Conduct Disorder (2)

Week 3 FM –Friday, September 18th 2020

 Diagnosis and Clinical Features
CD are characterized by a repetitive and persistent pattern of dissocial,
aggressive, or defiant conduct (ICD-10).
 CD doesnt develop overnight; many symptoms
evolve over time until a consistent pattern
develops that involves violating the rights of
others  difficulties with peer relationships.
 Aggressive antisocial behavior: bullying,
physical aggression, cruel behavior toward peers.
 Hostile, verbally abusive, impudent, defiant, and
negativistic toward adults.
 Persistent lying, frequent truancy, and vandalism
are common.
 Severe cases: destructiveness, stealing, and
physical violance often occur.
 Sexual behavior n regular use of tobacco, liquor,
or illicit psychoactive substances may occur.
Average onset
Boys: 10-12 years
Girls: 14-16 years
 Many children w/ CD have poor self-esteem, lack the skills
to communicate in socially acceptable ways.
 Suicidal thoughts, gestures, and acts are frequent in
children and adolescents with CD who are in conflict with
peers, family members, or the law and are unable to
problem-solve their difficulties.
 Often feel guilt or remorse for some of their behaviors, but
try to blame others to stay out of trouble.
 In evaluation interviews, children with aggressive CD are
typically uncooperative, hostile, n provocative.
 Severe punishments for behavior in children with CD
almost invariably increases their maladaptive expression of
rage and frustation rather than ameliorating the problem.
 Diagnosis and Clinical Features
 Evaluation of the family situation often reveals
severe marital disharmony, which initially may
center on disagreements about management of the
child.
 Some family social or psychological pathology is
usually evident. Patterns of paternal discipline are
rarely ideal and can vary from harshness n
excessive strictness to inconsistency or relative
absence of supervision and control.
Violent video games and violent behavior
Violent video game playing is related to aggressive affect,
physiologic arousal, and aggressive behaviors.
Individual having CD shows behavioral manifestations in the
following 4 categories as per DSM-5:
- Aggression to people n animals (threatening, freq physical
fights, using weapon that can cause damage to others or
showing physical cruelty to people or animals),
- Destruction of property (setting fire or deliberately
destroying others property),
- Deceitfulness or theft (stealing or breaking into other
house, building), and
- Serious violations of rules.
DSM-5 requires the persistent presence of three behaviors over period of
12 months with at least one of them present in the last 6 months.
Diagnosis and Clinical Features
 CD is frequently comorbid with various psychiatric disorders.
 ADHD is the most common childhood-onset psychiatric fisorder frequently occuring with CD.
 Primary symptoms of ADHD can be misinterpreted as antisocial which is present in CD. Careful history in
both setting will usually reveal ADHD. Symptoms of ADHD also come before the symptoms of CD.
 Differential Diagnoses
 Some behavioral disturbances or aggressive
behavior can be present in various
childhood’s psychiatric disorders such as
mood disorder and ADHD  essential to
differentiate those having other psychiatric
disorder and CD  a clinician should
obtain comprehensive history in relation
to the onset and progression of symptoms
to determine whether this behavior is
transient or persistent.
 Isolated acts of aggressive behavior do not
justify a diagnosis of CD; an entreched
pattern must be present.
Pathology and Lab Exam
 No specific lab tes or neurological pathology helps make the diagnosis of CD.
 Some evidence indicates that amounts of certain neurotransmitters, such as serotonin in the CNS, are low in
some persons with a history of violent or aggressive behavior toward others or themselves. Whether tihis
association is related to the cause, or is the effect, of violence or is unrelated to the violence is not clear.
 MRI has been used to compare structural brain differences b/w children with CD and normal controls and
have documented smaller brain structures and lower brain activity in children with CD.
 Abnormalities are primarily detected in the bilateral amygdala, right striatum, bilateral insula and left
medial/superior frontal gyrus as well as the left precuneus in individuals having ODD/CD.
 Higher plasma levels of serotonin in blood are positively associated with aggressive behavior in children.
 Impulsiveness n aggression along with violent behavior have been found to be associated with alteration in
the activity of certain brain structures. Areas mainly associated and affected are limbic structures and the
anterior cigulate and orbitofrontal areas of the prefrontal cortex.
Treatment
 As there are numerous RFs involved, to be effective
treatment must be multi-modal, involve a family-based
and social systems-based approach, address multiple
areas, and continue over a longer period. Nonpharmacological /
 Treatment should start with psychoeducating the patient Psychosocial Interventions
and his parents/caretakers about the disorder and its
potential complications and long-term consequences
and outcome.
 Various interventions are available that are effective in
Pharmacological Interventions
treating early emerging conduct problems, but their
effectiveness decreases in older children and
adolescents.
 Because of the heterogeneity in presentation, the
interventions need to be individualized.
 Treatment Nonpharmacological / Psychosocial Interventions

 Has been the mainstay of treatment in managing the CDs. There are various specific treatment
 Preventive program should form the most important of the approaches which are found to be
intervention strategies while talking about this issue. beneficial in treating the CD.
• Setting behavioral goals that slowly shape a child’s behavior in specific areas of interest
Contingency
• To monitor systematically whether the child is achieving these goals
Management • Positive reinforcement in taking steps in the direction of reaching these goals, and
Program • Penalty for undesired behavior.
• CD patients show deficits in social information processing mechanism.
Cognitive
• Teach the skills in the social context in children n adolescents with CD.
Behavioral Skill • Most of these programs teach the skills to decrease impulsivity and angry responding.
Training • Mainly consists of problem-solving steps, such as how to recognize problems, how to consider alternative
responses, and how to select the adaptive one to deal more effectively with the problems in hand.
Parent • Teach parents the skill of developing and implementing a systematic contingency management plan in home
Management setting.
Training • Aims to imptove the interaction between parent and child at home.

Other CBT treatment interventions that are proven to be efficacious : Kazdin’s Problem-Solving Skills Training
Others (PSST); Incredible Years (IY); Anger Coping Program.
Treatment Pharmacological Interventions

 Medication only is not sufficient

 Adjuncts in treatment for acute crisis
intervention and short term
management.
 Role mainly for the treatment of the
comorbid conditions, i.e., ADHD or the
symptomatic management of aggression
and impulsivity.
MMPI (Minnesota Multiphasic Personality
Inventory) test
 The best-documented instrument designed to
assess the presence of specific clinical
syndromes (Axis I).
MCMI (Millon Clinical Multiaxial Inventory) test
 Was designed to assess personality patterns and
disorders (Axis II).
 SKDI Conduct Disorder: 2
 Tingkat kemampuan 2: mendiagnosis dan merujuk
 Lulusan dokter mampu membuat diagnosis klinik terhadap penyakit tersebut berdasarkan anamnesis dan
pemeriksaan fisik dan menentukan rujukan yang paling tepat bagi penanganan pasien selanjutnya. Lulusan dokter
juga mampu menindaklanjuti sesudah kembali dari rujukan.
Prognosis
 Severe CD seem to be most vulnerable to comorbid disorders later in life, such as mood
disorders and substance use disorders.
 The best prognosis is predicted for mild CD in the absence of coexisting psychopathology and
the presence of normal intellectual functioning.
 Persistence into adulthood may leads to antisocial personality disorder (ASPD).
References
 Kaplan and Saddock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry. 11th Edition.
 Sagar R, Patra BN, Patil V. Clinical Practice Guidelines for the Management of Conduct Disorder. Indian Journal of
Psychiatry 2019;61:270-6.
 Standar Kompetensi Kedokteran Indonesia. Konsil Kedokteran Indonesia, 2012.
 Waschbusch, D. A., & Elgar, F. J. (2007). Development and validation of the conduct disorder rating scale. Assessment, 14, 65-
74.