Definition

  • Conduct Disorder (CD) is a disruptive behavior disorder characterized by a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated.
  • Diagnosis requires the presence of at least three criteria in the past 12 months, with at least one criterion present in the past 6 months (DSM-5).

Etiology and Risk Factors

  • Biological: Genetic predisposition; functional abnormalities in the amygdala and prefrontal cortex; reduced basal autonomic nervous system reactivity.
  • Environmental/Psychosocial: Maltreatment, physical/sexual abuse, harsh or inconsistent discipline, parental criminality or substance abuse, poverty, and peer rejection.
  • Comorbidities: High rates of co-occurring Attention-Deficit/Hyperactivity Disorder (ADHD), specific learning disorders, and substance use disorders.

Clinical Features

Symptoms are categorized into four primary domains:

1. Aggression to People and Animals

  • Bullies, threatens, or intimidates others.
  • Initiates physical fights or uses weapons that can cause serious harm.
  • Exhibits physical cruelty to people or animals.
  • Engages in forced sexual activity.

2. Destruction of Property

  • Deliberately engages in fire setting with the intent to cause serious damage.
  • Deliberately destroys others' property.

3. Deceitfulness or Theft

  • Breaks into houses, buildings, or cars.
  • Lies to obtain goods/favors or avoid obligations ("cons" others).
  • Steals items of nontrivial value without confronting the victim (e.g., shoplifting).

4. Serious Violations of Rules

  • Stays out at night despite parental prohibitions (beginning before age 13).
  • Has run away from home overnight at least twice.
  • Is often truant from school (beginning before age 13).

Subtypes

  • Childhood-Onset Type: Onset of at least one symptom prior to age 10 years. Predominantly male, frequently aggressive, high risk for persistent criminality.
  • Adolescent-Onset Type: No symptoms prior to age 10 years. More equal gender ratio, often less aggressive, better prognosis.
  • Specifier: "With limited prosocial emotions" (callous-unemotional traits) indicates a lack of remorse, guilt, or empathy.

Evaluation

  • Multi-informant clinical interviews involving the child, parents, and teachers.
  • Standardized behavioral rating scales (e.g., Child Behavior Checklist).
  • Comprehensive assessment for learning disabilities, ADHD, and substance use.

Management

  • First-Line Psychosocial Interventions:
    • Parent Management Training (PMT) to improve discipline and positive reinforcement.
    • Multisystemic Therapy (MST) addressing family, school, and peer networks.
    • Cognitive Behavioral Therapy (CBT) focusing on anger management and problem-solving skills.
  • Pharmacotherapy:
    • No FDA-approved medications specifically for CD.
    • Primary role is treating comorbidities (e.g., stimulants for ADHD).
    • Atypical antipsychotics (e.g., Risperidone) may be used off-label as adjuncts for severe, refractory, and dangerous aggression.

Prognosis

  • High risk for school dropout, legal issues, and substance use disorders.
  • The childhood-onset type carries a high likelihood of evolving into Antisocial Personality Disorder in adulthood.