Overview

Conduct disorder (CD) is one of the most difficult and intractable mental health
problems in children and adolescents. CD involves a number of problematic
behaviors, including oppositional and defiant behaviors and antisocial activities (eg,
lying, stealing, running away, physical violence, sexually coercive behaviors).
A preventable predisposing factor for the development of all mental health disorders
in children and adolescents has been found in a cross-sectional survey involving
second-hand smoke exposure in youth who are not themselves cigarette smokers.
The study adjusted for poverty, race/ethnicity, sex, asthma, hay fever, and maternal
smoking; serum cotinine level was positively associated with CD, especially for non-
Hispanic white males. [1]
Males with conduct disorder and aggression have brain-based differences that
resemble the differences found in persons with addiction, as compared with normally
developing controls, regarding brain structure and function. [2]
Studies have shown that females with conduct disorder as compared with subjects
without conduct disorder have similar abnormal (disrupted) brain function to that
previously observed in males, who tend to have increased aggression and conduct
disorder; however, more research is needed to tease out factors such as child abuse
that might cause similar findings. [3]
These differences may be due to genetic differences in DNA methylation, [4] which
result in deficits in the perception of emotions and impairment in affect regulation,
and this may cause early impairment in attachment that might possibly further
interfere with the normative development of empathy, despite intellectual capacity for
those cognitive functions. [5]
Conduct-disordered youth exhibit a decreased dopamine response to reward and
increased risk-taking behaviors related to abnormally disrupted frontal activity in the
anterior cingulate cortex (ACC), orbitofrontal cortices (OFC), and dorsolateral
prefrontal cortex (DLPFC) that worsens over time due to dysphoria activation of brain
stress systems and increases in corticotropin-releasing factor (CRF). [6]
Areas deep in the brain, especially the amygdala and insula, appear to exhibit
abnormal function reflected in overall decreases in resting state connectivity and
smaller overall size. [7] This decrease in brain structure and functionality is also seen
in youth with other diagnoses such as in cases of child abuse and neglect, causing
reactive attachment disorder and temper dysregulation as well as schizophrenia,
which makes careful attention to the differential of rule-breaking behaviors important
for accurate diagnosis. [8]
Recent research has found a possible association of changes in the dorsal mode
default network connectivity with callous unemotional traits in conduct disorder. [9]
This disorder is marked by chronic conflict with parents, teachers, and peers and can
result in damage to property and physical injury to the patient and others. These
patterns of behavior are consistent over time.
Behaviors used to classify CD fall into the 4 main categories of (1) aggression
toward people and animals; (2) destruction of property without aggression toward
people or animals; (3) deceitfulness, lying, and theft; and (4) serious violations of
rules.
CD usually appears in early or middle childhood as oppositional defiant behavior.
Nearly one half of children with early oppositional defiant behavior have an affective
disorder, CD, or both by adolescence. Thus, careful diagnosis to exclude irritability
due to another unrecognized internalizing disorder is important in childhood cases.
Evaluation of parent-child interactions and teacher-child interactions is also critical.
Even in a stable home environment, a small number of preschool-aged children
display significant irritability and aggression that results in disruption severe enough
to be classified as CD.
Diagnostic Criteria (DSM5)
In conduct disorder, a repetitive and persistent pattern of behavior occurs in which
the basic rights of others or major age-appropriate societal norms or rules are
violated. This manifests as the presence of at least 3 of the following 15 criteria in
the past 12 months from any of the categories below, with at least one criterion
present in the past 6 months: [10]
Aggression to people and animals:
• Often bullies, threatens, or intimidates others
• Often initiates physical fights
• Has used a weapon that can cause serious physical harm to others (eg,
a bat, brick, broken bottle, knife, gun)
• Has been physically cruel to people
• Has been physically cruel to animals
• Has stolen while confronting a victim (eg, mugging, purse snatching,
extortion, armed robbery)
• Has forced someone into sexual activity
Destruction of property:
• Has deliberately engaged in fire setting with the intention of causing
serious damage
• Has deliberately destroyed others’ property (other than by fire setting)
Deceitfulness or theft:
• Has broken into someone else’s house, building, or car
• Often lies to obtain goods or favors or to avoid obligations (ie, “cons”
others)
• Has stolen items of nontrivial value without confronting a victim (eg,
shoplifting, but without breaking and entering; forgery)
Serious violations of rules:
• Often stays out at night despite parental prohibitions, beginning before
age 13 years
• Has run away from home overnight at least twice while living in the
parental or parental surrogate home, or once without returning for a
lengthy period
• Is often truant from school, beginning before age 13 years
The disturbance in behavior causes clinically significant impairment in social,
academic, or occupational functioning.
If the individual is age 18 years or older, criteria are not met for antisocial personality
disorder.
Specify the following:
• 312.81(F91.1) Childhood-onset type: At least one symptom prior to age
10 years
• 312.82 (F91.2) Adolescent-onset type: No symptoms prior to age 10
years
• 312.89 (F91.9) Unspecified onset: Not enough information to determine
whether the onset of the first symptom was before or after age 10 years
With limited prosocial emotions: An individual must have displayed at least 2 of the
following characteristics persistently over at least 12 months and in multiple
relationships and setting. These characteristics reflect the individual’s typical pattern
of interpersonal and emotional functioning over this period and not just occasional
occurrences in some situations. Thus, to assess the criteria for the specifier, multiple
information sources are necessary. In addition to the individual’s self-report, it is
necessary to consider reports by others who have known the individual for extended
periods of time (eg, parents, teachers, coworkers, extended family members, peers).
Added specifier: Specify whether there is the presence of a lack of remorse or guilt.
The person does not feel bad or guilty when he or she does something wrong
(exclude remorse when expressed only when caught and/or facing punishment). The
individual shows a general lack of concern about the negative consequences of his
or her actions. For example, the individual is not remorseful after hurting someone or
does not care about the consequences of breaking rules.
Oppositional defiant disorder (ODD) is discriminated from CD based on the defiance
of rules and argumentative verbal interactions involved in ODD; CD involves more
deliberate aggression, destruction, deceit, and serious rule violations, such as
staying out all night or chronic school truancy.
The childhood-onset type is defined by the presence of 1 criterion characteristic of
CD before an individual is aged 10 years; these individuals are typically boys
displaying high levels of aggressive behavior. These individuals often also meet
criteria for attention deficit/hyperactivity disorder (ADHD). Poor peer and family
relationships are present, and these problems tend to persist through adolescence
into adult years. These children are more likely to develop adult antisocial personality
disorder than individuals with the adolescent-onset type.
Adolescent-onset type is defined by the absence of any criterion characteristic of CD
before an individual is aged 10 years. These individuals tend to be less aggressive
and have more normative peer relationships. They often display their conduct
behaviors in the company of a peer group engaged in these behaviors, such as a
gang. These patients are less likely to fit criteria for ADHD; however, the diagnosis of
ADHD is still possible. These individuals are also far less likely to develop adult
antisocial personality disorder. While boys are identified more often, the estimated
sex ratio of this type of CD approaches 50% for girls and boys in some communities.
The prognosis for an individual with adolescent-onset type is much better than for a
person with the childhood-onset type.
CD is highly resistant to treatment. It follows a clear developmental path with
indicators that can be present as early as the preschool period. Treatment is more
successful when initiated early and must include medical, mental health, and
educational components as well as family support. Close communication between
home and school is particularly important at younger ages. [11]