Conduct Disorder

Hassan M. Minhas, M.D.
Elizabeth A. Lowenhaupt, M.D.

Basic Information

Definition

Conduct disorder (CD) is a repetitive and persistent pattern of behaviors in which either the basic rights of others are violated and/or major age-appropriate societal rules are violated. Classified under the DSM-5 category “disruptive, impulse control, and conduct disorders.”

ICD-10CM CODES
F43.24	Adjustment disorder with disturbance of conduct
F43.25	Adjustment disorder with mixed disturbance of emotions and conduct
F91.0	Conduct disorder confined to family context
F91.1	Conduct disorder, childhood-onset type
F91.2	Conduct disorder, adolescent-onset type
F91.8	Other conduct disorders
F91.9	Conduct disorder, unspecified
I45.89	Other specified conduction disorders
I45.9	Conduction disorder, unspecified
DSM-5 CODES
312.81	Childhood onset
312.32	Adolescent onset
312.89	Unspecified onset

Epidemiology & Demographics

Incidence

1% (12 mo span, National Comorbidity Survey-Replication [NCS-R])

Prevalence

Approximately 2% to 10%; NCS-R: 9%. Disruptive behavior disorders are considered the most common reason for referral of children to mental health providers.

Predominant Sex

More common in males (4:1 preadolescence and 2:1 postadolescence). It is unclear if CD females are underrepresented because diagnostic criteria were validated on male samples. Nonconfrontational aggression and promiscuity are examples of possible gender-specific criteria that, at this time, have unknown predictive validity.

Predominant Age

Most common onset in early adolescence. Median age of onset is 11 yr.

Genetics

Risk increased if parent or sibling with disorder.

Risk Factors

There are various temperamental (including lower-than-average intelligence, especially verbal), family-level (including parental rejection or neglect, early institutional living, frequent caregiver changes, large family size, parental criminality or substance use), and community-level (including peer rejection, association with delinquent peer group, exposure to violence) risk factors.

Physical Findings & Clinical Presentation

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The DSM-5 lists 15 possible behavioral manifestations of CD, grouped into four categories: aggression to people and animals, destruction of property, deceitfulness or theft, and serious violations of rules. Three of the 15 behaviors are required to have occurred in the previous 12 mo, and one behavior must have occurred in the previous 6 mo.
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Specifiers describe the age of onset and the severity of the disorder.
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New to the DSM-5 is an additional specifier addressing issues relating to intent and reaction to the behaviors, including the following options: “With limited prosocial emotions,” “lack of remorse or guilt,” “callous lack of empathy,” “unconcerned about performance,” and “shallow or deficient affect.”
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CD represents a heterogeneous group with respect to presentation, etiology, severity, and course.
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Symptom severity often progresses over time with age (i.e., lying and truancy to sexual assault and robbery).
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Aggressive youth are more likely to interpret as negative or hostile the intent of neutral others and are more likely to believe that conflict can be adequately resolved via aggression.
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Poor frustration tolerance, irritability, temper outbursts, and recklessness are often associated with CD.
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Slow resting heart rate associated with reduced autonomic response to fear is the most replicated of all biologic markers for conduct problems.

Etiology

Estimated population variance in antisocial behavior accounted for by:

1.

Genes: 50%
2.

Environmental factors shared among family members: 20%
3.

Environmental factors unshared among family members: 20% to 30%

Diagnosis

Differential Diagnosis

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Oppositional defiant disorder
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ADHD
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Mood disorder
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Adjustment disorder
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Substance use disorder, intoxication, or withdrawal
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Posttraumatic stress disorder
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Antisocial personality disorder (for those >18 yr)
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Adaptive behavior or subcultural delinquency
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Underlying neurological disorder (rare)

Workup

Diagnosis is made based on history, including individual and family interviews as well as collateral data from additional sources (e.g., parents, teachers, other medical providers, therapists).

Laboratory Tests

Consider urine toxicology for possible substance use comorbidity.

Imaging Studies

None indicated; however, both structural and functional differences have been noted in certain areas of the brain in individuals with CD.

Treatment

Initial treatment of CD should include psychosocial and environmental interventions aimed at decreasing the frequency and severity of delinquent behaviors. If the interventions listed here are not effective or if serious concerns exist regarding safety or impairment in functioning, pharmacologic interventions targeting specific symptoms (e.g., aggression) or comorbid disorders (e.g., ADHD, anxiety disorders, or mood disorders) may help. There are currently no medications approved by the FDA for the treatment of CD.

Nonpharmacologic Therapy

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Parent management training.
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Cognitive problem-solving skills training (including elements of social skills, conflict resolution, anger management, impulse control, and vocational training).
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Multisystemic therapy (MST).
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Social skills training.
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Individual psychotherapy.
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Family psychotherapy.
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Higher levels of care such as a hospital or acute residential setting may be required for stabilization if acute safety concerns develop in the context of CD, such as severe aggression.
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Legal involvement or out-of-home-placements may be necessary to monitor safety of both the patient and the community.

Pharmacologic Therapy

Medication may be considered as an adjunct to behavioral treatment or in cases in which comorbidity is a factor. There is some evidence for symptom improvement with trials of several classes of psychotropic medications—including stimulants, mood stabilizers, atypical antipsychotics, antidepressants, and alpha-2 agonists—all of which seem to target aggressive symptoms in particular; medication, however, should never be used alone or as first-line treatment for CD.

Disposition

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Approximately half of those with early onset of CD persist with antisocial behaviors into adulthood. There is no reliable way to predict which 50% will persist.
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Approximately half of those with early onset of CD do not develop antisocial personality disorder in adulthood. This subgroup is at higher risk for depression, anxiety, and social isolation as adults.
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Approximately 85% of those with adolescent onset of CD do not demonstrate lifetime persistent violence, convictions, and incarcerations. However, adult prognosis may often include substance use and crimes that go largely undetected.

Pearls & Considerations

Comments

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Treatment noncompliance is common (expect 30% treatment noncompliance rate).
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Consider community-based resources (including unique strengths of patient and family) and recruit multiple multidisciplinary team members to create the most effective possible treatment plan.

Ferri – Conduct Disorder