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Conduct Disorder

Kathryn Patricelli, MA

What is Conduct Disorder?

Conduct Disorder is now classified in the DSM-5 in the category of Disruptive, Impulse-Control, and Conduct Disorders. All of the disorders in this category involve problems controlling behavior and emotions. They tend to first appear in childhood or adolescence.

Conduct Disorder is one of the most frequently diagnosed mental disorders in children. A child with Conduct Disorder engages in repetitive and persistent behaviors that violate the basic rights of other people or that violate age-appropriate societal rules and norms for behavior with others.

This behavior falls into four different categories including aggression to people and animals, destruction of property, deceitfulness or theft, and serious violations of rules.

Symptoms of conduct disorder vary with age, changing as children develop increased strength, cognitive abilities and sexual maturity. Less severe behaviors, such as lying and shoplifting, usually emerge first, while other, more severe behaviors, such as burglary or auto theft, usually emerge later.

Symptoms of conduct disorder may include:

  • Bullying, threatening, or intimidating behavior towards other children
  • Frequent starting of physical fights
  • Use of weapons or tools capable of causing serious physical harm to people or property (e.g., bricks, bats, broken bottles, knives, guns)
  • Physical cruelty toward animals or people
  • Stealing while confronting a victim (e.g., mugging, purse snatching, armed robbery)
  • Physical violence towards others (in the form of rape, assault, homicide, etc.)
  • Destruction of property (e.g., fire setting, breaking of windows, breaking into homes, buildings or cars)
  • Frequent and manipulative telling of lies or breaking of promises in order to obtain goods, favors, or to avoid debts or obligations (e.g., "conning" people)
  • Staying out at night despite parent's curfew rules (before the age of 13)
  • Repeatedly running away from home, or running away from home for a lengthy period of time
  • Use of alcohol or drugs
  • Truancy (skipping school) before the age of 13

According to the DSM-5, the child/adolescent must display at least three of the identified 15 behaviors in the past 12 months from any of the four categories and at least one must have occurred in the last six months for a diagnosis to be made.

In addition, the symptoms must also interfere with social, academic or occupational functioning.

There are two subtypes of Conduct Disorder: Childhood-Onset Type and Adolescent-Onset Type. The Childhood-Onset specifier applies when a child has exhibited at least one symptom of the disorder prior to age 10. In the Adolescent-Onset type, there are no symptoms of the disorder before age 10.

There is also a specifier for Conduct Disorder with limited prosocial emotions. In this situation, the person has displayed two of the following over at least 12 months and in multiple relationships or settings:

  • Lack of remorse or guilt - the person does not feel bad if they are caught doing something wrong or shows no concern about negative consequences for their behavior.
  • Callous - lack of empathy - the person is unconcerned about the feelings of others or how their behavior affects other people.
  • Unconcerned about performance - the person does not show concern about poor school or work performance, does not make an effort to improve, and often blames others for his/her own poor performance.
  • Shallow or deficient affect - the person does not show emotions when interacting with others or does so in an insincere or shallow way.

Finally, there are 3 severity codes that are used including:

  • Mild - few conduct problems except those required to be diagnosed and the problems that do exist cause relatively minor harm to others.
  • Moderate - the number of problems and effects on others are between the mild and severe levels.
  • Severe - there are many more problems present than required to make a diagnosis or the problems cause considerable harm to others (physical cruelty or harm, use of weapons, breaking and entering, etc.)

How common is Conduct Disorder?

The prevalence rate for Conduct Disorder ranges from 2-10% of the general population across various countries, races and ethnicities. The rates increase from childhood to adolescence, and are higher in males than females.

What are the risk factors for Conduct Disorder?

Research suggests that Conduct Disorder is influenced by a combination of temperament, genetic and environmental factors.

According to the DSM-5, children that are difficult, aggressive, and do not follow the rules, and whose parents do not try to control this behavior (known as the child having an undercontrolled temperament), as well as those with lower-than-average intelligence, particularly with regard to verbal IQ, are at risk of developing Conduct Disorder.

Environmental triggers include: family problems (including parental rejection or neglect, inconsistent parenting (such as sometimes enforcing rules and other times ignoring behavior that breaks those rules) or lack of supervision), abuse including physical and sexual, living in an institution during early developmental years, harsh discipline, large family size or frequent change in caregivers, peer rejection, association with delinquent peer groups, and neighborhood exposure to violence.

The disorder is more common among biological children of parents diagnosed with Alcohol Dependence, Mood Disorders (such as Major Depression or Bipolar Disorder), Schizophrenia, ADHD, or Conduct Disorder.

What other disorders or conditions often occur with Conduct Disorder?

ADHD and oppositional defiant disorder are both common in those with conduct disorder, and having either of these with conduct disorder causes worse outcomes than having just one disorder. Conduct disorder is also often seen with antisocial personality disorder, specific learning disorder, anxiety disorders, depression or bipolar disorder, and substance use disorders.

How is Conduct Disorder Treated?

The first type of treatment for Conduct Disorder is behavior therapy. These strategies focus on reducing blame (parents often blame themselves for creating the problem in addition to blaming their child), increasing parental monitoring and supervision of children's behavior (through role-playings and teaching), and on implementing behavioral contracting. In behavioral contracting, a specific agreement is drawn up between caregivers (parents, teachers, etc.) and children. Each behavioral contract describes in explicit detail exactly what behavior changes are desired. For example, a contract designed to reduce disrespectful behaviors might describe multiple ways that disrespect can be conveyed, such as mumbling under one's breath, talking back, rolling one's eyes, etc. The consequences for engaging in a disrespectful behavior are spelled out, as are more desirable alternative behaviors and the rewards that will accompany these appropriate behaviors.

In addition to addressing specific problem behaviors, therapy also tends to focus on helping parents understand how to be more effective and fair disciplinarians. Parenting skills such as figuring out which minor problematic behaviors to ignore and which to address, giving children clear rather than vague instructions for how to behave, and developing and communicating specific rules are often taught to parents as part of the therapy, as are conflict resolution (problem solving) and communication skills.

Cognitive-behavioral therapy is also often used to teach children and parents both to identify and address faulty beliefs that make conflict more likely. Therapists work with children to help them develop several important cognitive skills, including cognitive reframing of stressful events (helping children to generate alternative, more peaceful ways of thinking about the meaning of stressful situations so that anger is not an automatic consequence). Anger management training may also be taught. This generally involves teaching people to better manage frustration feelings by learning to recognize and reduce anger sensations with reframing and relaxation techniques such as muscle relaxation or deep breathing.

Other approaches that can be used Parent Management Training, Cognitive Problem-Solving Skills Training, Functional Family Therapy, and Medication.

During Parent Management Training, parents and therapists work together to develop a specific and systematic plan to change oppositional behavior in their child. These plans often include the setting of specific limits and boundaries, as children with Conduct Disorder often believe that they are entitled to behave any way they want to.

Cognitive Problem-Solving Skills Training (PSST) teaches children new and better ways of thinking about and solving stressful problem situations, particularly those that involve relating with others. Appropriate behavior is modeled for the children by the therapist (and later by the parents) and then children are reinforced and rewarded when they later choose to act appropriately according to the model.

Functional Family Therapy aims to change a child's communication and interaction styles by using various cognitive and behavioral techniques to create more positive exchanges and interactions within the family unit. This type of therapy examines family interactions (rather than focusing solely on the child), bonding styles, and roles, and relies on the presence and involvement of all family members.

Therapists look out for particular sorts of structural problems within the family context that can make it more likely that problems will occur. For example, parents who are not getting along well may use children as a messenger (rather than talking directly to each other). Alternatively, a child may exploit a lack of unity or communication between parents so as to get his or her way. Still another variation occurs when one parent plots with the child against the other parent. Typical family therapy sessions are designed to help the parents work together better as a unit, to help them cope better, to help them be better disciplinarians, and to strengthen the boundary between parents and children so that the children remain insulated from adult problems.

Stimulant medications, such as Ritalin, are sometimes prescribed for children with severe Conduct Disorder in order to reduce impulsivity and aggressive behavior.