Objectives

• To introduce the concept of conduct disorder to the students

• To understand the symptomatology and diagnosis of conduct disorder

• To identify and understand the causes of conduct disorder

• To explore the preventive measures of the disorder

• To discuss in detail the treatment options for conduct disorder

GLOSSARY

• ADHD: Attention Deficit Hyperactivity Disorder (ADHD) is a mental and behavioral

disorder characterized by behavioral problems such as hyperactivity, inattention,
concentration difficulty, and other mental symptoms.
• Aggression: Overly aggressive behavior.
• Anti-Social Personality Disorder: A psychiatric condition characterized by chronic
behavioral and social problems which often involves criminal behaviour.
• Intermittent Explosive Disorder: Episodes of explosively aggressive behavior.
• Mental health conditions: Medical conditions related to mental health, emotions,
behavior, personality, psychology, psychiatry, and so on.
• Oppositional Defiant Disorder: A behavioral problem that occurs in children and
involves persistent disobedience, defiance and hostility towards authority figures. The
behavioral problem is greater than the normal pattern of child misbehaviors. The severity
of the problem affects the child's ability to perform satisfactorily in home, school and
community environments.
• Personality disorders: A group of psychiatric disorders
Summary

Conduct disorder is a psychiatric syndrome occurring in childhood and adolescence, and is

characterized by a longstanding pattern of violations of rules and antisocial behavior. The
incidence of conduct disorder increases from childhood to adolescence. The primary diagnostic
features of conduct disorder include aggression, theft, vandalism, violations of rules and/or lying.
For a diagnosis, these behaviors must occur for at least a six-month period. Conduct disorder has
a multifactorial etiology that includes biologic, psychosocial and familial factors.

Children with conduct disorder tend to be impulsive, hard to control, and not concerned about
the feelings of other people. These children often make no effort to hide their aggressive
behaviors. They may have a hard time making real friends. The disturbance in behavior causes
clinically significant impairment in social, academic, or occupational functioning. Conduct
disorder is often associated with attention-deficit disorder. Both conditions carry a risk for
alcohol or other drug addiction. The diagnosis is more common among boys. Conduct disorder
also can be an early sign of depression or bipolar disorder.
Introduction

According to the American Academy of Child and Adolescent Psychiatry, “conduct disorder is a
complicated group of behavioral and emotional problems in youngsters. Children and
adolescents with this disorder have great difficulty following rules and behaving in a socially
acceptable way. They are often viewed by other children, adults, and social agencies as ‘bad’ or
delinquent, rather than mentally ill” (AACAP).

Etiology

The etiology of conduct disorder involves an interaction of genetic/constitutional, familial and

social factors. Children who have conduct disorder may inherit decreased baseline autonomic
nervous system activity, requiring greater stimulation to achieve optimal arousal. This hereditary
factor may account for the high level of sensation-seeking activity associated with conduct
disorder.

Potential Causes of conduct disorder:

• Early maternal rejection

• Separation from parents without an adequate alternative
• caregiver
• Early institutionalization
• Family neglect
• Abuse or violence
• Parental mental illness
• Parental marital discord
• Genetic Defects
• Poverty

Exposure to the antisocial behavior of a caregiver is a particularly important risk factor. Children
with conduct disorder, while present in all economic levels, appear to be overrepresented in
lower socioeconomic groups. Another common feature appears to be inconsistent parental
availability and discipline. As a result, children with conduct disorder do not experience a
consistent relationship between their behavior and its consequences.

It is hard to know how common the disorder is, because many of the qualities needed to make
the diagnosis (such as "defiance" and "rule breaking") can be hard to define. For an accurate
diagnosis, the behavior must be far more extreme than simple adolescent rebellion or boyish
enthusiasm.

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 listed in
the Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV), symptoms
typically include 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 and animals
• has stolen while confronting a victim (e.g., mugging, purse snatching, extortion)
• 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

School related factors concerning students with Conduct Disorder include:

• Low academic achievement from the outset of the school years

• Reading disabilities: One study found students with this disorder at a reading level 28
months behind peers
• Typically 2 or 3 years behind academically
• Lower verbal skills
• Lower abstract reasoning abilities

If the individual’s age is 18 years or older, criteria are not met for antisocial personality disorder.
Two subtypes of conduct disorder are provided based on the age at onset of the disorder
(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 underreport symptoms and
overestimate the age at onset.

1. 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 to develop adult antisocial personality
disorder than are those with adolescent-onset type.

2. 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 to 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.

Severity of Disorder:

• Mild: few if any conduct problems in excess of those required to make the diagnosis and
conduct problems cause only minor harm to others
• Moderate: number of conduct problems and effect on others intermediate between
"mild" and "severe"
• Severe: many conduct problems in excess of those required to make the diagnosis or
conduct problems cause considerable harm to others

Diagnosis

A child is diagnosed with CD 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. CD is diagnosed
and treated by a number of social workers, school counselors, psychiatrists, and psychologists.
Genuine diagnosis may require psychiatric expertise to rule out such conditions as bipolar
disorder or ADHD. A comprehensive evaluation of the child should ideally include interviews
with the child and parents, a full social and medical history, a cognitive evaluation, and a
psychiatric exam. One or more clinical inventories or scales may be used to assess the child for
conduct disorder—including the Youth Self-Report, the Overt Aggression Scale (OAS),
Behavioral Assessment System for Children (BASC), Child Behavior Checklist (CBCL), and
Diagnostic Interview Schedule for Children (DISC). The tests are verbal and/or written and are
administered in both hospital and outpatient settings.

Assessment and diagnosis of conduct disorder—or any emotional or behavioral disorder of

childhood—should be done by a mental health professional, preferably one who is trained in
children’s mental health. Any diagnosis must be made in consultation with the child’s family.
The assessment process should include observation of the child, discussion with the child and
family, the use of standardized instruments or structured diagnostic interviews, and history-
taking, including a complete medical and family / social history. When assessing and diagnosing
any childhood emotional or behavioral disorder, the mental health professional should consider
the social and economic context in which a child’s behavior occurs.

Accurate assessment and appropriate, individualized treatment will assure that all children are
equipped to navigate the developmental milestones of childhood and adolescence and make a
successful adaptation to adulthood. Treatment must be provided in the least restrictive setting
possible.

Examination and Tests

There is no real test for diagnosing conduct disorder. The diagnosis is made when a child or
adolescent has a history of conduct disorder behaviors. A physical examination and blood tests
can help rule out medical conditions that are similar to conduct disorder. Rarely, a brain scan
may also help rule out other disorders.

Differential Diagnosis and Co morbidity

Children with conduct disorder have a high risk of developing other adjustment problems.
Specifically, risk factors associated with conduct disorder and the effects of conduct disorder
symptomatology on a child’s psychosocial context have been linked to overlap with other
psychological disorders. The differential diagnosis should include attention-deficit/hyperactivity
disorder (ADHD), oppositional defiant disorder, mood disorder (major depression, dysthymia,
bipolar disorder), substance abuse and intermittent explosive disorder.
Prevention of conduct disorder in childhood:

As with oppositional defiant disorder (ODD), some experts believe that a developmental
sequence of experiences occurs in the development of conduct disorder. This sequence may start
with ineffective parenting practices, followed by academic failure and poor peer interactions.
These experiences then often lead to depressed mood and involvement in a deviant peer group.
Other experts, however, believe that many factors, including child abuse, genetic susceptibility,
history of academic failure, brain damage or a traumatic experience influence the expression of
conduct disorder. Early detection and intervention into negative family and social experiences
may be helpful in disrupting the development of the sequence of experiences that lead to more
disruptive and aggressive behaviors.

Treatment
Conduct disorder is difficult to overcome, but it is not hopeless. In situations where an effective
support network of parental figures, teachers, and peers can be assembled, the disorder is
manageable. Treatment may include:

• Psychotherapy: Treatment for conduct disorder is complicated by the negative attitudes

the disorder instills in your child. As such, psychotherapy and behavioral therapy are
often undertaken for long periods of time, and the entire family and support network of
your child is brought into the loop. The earlier the condition is diagnosed, the more
successful the therapy will be. While your child learns a better way to interact with the
world at large, you will learn the best ways to communicate with him.
• Cognitive-behavioral approaches - The goal of cognitive-behavioral therapy is to
improve problem solving skills, communication skills, impulse control and anger
management skills.
• Family therapy - Family therapy is often focused on making changes within the family
system, such as improving communication skills and family interactions.
• Peer group therapy - Peer group therapy is often focused on developing social skills and
interpersonal skills.
• Medication - While not considered effective in treating conduct disorder, medication
may be used if other symptoms or disorders are present and responsive to medication.
However, the most effective treatment for an individual with conduct disorder is one that seeks
to integrate individual, school, and family settings. Additionally, treatment should also seek to
address familial conflict such as marital discord or maternal depression. In this manner, a
treatment would serve to address many of the possible triggers of conduct problems. Several
treatments currently exist, the most effective of which is Multi-Systemic Treatment (MST).

MST is an intensive, integrative treatment that emphasizes how an individual’s conduct

problems fit within a broader context. The individual is viewed functioning within a series of
interconnected systems (home, school, neighborhood etc.), that reinforces their antisocial
behavior. MST seeks to break this connection through empowering the individual and family
members.

The success rate of MST among severely antisocial youths has been found to be superior to other
office-based therapy approaches. Adolescents that have undergone this treatment show decreased
levels of aggression and improved familial relations. MST has also been found to decrease long-
term rates of crime.

MST has not yet been shown to differentiate between rates of improvement for those presenting
a child-onset path and those with an adolescent-onset path. Perceived gains from this treatment
may stem from the fact that adolescent onset of the disorder is typically associated with troubled
teens befriending other troubled teens. MST may serve to deter these bonds and thus improve
their prognosis. The child-onset type has proved to be more impairing, and resilient, and thus
may not respond as well.

Outlook (Prognosis)

Children who have severe or frequent symptoms tend to have the poorest outlook. Expectations
are also worse for those who have other illnesses, such as mood and drug abuse disorders.

As the above text describes the diagnostic criteria of Conduct Disorder according
to the DSM-IV-TR, it is important to note the changes made regarding this disorder in the latest
edition i.e. DSM-V. Although there are no changes made in the diagnostic criteria of the
disorder, it is important to note that the disorder in DSM-IV-TR has been categorized under
“Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence”, in DSM-V it has
been categorized under “Disruptive, Impulse-Control, and Conduct Disorders”.

Case Study - 1

Tim is a six-year-old boy brought to the family medicine clinic for an initial visit. On entering
the examination room, the physician observed Tim spinning in circles on the stool while his
mother pled, “If I have to tell you one more time to sit down…” Tim was not permitted to begin
first grade until his immunizations were updated. His mother explained that Tim had visited
several physicians for immunization but was so disruptive that the physicians and nurses always
gave up. She hoped that with a new physician, Tim might comply. The mother described a
several-year history of aggressive and destructive behavior, as well as four school suspensions
during kindergarten. He often becomes “uncontrollable” at home and has broken dishes and
furniture. Last year, Tim was playing with the gas stove and started a small fire. Tim frequently
pulls the family dog around by its tail. Tim's older sisters watched him in the past but have
refused to do so since he threw a can of soup at one of them. Tim's father is a long-haul truck
driver who sees Tim every three to four weeks.

Case Study – 2

Sharon, a 15-year-old girl, was brought to the office by her mother. Her mother explained that
Sharon was suspended from school for assaulting a teacher and needed a “doctor's evaluation”
before she could return to class. The history reveals that this is Sharon's 10th school suspension
during the past three years. She has previously been suspended for fighting, carrying a knife to
school, smoking marijuana and stealing money from other students' lockers. When asked about
her behavior at home, Sharon reports that her mother frequently “gets on my nerves” and, at
those times, Sharon leaves the house for several days. The family history indicates that Sharon's
father was incarcerated for auto theft and assault. Sharon's mother frequently leaves Sharon and
her eight-year-old brother unsupervised overnight.
REFERENCES

• Hill,J.& Maughan,B. (2000). Conduct Disorders in Childhood and Adolescence.

Cambridge Child and Adolescent Psychiatry Series.
• Kazdin, A.E. (1995). Conduct disorders in childhood and adolescence.Sage Publications,
Inc,U.S.A.

• Kernberg, P.F. & Chazan, S. (1991). Children with Conduct Disorders: A Psychotherapy
Manual. Basic Books Inc, U.S.A.
• Sholever, G.P. (1995). Conduct disorders in childhood and adolescence. American
Psychiatric Publications.
WEB LINKS

• http://psychcentral.com/disorders/sx67.htm
• http://behavenet.com/conduct-disorder
• http://www.mentalhealthamerica.net/go/conduct-disorder
• http://www.childmind.org/en/health/disorder-guide/conduct-disorder
• http://www.chw.org/display/PPF/DocID/22137/router.asp
• www.youtube.com/watch?v=x0MaaU-MM0U
• www.youtube.com/watch?v=g58qUHEq6fU
• www.youtube.com/watch?v=pr5k_MEXz6E
• www.youtube.com/watch?v=aFjHWXfRHfQ
• www.youtube.com/watch?v=_0jgXDlf4rM
FAQs

1. What are the signs and symptoms of Conduct Disorder?

Behaviors characteristic of conduct disorder include:

• Aggressive behavior that causes or threatens harm to other people or animals, such as
bullying or intimidating others, often initiating physical fights, or being physically cruel
to animals.
• Non-aggressive conduct that causes property loss or damage, such as fire-setting or the
deliberate destruction of others’ property.
• Deceitfulness or theft, such as breaking into someone’s house or car, or lying or
“conning” others.
• Serious rule violations, such as staying out at night when prohibited, running away from
home overnight, or often being truant from school.

2. What causes conduct disorder?

The conditions that contribute to the development of conduct disorder are considered to be
multifactorial, with many factors (multifactorial) contributing to the cause. Neuropsychological
testing has shown that children and adolescents with conduct disorders seem to have an
impairment in the frontal lobe of the brain that interferes with their ability to plan, avoid harm
and learn from negative experiences. Childhood temperament is considered to have a genetic
basis. Children or adolescents who are considered to have a difficult temperament are more
likely to develop behavior problems. Children or adolescents from disadvantaged, dysfunctional
and disorganized home environments are more likely to develop conduct disorders. Social
problems and peer group rejection have been found to contribute to delinquency. Low
socioeconomic status has been associated with conduct disorders. Children and adolescents
exhibiting delinquent and aggressive behaviors have distinctive cognitive and psychological
profiles when compared to children with other mental health problems and control groups. All of
the possible contributing factors influence how children and adolescents interact with other
people.
3. Who is affected by conduct disorder?

Rates of CD in children vary widely, with reported ranges of 6 to 16 percent for males and 2 to 9
percent for females. The disorder is more common in boys than in girls by a 4:1 ratio and is
believed to be more prevalent in urban rather than in rural settings. Children and adolescents
with conduct disorders often have other psychiatric problems as well that may be a contributing
factor to the development of the conduct disorder. The prevalence of conduct disorders has
increased over recent decades. Aggressive behavior is the reason for one-third to one-half of the
referrals made to child and adolescent mental health services.

4. How is conduct disorder diagnosed?

A child psychiatrist or a qualified mental health professional usually diagnoses conduct disorders
in children and adolescents. A detailed history of the child's behavior from parents and teachers,
observations of the child's behavior, and, sometimes, psychological testing contribute to the
diagnosis. Parents who note symptoms of conduct disorder in their child or teen can help by
seeking an evaluation and treatment early. Early treatment can often prevent future problems.

5. How common is Conduct Disorder?

Conduct disorder is more common among boys than girls, with studies indicating that the rate
among boys in the general population ranges from 6% to 16% while the rate among girls ranges
from 2% to 9%. Conduct disorder can have its onset early, before age 10, or in adolescence.
Children who display early-onset conduct disorder are at greater risk for persistent difficulties,
however, and they are also more likely to have troubled peer relationships and academic
problems. Among both boys and girls, conduct disorder is one of the disorders most frequently
diagnosed in mental health settings.