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Conduct Disorder

By Josephine Elia, MD, Professor of Psychiatry and Human Behavior, Professor of Pediatrics;Attending Physician, Sidney Kimmel Medical College of Thomas Jefferson University;Nemours/A.I. duPont Hospital for Children

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Conduct disorder is a recurrent or persistent pattern of behavior that violates the rights of others or violates major age-appropriate societal norms or rules. Diagnosis is by history. Treatment of comorbid disorders and psychotherapy may help; however, many children require considerable supervision.

Prevalence of some level of conduct disorder (CD) is about 10%. Onset is usually during late childhood or early adolescence, and the disorder is much more common among boys than girls.

Etiology is likely a complex interplay of genetic and environmental factors. Parents of adolescents with conduct disorder often have engaged in substance abuse and antisocial behaviors and frequently have been diagnosed with ADHD, mood disorders, schizophrenia, or antisocial personality disorder. However, conduct disorder can occur in children from high-functioning, healthy families.

Symptoms and Signs

Children or adolescents with conduct disorder lack sensitivity to the feelings and well-being of others and sometimes misperceive the behavior of others as threatening. They may act aggressively, by bullying and making threats, brandishing or using a weapon, committing acts of physical cruelty, or forcing someone into sexual activity, and have few or no feelings of remorse. Sometimes their aggression and cruelty is directed at animals. These children or adolescents may destroy property, lie, and steal. They tolerate frustration poorly and are commonly reckless, violating rules and parental prohibitions (eg, by running away from home, being frequently truant from school).

Aberrant behaviors differ between the sexes: Boys tend to fight, steal, and vandalize; girls are likely to lie, run away, and engage in prostitution. Both sexes are likely to use and abuse illicit drugs and have difficulties in school. Suicidal ideation is common, and suicide attempts must be taken seriously.

Diagnosis

  • Clinical criteria

Conduct disorder is diagnosed in children or adolescents who have demonstrated 3 of the following behaviors in the previous 12 mo plus at least 1 in the previous 6 mo:

  • Aggression toward people and animals

  • Destruction of property

  • Deceitfulness, lying, or stealing

  • Serious violations of parental rules

Symptoms or behaviors must be significant enough to impair functioning in relationships, at school, or at work.

Prognosis

Usually, disruptive behaviors stop during early adulthood, but in about one third of cases, they persist. Many of these cases meet the criteria for antisocial personality disorder. Early onset is associated with a poorer prognosis.

Some children and adolescents subsequently develop mood or anxiety disorders, somatic symptom or related disorders, substance-related disorders, or early adult–onset psychotic disorders. Children and adolescents with conduct disorder tend to have higher rates of physical and other mental disorders.

Treatment

  • Drugs to treat comorbid disorders

  • Psychotherapy

  • Sometimes placement in a residential center

Treating comorbid disorders with drugs and psychotherapy may improve self-esteem and self-control and ultimately improve control of conduct disorder. Drugs may include stimulants, mood stabilizers, and atypical antipsychotics, especially short-term use of risperidone.

Moralization and dire admonitions are ineffective and should be avoided. Individual psychotherapy, including cognitive therapy and behavior modification, may help. Often, seriously disturbed children and adolescents must be placed in residential centers where their behavior can be managed appropriately, thus separating them from the environment that may contribute to their aberrant behavior.

Key Points

  • Children with conduct disorder repeatedly act aggressively, violating the rights of others and/or societal norms or rules; they have few or no feelings of remorse.

  • Disruptive behaviors continue into adulthood in about one third of patients; many of these cases then meet the criteria for antisocial personality disorder.