Conduct Disorder

Aka: Conduct Disorder, Conduct Behavior Disorder, Disturbed Conduct

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II. Epidemiology

  1. Lifetime Prevalence: 9.5% (12% for males, 7.1% for females)

III. Risk Factors

  1. Male gender
  2. Childhood poverty
  3. Maternal Tobacco Abuse during pregnancy
  4. Parental conditions (e.g. Substance Abuse, criminality)
  5. Exposure to physical or sexual abuse in childhood (or witness to Intimate Partner Violence)
  6. Lower cognitive ability
  7. Family Instability
  8. Peers with behavior problems (Substance Abuse, Truancy, criminality)
  9. Parents who Exercise severe Discipline or practice a cruel attitude

IV. History

  1. Skipped school (when and why)?
  2. School suspensions or expulsions?
  3. Physical fights (when and why) at school or elsewhere?
  4. Police trouble (negative interactions, arrests, charges filed)?
  5. Stealing?
  6. Do you use Alcohol, drugs?
  7. Are you sexually active?
  8. Stay out late past family curfew?

V. Symptoms: Aggression

  1. Intimidates, bullies or threatens others
  2. Starts physical fights
  3. Weapon use that could cause serious physical harm to others (e.g. knife or gun, broken bottle or bat)
  4. Physically cruel to people
  5. Physically cruel to animals
  6. Stealing while confronting a victim (e.g. Mugging, Extortion, or armed robbery)
  7. Forced sexual activity

VI. Symptoms: Property destruction

  1. Arson with intent of causing serious damage
  2. Deliberate property destruction (property that does not belong to them)

VII. Symptoms: Lying or Theft

  1. Broken into another person's car or building
  2. Lies to obtain goods or favors or to avoid obligations (e.g. Con-Artist)
  3. Theft without confronting the owner (e.g. shoplifting or forgery)

VIII. Symptoms: Rule violation

  1. Disregards curfews before age 13 years
  2. Truant from school before age 13 years
  3. Run away from home overnight
    1. Once if gone for prolonged period
    2. Twice for other cases

IX. Diagnosis: DSM-5 (based on 4 symptom criteria as above)

  1. Repetitive and persistent violation of other's basic rights or major age appropriate social norms or rules
  2. Three or more of symptom criteria in last 12 months (from 15 possible in any of the 4 symptom categories)
  3. At least one of symptom criteria in last 6 months
  4. Impaired social, school or work functioning
  5. Criteria not met for Antisocial Personality disorder
    1. Applies only to patients over age 18 years
  6. Specifiers
    1. Onset
      1. Childhood onset (one or more characteristic symptoms before age 10 years old)
      2. Adult onset (No characteristic symptoms before age 10 years old)
      3. Unspecified onset
    2. Limited prosocial emotions (2 or more characteristics in multiple settings, relationships for 12 months)
      1. Lack of remorse or guilt
      2. Callous or lack of empathy (cold and uncaring)
      3. Unconcerned with performance at school, work or important activities
      4. Shallow or deficient affect
  7. Severity
    1. Mild (minimal criteria met for diagnosis or relatively minor harm to others)
    2. Moderate
    3. Severe (many criteria met beyond diagnosis or significant harm to others)
  8. References
    1. (2013) DSM-5, APA, Washington DC, p. 469-71

X. Diagnosis: Scales

  1. Child Behavior Checklist
  2. Disruptive Behavior Disorders Rating Scale
  3. Vanderbilt Assessment Scale
    1. Typically used for ADHD evaluation, but does have questions related to ODD and Conduct Disorder
    2. Test Sensitivity for Conduct Disorder is only 67%
    3. Becker (2012) J Dev Behav Pediatr 33(3): 221-8 [PubMed]

XI. Differential Diagnosis

  1. Oppositional Defiant Disorder
  2. Attention Deficit Hyperactivity Disorder
  3. Substance Abuse
  4. Major Depression
  5. Bipolar Disorder
  6. Disruptive mood dysregulation disorder
  7. Adjustment Disorder (with depressed mood or Disturbed Conduct)
  8. Intermittent Explosive Disorder (impulsive, but not predatory)
  9. Posttraumatic Stress Disorder

XII. Associated Conditions

  1. Attention Deficit Disorder (comorbid in up to 20% of Conduct Disorder)
  2. Oppositional Defiant Disorder (comorbid in 50-60% of Conduct Disorder)
  3. Substance Abuse (esp. Tobacco and Alcohol Abuse when ADHD is comorbid)
  4. Mood Disorder (Major Depression, Anxiety Disorder)

XIII. Management: General Measures

  1. Parents should have their own physical and mental health conditions managed appropriately
  2. Model positive listening and communication behaviors
  3. Involve professionals that communicate with one another
    1. School social workers
    2. Subspecialty Consultation as needed
  4. Parents should monitor their child's activities
    1. Where and with whom their children are spending time
    2. Curfews should be enforced
    3. Encourage organized school activities (under the direction of coaches, teachers or parents)
    4. Encourage healthy activities (e.g. sports, school clubs, community groups)
    5. Planned daily family activities (e.g. dinner together, board games)
    6. Parents and children can review together their phone messaging and online Social Media
  5. Enforce well-defined and pre-defined behavior-based rewards and consequences
  6. Treat comorbid mental health conditions
    1. Attention Deficit Disorder
    2. Mood Disorder
    3. Substance Abuse

XIV. Management: Medications

  1. Precautions
    1. When ADHD is present, its effective management will typically improve conduct behaviors
    2. Conduct Disorder behavior management (see above) is the primary management strategy
    3. Other medications (esp. Risperidone) are only indicated in refractory cases
  2. Attention Deficit Disorder (with or without ODD, Conduct Disorder)
    1. ADHD Stimulants
    2. Atomoxetine (Straterra)
    3. Guanfacine
  3. Oppositional behavior or Conduct Disorder
    1. Risperidone or Risperdal (high quality evidence)
    2. Other agents with low quality evidence
      1. Clonidine (low quality evidence)
      2. Valproate (low quality evidence)
  4. Medications to Avoid (ineffective or harmful)
    1. Avoid Quetiapine (Seroquel)
    2. Avoid Haloperidol
    3. Avoid Lithium
    4. Avoid Carbamazepine (Tegretol)

XV. Resources

  1. First Step To Success (Kindergarten)
    1. http://www.firststeptosuccess.org/
  2. Second Step (School-based program)
    1. https://www.secondstep.org/
  3. Coping Power (Ages 10-12 years old, Grades 4-6)
    1. http://www.copingpower.com/
  4. Incredible Years (ages 2 to 12 years)
    1. http://www.incredibleyears.com/
  5. Triple P (Positive Parenting Program)
    1. https://www.triplep-parenting.com/us/triple-p/

XVI. Complications

  1. Antisocial Personality Disorder (esp. with early onset Alcohol Abuse)
    1. Develops in 45-70% of Conduct Disorder
    2. Borderline Personality Disorder is also more common
    3. Increased risk of violent crime and Substance Abuse
  2. Substance Abuse
    1. Alcohol Abuse (78% in men, 65% in women)
    2. Drug use (48% in men, 46% in women)
  3. Failure to Complete High School
  4. Criminality

XVII. References

  1. (2013) DSM-5, APA, Washington DC, p. 469-71
  2. Lillig (2018) AM Fam Physician 98(10):584-92 [PubMed]
  3. Searight (2001) Am Fam Physician 63(8): 1579-88 [PubMed]

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