Conduct Disorder

Descriptive Characteristics and Phenomenology

Conduct disorder (CD) is defined by serious rule-breaking and persistent pattern of aggressive behavior in which the rights of others are violated and societal norms or rules are disregarded.

Although, slightly less common, with prevalence rates estimated between 6 and 16% for males and between 2 and 9% for females, conduct disorder is usually abnormally aggressive and can frequently lead to destruction of property or physical injury (American Psychiatry [APA], 2013).

Persons with conduct disorder initiate physical fights and bullyOpens in new window, and they may steal or use a weapon to intimidate or hurt others. Coercion into an activity against another’s will, including sexual activity, is characteristic of this disorder. These behaviors are enduring patterns and continue over a period of 6 months and beyond.

Interestingly, CD includes a specifier of “limited prosocial emotions,” which indicates lack of remorse or guiltOpens in new window, callousness (i.e., lack of empathy), lack of concern about performance, and shallow affect. These “limited prosocial emotions” are seen as a precursor to adult psychopathy (Frick & Nigg, 2012).

People affected by this disorder may have a normal intelligence, but they tend to skip class or disrupt school so much that they fall behind and may fail, be expelled, or drop out.

Complications associated with conduct disorder include juvenile delinquency, drug and alcohol abuse and dependency, and juvenile court involvement (Harvard Medical School, 2011).

People with conduct disorder crave excitement and do not worry as much about consequences as others do.

Though the literature tends to focus on children and adolescents with conduct disorder, it is quite a problem in adults as well. In adults, conduct disorder has similar characteristics of aggression, destruction of property, stealing, deceitfulness, and criminal behavior.

There are two subtypes of conduct disorder—child-onset and adolescents-onset—both of which can occur in mild, moderate, or severe forms.

Childhood-onset conduct disorder occurs before age 10 and occurs mostly in males.

These boys are physically aggressive, have poor peer relationships, show little concern for others, and lack feelings of guilt or remorse. They tend to interpret others’ intentions as hostile and believe their aggressive responses are justified.

Violent children also often display antisocial reasoning, such as “he deserved it,” when rationalizing aggressive behaviors.

Children with childhood-onset conduct disorder attempt to project a strong image, but they actually have a low self-esteem. Limited frustration tolerance, irritability, and temper outbursts are hallmarks of this disorder.

Individuals with childhood-onset conduct disorder are more likely to have problems that persist through adolescence, and without intensive treatment they may later develop antisocial personality disorder as adults.

In adolescent-onset conduct disorder, no clinically significant symptoms are present before age 10. Affected adolescents tend to act out in the context of their peer group through sexual behavior, substance use, or risk-taking behaviors.

Males are more likely to fight, steal, vandalize, and have school discipline problems. Girls tend to lie, be truant, run away, abuse substances, and engage in promiscuity. The male-to-female ratio is not as high as for the childhood-onset type indicating that more girls become aggressive during this period of development.

A subset of people with conduct disorder is referred to by the especially dangerous terms of callous and unemotional.

Callousness is characterized by a lack of empathy and being unconcerned about the feelings of others.

Expression of guilt is absent except when facing punishment. School and family obligations are unimportant to affected individuals. Callousness may be a predictor of future antisocial personality disorder in adults (Burke et al., 2010).

Unemotional traits include a shallow, unexpressive, and superficial affect.

Diagnostic criteria for conduct disorder are listed in the DSM-5 box.

DSM-5 Criteria for Conduct Disorder
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 three of the following 15 criteria in the past 12 months from any of the following categories with at least one criterion present in the past 6 months: Aggression to People and Animals Often bullies, threatens, or intimidate others. Often initiates physical fights. Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun). Has been physically cruel to people. Has been physically cruel to animals. Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery). Has forced someone into sexual activity. Destruction of Property Has deliberately engaged in fire setting with the intention of causing serious damage. Has deliberately destroyed others’ property (other than by fire setting). Deceitfulness or Theft Has broken into someone else’s house, building, or car. Often lies to obtain goods or favors to avoid obligations (i.e., “cons” others). Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting but without breaking and entering; forgery). Serious Violations of Rules Often stays out at night despite parental prohibitions, beginning before age 13 years. 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. Is often truant from school beginning before age 13 years. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning. If the individual is age 18 years or older, criteria are not met for antisocial personality disorder. Specify whether: Childhood-onset type: Individuals show at least one symptom characteristic of conduct disorder before age 10 years. Adolescent-onset type: Individuals show no symptom characteristic of conduct disorder before 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. Specify if: With limited prosocial emotions Specify current severity: Mild, Moderate, Severe
From the American Psychiatric Association, (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

DSM-5 Criteria for Conduct Disorder

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 three of the following 15 criteria in the past 12 months from any of the following categories with at least one criterion present in the past 6 months:

Aggression to People and Animals

Often bullies, threatens, or intimidate others.
Often initiates physical fights.
Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun).
Has been physically cruel to people.
Has been physically cruel to animals.
Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery).
Has forced someone into sexual activity.

Destruction of Property

Has deliberately engaged in fire setting with the intention of causing serious damage.
Has deliberately destroyed others’ property (other than by fire setting).

Deceitfulness or Theft

Has broken into someone else’s house, building, or car.
Often lies to obtain goods or favors to avoid obligations (i.e., “cons” others).
Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting but without breaking and entering; forgery).

Serious Violations of Rules

Often stays out at night despite parental prohibitions, beginning before age 13 years.
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.
Is often truant from school beginning before age 13 years.

The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
If the individual is age 18 years or older, criteria are not met for antisocial personality disorder.

Specify whether:

Childhood-onset type: Individuals show at least one symptom characteristic of conduct disorder before age 10 years.
Adolescent-onset type: Individuals show no symptom characteristic of conduct disorder before 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.
Specify if: With limited prosocial emotions
Specify current severity: Mild, Moderate, Severe

From the American Psychiatric Association, (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Epidemiology

Conduct disorder carries a lifetime prevalence of nearly 7%. Conduct disorder may be higher in urban settings as compared with rural areas. Childhood onset is more common in males than in females; in adolescent onset, the numbers are nearly equal. It is stable across races and ethnicities (Polancyzk et al., 2015).

The diagnosis of conduct disorder is four times more common in individuals who have previously been diagnosed with oppositional defiant disorder (Loeber et al., 2009).

Comorbidity

Attention-deficit/hyperactivity disorderOpens in new window and oppositional defiant disorderOpens in new window are both common in people with conduct disorder. The combination of both predicts worse outcomes. Conduct disorders are often comorbid with one or more of the following disorders: specific learning disorder, anxiety disordersOpens in new window, depressive or bipolar disordersOpens in new window, and substance use disordersOpens in new window.

Biological Factors

Physiological

A slower resting heart rate has been associated with people who have conduct disorder. Increased testosterone is also found in males with conduct disorder.

Genetic

Conduct disorder seems to be influenced by genetic factors. The risk is increased in children with a biological parent or a sibling with the disorder. However, it is difficult to tease out the contribution of genetics versus that of the environment. Do people inherit traits associated with antisocial behavior or do they learn to be antisocial by the intergenerational mirroring of characteristics?

Neurobiological

Adolescents with conduct disorder have been found to have significantly reduced gray matter in the anterior insulate cortex and the left amygdale. The insulate cortex is believed to be involved in emotion and empathy, and the amygdale helps process emotional reactions and rewards (Byrd et al., 2013).

Individuals with conduct disorder who display limited prosocial emotions, specifically those who are callous and unemotional, have more folds in their cortical insula (Fairchild et al., 2015).

Brain changes in people with conduct disorder are not simply structural, they are also functional. Investigators asked children with conduct disorder who displayed callousness to respond to images of others being harmed.

Functional MRIs indicated the children experienced diminished blood flow in the region of the brain associated with empathy and emotional response as compared to healthy controls (Michalska et al., 2015).

Environmental

Environmental factors associated with conduct disorders include parental rejection and neglect, inconsistent parenting with harsh discipline, early institutional living, chaotic home life, large family size, absent or alcoholic father, and antisocial and drug-dependent family members. Social factors include peer rejection, violent neighborhoods, and association with delinquent peers.

Treatment Approaches

Psychosocial Interventions

Conduct disorder is treated similarly to oppositional defiant disorder. Treatment methods are selected based on the behaviors being targeted. For example, anger management might be targeted for one individual, while helping to improve a dysfunctional parent-child relationship might be the goal for another.

Parent management skills, problem-solving skills, and multisystemic therapy are useful in conduct disorder. The most successful treatments require parental participation. However, if the parents have antisocial traits as well, they are less likely to be involved in treatment (Taylor et al., 2014).

Pharmacological Treatment

Children and adolescents with conduct disorders may have behaviors (i.e., anger, aggression, etc.) that are so disruptive that families are unable to implement change. Psychopharmacological intervention may help decrease the intensity of outbursts. This, in turn, may help those with conduct disorders better respond to psychotherapeutic interventions (Wu et al., 2015, p. 135).

As with oppositional defiant disorderOpens in new window and intermittent explosive disorder, comorbid conditions can exacerbate the symptoms. Treating the comorbid conditions often improves conduct disorder symptoms. Medications for conduct disorder are directed at problematic behaviors such as aggression, impulsivity, hyperactivity, and mood symptoms.

Five classes of medications are used for children and adolescents with conduct disorder: antidepressants, mood stabilizers, stimulants, antipsychotics, anticonvulsants, and adrenergic medications all show some efficacy (Taylor et al., 2014). Aripiprazole (Abilify) and risperidone (Risperdal) are two second-generation antipsychotics that have some proven efficacy in diminishing aggression associated with conduct disorder.

The series:

Citation

Harvard Medical School. (2011). Options for managing conduct disorder: Treatment works best when it involves and empowers parents. The Harvard Mental Health Letter, 27 (9), 1 – 3.
Taylor, B. P., Weiss, M., Ferretti, C. J., Berlin, G., & Hollander, E. (2014). Disruptive, impulsive-control, and conduct disorders. In R. E. Hales, S. C. Yudofsky, & L. W. Roberts (Eds.), The American psychiatric publishing textbook of psychiatry (6th ed.) (pp. 703 – 734). Washington, DC: American Psychiatric Publishing.
Wu, T., Howells, N., Burger, J., Lopez, P., Lundeen, R., & Sikkenga, A. V. (2015). Conduct disorder. In G. M. Kapalka (Ed.), Treating disruptive disorders: A guide to psychological, pharmacological, and combined therapies. Devon, UK: Routledge.
Lacourse, E., Baillargeon, R., Dupere, V., Vitaro, F., Romano, E., & Tremblay, R. (2010). Two-year predictive validity of conduct disorder subtypes in early adolescence. A latent class analysis of a Canadian longitudinal sample. Journal of Child Psychology and Psychiatry, 51, 1386 – 1394.
Lin, W., & Yi, C. (2015). Unhealthy sleep practices, conduct problems, and daytime functioning during adolescence. Journal of Youth and Adolescence, 44(2), 431 – 446.

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