CONDUCT DISORDER

Dr. Jayanta Kurmi

Junior Resident
Dept Of Psychiatry
SMCH

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 Plan of presentation
• Introduction
• History
• Epidemiology
• Etiology
• Diagnosis
• Course And Prognosis
• Differential Diagnosis
• Management
• Conclusion
• Bibliography

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 INTRODUCTION
• The essential characteristic of CD is a repetitive and
persistent pattern of behavior in which the basic rights of
others or major age-appropriate societal norms or rules are
repeatedly violated beginning in childhood or adolescence.

• These behaviors fall into four main groupings: aggression to

people or animals, destruction of property, deceitfulness or
theft, and serious rule violations.

• Persistent and extreme patterns of these behaviours among

children and adolescents reflect a serious clinical problem
with broad personal and social impact and these more
extreme patterns comprise conduct disorder

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 INTRODUCTION
• Externalizing behaviours (under- controlled) refers to those
acts that impinges on others and disrupt the environment.
• Internalizing (over-controlled) behaviour refers to
characteristics that are more internally focused: anxiety,
shyness, withdrawal- hypersensitivity and physical
complaints.
• The characters that delineate conduct disorders are
frequency and intensity of the behaviours, repetitiveness
and chronicity, multiple antisocial behaviours as a package
and impairment in everyday functioning.
• CD remains perhaps one of the most commonly given
diagnosis within child psychiatry in both inpatient and
outpatient psychiatric pediatric facilities (American
Psychiatric Association 2000)

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 HISTORY
• As early as 1837, Prichard used the term moral insanity to
describe young adult patients with recurrent patterns of
antisocial behavior who were not overtly psychotic.
• Benjamin Rush, the father of American psychiatry, described
cases exhibiting “innate, preternatural moral depravity” and
speculated that these patients had a defect in the “moral
faculties of the mind.”
• In the 19th century, scientific thought emphasized the inherent
traits and physical defects (i.e., phrenology) that appeared to
mark the antisocial individual.
• Beginning in the early 20th century, a shift in thinking occurred
as clinicians, social workers, pediatricians, welfare workers, and
academics began to consider the impact of the environment and
adverse individual or social conditions on the young juvenile
offender.

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 HISTORY
• This shift in thinking combined with hope for new
treatments led to the beginning of the child guidance
movement in the United States with the opening of the
Juvenile Psychopathic Institute in Chicago in 1909, and the
Judge Baker Clinic in Boston in 1917.

• The initial purpose of these clinics was to advise the courts

on the psychology of juveniles under arrest.

• In 1923, Karl Menninger brought together a group of

psychiatrists concerned with youthful offenders and started
the American Orthopsychiatric Association.

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 HISTORY
• Today, the thinking about the etiology of CD has evolved
into considerations about the interaction between
vulnerability genes and adverse environmental rearing
experiences in the shaping of the individual across
development.

• This evolution in thinking is reflected in changes describing

antisocial individuals in the DSM system.

• The diagnosis of sociopathic personality with antisocial

reaction for adults was first codified in 1952 in DSM-I.

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 HISTORY
• DSM-II published in 1968 contained for the first time, a
section on behavior disorders of childhood and
adolescence.
• The diagnosis for children with conduct problems
became unsocialized aggressive reaction of childhood
(or adolescence)
• The diagnosis of CD first appeared in 1980 with the
publication of DSM-III and contained four subtypes:
aggressive, nonaggressive, socialized, and
undersocialized.
• In DSM-III-R, published in 1987, three new subtypes of
CD were introduced as solitary aggressive type, group
type, and undifferentiated type

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 HISTORY
• DSM-IV (1994) and DSM-IV-TR (2000) expanded
the symptom criteria list to 15 items

• The subtypes were changed to a

childhood-onset type - prior to 10 year
adolescent-onset type – after 10 year
unspecified-onset – not determined

• DSM-5 retained the age of onset subtypes and

added a specifier identifying the presence of
limited prosocial emotions.

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 EPIDEMIOLOGY
• Prevalence estimates of CD in the general population range
widely, from < 1% to > 10%, depending on the type of
population studied and the diagnostic methods and criteria
used (Maughan et al. 2004).

• What consistently emerges, however, is that CD is more

common among males than females (with ratios ranging
from 2:1 to 4:1) (Moffitt et al. 2001)

• The childhood-onset subtype demonstrates a considerable

male predominance and may be predictive of more
numerous and severe symptoms.

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 EPIDEMIOLOGY
• The prevalence of CD increases with age and levels
off at approximately 15–16 years, with males showing
a more linear year-to-year increase than females, who
demonstrate a greater increase starting mostly in
adolescence (Maughan et al. 2004).
• Rates are higher in clinically referred youths and in
juvenile detention populations.
• Onset after adolescence is rare.
• Lifetime prevalence of CD is associated with younger
age, male gender, and low educational attainment,
being separated or divorced as an adult, and residing
in urban settings.

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EPIDEMIOLOGY- Indian Scenario
• Prevalence as per CD 0.2%, ODD 0.9%,
Srinath et al, 2005).
• M:F= 9:1 (Sundaram et al , 2005).

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 ETIOLOGY
• most important risk factors that predict conduct
disorder include impulsivity, physical or sexual
abuse or neglect, poor parental supervision and
harsh and punitive parental discipline, low
intelligence quotient (IQ), and poor school
achievement.

• However for better understanding it can be

divided into individual ,family level & beyond
family level influences

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ETIOLOGY- Individual-level influences
1. Overall genetic effects :-
• Genetic contribution is higher for antisocial behavior in
the presence of inattention and hyperactivity, callous
unemotional traits or high levels of physical aggression and
also if the antisocial behavior is pervasive across situations.
• A functional polymorphism in the gene for monoamine
oxidase A (MAOA), which is widely involved in metabolizing
a broad range of neurotransmitters, had no main effect on
children, but a form of the gene which is associated with
lower MAOA made individuals especially prone to develop
antisocial behavior if they had been maltreated.

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 ETIOLOGY- Individual-level influences
2. Pregnancy and perinatal complications
• Several influences during pregnancy have been
associated with increased antisocial behavior in children.
• Alcohol intake and smoking during pregnancy- imp
contributory factor

3. Temperament
• a “difficult” temperament becomes more likely to lead to
disruptive behavior problems when it interacts with a harsh
inconsistent parenting style

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 ETIOLOGY- Individual-level influences
4. Brain function
• Studies have reported that children with conduct disorder had
decreased gray matter in limbic brain structures, and in the bilateral
anterior insula and left amygdala compared to healthy controls.
5. Language, IQ, and educational attainment deficits
• Low IQ and low school achievement are important predictors of
ODD/CD and delinquency
• Longitudinal studies show that persistence in antisocial behavior
over periods of years is predicted by low language ability/verbal IQ
in childhood (Petersen et al., 2013).
• Possible mechanisms may include lower abilities to recall oral
instructions and to use language to think through the
consequences of actions contributing to the poorer control of
actions

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 ETIOLOGY- Individual-level influences
5. Language, IQ, and educational attainment deficits
• Children who cannot reason or assert themselves verbally
may attempt to gain control of social exchanges using
aggression.
• Low IQ can contribute to academic difficulties which in
turn mean that school becomes unrewarding, rather than
a source of self-esteem and support
6. Executive dysfunction
• Children and adolescents with conduct problems have
been shown consistently to have poor executive functions.
• Fairchild et al. (2009) found that children with ODD/CD
were more likely to take risky decisions and were less
sensitive to punishment.

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 ETIOLOGY- Individual-level influences
7. Autonomic reactivity and the HPA axis
• low heart rate has been found consistently to be associated
with antisocial behavior
• Lorber (2004) conducted a meta-analysis and found
children with conduct problems had lower skin conductance
activity & low levels of cortisol
• The explanation for the link between slow autonomic
activity and antisocial behavior remains unclear

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 ETIOLOGY- Individual-level influences
8. Information processing & social cognition
• This model hypothesises that children who are
prone to aggression focus on threatening aspects
of others’ actions, interpret hostile intent in the
neutral actions of others (a hostile attributional
style), and are more likely to select and to favor
aggressive solution to social challenges (response
and evaluation decision).

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ETIOLOGY- Family-level influences
1. Child rearing practises
• CD is associated with less than optimal parenting
practises, characterized by harsh inconsistent
discipline, low warmth and involvement, and high
criticism
• Studies indicate that parents of children with
conduct disorder have high rates of serious
psychopathology, including psychotic disorders

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 ETIOLOGY- Family-level influences
2. Attachment insecurity
• John Bowlby’s (1944) study of juvenile thieves implicated,
Insecure attachment patterns, especially disorganization
with their parents are fairly strongly associated with
antisocial behavior.
3. Maltreatment
• associations between physical abuse and conduct problems
are well established
• Little is known about the possible mechanisms linking
maltreatment to conduct problems, although threats to
security of attachment, difficulties in affect regulation,
distortions of information processing and self-concept and
failure to model and reward prosocial behavior are likely to
be relevant.

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ETIOLOGY- Influences beyond the family
1. Peer Effects
• children with ODD/CD have more negative interchanges with
other children, across the age range from early childhood up
to adolescence, and tend to be rejected by nondeviant peers
(Boivin et al., 2013)
• Three processes could be at work:
the child’s individual antisocial behavior could
lead to peer problems, or vice versa,

deviant peer relationships could lead to antisocial behavior,

or finally, some common factor could lead to both

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ETIOLOGY- Influences beyond the family
2. Sociocultural Factors
• greater population density.
• lack of a supportive social network,
• and lack of positive participation in community
activities seem to predict conduct disorder
• urban areas are increased exposure to and
prevalence of substance use

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 ETIOLOGY
• Comorbid Factors
• ADHD and conduct disorder are often found to
coexist, with ADHD often predating the
development of conduct disorder, and not
infrequently substance abuse.
• Central nervous system injury, dysfunction, or
damage predispose a child to impulsivity and
behavioral disturbances, which sometimes evolve
into conduct disorder.

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Figure:- Interaction between selected risk & protective factors

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Assessment & diagnosis

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 Assessment
• Strength and Difficulties Questionnaire
• Achenbach System of Empirically Based Assessment (ASEBA
• Eyberg Child Behavior Inventory (ECBI

• Child should be interviewed separately to establish a direct

rapport; children have a unique perspective in reporting their
own peer relations, patterns of substance abuse, emotional
symptoms and details of their disruptive behaviour
• However, getting both parent and teacher to fill in
questionnaires is helpful for a number of reasons. First, it is
important to get the perspective of the school.Second,
comorbidity can more easily be picked up.

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presence of at least three of the following 1 5 criteria i n the past 1 2 months
from any of the categories, with at least one criterion present in the past 6
months. 28
• Specify whether:
Childhood/ Adolescent/Unspecified onset
• Specify whether:
With limited prosocial emotions /
Lack of remorse or guilt /
Callous - lack of empathy /
Unconcerned about performance /
Shallow or deficient affect
• Specify whether:
Mild/Moderate/Severe

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 D I FFERENTIAL D IAG NOSIS
1. Attention Deficit Hyperactivity Disorder.
• Any of the three core symptoms, impulsivity, inattention
and motor overactivity can be misconstrued as antisocial,
particularly impulsivity, which is also present in ODD/CD
and does not of itself indicate ADHD
• antisocial behavior is not a feature of pure ADHD
2. Mood Disorders.
• Depression can present with irritability and oppositional
symptoms but unlike typical CD, mood is usually clearly
low and there are often vegetative features
• Low self-esteem is the norm in CD, as is a lack of friends
or constructive pastimes. Therefore it is easy to overlook
more pronounced depressive symptoms

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3. Adjustment Reaction.
• This can be diagnosed when onset occurs soon
after exposure to an identifiable psychosocial
stressor such as divorce, bereavement, trauma,
abuse, or adoption.
• The onset should be within 1 month for ICD-
10,and 3 months for DSM-5, and symptoms
should not persist for more than 6 months after
the cessation of the stress or its sequelae

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4. Autistic Spectrum Disorders (ASD).
• These are often accompanied by marked
tantrums or destructiveness, which may be the
reason for seeking a referral.
• unlike children with ODD/CD who have callous-
unemotional traits, children with ASD fail to
understand social situations and judge accurately
the emotions of others.
5. Antisocial/Dyssocial Personality Disorder
(ASPD).
• In DSM-5 ASPD cannot be diagnosed under 18

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Development pathway

Prosocial
outcome

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 What happen to youths with conduct
disorder as they enter adulthood?
• One of the most dramatic illustrations of the long-
term prognosis of these children was the
landmark study by Robins (1978) who evaluated
their status 30 years later and found half of them
develop antisocial personality disorder as adults.

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major characteristics likely to be evident in
adulthood
• Psychiatric status: Greater psychiatric impairment,
including antisocial personality, alcohol and drug abuse,
and isolated symptoms (e.g. anxiety, somatic
complaints); also greater history of psychiatric
hospitalization.
• Criminal behaviour: Higher rates of driving while
intoxicated, criminal behaviour, arrests, convictions and
periods of time spent in jail; greater seriousness of the
criminal acts.
• Occupational adjustment: Less likely to be employed,
shorter history of employment, lower status jobs, more
frequent job changes, lower wages, serving less
frequently and performing less well in armed forces.

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• Educational attainment: Higher rates of
dropping out of school, lower levels of educational
attainment among those who remain in school.
• Marital status: Higher rates of divorce,
remarriage and separation.
• Social participation: Less contact with relatives,
friends, and neighbours, little participation in
religious organizations.
• Physical health: Higher mortality rates, higher
rates of hospitalization for physical as well as
psychiatric problems

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MANAGEMENT

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 TREATMENT
• The objective of treatment is to enable the child
to cope with the environment he or she lives in
usually, and alter the environment where it is
harmful
A. PSYCHOSOCIAL INTERVENTIONS:-
1. Parent Management Training(PMT)
• Parent training programs are the mainstay of
treatment of CD, especially with younger children
below the age of about eight
• designed to improve parents’ behavior
management skills and the quality of the parent–
child relationship
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 TREATMENT
• Helping the Noncompliant Child
• Parent Child Interaction Therapy individual
• Incredible Years Program
• Positive Parenting Program Group

• Most parenting programs target skills, such as promoting

play and developing a positive parent–child relationship,
using praise and rewards to increase desirable social
behavior, giving of clear directions and rules, using
consistent and calm consequences for unwanted behavior,
and reorganizing the child’s day to prevent problems.

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 TREATMENT
2. Family systemic therapies
• structural family therapy as pioneered by leaders
such as Minuchin (1974) would try to restore clear
boundaries of authority of the parents over the
child, since often antisocial children have become
domineering in their own homes.
• Other forms of family therapy try to improve
patterns of communication that have gone wrong,
and
• “systemic” variants try to reveal and address
relevant factors that impinge on the family system
from both within and outside the family.
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3. Child therapies
• Cognitive-behavioral therapies and social skills
therapies for CD typically aim to
(i) reduce children’s aggressive behavior such as shouting,
pushing and arguing;
(ii) Increase prosocial interactions such as entering a group,
starting a conversation, participating in group activities,
sharing, cooperating
(iii) correct the cognitive deficiencies, distortions and
inaccurate self-evaluation and
(iv) ameliorate emotional regulation and self-control
problems so as to reduce emotional lability, impulsivity, and
explosiveness, enabling the child to be more reflective and
able to consider how best to respond in provoking situations

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4. Community based intervention and societal
intervention
• School based programs of improved awareness
and monitoring, tailored curricula, individual
intervention are partially useful
• Societal intervention like reduction in exposure to
toxins, community crime, parental risk factors are
helpful too.

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B. PHARMACOLOGICAL INTERVENTION
• Risperidone
• Quetiapine
• Clonidine
• SSRIs

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• When might antipsychotics be contemplated?
• Clinical experience suggests they can lead to the
helpful reductions in aggression in some cases,
especially where there is poor emotional regulation
characterized by prolonged rages.
• Prescribing antipsychotics for relatively short periods
(say up to 4 months) in lower doses (say no more than
1–1.5mg risperidone perday) where full evidence-
based psychosocial interventions with both the family
and the child are failing can help families cope;
• during this time it is crucial to continue to work at
effective psychological management.

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• PREVENTION

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 conclusion
• Conduct disorder is different from normal
disruptive behaviour expected from children and
adolescents as they develop their personalities.

• Serious problem for individual and society if left

untreated, may lead to antisocial personality
disorder.

• Conduct problems predict in adulthood not just

increased rates of psychiatric diagnoses, but
wide spread social dysfunction
• Need multidisciplinary collaborative effort.

• Need to intervene in early ages.

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 Bibliography
1. Kaplan ctp 10th ed
2. Rutters Child and Adolescent Psychiatry 6Ed
3. Kaplan & Sadock's Synopsis Of Psychiatry
4. APA publishing 2018 edition/Psychiatry Online
5. ICD-10
6. DSM-5
7. Lewis-s-Child-and-Adolescent-Psychiatry-A-
Comprehensive-Textbook

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• Thank you

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