Conduct disorder

Conduct disorder
Classification and external resources
ICD-10 F91
ICD-9 312
MeSH D019955

Conduct disorder is a psychological disorder diagnosed in childhood that presents itself through a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate norms are violated. These behaviors are often referred to as "antisocial behaviors."[1] Indeed, the disorder is often seen as the childhood counterpart of antisocial personality disorder.

Contents

DSM IV-TR Criteria

According to the current DSM classification system[2], a diagnosis of conduct disorder is based on the following criteria:

A. 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 three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past 6 months:

Aggression to people and animals

(1) often bullies, threatens, or intimidates others

(2) often initiates physical fights

(3) has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun)

(4) has been physically cruel to people

(5) has been physically cruel to animals

(6) has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery)

(7) has forced someone into sexual activity

Destruction of property

(8) has deliberately engaged in fire setting with the intention of causing serious damage

(9) has deliberately destroyed others' property (other than by fire setting)

Deceitfulness or theft

(10) has broken into someone else’s house, building, or car

(11) often lies to obtain goods or favors or to avoid obligations (i.e., “cons” others)

(12) has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery)

Serious violations of rules

(13) often stays out at night despite parental prohibitions, beginning before age 13 years

(14) has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period)

(15) is often truant from school, beginning before age 13 years

B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

C. If the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder.

Code type based on age at onset

312.81 Conduct Disorder, Childhood-Onset Type: onset of at least one criterion characteristic of Conduct Disorder prior to age 10 years

312.82 Conduct Disorder, Adolescent-Onset Type: absence of any criteria characteristic of Conduct Disorder prior to age 10 years

312.89 Conduct Disorder, Unspecified Onset: age at onset is not known

Specify severity

Mild: few if any conduct problems in excess of those required to make the diagnosis and conduct problems cause only minor harm to others (e.g., lying, truancy, staying out after dark without permission)

Moderate: number of conduct problems and effect on others intermediate between “mild” and “severe” (e.g., stealing without confronting a victim, vandalism)

Severe: many conduct problems in excess of those required to make the diagnosis or conduct problems cause considerable harm to others (e.g., rape, physical cruelty, use of a weapon, stealing while confronting a victim, breaking and entering)

Proposed Changes for the DSM-V

Currently, there are no proposed revisions for the main criteria of conduct disorder in the DSM-V. However, there is a recommendation by the work group to add an additional specifier for Callous and Unemotional Traits[3]. For this specifier, the individual must:

A. Meet full DSM-IV criteria for conduct disorder

B. Show 2 or more of the following characteristics persistently over at least 12 months and in more than one relationship or setting.

  1. Lack of Remorse or Guilt: Does not feel bad or guilty when he/she does something wrong (except if expressing remorse when caught and/or facing punishment).
  2. Callous-Lack of Empathy: Disregards and is unconcerned about the feelings of others.
  3. Unconcerned about Performance: Does not show concern about poor/problematic performance at school, work, or in other important activities.
  4. Shallow or Deficient Affect: Does not express feelings or show emotions to others, except in ways that seem shallow or superficial (e.g., emotions are not consistent with actions; can turn emotions “on” or “off” quickly) or when they are used for gain (e.g., to manipulate or intimidate others).

The clinician should consider multiple sources of information to determine the presence of these traits, such as whether the person self-reports them as being characteristic of him or herself and if they are reported by others (e.g., parents, other family members, teachers, peers) who have known the person for significant periods of time.

Etiology

While the etiology of conduct disorder is complicated by an intricate interplay of biological and environmental factors, identifying etiological mechanisms is crucial for obtaining accurate assessment and implementing effective treatment[4]. These mechanisms serve as the fundamental building blocks on which evidence-based treatments are developed. Despite the complexities, several domains have been implicated in the development of conduct disorder including cognitive variables, neurological factors, intraindividual factors, familial and peer influences, and wider contextual factors [1]. These factors may also vary based on the age of onset, with different variables related to early (e.g., neurodevelopmental basis) and adolescent (e.g., social/peer relationships) onset [5].

Cognitive Factors

In terms of cognitive function, intelligence and cognitive deficits are common among youth with conduct disorder, particularly for those with early-onset who have intelligence quotients (IQ) one standard deviation below the mean[6] and severe deficits in verbal reasoning and executive function[7]. Executive function difficulties may manifest in terms of one’s ability to plan and organize, inhibit a prepotent response, or shift between tasks. These findings hold true even after taking into account other variables such as race, socioeconomic status (SES), and education. It is important to note that IQ and executive function deficits are only one piece of the puzzle, and the magnitude of their influence on the development of conduct disorder is increased during transactional processes with environmental factors[8].

Structural and Functional Brain Differences

Beyond difficulties in executive function, youth with conduct disorder may also demonstrate differences in brain anatomy and function. Compared to normal controls, youth with early and adolescent onset of conduct disorder displayed reduced responses in brain regions associated with antisocial behavior (i.e., amygdala, ventromedial prefrontal cortex, insula, and orbitofrontal cortex)[5]. In addition, youth with conduct disorder also demonstrated less responsiveness in the orbitofrontal regions of the brain during a stimulus-reinforcement and reward task[9]. This provides a neural explanation for why youth with conduct disorder may be more likely to repeat poor decision making patterns. Lastly, youth with conduct disorder display grey matter volume reduction in the amygdala, which may account for the fear conditioning deficits in this population[10]. This reduction has been linked to difficulty processing social emotional stimuli, regardless of the age of onset[11]. Aside from the differences in neuroanatomy and activation patterns between youth with conduct disorder and controls, neurochemical profiles also vary between groups<[12]. Individuals with conduct disorder are characterized as having reduced serotonin and cortisol levels (e.g., reduced hyporthalamic-putitary-adrenal (HPA) axis), as well as reduced autonomic nervous system (ANS) functioning. These reductions are associated with the inability to regulate mood and impulsive behaviors, weakened signals of anxiety and fear, and decreased self-esteem [12]. Taken together, these findings may account for some of the variance in the psychological and behavioral patterns of youth with conduct disorder.

Intraindividual Factors

Aside from findings related to neurological and neurochemical profiles of youth with conduct disorder, intraindividual factors such as genetics may also be relevant. Having a sibling or parent with conduct disorder increases the likelihood of having the disorder, with a heritability rate of .53[13]. There also tends to be a stronger genetic link for individuals with childhood-onset compared to adolescent onset[14]. In addition, youth with conduct disorder also exhibit polymorphism in the monoamine oxidase A gene[15], low resting heart rates[16], and increased testosterone[17].

Familial and Peer Influences

Elements of the family and social environment may also play a role in the development and maintenance of conduct disorder. For instance, antisocial behavior suggestive of conduct disorder is associated with single parent status, parental divorce, large family size, and young age of mothers [1]. However, these factors are difficult to tease apart from other demographic variables that are known to be linked with conduct disorder, including poverty and low SES. Family functioning and parent-child interactions also play a substantial role in childhood aggression and conduct disorder, with low levels of parental involvement, inadequate supervision, and unpredictable discipline practices reinforcing youth’s defiant behaviors. Peer influences have also been related to the development of antisocial behavior in youth, particularly peer rejection in childhood and association with deviant peers [1]. Peer rejection is not only a marker of a number of externalizing disorders, but also a contributing factor for the continuity of the disorders over time. Hinshaw and Lee (2003)[1] also explain that association with deviant peers has been thought to influence the development of conduct disorder in two ways: 1) a “selection” process whereby youth with aggressive characteristics choose deviant friends, and 2) a “facilitation” process whereby deviant peer networks bolster patterns of antisocial behavior.

Wider Contextual Factors

In addition to the individual and social factors associated with conduct disorder, research has highlighted the importance of environment and context in youth with antisocial behavior[1]. However, it is important to note that these are not static factors, but rather transactional in nature (e.g., individuals are influenced by and also influence their environment). For instance, neighborhood safety and exposure to violence has been studied in conjunction with conduct disorder, but it is not simply the case that youth with aggressive tendencies reside in violent neighborhoods. Transactional models propose that youth may resort to violence more often as a result of exposure to community violence, but their predisposition towards violence also contributes to neighborhood climate.

Developmental Course

Currently, there are thought to be two possible developmental courses to conduct disorder. The first is known as the "childhood-onset type" and occurs when conduct disorder symptoms are present before the age of 10 years. This course is often linked to a more persistent life course and more pervasive behaviors. Specifically, children in this group have greater levels of ADHD symptoms, neuropsychological deficits, more academic problems, increased family dysfunction, and higher likelihood of aggression and violence[18].

The second developmental course is known as the "adolescent-onset type" and occurs when conduct disorder symptoms are present after the age of 10 years. Individuals with adolescent-onset conduct disorder exhibit less impairment than those with the childhood-onset type and are not characterized by similar psychopathology [19]. At times, these individuals will remit in their deviant patterns before adulthood. Research has shown that there is a greater number of children with adolescent-onset conduct disorder than those with childhood-onset, suggesting that adolescent-onset conduct disorder is an exaggeration of developmental behaviors that are typically seen in adolescence, such as rebellion against authority figures and rejection of conventional values [18]. However, this argument is not established[20] and empirical research suggests that these subgroups are not as valid as once thought [1].

In addition to these two courses that are recognized by the DSM-IV-TR, there appears to be a relationship among oppositional defiant disorder, conduct disorder and antisocial personality disorder. Specifically, research has demonstrated continuity in the disorders such that conduct disorder is often diagnosed in children who have been previously diagnosed with oppositional defiant disorder, and most adults with antisocial personality disorder were previously diagnosed with conduct disorder. For example, some research has shown that 90% of children diagnosed with conduct disorder had a previous diagnosis of oppositional defiant disorder[21]. Moreover, both disorders share relevant risk factors and disruptive behaviors, suggesting that oppositional defiant disorder is a developmental precursor and milder variant of conduct disorder. However, this is not to say that this trajectory occurs in all individuals. In fact, only about 25% of children with oppositional defiant disorder will receive a later diagnosis of conduct disorder [21]. Correspondingly, there is an established link between conduct disorder and the diagnosis of antisocial personality disorder as an adult. In fact, the current diagnostic criteria for antisocial personality disorder require a conduct disorder diagnosis before the age of 15 [2]. However, again, only 25-40% of youths with conduct disorder will develop antisocial personality disorder[22]. Nonetheless, many of the individuals who do not meet full criteria for antisocial personality disorder still exhibit a pattern of social and personal impairments or antisocial behaviors[23]. These developmental trajectories suggest the existence of antisocial pathways in certain individuals [1], which have important implications for both research and treatment.

Epidemiology

Prevalence & Incidence

Prevalence estimates for conduct disorder range from 1-10% [1]. However, among incarcerated youth or youth in juvenile detention facilities, rates of conduct disorder are between 23-87%[24].

Gender Differences

The majority of research on conduct disorder suggests that there are a significantly greater number of males than females with the diagnosis, with some reports demonstrating a three-to-four fold difference in prevalence [25]. However, this difference may be somewhat biased by the diagnostic criteria which focus on more overt behaviors, such as aggression and fighting, which are more often exhibited by males. Females are more likely to be characterized by covert behaviors, such as stealing or running away. Moreover, conduct disorder in females is linked to several negative outcomes, such as antisocial personality disorder and early pregnancy[26], suggesting that sex differences in disruptive behaviors need to be more fully understood.

Racial/Ethnic Differences

Research on racial or cultural differences on the prevalence or presentation of conduct disorder is limited. However, it appears that African-American youth are more often diagnosed with conduct disorder[27], while Asian youth are about one-third as likely[28] to develop conduct disorder when compared to Caucasian youth.

Risk & Protective Factors

It is important to note that the development of conduct disorder is not immutable or predetermined. There are a number of interactive risk and protective factors that can influence and change outcomes, and in most cases conduct disorder develops due to an interaction and gradual accumulation of risk factors [29]. In addition to the risk factors identified under etiology, several other variables place youth at increased risk for developing the disorder, including child physical abuse [29] and prenatal alcohol abuse and maternal smoking during pregnancy[30]. Protective factors have also been identified, and most notably include high IQ, being female, positive social orientations, good coping skills, and supportive family and community relationships[31].

Comorbidity

Children with conduct disorder have a high risk of developing other adjustment problems. Specifically, risk factors associated with conduct disorder and the effects of conduct disorder symptomatololgy on a child’s psychosocial context have been linked to overlap with other psychological disorders[32]. In this way, there seems to be reciprocal effects of comorbidity with certain disorders, leading to increased overall risk for these youth.

Attention-Deficit/Hyperactivity Disorder

ADHD is the condition most commonly associated with conduct disorders, with approximately 36% of boys and 57% of girls with conduct disorder having a comorbid ADHD diagnosis [33]. While it is unlikely that ADHD alone is a risk factor for developing conduct disorder, children who exhibit hyperactivity and impulsivity along with aggression is associated with the early onset of conduct problems [1]. Moreover, children with comorbid conduct disorder and ADHD show more severe aggression [33].

Substance Use Disorders

Conduct disorder is also highly associated with both substance use and abuse. Children with conduct disorder have an earlier onset of substance use, as compared to their peers, and also tend to use multiple substances[34]. As mentioned above, it seems that there is a transactional relationship between substance use and conduct problems, such that aggressive behaviors increase substance use, which leads to increased aggressive behavior[35].

Learning Disabilities

While language impairments are most common[36], approximately 20-25% of youth with conduct disorder have some type of learning disability[37]. Although the relationship between the disorders is complex, it seems as if learning disabilities result from a combination of ADHD, a history of academic difficulty and failure, and long-standing socialization difficulties with family and peers [38]. However, confounding variables, such as language deficits, SES disadvantage, or neurodevelopmental delay also need to be considered in this relationship, as they could help explain some of the association between conduct disorder and learning problems [1].

See also

References

  1. ^ a b c d e f g h i j k >Hinshaw, S. P., & Lee, S. S. (2003). Conduct and oppositional defiant disorders. In E. J. Mash & R. A. Barkley (Eds.), Child psychopathology (pp. 144-198). New York: Guilford Press.
  2. ^ a b American Psychiatric Association. (2000). Diagnostic and Statistical Manual of Mental Disorders (4th ed., text revision). Washington, DC: Author.
  3. ^ American Psychiatric Association. (2010). DSM 5 Development: Conduct Disorder. Retrieved from: http://www.dsm5.org/ProposedRevision/Pages/proposedrevision.aspx?rid=370Baker.
  4. ^ Murrihy, R., Kidman, A., & Ollendick, T (2010). Clinical Handbook of Assessing and Treating Conduct Problems in Youth. Springer: New York.
  5. ^ a b Passamonti, L., Fairchild, G., Goodyer, I., Hurford, G., Hagan, C., Rowe, J., & Calder, A. (2010). Neural abnormalities in early-onset and adolescence-onset conduct disorder. Archives of General Psychiatry, 67(7), 729-738.
  6. ^ Lynham, D. & Henry, B. (2001). The role of neuropsychological deficits in conduct disorders. In J. Hill & B. Maughan (Eds.), Conduct disorders in childhood and adolescence (pp.235-263). New York: Cambridge University Press.
  7. ^ Moffitt, T. & Lynam, D. (1994). The neuropsychology of conduct disorder and delinquency: Implications for understanding antisocial behavior. In D.C. Fowles, P. Sutker, & S.H. Goodman (Eds.), Progress in experimental personality and psychopathology research (pp. 233-262). New York: Springer.
  8. ^ Pennington, B. & Benneto, L. (1993). Main effects or transactions in the neuropsychology of conduct disorder? Commentary on “The neuropsychology of conduct disorder.” Developmental Psychopatholgy, 5(1993), 153-164.
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Further reading

External links

Emotional and behavioral
ADHD · Conduct disorder (ODD) · emotional disorder (Separation anxiety disorder) · social functioning (Selective mutism, RAD, DAD) · Tic disorder (Tourette syndrome) · Speech (Stuttering, Cluttering) · Movement disorder (Stereotypic) · Nose-picking · Nail biting

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