disorders grow up to be antisocial adults with impoverished and destructive lifestyles; a significant minority will develop antisocial personality disorder, among whom the more severe will meet criteria for psychopathy ¹. Conduct disorders in childhood and adolescence are becoming more frequent in Western countries and place a large personal and economic burden on individuals and society, involving not just healthcare services and social care agencies but all sectors of society including the family, schools, police and criminal justice agencies.

A conduct disorder involves both behavioral and emotional problems found in children who do not adhere to what is socially acceptable. Kids who understand, but choose not to follow rules, can often fall into the category of conduct disorder. Teachers frequently reprimand these children more often than others from an early grade.

Conduct disorder general behavior includes:

• Criminal behavior, such as stealing.
• A lack of respect for rules, such as skipping class.
• Lack of empathy. Children who hurt animals on purpose usually fall into this category.
• Bullying. Acting out with the intention of purposely hurting other children is a common sign of conduct disorder.
• Lack of respect for boundaries, such as vandalism. Destroying other people’s property, whether it’s someone’s home or another child’s toy, is a good representation of both breaking boundaries and bullying.
• Persistent lying. When a child knows the truth and lies anyway, especially for no apparent reason, this can be seen as a red flag.

Conduct disorder may impact your child if you notice:

• Burn marks
• Difficulty concentrating
• False sense of grandiosity or egotism
• Low esteem
• Inability to plan

Many children diagnosed with conduct disorder have co-existing conditions. Some of these include: ADHD, personality disorders, anxiety, and learning difficulties.

If a conduct disorder is left untreated, the outcome can be dangerous not only for the child diagnosed, but for those around him/her.

Problems from lack of treatment can include:

• Risky sexual behavior
• Substance abuse
• Abuse of others
• Antisocial personality disorder diagnosis
• Incarceration

Children who display signs of conduct disorder in early development are at greater risk for long-term difficulties. They are more likely to struggle with relationships and less likely to finish school.

Treatment options

The most successful approaches intervene as early as possible, are structured and intensive, and address the multiple contexts in which children exhibit problem behavior, including the family, school, and community. Examples of effective treatment approaches include functional family therapy, multi-systemic therapy, and cognitive behavioral approaches which focus on building skills such as anger management. Pharmacological intervention alone is not sufficient for the treatment of conduct disorder.

In younger children, treatment for conduct disorder can resemble treatment for oppositional defiant disorder—parent management training may be undertaken by a therapist to teach parents how to encourage desired behaviors. In adolescents, therapy may target not just the home life but interactions with authority figures at school, and ensuring that peer relations are beneficial, not harmful.

Involving both family and school. Discipline for certain behavior should be consistent, whether the child is at home or in school. When teachers and parents work together, they have a clearer sense of what needs to be accomplished and how.

In addition to focusing on how to overcome the negative aspects of conduct disorder, focus on the positive. Engaging your child in healthy social structures will benefit him/her in the future. Using praise for healthy behavior is also suggested.

Recent research on Conduct Disorder has been very promising. For example, research has shown that most children and adolescents with conduct disorder do not grow up to have behavioral problems or problems with the law as adults; most of these youth do well as adults, both socially and occupationally. Researchers are also gaining a better understanding of the causes of conduct disorder, as well as aggressive behavior more generally. Conduct disorder has both genetic and environmental components. That is, although the disorder is more common among the children of adults who themselves exhibited conduct problems when they were young, there are many other factors which researchers believe contribute to the development of the disorder. For example, youth with conduct disorder appear to have deficits in processing social information or social cues, and some may have been rejected by peers as young children.

Conduct disorder subtypes

Two subtypes of conduct disorder are provided based on the age at onset of the disorder (i.e., childhood-onset type and adolescent-onset type). The subtypes differ in regard to the characteristic nature of the presenting conduct problems, developmental course and prognosis, and gender ratio. Both subtypes can occur in a mild, moderate, or severe form. In assessing the age at onset, information should preferably be obtained from the youth and from caregiver(s). Because many of the behaviors may be concealed, caregivers may under report symptoms and overestimate the age at onset.

Childhood-Onset Type

This subtype is defined by the onset of at least one criterion characteristic of conduct disorder prior to age 10 years.

Individuals with childhood-onset type are usually male, frequently display physical aggression toward others, have disturbed peer relationships, may have had oppositional defiant disorder during early childhood, and usually have symptoms that meet full criteria for conduct disorder prior to puberty. These individuals are more likely to have persistent conduct disorder and develop adult antisocial personality disorder than are those with adolescent-onset type.

Adolescent-Onset Type

This subtype is defined by the absence of any criteria characteristic of conduct disorder prior to age 10 years.

Compared with those with the childhood-onset type, these individuals are less likely to display aggressive behaviors and tend to have more normative peer relationships (although they often display conduct problems in the company of others). These individuals are less likely to have persistent conduct disorder or develop adult antisocial personality disorder. The ratio of males to females with conduct disorder is lower for the adolescent-onset type than for the childhood-onset type.

Conduct disorder causes

There is no known cause of conduct disorder. While it was originally thought to have been a product of poor parenting, the general consensus has changed. There are multiple factors that may play a role in this particular development. The most common areas of concern are: genetics, environment, and psychological problems.

Environmental factors include the family and school. Alcoholic parents who fight or neglect their children may fall into this category. Being bullied in school or having issues with specific teachers can be an environmental cause. Inconsistent discipline, whether at school or at home, has a huge impact on the behavior of a child.

Psychological problems including cognitive processing can cause a shift in normal behavior. Problems feeling remorse or guilt can arise from this segment of the disorder.

Genetics can also play an important role. Families with a history of mental illness may be more susceptible to behavioral disorders in children. Mood disorders and anxiety disorders can occur under a parent’s or teacher’s radar. If the intensity of emotion is experienced differently than others their age, children may not know how to handle their surroundings in a socially acceptable way.

At home, the child or young person with a conduct disorder is often exposed to high levels of criticism and hostility, and sometimes made a scapegoat for a catalogue of family misfortunes. Frequent punishments and physical abuse are not uncommon. The whole family atmosphere is often soured and siblings also affected. Maternal depression is often present, and families who are unable to cope may, as a last resort, give up the child to be cared for by the local authority. At school, teachers may take a range of measures to attempt to control the child or young person, bring order to the classroom and protect the other pupils, including sending the child or young person out of the class, which sometimes culminates in permanent exclusion from the school. This may lead to reduced opportunity to learn subjects on the curriculum and poor examination results. The child or young person typically has few, if any, friends, and any friends become annoyed by their aggressive behavior. This often leads to exclusion from many group activities, games and trips, thus restricting the child or young person’s quality of life and experiences. On leaving school, the lack of social skills, low level of qualifications and, possibly, a police record make it harder to gain employment.

Risk factors for conduct disorder

Children with a parent (biological or adoptive) or a sibling with conduct disorder are more likely to develop conduct disorder. Kids whose biological parents have ADHD, alcohol use disorder, depression, bipolar disorder, or schizophrenia are also at risk. Children who experienced abuse, parental rejection or neglect, and harsh or inconsistent parenting are more at risk, as are those exposed to neighborhood violence, peer rejection, and peer delinquency.

Conduct disorder symptoms

One of the hallmarks of conduct disorder is a seemingly callous disregard for societal norms and the rights, feelings, and personal space of other people. Children and adolescents with conduct disorder seem to “get a rise” out of causing harm. For them, aggression, deceit, coercion—behaviors that result in a power differential—are gratifying. Picking fights, trespassing, lying, cheating, stealing, vandalism, and emotionally or physically abusive behavior, including wielding a deadly weapon or forcing sex, are all signs that an older child may have conduct disorder. Signs of the disorder in younger children may be harder to discern from more normal acting out, but are similarly coercive: relentless bullying, lying for the sake of lying, stealing items of no apparent worth.

Severe antisocial behavior is less common in girls than in boys; they are less likely to be physically aggressive and engage in criminal behavior, but more likely to show spitefulness and emotional bullying (such as excluding children from groups and spreading rumors so others are rejected by their peers), and engage in frequent unprotected sex (which can lead to sexually transmitted disease and pregnancy), drug abuse and running away from home. Whether there should be specific criteria for diagnosing conduct disorder in girls is debated ⁶.

The severity of conduct disorder is not determined by the presence of any one symptom or any particular constellation, but is due to the overall volume of symptoms, determined by the frequency and intensity of antisocial behaviors, the variety of types, the number of settings in which they occur (for example home, school, in public) and their persistence. For general populations of children, the correlation between parent and teacher ratings of conduct problems on the same measures is low (only 0.2 to 0.3), which means that there are many children who are perceived to be mildly or moderately antisocial at home but well behaved at school, and vice versa. However, for more severe antisocial behavior there are usually manifestations both at home and at school.

Since all kids and adolescents act out from time to time, experts caution that a persistent pattern of this sort of behavior must be in evidence before conduct disorder is considered. Professionals also attempt to determine if the behavior is a negative adaptation to a troubled environment, a “learned” behavior, or if the gratification that comes from aggression seems to originate from within.

Specific Symptoms of Conduct Disorder

Conduct disorder is characterized by 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 three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past 6 months:

Aggression to people and animals

• often bullies, threatens, or intimidates others
• often initiates physical fights
• has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun)
• has been physically cruel to people
• has been physically cruel to animals
• has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery)
• has forced someone into sexual activity

Destruction of property

• has deliberately engaged in fire setting with the intention of causing serious damage
• has deliberately destroyed others’ property (other than by fire setting)

Deceitfulness or theft

• has broken into someone else’s house, building, or car
• often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others)
• has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery)

Serious violations of rules

• often stays out at night despite parental prohibitions, beginning before age 13 years
• has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period)
• is often truant from school, beginning before age 13 years

The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

Changes in clinical features of conduct disorder with age

Younger children aged 3 to 7 years usually present with general defiance of adults’ wishes, disobedience of instructions, angry outbursts with temper tantrums, physical aggression to other people (especially siblings and peers), destruction of property, arguing, blaming others for things that have gone wrong, and a tendency to annoy and provoke others.

In middle childhood, from 8 to 11 years, the above features are often present, but as the child grows older and stronger, and spends more time outside the home, other behaviors are seen. They include: swearing, lying about what they have been doing, stealing others’ belongings outside the home, persistent breaking of rules, physical fights, bullying other children, being cruel to animals and setting fires.

In adolescence, from 12 to 17 years, more antisocial behaviors are often added: being cruel to and hurting other people, assault, robbery using force, vandalism, breaking and entering houses, stealing from cars, driving and taking away cars without permission, running away from home, truanting from school, and misusing alcohol and drugs.

Not all children who start with the type of behaviors listed in early childhood progress on to the later, more severe forms. Only about half continue from those in early childhood to those in middle childhood; likewise, only about a further half of those with the behaviors in middle childhood progress to show the behaviors listed for adolescence ⁷. However, the early onset group are important as they are far more likely to display the most severe symptoms in adolescence, and to persist in their antisocial tendencies into adulthood. The most antisocial 5% of children aged 7 years are 500 to 1000% more likely to display indices of serious life failure at 25 years, for example drug dependency, criminality, unwanted teenage pregnancy, leaving school with no qualifications, unemployment and so on ⁸. Follow-back studies show that most children and young people with conduct disorders had prior oppositional defiant disorder and most (if not all) adults with antisocial personality disorder had prior conduct disorders. Likewise about 90% of severe, recurrent adolescent offenders showed marked antisocial behavior in early childhood ⁹. In contrast, there is a large group who only start to be antisocial in adolescence, but whose behaviors are less extreme and who tend to become less severe by the time they are adults ¹⁰.

Conduct disorder diagnosis

A child is diagnosed with conduct disorder if he exhibits a callous disregard for others and a sustained pattern of behaviors that fit into these general categories: aggression against people and animals, destruction of property, deceitfulness and theft, and serious violations of rules. A professional will talk with parents, teachers and other adults involved in his life to rule out other possible causes.

Conduct disorder DSM 5

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, th reatens, 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 home, or once without returning for a lengthy period.
• 15. Is often truant from school, beginning before age 13 years.

B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

C. If the individual is age 1 8 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 tum 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).

Conduct disorder treatment

Treatment for conduct disorder is complicated by the negative attitudes the conduct disorder instills. As such, psychotherapy and behavioral therapy are often undertaken for long periods of time, and the entire family and support network of the child is brought into the loop. The earlier the condition is diagnosed, the more successful the therapy will be. While a child learns a better way to interact with the world at large, the family learns the best ways to communicate with him.

Treatment for conduct disorders typically involves therapy focusing on behaviors, thoughts and feelings. Therapy can help children learn to change their thinking and control angry feelings. Therapy can be individual, group or family therapy. Treatment may include parent management training and family therapy, such as Functional Family Therapy. Functional Family Therapy helps families understand the disorder and related problems, teaches positive parenting skills and helps build family relationships. Functional Family Therapy involves training for the parents on how to respond to challenging behaviors and how to help their children. Functional Family Therapy can help families apply positive changes to other problem areas and situations.

People with conduct disorder may be fearful and distrustful and may not want to participate in treatment.

Medications are generally not used to directly treat conduct disorders (but can be used for intermittent explosive disorder). However, medications may be used for other conditions that frequently occur along with these conditions. For example, if a child or teen also has as attention-deficit/hyperactivity disorder (ADHD) or depression, medication may be useful.

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