Conduct Disorder

Overview

Conduct disorder represents one of the most challenging mental health conditions affecting young people. It goes beyond typical childhood misbehavior or adolescent rebellion, involving a pattern of disruptive and violent behaviors that persist over time. The disorder affects approximately 2-10% of children and adolescents, with higher rates among boys than girls, though this gender gap narrows in adolescence.

The behaviors associated with conduct disorder fall into four main categories: aggression toward people and animals, destruction of property, deceitfulness or theft, and serious violations of rules. These behaviors cause significant impairment in social, academic, or occupational functioning and often lead to contact with the juvenile justice system. The disorder can have profound effects not only on the affected individual but also on their family, peers, and community.

Early identification and intervention are crucial, as conduct disorder in childhood is one of the strongest predictors of antisocial personality disorder in adulthood. Without proper treatment, approximately 40% of children with conduct disorder will develop antisocial personality disorder as adults. However, with appropriate intervention, many young people with conduct disorder can learn to manage their behaviors and develop into well-functioning adults.

Symptoms

The symptoms of conduct disorder are complex and multifaceted, often varying in severity and presentation. These behaviors must be persistent, occurring over at least 12 months, and cause significant impairment in functioning to meet diagnostic criteria.

Behavioral Symptoms

• Hostile behavior - Aggressive actions toward others, including bullying, threatening, or intimidating
• Excessive anger - Intense rage reactions disproportionate to situations
• Temper problems - Frequent tantrums and inability to control emotions
• Hysterical behavior - Extreme emotional outbursts and dramatic reactions
• Physical aggression - Fighting, using weapons, physical cruelty to people or animals
• Destruction of property - Deliberate fire-setting or vandalism
• Theft and deceitfulness - Lying, shoplifting, breaking into houses or cars
• Serious rule violations - Running away, truancy, staying out despite parental prohibitions

Emotional and Psychological Symptoms

• Depression - Persistent sadness, hopelessness, and loss of interest
• Depressive or psychotic symptoms - Mood disturbances, hallucinations, or delusions in severe cases
• Low self-esteem despite outward bravado
• Lack of empathy or remorse
• Callous-unemotional traits
• Poor frustration tolerance

Associated Problems

• Abusing alcohol - Early onset substance use and abuse
• Lack of growth - Emotional and sometimes physical developmental delays
• Seizures - May occur with comorbid neurological conditions
• Fainting - Can occur during extreme emotional episodes
• Academic difficulties and learning problems
• Poor peer relationships
• Risky sexual behavior
• Suicidal ideation or attempts

The presentation of conduct disorder can vary by age of onset. Childhood-onset type (before age 10) tends to be more severe and persistent, while adolescent-onset type may have a better prognosis. The severity is classified as mild, moderate, or severe based on the number of symptoms and their impact.

Causes

Conduct disorder results from a complex interaction of biological, psychological, and social factors. No single cause has been identified, but research has revealed multiple contributing factors that increase risk.

Biological Factors

• Genetic predisposition: Twin and adoption studies suggest 40-50% heritability
• Neurobiological abnormalities: Differences in brain structure and function, particularly in areas controlling impulse and emotion
• Neurotransmitter imbalances: Abnormalities in serotonin, dopamine, and norepinephrine systems
• Low arousal: Reduced autonomic nervous system reactivity
• Prenatal factors: Maternal smoking, alcohol use, or drug exposure during pregnancy
• Birth complications: Low birth weight, prematurity, or perinatal trauma

Psychological Factors

• Cognitive deficits: Problems with executive functioning, attention, and verbal skills
• Information processing biases: Tendency to interpret neutral situations as hostile
• Poor emotional regulation: Difficulty managing and expressing emotions appropriately
• Attachment problems: Insecure or disorganized attachment patterns
• Trauma history: Physical, sexual, or emotional abuse; neglect
• Comorbid conditions: ADHD, learning disabilities, mood disorders

Environmental Factors

• Family dysfunction: Parental psychopathology, substance abuse, criminality
• Parenting practices: Harsh, inconsistent discipline; lack of supervision; rejection
• Socioeconomic factors: Poverty, neighborhood violence, limited resources
• Peer influences: Association with delinquent peer groups
• School factors: Academic failure, poor school climate, lack of connection
• Community factors: High crime rates, lack of community support
• Media exposure: Violent media content may contribute in vulnerable individuals

Risk Factors

Understanding risk factors helps identify children who may be vulnerable to developing conduct disorder and guides prevention efforts:

• Male gender: Boys are 3-4 times more likely to develop conduct disorder
• Early behavioral problems: Oppositional defiant disorder often precedes conduct disorder
• Family history: Parents with antisocial behavior, substance abuse, or mood disorders
• Temperament: Difficult temperament in infancy, high activity level
• Neuropsychological deficits: Low IQ, learning disabilities, language delays
• ADHD: Especially when combined with aggression
• Early substance use: Experimentation before age 13
• Trauma exposure: Witnessing or experiencing violence
• Parental factors: Young maternal age, single parenthood, large family size
• Peer rejection: Social isolation or bullying
• Urban environment: Higher rates in urban versus rural settings
• Cultural factors: Societal acceptance of violence

Diagnosis

Diagnosing conduct disorder requires comprehensive assessment by qualified mental health professionals. The evaluation process involves multiple sources of information and careful consideration of differential diagnoses.

Diagnostic Criteria (DSM-5)

At least 3 of the following 15 criteria must be present in the past 12 months, with at least one present in the past 6 months:

• Aggression to people and animals:
  • Bullies, threatens, or intimidates others
  • Initiates physical fights
  • Has used a weapon that can cause serious harm
  • Has been physically cruel to people
  • Has been physically cruel to animals
  • Has stolen while confronting a victim
  • Has forced someone into sexual activity
• Destruction of property:
  • Deliberate fire setting with intent to cause damage
  • Deliberate destruction of others' property
• Deceitfulness or theft:
  • Has broken into someone's house, building, or car
  • Lies to obtain goods or favors
  • Has stolen items of value without confrontation
• Serious violations of rules:
  • Stays out at night despite parental prohibitions (before age 13)
  • Has run away from home overnight at least twice
  • Truant from school (before age 13)

Assessment Process

• Clinical interviews: With child/adolescent, parents, teachers
• Behavioral rating scales: Standardized questionnaires
• Psychological testing: Cognitive and personality assessments
• Medical evaluation: Rule out medical causes
• School records: Academic performance, disciplinary actions
• Collateral information: From multiple settings

Differential Diagnosis

• Oppositional defiant disorder
• ADHD
• Mood disorders (bipolar, depression)
• Intermittent explosive disorder
• Adjustment disorder
• Post-traumatic stress disorder
• Substance use disorders
• Autism spectrum disorder

Treatment Options

Treatment for conduct disorder requires a comprehensive, multimodal approach tailored to the individual's needs and circumstances. Early intervention and family involvement are critical for success.

Psychotherapeutic Interventions

• Cognitive Behavioral Therapy (CBT):
  • Problem-solving skills training
  • Anger management techniques
  • Social skills development
  • Cognitive restructuring for hostile attribution biases
• Family-based interventions:
  • Parent Management Training (PMT)
  • Functional Family Therapy (FFT)
  • Multisystemic Therapy (MST)
  • Parent-Child Interaction Therapy (PCIT)
• Group therapy: Social skills groups, anger management groups
• Individual psychotherapy: Building therapeutic alliance, addressing trauma

Medication Management

While no medications are specifically approved for conduct disorder, various medications may help manage symptoms:

• Stimulants: For comorbid ADHD symptoms
• Antipsychotics: For severe aggression (risperidone, aripiprazole)
• Mood stabilizers: For emotional dysregulation (lithium, valproate)
• Antidepressants: For comorbid depression or anxiety
• Alpha-2 agonists: For impulsivity and aggression (clonidine, guanfacine)

School-Based Interventions

• Individualized Education Plan (IEP): Academic accommodations
• Behavioral intervention plans: Structured behavior management
• School counseling: Regular support and monitoring
• Alternative education settings: When necessary
• Vocational training: For older adolescents

Community Interventions

• Wraparound services: Coordinated care across systems
• Mentoring programs: Positive adult relationships
• After-school programs: Structured activities and supervision
• Juvenile justice diversion: Treatment instead of incarceration
• Therapeutic foster care: For severe cases
• Residential treatment: Intensive 24-hour care when needed

Treatment Principles

• Early intervention is more effective than later treatment
• Family involvement is crucial for success
• Treatment should address multiple domains of functioning
• Consistency across settings (home, school, community)
• Long-term follow-up and support
• Address comorbid conditions simultaneously
• Build on strengths, not just reduce problems

Prevention

Prevention strategies for conduct disorder focus on early identification and intervention, strengthening protective factors, and reducing risk factors:

• Early childhood interventions: Home visiting programs for at-risk families
• Parent education: Teaching positive parenting skills from infancy
• Preschool programs: High-quality early education with social-emotional focus
• School-based prevention: Social-emotional learning curricula
• Screening programs: Early identification of at-risk children
• Treatment of ADHD: Early management reduces conduct disorder risk
• Family support services: Address parental stress and mental health
• Community programs: Safe after-school activities, mentoring
• Addressing trauma: Trauma-informed care in schools and communities
• Substance abuse prevention: Delay onset of use
• Reduce exposure to violence: In media, home, and community
• Strengthen school engagement: Academic support, positive climate
• Economic support: Address family poverty and stress

When to See a Doctor

Seek professional help if a child or adolescent displays:

• Persistent hostile behavior toward others
• Repeated violations of rules at home, school, or in the community
• Excessive anger or temper problems beyond typical development
• Cruelty to animals or younger children
• Destruction of property or fire-setting
• Stealing or frequent lying
• Running away or staying out all night
• Truancy or suspension from school
• Signs of depression or suicidal thoughts
• Substance abuse
• Involvement with law enforcement
• Significant impairment in functioning

Seek immediate help if:

• The child poses a danger to self or others
• There are threats or plans of violence
• Suicidal ideation or attempts
• Severe aggression or weapon use

Related Conditions

Frequently Asked Questions

References

1. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). 2013.
2. Frick PJ, et al. Annual Research Review: A developmental psychopathology approach to understanding callous-unemotional traits. J Child Psychol Psychiatry. 2014;55(6):532-548.
3. Burke JD, Loeber R, Birmaher B. Oppositional defiant disorder and conduct disorder: a review of the past 10 years, part II. J Am Acad Child Adolesc Psychiatry. 2002;41(11):1275-1293.
4. Kazdin AE. Psychosocial treatments for conduct disorder in children and adolescents. A Guide to Treatments That Work. 2018:141-172.
5. Scott S. Conduct disorders in children. BMJ. 2015;350:h2168.