Conduct disorder
Synonyms and keywords: Conduct problems, disordered conduct, behavioral problems

# Overview
Conduct disorder is a psychiatric disorder characterized by a pattern of repetitive behavior wherein social norms or the rights of others are routinely violated. Possible symptoms include excessively aggressive behavior, bullying, physical aggression, cruel behavior toward people and animals, destructive behavior, lying, truancy, vandalism, and stealing. After the age of 18, conduct disorder may develop into antisocial personality disorder.

# Historical Perspective
- In 1880, the origins of conduct disorder lie within the social and legal problem of delinquency.
- In 1904, Stanley Hall published the book, "Adolescence". This marked the beginning of the recognition of adolescence as a distinct developmental period.
- From 1910 until 1968, there was increased research interest in conduct problems of children as researchers attempted to identify the causes of inappropriate behaviors.
- In 1968, a rapid accumulation in the knowledge around VI conduct disorders and an increasingly holistic perception of the cause and treatment of conduct disorders occurred.
- At the end of the 19th century, therefore, the "norm" shifted from children working as young adults to focusing on becoming a young adult.
- In 1968, conduct disorders were established as a valid medical diagnosis.
- At the end of the 19th century and the start of the 20th century, Phrenology laid the foundation for biological determinism.
- Biological determinism is a large contributing factor to children who are delinquents and commit a crime.
- 'Uri Bronfenbrenner's Ecological Systems Theory' has largely contributed to the development and maintenance of conduct disorders.
- Developmental psychopathology has helped to integrate how biological, cognitive, and environmental factors have accumulated to increases the risk of a pathological outcome, such as conduct disorders.

# Classification
- Conduct disorder is classified in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM).
- There are four categories that could present behavior similar to conduct disorder:
Aggression to people and animal
Destruction of property
Deceitfulness or theft
Serious violation of rules
- Aggression to people and animal
- Destruction of property
- Deceitfulness or theft
- Serious violation of rules
- Early-onset (EO-CD) and adult-onset (AO-CD) conduct disorder are widely considered distinct diseases with divergent etiologies, though severe executive function is observed in both diseases.
Children with EO-CD are more likely to experience psychosis and to commit acts of violence.
- Children with EO-CD are more likely to experience psychosis and to commit acts of violence.

# Pathophysiology
- Patients with adult-onset conduct disorder (AO-CD) show increased cortical thinning in the paralimbic system, particularly in the precuneus/posterior cingulate cortex, as compared to healthy controls. This finding has not been reported in patients with early-onset conduct disorder (EO-CD).
- In children, the onset of conduct disorder (CD) seems to be associated with abnormalities in white matter pathways, particularly in the form of increased axial and radial diffusivity.
This effect seems to be especially prominent in girls with CD.
- This effect seems to be especially prominent in girls with CD.

## Commonly Comorbid Conditions
Conditions that are commonly comorbid with conduct disorder include:
- ADHD
- Substance abuse disorder
- Depression
- Oppositional defiant disorder (ODD)
- Disruptive behavior disorders

# Differentiating conduct disorder from other diseases
Conduct disorder must be differentiated from diseases that share common symptoms, including:
- Adjustment disorders
- Attention-deficit/hyperactivity disorder
- Bipolar disorder
- Depressive disorder
- Intermittent explosive disorder
- Oppositional defiant disorder

# Epidemiology and Demographics

## Prevalence
- The one year prevalence of conduct disorder is 2,000 to >10,000 per 100,000 people (2% to >10%) within the overall population.
- Worldwide, estimates of the prevalence of ODD and CD range from 3-5%. A recent meta-analysis estimated the combined prevalence of ODD/CD to be 6.1%.

## Age
- Among American children and adolescents aged 8 to 15 years, the prevalence of conduct disorder is approximately 2.1%.
- Children diagnosed with conduct disorder tend to be >10 years of age.
- In 2007, 4.6% of children between the ages of 3-17 years were diagnosed with conduct disorder.

## Gender
- The lifetime prevalence of CD was 10.2% in an adult community sample, with men at 11.2% and women at 9.2%.

## Race
- Currently, there are no population- or national-level data on the prevalence trends of ODD or CD among caucasion U.S. children.

# Risk Factors
- The cause of conduct disorder is not fully understood. Family history plays a role that stems primarily from genetics, though common environmental circumstances also have an effect.
- While the male children of women who experience moderate or severe anxiety during the pre- and post-natal periods are more likely to experience conduct disorder than male children of women who do not, the same effect does not apply to female children.
- There exists evidence that a parenting style may have an outcome in CD:
Excessive controlling parenting/behavior
Substandard involvement with or supervision of children
Tendency to avoid expressing one's emotions may facilitate the development of conduct disorder in children
- Excessive controlling parenting/behavior
- Substandard involvement with or supervision of children
- Tendency to avoid expressing one's emotions may facilitate the development of conduct disorder in children
- Risk factors for the development of conduct disorder include:
- Association with a delinquent peer group
- Association with a delinquent peer group
- Biological parents with:
Severe alcohol use disorder (alcholism)
Depressive and bipolar disorders
Schizophrenia
ADHD
Anxiety disorder
Conduct disorder
Childhood access to violent video games
Difficult under controlled infant temperament
Early institutionalization
Familial psychopathology
Frequent changes of caregivers
Harsh discipline
Inconsistent child-rearing practices
Lack of supervision
Large family size
Lower-than-average intelligence
Neighborhood exposure to violence
Parental criminality
Parental neglect or rejection
Physical or sexual abuse
The prevalence of a history of sexual abuse as a child is estimated to be 27% in individuals who suffer from conduct disorder.
Childhood abuse is more common among individuals with early-onset conduct disorder as compared to those with adult-onset conduct disorder.
- Biological parents with:
Severe alcohol use disorder (alcholism)
Depressive and bipolar disorders
Schizophrenia
ADHD
Anxiety disorder
Conduct disorder
- Severe alcohol use disorder (alcholism)
- Depressive and bipolar disorders
- Schizophrenia
- ADHD
- Anxiety disorder
- Conduct disorder
- Childhood access to violent video games
- Difficult under controlled infant temperament
- Early institutionalization
- Familial psychopathology
- Frequent changes of caregivers
- Harsh discipline
- Inconsistent child-rearing practices
- Lack of supervision
- Large family size
- Lower-than-average intelligence
- Neighborhood exposure to violence
- Parental criminality
- Parental neglect or rejection
- Physical or sexual abuse
The prevalence of a history of sexual abuse as a child is estimated to be 27% in individuals who suffer from conduct disorder.
Childhood abuse is more common among individuals with early-onset conduct disorder as compared to those with adult-onset conduct disorder.
- The prevalence of a history of sexual abuse as a child is estimated to be 27% in individuals who suffer from conduct disorder.
- Childhood abuse is more common among individuals with early-onset conduct disorder as compared to those with adult-onset conduct disorder.
- Social isolation
- Substance abuse

# Natural History, Complications, and Prognosis
- Childhood conduct disorder is a known risk factor for the development of substance abuse disorder during a patient's youth.
Substance abuse may also intensify the symptoms of conduct disorder and negatively impact a patient's prognosis.
- Substance abuse may also intensify the symptoms of conduct disorder and negatively impact a patient's prognosis.
- Childhood conduct disorder may be a risk factor for the development of schizophrenia.
- Children who suffer from conduct disorder are more likely than their unaffected peers to become violent, an effect that may continue into adulthood.

# Diagnosis

## Diagnostic Criteria

### DSM-V Diagnostic Criteria for Conduct Disorder

## History and Symptoms
Symptoms of conduct disorder include:
- Compromised executive function
- Violent behavior
- Disregard for the rights of others
- Cruelty toward people and animals

## Psychiatric Examination
- A child with conduct disorder may display a pattern of disruptive and violent behavior and have problems following rules.

## Laboratory Findings
- No laboratory test has been found to help diagnose this disorder.

## Imaging Findings
- No recent imaging findings are available for this disorder.

# Treatment

## Medical Therapy
- Therapy is recommended mong all patients who develop conduct disorder.
- Three main therapies are used to treat conduct disorder:
Family therapy
Behavior modification
Pharmacotherapy
- Family therapy
- Behavior modification
- Pharmacotherapy

# Criticism
- Some critics of psychiatry allege that individuals exhibiting symptoms of a "conduct disorder" (similar to oppositional defiant disorder) may be reacting to an abnormal circumstance.
- Patients may also be committing criminal and/or uncivil acts out of selfishness.
- Critics of the classification of this disorder also may state that the coming of age of an individual does not automatically signify a new disorder.
- It has also been noted that the criteria for diagnosis can often be subjective and that only exemplifying a few of the above behaviors may just indicate normal teenage rebellion.