Conduct disorder (CD) is a behavioral and emotional disorder of childhood and adolescence. Children with conduct disorder act inappropriately, infringe on the rights of others, and violate the behavioral expectations of others.
Children and adolescents with conduct disorder act out aggressively and express anger inappropriately. They engage in a variety of antisocial and destructive acts, including violence towards people and animals, destruction of property, lying, stealing, truancy, and running away from home. They often begin using and abusing drugs and alcohol and having sex at an early age. Irritability, temper tantrums, and low self-esteem are common personality traits of children with CD.
Conduct disorder is present in approximately 6–16 percent of boys and 2–9 percent of girls under the age of 18. The incidence of CD increases with age. Girls tend to develop CD later in life (age 12 or older) than boys. Up to 40 percent of children with conduct disorder grow into adults with antisocial personality disorder.
Causes and symptoms
There are two subtypes of CD, one beginning in childhood (childhood onset) and the other in adolescence (adolescent onset). Research suggests that this disease may be caused by one or more of the following factors:
- poor parent-child relationships
- dysfunctional families
- inconsistent or inappropriate parenting habits
- substance abuse
- physical and/or emotional abuse
- poor relationships with other children
- cognitive problems leading to school failures
- brain damage
- biological defects
Difficulty in school is an early sign of potential conduct disorder problems. While the child's IQ may be in the normal range, he or she can have trouble with verbal and abstract reasoning skills and may lag behind classmates, and consequently feel as if he/she does not "fit in." The frustration and loss of self-esteem resulting from this academic and social inadequacy can trigger the development of CD.
A dysfunctional home environment can be another major contributor to CD. An emotionally, physically, or sexually abusive household member; a family history of antisocial personality disorder; or parental alcoholism or substance abuse can damage a child's self-perception and put him or her on a path toward negative or aggressive behavior. Other less obvious environmental factors can also play a part in the development of conduct disorder; several long-term studies have found an association between maternal smoking during pregnancy and the development of CD in offspring.
Other conditions that may cause or co-exist with conduct disorder include head injury, substance abuse disorder, major depressive disorder, and attention deficit hyperactivity disorder (ADHD). Fifty to seventy-five percent of children diagnosed with CD also have ADHD, a disorder characterized by a persistent pattern of inattention and/or hyperactivity.
CD is defined as a repetitive behavioral pattern of violating the rights of others or societal norms. Three of the following criteria or symptoms are required over the previous 12 months for a diagnosis of CD (one of the three must have occurred in the past six months):
- bullies, threatens, or intimidates others
- picks fights
- has used a dangerous weapon
- has been physically cruel to people
- has been physically cruel to animals
- has stolen while confronting a victim (for example, mugging or extortion)
- has forced someone into sexual activity
- has deliberately set a fire with the intention of causing damage
- has deliberately destroyed property of others
- has broken into someone else's house or car
- frequently lies to get something or to avoid obligations
- has stolen without confronting a victim or breaking and entering (e.g., shoplifting or forgery)
- stays out at night; breaks curfew (beginning before 13 years of age)
- has run away from home overnight at least twice (or once for a lengthy period)
- is often truant from school (beginning before 13 years of age)
When to call the doctor
When symptoms of conduct disorder are present, a child should be taken to his or her health care provider as soon as possible for evaluation and possible referral to a mental health care professional. If a child or teen diagnosed with conduct disorder reveals at any time that he/she has had recent thoughts of self-injury or suicide, or if he/she demonstrates behavior that compromises personal safety or the safety of others, professional assistance from a mental health care provider or care facility should be sought immediately.
Conduct disorder may be diagnosed by a family physician or pediatrician, social worker, school counselor, psychiatrist, or psychologist. Diagnosis may require psychiatric expertise to rule out such conditions as oppositional defiant disorder, 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, review of educational records, 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), the Nisonger Child Behavior Rating Form (N-CBRF), Clinical Global Impressions scale (CGI), and Diagnostic Interview Schedule for Children (DISC). The tests are verbal and/or written and are administered in both hospital and outpatient settings.
Treating conduct disorder requires an approach that addresses both the child and his/her environment. Behavioral therapy and psychotherapy can help a child with CD to control his/her anger and develop new coping techniques. Social skills training can help a child improve his/her relationship with peers.
Family group therapy may also be effective in some cases. Parents should be counseled on how to set appropriate limits with their child and be consistent and realistic when disciplining. A parental skills training program may be recommended. If an abusive home life is at the root of the conduct problem, every effort should be made to move the child into a more supportive environment.
For children with coexisting ADHD, substance abuse, depression, anxiety, or learning disorders, treating these conditions first is preferred, and may result in a significant improvement in behavior. In all cases of CD, treatment should begin when symptoms first appear. Several studies have shown methylphenidate (Ritalin) to be a useful drug for both ADHD and CD in some children.
When aggressive behavior is severe, mood stabilizing medication, including lithium (Cibalith-S, Eskalith, Lithobid, Lithonate, Lithotabs), and carbamazepine (Tegretol, Carbatrol, Epitol) may be an appropriate option for treating the aggressive symptoms. However, placing the child into a structured setting or treatment program such as a psychiatric hospital may be just as beneficial for easing aggression as medication.
Follow-up studies of conduct-disordered children have shown a high incidence of antisocial personality disorder, affective illnesses, and chronic criminal
Conduct disorder that first occurs in adolescence is thought to have a statistically better prognosis than childhood-onset conduct disorder. Adolescents with CD tend to have better relationships with their peers and are less likely to develop antisocial personality disorder in adulthood than those with childhood-onset CD. There is also less of a gender gap in adolescent-onset conduct disorder, as girls approach boys in CD incidence. Childhood-onset CD is much more common among boys.
A supportive, nurturing, and structured home environment is believed to be the best defense against conduct disorder. Children with learning disabilities and/or difficulties in school should get immediate and appropriate academic assistance. Addressing these problems when they first appear helps to prevent the frustration and low self-esteem that may lead to CD later on.
A child with conduct disorder can have a tremendous impact on the home environment and on the physical and emotional welfare of siblings and others sharing the household. While seeking help for their child with CD, parents must remain sensitive to the needs of their other children and adjust household routines accordingly. This may mean avoiding leaving siblings alone together, getting assistance with childcare, or even seeking residential or hospital treatment for the conduct disordered child if the safety and well-being of other family members is in jeopardy.
Attention deficit hyperactivity disorder (ADHD)—A condition in which a person (usually a child) has an unusually high activity level and a short attention span. People with the disorder may act impulsively and may have learning and behavioral problems.
Major depressive disorder—A mood disorder characterized by profound feelings of sadness or despair.
Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR). Washington, DC: American Psychiatric Press, Inc., 2000.
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Black, Susan. "New Remedies for High School Violence." Education Digest. 69, no.3 (November 2003): 43.
"Conduct Disorder and Oppositional Defiant Disorder: Trends and Treatment." The Brown University Child and Adolescent Psychopharmacology Update. 6, no.8 (August 2004): 1+.
The American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Ave., N.W., Washington, D.C. 20016. (202) 966–7300. Web site: <www.aacap.org>.
Goodman, Robin and Anita Gurian. "About Conduct Disorder." NYU Child Study Center. Available online at: <www.aboutourkids.org/aboutour/articles/about_conduct.html> (accessed September 12, 2004).