Conduct Disorder

Primer

Conduct Disorder is a mental disorder characterized by a repetitive and persistent pattern of behaviour in which the basic rights of others or major age-appropriate societal norms or rules are violated. These behaviours fall into four main categories: aggressive conduct that causes or threatens physical harm to other people or animals, non-aggressive conduct that causes property loss or damage, deceitfulness or theft, and serious violations of rules.

Epidemiology
  • In the United States, the 1-year population prevalence ranges from 2 to 10% (average 4%)[1]
  • Prevalence rates increase from childhood to adolescence
  • Conduct disorder is more common among males than among females.[2]
Prognosis
  • The onset of conduct disorder may start as early as the preschool years, but the significant symptoms usually begin during middle childhood to middle adolescence.[3]
    • Behaviours may lead to school suspension/expulsion, problems at work, legal difficulties, unplanned pregnancy, sexually transmitted diseases, and injuries from accidents/fights.
  • Oppositional defiant disorder is a common precursor to childhood-onset type of conduct disorder.
  • Approximately 40% of children and adolescents with conduct disorder may become adults with antisocial personality disorder.[4]
    • Once someone qualifies for the diagnosis of antisocial personality disorder, they no longer have conduct disorder.
  • Individuals very commonly come into contact with the criminal justice system for engaging in illegal behavior, and it is frequently diagnosed in mental health facilities for children (especially in forensic practice).
  • The course of conduct disorder is quite variable, however. In the majority of individuals, the disorder actually remits by adulthood.[5]
    • The risk that conduct disorder will persist into adulthood is increased by the presence of comorbid attention-deficit/hyperactivity disorder (ADHD) and substance use disorders.
  • Those with lower severity and fewer symptoms are able to achieve adequate social and occupational adjustment as adults.[6]
  • Although conduct disorder can be diagnosed in adults, symptoms usually already emerge in childhood or adolescence. Thus, onset is quite rare after age 16.[7]
  • Gender differences also exist between males and females:
    • Males often have fighting, stealing, vandalism, and school discipline problems.
    • Females are more likely to have lying, truancy, running away, substance use, and prostitution.
    • While males exhibit both physical and relational aggression (behaviour that harms social relationships with others), females tend to exhibit only relational aggression.[8]
Comorbidity
  • Individuals are more likely to have specific learning disorder, lower intelligence, ADHD, mood disorders, anxiety disorders, posttraumatic stress disorder (PTSD), psychotic disorders, somatic symptom disorders, impulse-control disorders, and substance-related disorders as adults.
  • Substance use disorders is common, particularly in adolescent females.[9]
  • Suicidal ideation, suicide attempts, and completed suicide are also higher.[10]
Risk Factors
  • It is more common in children of biological parents with severe alcohol use disorder, depressive disorders, bipolar disorders, schizophrenia, ADHD, and conduct disorder.[11]
  • Temperamental risk factors include a difficult infant temperament and low intelligence (most associated with low verbal IQ).[12]
  • Adverse childhood events such as parental rejection and neglect, inconsistent parenting, physical or sexual abuse, lack of supervision, early institutional living, frequent loss of caregivers, large family sizes, parental criminality, and familial substance use disorders are risk factors.
  • Peer rejection, association with a delinquent peer groups, and neighbourhood exposure to violence are societal and environmental risk factors.[13]

DSM-5 Diagnostic Criteria

Criterion A

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 manifested by the presence of at least 3 of the following 15 criteria in the past 12 months from any of the categories below, with at least 1 criterion present in the past 6 months:

Aggression to People and Animals
  1. Often bullies, threatens, or intimidates others
  2. Often initiates physical fights
  3. Has used a weapon that can cause serious physical harm to others (e.g. - a bat, brick, broken bottle, knife, gun)
  4. Has been physically cruel to people
  5. Has been physically cruel to animals
  6. Has stolen while confronting a victim (e.g. - mugging, purse snatching, extortion, armed robbery)
  7. Has forced someone into sexual activity
Destruction of Property
  1. Has deliberately engaged in fire setting with the intention of causing serious damage
  2. Has deliberately destroyed others’ property (other than by fire setting)
Deceitfulness or Theft
  1. Has broken into someone else’s house, building, or car
  2. Often lies to obtain goods or favours or to avoid obligations (i.e. - “cons” others)
  3. Has stolen items of nontrivial value without confronting a victim (e.g. - shoplifting, but without breaking and entering; forgery)
Serious Violations of Rules
  1. Often stays out at night despite parental prohibitions, beginning before age 13 years
  2. Has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period
  3. Is often truant from school, beginning before age 13 years
Criterion B

The disturbance in behaviour causes clinically significant impairment in social, academic, or occupational functioning.

Criterion C

If the individual is age 18 years or older, criteria are not met for antisocial personality disorder.

Mnemonic

The mnemonic BAD FOR A BUSINESS can be used to remember the 15 criteria of conduct disorder:
  • B - Bullying
  • A - Animal cruelty
  • D - Destroying other's property


  • F - Fighting
  • O - Out late at night
  • R - Running away from home


  • A - Actively forcing sex


  • B - Being cruel to people
  • U - Using a weapon
  • S - Setting fires
  • I - Into someone's house, building, or car
  • N - Not going to school
  • E - Everyday lying or conning others
  • S - Stealing while confronting a victim
  • S - Stealing without confronting a victim

Mnemonic

The mnemonic TRAP can be used to remember the four categories of conduct disorder:
  • T - Trespassing and theft
  • R - Rule-breaking
  • A - Aggression
  • P - Property destruction

Specifiers

Onset

Specify if:

  • Childhood-onset type: Individuals show at least 1 symptom characteristic of conduct disorder prior to age 10 years.
  • Adolescent-onset type: Individuals show no symptom characteristic of conduct disorder prior to age 10 years.
  • Unspecified onset: Criteria for a diagnosis of conduct disorder are met, but there is not enough information available to determine whether the onset of the first symptom was before or after age 10 years.

Severity Specifier

Specify if:

  • Mild: Few if any conduct problems in excess of those required to make the diagnosis are present, and conduct problems cause relatively minor harm to others (e.g. - lying, truancy, staying out after dark without permission, other rule breaking).
  • Moderate: The number of conduct problems and the effect on others are intermediate between those specified in “mild” and those in “severe” (e.g. - stealing without confront ing a victim, vandalism).
  • Severe: Many conduct problems in excess of those required to make the diagnosis are present, or conduct problems cause considerable harm to others (e.g. - forced sex, physical cruelty, use of a weapon, stealing while confronting a victim, breaking and entering).

Specifiers

Specify whether:

  • With limited prosocial emotions: To qualify for this specifier, an individual must have displayed at least 2 of the following characteristics persistently over at least 12 months and in multiple relationships and settings. These characteristics reflect the individual’s typical pattern of interpersonal and emotional functioning over this period and not just occasional occurrences in some situations. Thus, to assess the criteria for the specifier, multiple information sources are necessary. In addition to the individual’s self-report, it is necessary to consider reports by others who have known the individual for extended periods of time (e.g. - parents, teachers, co-workers, extended family members, peers).
    • Lack of remorse or guilt: Does not feel bad or guilty when he or she does some thing wrong (exclude remorse when expressed only when caught and/or facing punishment). The individual shows a general lack of concern about the negative consequences of his or her actions. For example, the individual is not remorseful after hurting someone or does not care about the consequences of breaking rules.
    • Callous—lack of empathy: Disregards and is unconcerned about the feelings of others. The individual is described as cold and uncaring. The person appears more concerned about the effects of his or her actions on himself or herself, rather than their effects on others, even when they result in substantial harm to others.
    • Unconcerned about performance: Does not show concern about poor/problematic performance at school, at work, or in other important activities. The individual does not put forth the effort necessary to perform well, even when expectations are clear, and typically blames others for his or her poor performance.
    • Shallow or deficient affect: Does not express feelings or show emotions to others, except in ways that seem shallow, insincere, or superficial (e.g. - actions contradict the emotion displayed; can turn emotions “on” or “off’ quickly) or when emotional expressions are used for gain (e.g. - emotions displayed to manipulate or intimidate others).

Subtypes

  • Conduct disorder is divided into 3 subtypes (childhood-onset, adult-onset, and unspecified), based on the age at onset of the disorder.
    • In childhood-onset, individuals are usually male, have physical aggression toward others, disturbed peer relationships, may have had oppositional defiant disorder during early childhood.[14]
      • The severity of behaviours is such that the full criteria for conduct disorder is usually met prior to puberty.
      • Childhood-onset is predominated by males.[15]
    • Many children with this subtype also have concurrent attention-deficit/hyperactivity disorder (ADHD) or other neurodevelopmental difficulties.
    • The prognosis is also worse for these individuals, as they are likely to have persistent conduct disorder into adulthood (compared to those with adolescent-onset type).
    • Individuals with adolescent-onset are less likely to have aggressive behaviors and tend to have more normative peer relationships. These individuals are less likely to have conduct disorder that persists into adulthood.
      • The ratio of males to females is also more balanced.

Screening and Rating Scales

  • Conduct Disorder Scale (CDS)

Pathophysiology

  • Slower resting heart rate has interestingly and reliably been noted in individuals with conduct disorder, and this biomarker is not characteristic of any other mental disorder.[16]
    • Reduced autonomic fear conditioning, particularly low skin conductance, is also well documented.

Neuroimaging

  • Neuroanatomical differences in affect regulation and processing, particularly frontotemporal-limbic connections involving the ventral prefrontal cortex and amygdala are seen in conduct disorder.
    • However, neuroimaging findings are not diagnostic for the disorder.

Differential Diagnosis

  • Oppositional defiant disorder (ODD)
    • Conduct disorder and ODD are both related to symptoms that bring the individual in conflict with adults or authority figures (e.g. - parents, teachers, employers). The behaviours of ODD, however, are less severe than conduct disorder. It additionally does not include aggression toward individuals or animals, destruction of property, or a pattern of theft or deceit. ODD also includes difficulties with emotional dysregulation (i.e. - angry and irritable mood) that is not seen in conduct disorder. If criteria are met for both ODD and conduct disorder, then both diagnoses can be made.[17]
  • Attention-deficit/hyperactivity disorder (ADHD)
    • Although children with ADHD often exhibit hyperactive and impulsive behavior that may be disruptive, this behaviour does not by itself violate societal norms or the rights of others and therefore does not typically meet criteria for conduct disorder. If criteria are met for both ADHD and conduct disorder are met, then both diagnoses should be made.
  • Depressive and bipolar disorders
    • Aggression, irritability, and conduct problems can occur in children or adolescents with major depressive disorder, bipolar disorder, or disruptive mood dysregulation disorder (DMDD). The behavioural issues in these mood disorders can be distinguished from conduct disorder based on the course of symptoms. In conduct disorder, there are substantial levels conduct problems during periods in which there is no mood disturbance. In cases where criteria for conduct disorder and a mood disorder are met, both diagnoses can be given.
  • Intermittent explosive disorder (IED)
    • Both conduct disorder and IED involve severe aggression. However, in IED, this is limited to impulsive aggression, is not premeditated, and is not committed in order to achieve an objective (e.g. - money, power, intimidation). Also, IED does not include the non-aggressive symptoms of conduct disorder. If criteria for both disorders are met, the diagnosis of IED should be given only when the recurrent impulsive aggressive outbursts warrant independent clinical attention.
  • Adjustment disorders
    • Adjustment disorder (plus specifier: with disturbance of conduct or with mixed disturbance of emotions and conduct) should be considered if clinically significant conduct problems develop in clear association with the onset of a psychosocial stressor and do not resolve within 6 months of the termination of the stressor (or its consequences). Conduct disorder is diagnosed only when the conduct problems represent a repetitive and persistent pattern that is associated with impairment in social, academic, or occupational functioning.

Investigations

Treatment

  • Evidence-based psychosocial interventions with a psychiatrist, psychologist or therapist is an important part of long-term treatment.
  • There are no pharmacotherapies to treat conduct disorder.
    • Treating any comorbid disorders, such as ADHD is important.

Resources

For Patients

For Providers

Articles
Research

References

1) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
2) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
3) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
4) Gelhorn, H. L., Sakai, J. T., Price, R. K., & Crowley, T. J. (2007). DSM-IV conduct disorder criteria as predictors of antisocial personality disorder. Comprehensive psychiatry, 48(6), 529-538.
5) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
6) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
7) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
8) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
9) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
10) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
11) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
12) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
13) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
14) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
15) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
16) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.
17) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.