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Conduct Disorder

By

Josephine Elia

, MD, Nemours/A.I. duPont Hospital for Children

Last full review/revision Apr 2021| Content last modified Apr 2021
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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 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 Overview of Substance-Related Disorders Substance-related disorders involve drugs that directly activate the brain's reward system. The activation of the reward system typically causes feelings of pleasure; the specific pleasurable... read more and antisocial behaviors and frequently have been diagnosed with attention-deficit/hyperactivity disorder (ADHD) Attention-Deficit/Hyperactivity Disorder (ADD, ADHD) Attention-deficit/hyperactivity disorder (ADHD) is a syndrome of inattention, hyperactivity, and impulsivity. The 3 types of ADHD are predominantly inattentive, predominantly hyperactive/impulsive... read more , mood disorders Overview of Mood Disorders Mood disorders are emotional disturbances consisting of prolonged periods of excessive sadness, excessive joyousness, or both. Mood disorders can occur in children and adolescents (see Depressive... read more , schizophrenia Schizophrenia in Children and Adolescents Schizophrenia is the presence of hallucinations and delusions causing considerable psychosocial dysfunction and lasting ≥ 6 months. (See also Schizophrenia in adults.) Onset of schizophrenia... read more , or antisocial personality disorder Antisocial Personality Disorder (ASPD) Antisocial personality disorder is characterized by a pervasive pattern of disregard for consequences and for the rights of others. Diagnosis is by clinical criteria. Treatment may include cognitive-behavioral... read more . Tetrahydrocannabinol (THC) has been reported to be a risk factor for physical violence even when socioeconomic factors and other substance use Overview of Substance-Related Disorders Substance-related disorders involve drugs that directly activate the brain's reward system. The activation of the reward system typically causes feelings of pleasure; the specific pleasurable... read more are accounted for (1 General reference 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... read more ). However, conduct disorder can occur in children from high-functioning, healthy families.

General reference

  • 1. Dellazizzo K, Potvin S, Dou BY, et al: Association between the use of cannabis and physical violence in youths: A meta-analytical investigation. Am J Psychiatry 177(7):appi.ajp.2020.1, 2020. https://doi.org/10.1176/appi.ajp.2020.19101008

Symptoms and Signs of Conduct Disorder

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 Suicidal Behavior in Children and Adolescents Suicidal behavior includes completed suicide, attempted suicide (with at least some intent to die), and suicide gestures; suicidal ideation is thoughts and plans about suicide. Psychiatric referral... read more must be taken seriously.

Diagnosis of Conduct Disorder

  • Clinical criteria

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

  • 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 for Conduct Disorder

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 Antisocial Personality Disorder (ASPD) Antisocial personality disorder is characterized by a pervasive pattern of disregard for consequences and for the rights of others. Diagnosis is by clinical criteria. Treatment may include cognitive-behavioral... read more . 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 of Conduct Disorder

  • 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.

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