Conduct disorder

Medical quality assurance by Dr. Albrecht Nonnenmacher, MD at July 28, 2016
StartDiseasesConduct disorder

Conduct disorder (CD) is a severe emotional and behavioral disorder that affects teenagers and children. The child or adolescent with conduct disorder is unable to follow rules or behave in a socially acceptable manner. It is common for children and teens to have behavior-related problems at some point in their development. However, it is considered to be a conduct disorder when the behavior patterns are repetitive and persistent in nature and are presented in a variety of settings: at home, at school, and in social situations. 

Contents

Definition & Facts

Conduct disorder refers to a broad range of persistent behaviors that violate social norms. The behaviors and symptoms of conduct disorder may vary, and are classified into one of four categories:

  • Aggressive behavior
  • Destructive behavior
  • Deceitfulness or theft
  • Serious infraction of established rules.

Conduct disorder affects one to four percent of nine to 17-year olds in the United States. The disorder is predominant among boys and more common in cities than in rural areas. Between six to 16 percent of boys and two to nine percent of girls meet the criteria to be diagnosed with CD. It is estimated 40 percent of these children will grow up to be adults with antisocial personality disorder.

Symptoms & Complaints

The symptoms of conduct disorder in children and adolescents may vary based on their age and the severity of the illness. The Diagnostic and Statistical Manual of Mental Disorders includes the following symptoms of conduct disorder, which fall into one of the aforementioned four categories.

Aggressive behavior:

  • Bullies, threatens or intimidates others
  • Often initiates physical fights
  • Has used a weapon that could cause serious physical harm to others
  • Is physically cruel to people or animals
  • Steals from a victim while confronting them
  • Forces someone into sexual activity

Destructive behavior:

  • Fire-setting
  • Vandalism
  • Deliberate destruction of another person’s property

Deceitfulness or theft:

  • Breaking into someone else's property or car
  • Lying to obtain goods or to avoid obligations
  • Stealing items without confrontation (shoplifting, burglary)

Serious infraction of established rules:

  • Stays out at night despite clear orders from parents
  • Runs away from home
  • Truancy

Causes

The causes of conduct disorder are complex and poorly understood. A combination of biological factors, genetic factors, environmental factors, psychological factors, and social factors are believed to play a role.

When it comes to biological factors, it is widely believed that birth defects or injuries to different areas of the brain can lead to behavior disorders. Biological risk factors include fetal alcohol spectrum disorder; injury before or just after birth; and childhood or in utero exposure to lead, mercury, and other environmental toxicants.

Genetics may also be at play. Many children and teens with conduct disorder have close family members with mental illnesses. Possibly genetic or hereditable risk factors include parental depression and parental antisocial behaviors. Having an immediate family member with attention deficit hyperactivity disorder (ADHD), a mood disorder, or a personality disorder can increase the risk of conduct disorder.

A dysfunctional family life and traumatic experiences in early childhood may contribute to the development of conduct disorder. Environmental risk factors include verbal abuse of child; witnessing violence; physical or sexual abuse; harsh punishment; academic failure; peer rejection; witnessing marital conflict or family conflict; divorce; or parent-child conflict.

It is believed that conduct disorders can reflect psychological problems related to deficits in moral awareness that stem from cognitive impairment. Psychological risk factors include difficult temperament, inflexibility, poor concentration, perceived incompetence, insecure attachment, and lack of guilt and remorse.

Low socioeconomic status and peer rejection appear to contribute to the development of conduct disorder. Social risk factors include peer rejection, poverty, community-level stressful or traumatic events, school-level stressful or traumatic events, community violence, school violence, societal and community norms favoring alcohol use and drug use.

Diagnosis & Tests

If symptoms of conduct disorder are present, the doctor may begin an evaluation by establishing the patient's complete medical history and psychiatric history. A physical examination and laboratory tests may be ordered if there is concern that a physical illness is the cause of the symptoms. The doctor will check for signs of other disorders that often present with conduct disorder such as ADHD and depression. 

The patient will likely be referred to a psychiatrist, psychologist, or mental health professional for an in-depth evaluation. Psychiatrists and psychologists use specific interview and assessment tools to evaluate a child for a mental disorder.

The doctor will diagnose the child using his or her intake of the child's symptoms and observation of the child's attitude. The doctor will also ask for reports from the child's parents, teachers, and other adults to further understand their symptoms. The mental health professional should be careful to consider the social and economic context in which a child’s behavior occurs.

Treatment & Therapy

Treatment for conduct disorder is complex and varies depending on the age, the extent of the child’s symptoms, and the child’s tolerance for medications and therapy treatments. Treatment can be provided in a variety of settings. Psychological treatments that help parents exercise positive discipline are helpful. Medications may also be effective in controlling symptoms.

  • Cognitive behavioral therapy is a type of psychotherapy aimed at improving problem solving and communication skills. The patient will be guided in practicing safe and healthy ways to control his or her anger. 
  • Family therapy helps the family unit to build communication skills and foster positive family interactions.
  • Peer group therapy. Peer group therapy focuses on developing the child’s social skills and interpersonal skills.
  • Psychiatric medication. While there is no medication effective for conduct disorder, medication may be used if other symptoms or disorders like ADHD or depression are present.

Prevention & Prophylaxis 

Early detection is crucial in preventing a child from developing the highly damaging and aggressive behaviors associated with conduct disorder.

The most effective prevention programs start early in a child’s life. Programs and initiatives that help high-risk families - such as home visits by public health nurses or the expansion of access to early childhood education - are the most beneficial.

Public and environmental initiatives at lead remediation are crucial to ensuring that children are not exposed to this toxic substance and the risk it poses for their development. Prevention programs aimed at educating children about the dangers of drugs and alcohol and discouraging their use may help prevent conduct disorder.