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Conduct Disorder

Definition

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.

Description

CD is present in approximately 9% of boys and 2-9% of girls under the age of 18. Children 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.

Causes and symptoms

There are two sub-types of CD, one beginning in childhood and the other in adolescence. There is no known cause. Researchers and physicians suggest that this disease may be caused by the following:

poor parent-child relationships
dysfunctional families
drug abuse
physical 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 patient's IQ tends to be in the normal range, they can have trouble with verbal and abstract reasoning skills and may lag behind their classmates, and consequently, feel as if they don't "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 home environment, a family history of antisocial personality disorder, or parental substance abuse can damage a child's perceptions of himself and put him on a path toward negative behavior. Other less obvious environmental factors can also play a part in the development of conduct disorder. Long-term studies have shown that maternal smoking during pregnancy may be linked to the development of CD in boys. Animal and human studies point out that nicotine can have undesirable effects on babies. These include altered structure and function of their nervous systems, learning deficits, and behavioral problems. In a study of 177 boys ages seven to 12 years, those with mothers who smoked over one-half a package of cigarettes daily while pregnant were more apt to have a CD than those with mothers who did not smoke.

Other conditions that may cause or co-exist with CD include head injury, substance abuse disorder, major depressive disorder, and attention deficit hyperactivity disorder (ADHD). Thirty to fifty percent of children diagnosed with ADHD, a disorder characterized by a persistent pattern of inattention and/or hyperactivity, also have CD.

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)

Diagnosis

CD is diagnosed and treated by a number of social workers, school counselors, psychiatrists, and psychologists. Genuine diagnosis may require psychiatric expertise to rule out such conditions as 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, 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), and Diagnostic Interview Schedule for Children (DISC). The tests are verbal and/or written and are administered in both hospital and outpatient settings.

Treatment

Treating conduct disorder requires an approach that addresses both the child and his environment. Behavioral therapy and psychotherapy can help a child with CD to control his anger and develop new coping skills. 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. 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. Parent training programs are increasing in number.

For children with coexisting ADHD, substance abuse, depression, or learning disorders, treating these conditions first is preferred, and may result in a significant improvement to the CD condition. In all cases of CD, treatment should begin when symptoms first appear. Recent studies have shown Ritalin to be a useful drug for both ADHD and CD.

When aggressive behavior is severe, mood stabilizing medication, including lithium (Cibalith-S, Eskalith, Lithane, Lithobid, Lithonate, Lithotabs), carbamazepine (Tegretol, Atretol), and propranolol (Inderal), 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.

Key terms

ADHD — Attention deficit hyperactivity disorder; a disorder characterized by a persistent pattern of inattention and/or hyperactivity.

Major depressive disorder — A mood disorder characterized by profound feelings of sadness or despair.

Prognosis

The prognosis for children with CD is not bright. Follow-up studies of conduct disordered children have shown a high incidence of antisocial personality disorder, affective illnesses, and chronic criminal behavior later in life. However, proper treatment of co-existing disorders, early identification and intervention, and long-term support may improve the outlook significantly.

Prevention

A supportive, nurturing, and structured home environment is believed to be the best defense against CD. 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.

Resources

Books

Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association, 2000.

Organizations

American Academy of Child and Adolescent Psychiatry (AACAP). 3615 Wisconsin Ave. NW, Washington, DC 20016. (202) 966-7300. http://www.aacap.org.

disorder /dis·or·der/ (dis-or´der) a derangement or abnormality of function; a morbid physical or mental state.

acute stress disorder an anxiety disorder characterized by development of anxiety, dissociative, and other symptoms within one month following exposure to an extremely traumatic event. If persistent, it may become posttraumatic stress disorder.

adjustment disorder maladaptive reaction to identifiable stress (e.g., divorce, illness), which is assumed to remit when the stress ceases or when the patient adapts.

affective disorders mood d's.

amnestic disorders mental disorders characterized by acquired impairment in the ability to learn and recall new information, sometimes accompanied by inability to recall previously learned information.

anxiety disorders mental disorders in which anxiety and avoidance behavior predominate, i.e., panic disorder, agoraphobia, social phobia, specific phobia, obsessive-compulsive disorder, posttraumatic stress disorder, acute stress disorder, generalized anxiety disorder, and substance-induced anxiety disorder.

attention-deficit/hyperactivity disorder a controversial childhood mental disorder with onset before age seven, and characterized by inattention (e.g., distractibility, forgetfulness, not appearing to listen), by hyperactivity and impulsivity (e.g., restlessness, excessive running or climbing, excessive talking, and other disruptive behavior), or by a combination of both types of behavior.

autistic disorder autism; a severe pervasive developmental disorder with onset usually before three years of age and a biological basis; it is characterized by qualitative impairment in reciprocal social interaction, verbal and nonverbal communication, and capacity for symbolic play, by restricted and unusual repertoire of activities and interests, and often by cognitive impairment.

behavior disorder conduct d.

binge-eating disorder an eating disorder characterized by repeated episodes of binge eating, as in bulimia nervosa, but not followed by inappropriate compensatory behavior such as purging, fasting, or excessive exercise.

bipolar disorders mood disorders with a history of manic, mixed, or hypomanic episodes, usually with present or previous history of one or more major depressive episodes; included are bipolar I d., characterized by one or more manic or mixed episodes, bipolar II d., characterized by one or more hypomanic episodes but no manic episodes, and cyclothymic disorder. The term is sometimes used in the singular to denote either bipolar I disorder, bipolar II disorder, or both.

body dysmorphic disorder a somatoform disorder characterized by a normal-looking person's preoccupation with an imagined defect in appearance.

breathing-related sleep disorder any of several disorders characterized by sleep disruption due to some sleep-related breathing problem, resulting in excessive sleepiness or insomnia.

brief psychotic disorder an episode of psychotic symptoms with sudden onset, lasting less than one month.

catatonic disorder catatonia due to the physiological effects of a general medical condition and neither better accounted for by another mental disorder nor occurring exclusively during delirium.

character disorders personality d's.

childhood disintegrative disorder pervasive developmental disorder characterized by marked regression in various developmental skills, including language, play, and social and motor skills, after two to ten years of initial normal development.

circadian rhythm sleep disorder a lack of synchrony between the schedule of sleeping and waking required by the external environment and that of a person's own circadian rhythm.

collagen disorder an inborn error of metabolism involving abnormal structure or metabolism of collagen, e.g., Marfan syndrome, cutis laxa. Cf. collagen disease.

communication disorders mental disorders characterized by difficulties with speech or language, severe enough to interfere academically, occupationally, or socially.

conduct disorder a type of disruptive behavior disorder of childhood and adolescence marked by persistent violation of the rights of others or of age-appropriate societal norms or rules.

conversion disorder a somatoform disorder characterized by conversion symptoms (loss or alteration of voluntary motor or sensory functioning suggesting physical illness) with no physiological basis and not produced intentionally or feigned; a psychological basis is suggested by exacerbation of symptoms during psychological stress, relief from tension (primary gain), or gain of outside support or attention (secondary gains).

cyclothymic disorder a mood disorder characterized by alternating cycles of hypomanic and depressive periods with symptoms like those of manic and major depressive episodes but of lesser severity.

delusional disorder a mental disorder marked by well-organized, logically consistent delusions of grandeur, persecution, or jealousy, with no other psychotic feature. There are six types: persecutory, jealous, erotomanic, somatic, grandiose, and mixed.

depersonalization disorder a dissociative disorder characterized by intense, prolonged, or otherwise troubling feelings of detachment from one's body or thoughts, not secondary to another mental disorder.

depressive disorders mood disorders in which depression is unaccompanied by manic or hypomanic episodes.

developmental coordination disorder problematic or delayed development of gross and fine motor coordination skills, not due to a neurological disorder or to general mental retardation, resulting in the appearance of clumsiness.

disruptive behavior disorders a group of mental disorders of children and adolescents consisting of behavior that violates social norms and is disruptive.

dissociative disorders mental disorders characterized by sudden, temporary alterations in identity, memory, or consciousness, segregating normally integrated parts of one's personality from one's dominant identity.

dissociative identity disorder a dissociative disorder characterized by the existence in an individual of two or more distinct personalities, with at least two of the personalities controlling the patient's behavior in turns. The host personality usually is totally unaware of the alternate personalities; alternate personalities may or may not have awareness of the others.

dream anxiety disorder nightmare d.

dysthymic disorder a mood disorder characterized by depressed feeling, loss of interest or pleasure in one's usual activities, and other symptoms typical of depression but tending to be longer in duration and less severe than in major depressive disorder.

eating disorder abnormal feeding habits associated with psychological factors, including anorexia nervosa, bulimia nervosa, pica, and rumination disorder.

expressive language disorder a communication disorder occurring in children and characterized by problems with the expression of language, either oral or signed.

factitious disorder a mental disorder characterized by repeated, intentional simulation of physical or psychological signs and symptoms of illness for no apparent purpose other than obtaining treatment.

factitious disorder by proxy a form of factitious disorder in which one person (usually a mother) intentionally fabricates or induces physical (Munchausen syndrome by proxy) or psychological disorders in another person under their care (usually their child) and subjects that person to needless diagnostic procedures or treatment, without any external incentives for the behavior.

female orgasmic disorder consistently delayed or absent orgasm in a female, even after a normal phase of sexual excitement and adequate stimulation.

female sexual arousal disorder a sexual dysfunction involving failure by a female either to attain or maintain lubrication and swelling during sexual activity, after adequate stimulation.

functional disorder a disorder of physiological function having no known organic basis.

gender identity disorder a disturbance of gender identification in which the affected person has an overwhelming desire to change their anatomic sex or insists that they are of the opposite sex, with persistent discomfort about their assigned sex or about filling its usual gender role.

generalized anxiety disorder (GAD) an anxiety disorder characterized by excessive, uncontrollable worry about two or more life circumstances for six months or more.

hypoactive sexual desire disorder a sexual dysfunction consisting of persistently or recurrently low level or absence of sexual fantasies and desire for sexual activity.

impulse control disorders a group of mental disorders characterized by repeated failure to resist an impulse to perform some act harmful to oneself or to others.

induced psychotic disorder shared psychotic d.

intermittent explosive disorder an impulse control disorder characterized by multiple discrete episodes of loss of control of aggressive impulses resulting in serious assault or destruction of property that are out of proportion to any precipitating stressors.

learning disorders a group of disorders characterized by academic functioning that is substantially below the level expected on the basis of the patient's age, intelligence, and education.

lymphoproliferative disorders a group of malignant neoplasms arising from cells related to the common multipotential lymphoreticular cell, including lymphocytic, histiocytic, and monocytic leukemias, multiple myeloma, plasmacytoma, and Hodgkin's disease.

lymphoreticular disorders a group of disorders of the lymphoreticular system, characterized by the proliferation of lymphocytes or lymphoid tissues.

major depressive disorder a mood disorder characterized by the occurrence of one or more major depressive episodes and the absence of any history of manic, mixed, or hypomanic episodes.

male erectile disorder a sexual dysfunction involving failure by a male to attain or maintain an adequate erection until completion of sexual relations.

male orgasmic disorder consistently delayed or absent orgasm in a male, even after a normal phase of sexual excitement and stimulation adequate for his age.

manic-depressive disorder former name for a mood disorder now known as bipolar I d. or bipolar II d. and often called bipolar d. (q.v.).

mendelian disorder a genetic disease showing a mendelian pattern of inheritance, caused by a single mutation in the structure of DNA, which causes a single basic defect with pathologic consequences.

mental disorder any clinically significant behavioral or psychological syndrome characterized by the presence of distressing symptoms, impairment of functioning, or significantly increased risk of suffering death, pain, or other disability.

minor depressive disorder a mood disorder closely resembling major depressive disorder and dysthymic disorder but intermediate in severity between the two.

mixed receptive-expressive language disorder a communication disorder involving both the expression and the comprehension of language, either spoken or signed.

monogenic disorder mendelian d.

mood disorders mental disorders characterized by disturbances of mood manifested as one or more episodes of mania, hypomania, depression, or some combination, the two main subcategories being bipolar disorders and depressive disorders.

motor skills disorder any disorder characterized by inadequate development of motor coordination severe enough to restrict locomotion or the ability to perform tasks, schoolwork, or other activities.

multifactorial disorder one caused by the interaction of genetic and sometimes also nongenetic, environmental factors, e.g., diabetes mellitus.

multiple personality disorder dissociative identity d.

myeloproliferative disorders a group of usually neoplastic diseases possibly related histogenetically, including granulocytic leukemias, myelomonocytic leukemias, polycythemia vera, and myelofibroerythroleukemia.

neurotic disorder neurosis.

nightmare disorder repeated episodes of nightmares that awaken the sleeper, with full orientation and alertness and vivid recall of the dreams.

obsessive-compulsive disorder (OCD) an anxiety disorder characterized by recurrent obsessions or compulsions, which are severe enough to interfere significantly with personal or social functioning. Cf. obsessive-compulsive personality disorder, under personality .

obsessive-compulsive personality disorder see under personality.

oppositional defiant disorder a type of disruptive behavior disorder characterized by a recurrent pattern of defiant, hostile, disobedient, and negativistic behavior directed toward those in authority.

organic mental disorder a term formerly used to denote any mental disorder with a specifically known or presumed organic etiology. It was sometimes used synonymously with organic mental syndrome.

orgasmic disorders sexual dysfunctions characterized by inhibited or premature orgasm; see female orgasmic d., male orgasmic d., and premature ejaculation.

pain disorder a somatoform disorder characterized by a chief complaint of severe chronic pain which is neither feigned nor intentionally produced, but in which psychological factors appear to play a major role in onset, severity, exacerbation, or maintenance.

panic disorder an anxiety disorder characterized by attacks of panic (anxiety), fear, or terror, by feelings of unreality, or by fears of dying, or losing control, together with somatic signs such as dyspnea, choking, palpitations, dizziness, vertigo, flushing or pallor, and sweating. It may occur with or, rarely, without agoraphobia.

paranoid disorder older term for delusional d.

personality disorders a category of mental disorders characterized by enduring, inflexible, and maladaptive personality traits that deviate markedly from cultural expectations and either generate subjective distress or significantly impair functioning. For specific disorders, see under personality.

pervasive developmental disorders disorders in which there is impaired development in multiple areas, including reciprocal social interactions, verbal and nonverbal communications, and imaginative activity, as in autistic disorder.

phagocytic dysfunction disorders a group of immunodeficiency conditions characterized by disordered phagocytic activity, occurring as both extrinsic and intrinsic types. Bacterial or fungal infections may range from mild skin infection to fatal systemic infection.

phobic disorders see phobia.

phonological disorder a communication disorder characterized by failure to use age- and dialect-appropriate sounds in speaking, with errors occurring in the selection, production, or articulation of sounds.

plasma cell disorders see under dyscrasia.

postconcussional disorder see under syndrome.

posttraumatic stress disorder (PTSD) an anxiety disorder caused by an intensely traumatic event, characterized by mentally reexperiencing the trauma, avoidance of trauma-associated stimuli, numbing of emotional responsiveness, and hyperalertness and difficulty in sleeping, remembering, or concentrating.

premenstrual dysphoric disorder premenstrual syndrome viewed as a psychiatric disorder.

psychoactive substance use disorders substance use d's.

psychosomatic disorder one in which the physical symptoms are caused or exacerbated by psychological factors, as in migraine headaches, lower back pain, or irritable bowel syndrome.

psychotic disorder psychosis.

reactive attachment disorder a mental disorder of infancy or early childhood characterized by notably unusual and developmentally inappropriate social relatedness, usually associated with grossly pathological care.

rumination disorder excessive rumination of food by infants, after a period of normal eating habits, potentially leading to death by malnutrition.

schizoaffective disorder a mental disorder in which symptoms of a mood disorder occur along with prominent psychotic symptoms characteristic of schizophrenia.

schizophreniform disorder a mental disorder with the signs and symptoms of schizophrenia but of less than six months' duration.

seasonal affective disorder (SAD) depression with fatigue, lethargy, oversleeping, overeating, and carbohydrate craving recurring cyclically during specific seasons, most commonly the winter months.

separation anxiety disorder prolonged, developmentally inappropriate, excessive anxiety and distress in a child concerning removal from parents, home, or familiar surroundings.

sexual disorders

1. any disorders involving sexual functioning, desire, or performance.

2. specifically, any such disorder that is caused at least in part by psychological factors; divided into sexual dysfunctions and paraphilias.

sexual arousal disorders sexual dysfunctions characterized by alterations in sexual arousal; see female sexual arousal d. and male erectile d.

sexual aversion disorder feelings of repugnance for and active avoidance of genital sexual contact with a partner, causing substantial distress or interpersonal difficulty.

sexual desire disorders sexual dysfunctions characterized by alteration in sexual desire; see hypoactive sexual desire d. and sexual aversion d.

sexual pain disorders sexual dysfunctions characterized by pain associated with intercourse; it includes dyspareunia and vaginismus not due to a general medical condition.

shared psychotic disorder a delusional system that develops in one or more persons as a result of a close relationship with someone who already has a psychotic disorder with prominent delusions.

sleep disorders chronic disorders involving sleep, either primary (dyssomnias, parasomnias) or secondary to factors including a general medical condition, mental disorder, or substance use.

sleep terror disorder a sleep disorder of repeated episodes of pavor nocturnus.

sleepwalking disorder a sleep disorder of the parasomnia group, consisting of repeated episodes of somnambulism.

social anxiety disorder social phobia.

somatization disorder a somatoform disorder characterized by multiple somatic complaints, including a combination of pain, gastrointestinal, sexual, and neurological symptoms, and not fully explainable by any known general medical condition or the direct effect of a substance, but not intentionally feigned or produced.

somatoform disorders mental disorders characterized by symptoms suggesting physical disorders of psychogenic origin but not under voluntary control, e.g., body dysmorphic disorder, conversion disorder, hypochondriasis, pain disorder, somatization disorder, and undifferentiated somatoform disorder.

somatoform pain disorder pain d.

speech disorder defective ability to speak; it may be either psychogenic (see communication d. ) or neurogenic. See also aphasia, aphonia, dysphasia, and dysphonia.

stereotypic movement disorder a mental disorder characterized by repetitive nonfunctional motor behavior that often appears to be driven and can result in serious self-inflicted injuries.

substance-induced disorders a subgroup of the substance-related disorders comprising a variety of behavioral or psychological anomalies resulting from ingestion of or exposure to a drug of abuse, medication, or toxin. Cf. substance use d's.

substance-related disorders any of the mental disorders associated with excessive use of or exposure to psychoactive substances, including drugs of abuse, medications, and toxins. The group is divided into substance use d's and substance-induced d's .

substance use disorders a subgroup of the substance-related disorders, in which psychoactive substance use or abuse repeatedly results in significantly adverse consequences. The group comprises substance abuse and substance dependence.

undifferentiated somatoform disorder one or more physical complaints, not intentionally produced or feigned and persisting for at least six months, that cannot be fully explained by a general medical condition or the direct effects of a substance.

unipolar disorders depressive d's.

con·duct disorder (k

)

A behavior disorder of childhood or adolescence characterized by a pattern of conduct in which either the basic rights of others or the societal norms or rules appropriate for a certain age are violated.

conduct disorder

[kon′dukt]

(in psychiatry) an enduring set of behaviors that evolves over time, characterized by aggression and violations of the rights of others.

conduct disorder

Psychiatry A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate social norms or rules are violated–criterion A Groupings Aggressive conduct that causes or threatens physical harm to other people or animals; nonaggressive conduct that causes property loss or damage; deceitfulness or theft; serious violations of rules Prevalence 3 to 9% ♀; 1% to 16% ♂. See Oppositional defiant disorder.