Conduct disorder

Definition

Conduct disorder (CD) is a behavioral and emotional disorder of childhood and adolescence. Children with conduct disorder act inappropriately, infringe on the rights of others, and violate the behavioral expectations of others.

Description

CD is present in approximately 9% of boys and 2–9% of girls under the age of 18. Children with conduct disorder act out aggressively and express anger inappropriately. They engage in a variety of antisocial and destructive acts, including violence towards people and animals, destruction of property, lying, stealing, truancy, and running away from home. They often begin using and abusing drugs and alcohol, and having sex at an early age. Irritability, temper tantrums, and low self-esteem are common personality traits of children with CD.

— Paula Anne Ford-Martin

Definition

Conduct disorder (CD) is a behavioral and emotional disorder of childhood and adolescence. Children with conduct disorder act inappropriately, infringe on the rights of others, and violate the behavioral expectations of others.

Description

Children and adolescents with conduct disorder act out aggressively and express anger inappropriately. They engage in a variety of antisocial and destructive acts, including violence towards people and animals, destruction of property, lying, stealing, truancy, and running away from home. They often begin using and abusing drugs and alcohol and having sex at an early age. Irritability, temper tantrums, and low self-esteem are common personality traits of children with CD.

Demographics

Conduct disorder is present in approximately 6–16 percent of boys and 2–9 percent of girls under the age of 18. The incidence of CD increases with age. Girls tend to develop CD later in life (age 12 or older) than boys. Up to 40 percent of children with conduct disorder grow into adults with antisocial personality disorder.

Causes and Symptoms

There are two subtypes of CD, one beginning in childhood (childhood onset) and the other in adolescence (adolescent onset). Research suggests that this disease may be caused by one or more of the following factors:

• poor parent-child relationships
• dysfunctional families
• inconsistent or inappropriate parenting habits
• substance abuse
• physical and/or emotional abuse
• poor relationships with other children
• cognitive problems leading to school failures
• brain damage
• biological defects

Difficulty in school is an early sign of potential conduct disorder problems. While the child's IQ may be in the normal range, he or she can have trouble with verbal and abstract reasoning skills and may lag behind classmates, and consequently feel as if he/she does not "fit in." The frustration and loss of self-esteem resulting from this academic and social inadequacy can trigger the development of CD.

A dysfunctional home environment can be another major contributor to CD. An emotionally, physically, or sexually abusive household member; a family history of antisocial personality disorder; or parental alcoholism or substance abuse can damage a child's self-perception and put him or her on a path toward negative or aggressive behavior. Other less obvious environmental factors can also play a part in the development of conduct disorder; several long-term studies have found an association between maternal smoking during pregnancy and the development of CD in offspring.

Other conditions that may cause or co-exist with conduct disorder include head injury, substance abuse disorder, major depressive disorder, and attention deficit hyperactivity disorder (ADHD). Fifty to seventy-five percent of children diagnosed with CD also have ADHD, a disorder characterized by a persistent pattern of inattention and/or hyperactivity.

CD is defined as a repetitive behavioral pattern of violating the rights of others or societal norms. Three of the following criteria or symptoms are required over the previous 12 months for a diagnosis of CD (one of the three must have occurred in the past six months):

• bullies, threatens, or intimidates others
• picks fights
• has used a dangerous weapon
• has been physically cruel to people
• has been physically cruel to animals
• has stolen while confronting a victim (for example, mugging or extortion)
• has forced someone into sexual activity
• has deliberately set a fire with the intention of causing damage
• has deliberately destroyed property of others
• has broken into someone else's house or car
• frequently lies to get something or to avoid obligations
• has stolen without confronting a victim or breaking and entering (e.g., shoplifting or forgery)
• stays out at night; breaks curfew (beginning before 13 years of age)
• has run away from home overnight at least twice (or once for a lengthy period)
• is often truant from school (beginning before 13 years of age)

When to Call the Doctor

When symptoms of conduct disorder are present, a child should be taken to his or her health care provider as soon as possible for evaluation and possible referral to a mental health care professional. If a child or teen diagnosed with conduct disorder reveals at any time that he/she has had recent thoughts of self-injury or suicide, or if he/she demonstrates behavior that compromises personal safety or the safety of others, professional assistance from a mental health care provider or care facility should be sought immediately.

Diagnosis

Conduct disorder may be diagnosed by a family physician or pediatrician, social worker, school counselor, psychiatrist, or psychologist. Diagnosis may require psychiatric expertise to rule out such conditions as oppositional defiant disorder, bipolar disorder, or ADHD. A comprehensive evaluation of the child should ideally include interviews with the child and parents, a full social and medical history, review of educational records, a cognitive evaluation, and a psychiatric exam.

One or more clinical inventories or scales may be used to assess the child for conduct disorder, including the Youth Self-Report, the Overt Aggression Scale (OAS), Behavioral Assessment System for Children (BASC), Child Behavior Checklist (CBCL), the Nisonger Child Behavior Rating Form (N-CBRF), Clinical Global Impressions scale (CGI), and Diagnostic Interview Schedule for Children (DISC). The tests are verbal and/or written and are administered in both hospital and outpatient settings.

Treatment

Treating conduct disorder requires an approach that addresses both the child and his/her environment. Behavioral therapy and psychotherapy can help a child with CD to control his/her anger and develop new coping techniques. Social skills training can help a child improve his/her relationship with peers.

Family group therapy may also be effective in some cases. Parents should be counseled on how to set appropriate limits with their child and be consistent and realistic when disciplining. A parental skills training program may be recommended. If an abusive home life is at the root of the conduct problem, every effort should be made to move the child into a more supportive environment.

For children with coexisting ADHD, substance abuse, depression, anxiety, or learning disorders, treating these conditions first is preferred, and may result in a significant improvement in behavior. In all cases of CD, treatment should begin when symptoms first appear. Several studies have shown methylphenidate (Ritalin) to be a useful drug for both ADHD and CD in some children.

When aggressive behavior is severe, mood stabilizing medication, including lithium (Cibalith-S, Eskalith, Lithobid, Lithonate, Lithotabs), and carbamazepine (Tegretol, Carbatrol, Epitol) may be an appropriate option for treating the aggressive symptoms. However, placing the child into a structured setting or treatment program such as a psychiatric hospital may be just as beneficial for easing aggression as medication.

Prognosis

Follow-up studies of conduct-disordered children have shown a high incidence of antisocial personality disorder, affective illnesses, and chronic criminal behavior in adulthood. However, proper treatment of coexisting disorders, early identification and intervention, and long-term support may improve the outlook significantly.

Conduct disorder that first occurs in adolescence is thought to have a statistically better prognosis than childhood-onset conduct disorder. Adolescents with CD tend to have better relationships with their peers and are less likely to develop antisocial personality disorder in adulthood than those with childhood-onset CD. There is also less of a gender gap in adolescent-onset conduct disorder, as girls approach boys in CD incidence. Childhood-onset CD is much more common among boys.

Prevention

A supportive, nurturing, and structured home environment is believed to be the best defense against conduct disorder. Children with learning disabilities and/or difficulties in school should get immediate and appropriate academic assistance. Addressing these problems when they first appear helps to prevent the frustration and low self-esteem that may lead to CD later on.

Parental Concerns

A child with conduct disorder can have a tremendous impact on the home environment and on the physical and emotional welfare of siblings and others sharing the household. While seeking help for their child with CD, parents must remain sensitive to the needs of their other children and adjust household routines accordingly. This may mean avoiding leaving siblings alone together, getting assistance with childcare, or even seeking residential or hospital treatment for the conduct disordered child if the safety and well-being of other family members is in jeopardy.

See also Aggression; Oppositional defiant disorder.

Resources

Books

Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR). Washington, DC: American Psychiatric Press, Inc., 2000.

Eddy, J. Mark. Conduct Disorders: The Latest Assessment and Treatment Strategies. Kansas City, MO: Compact Clinicals, 2003.

Periodicals

Black, Susan. "New Remedies for High School Violence." Education Digest. 69, no.3 (November 2003): 43.

"Conduct Disorder and Oppositional Defiant Disorder: Trends and Treatment." The Brown University Child and Adolescent Psychopharmacology Update. 6, no.8 (August 2004): 1+.

Organizations

The American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Ave., N.W., Washington, D.C. 20016. (202) 966–7300. Web site: www.aacap.org.

Web Sites

Goodman, Robin and Anita Gurian. "About Conduct Disorder." NYU Child Study Center. Available online at: www.aboutourkids.org/aboutour/articles/about_conduct.html (accessed September 12, 2004).

[Article by: Paula Ford-Martin]

A behavior disorder of childhood or adolescence characterized by a pattern of conduct in which either the basic rights of others or the societal norms or rules appropriate for a certain age are violated.

Conduct disorder
Classification and external resources
ICD-10	F91.
ICD-9	312
MeSH	D019955

Conduct disorder is a psychiatric category marked by a pattern of repetitive behavior wherein the rights of others or social norms are violated.

Symptoms include verbal and physical aggression, cruel behavior toward people and pets, destructive behavior, lying, truancy, vandalism, and stealing.^[1]

Conduct disorder is a major public health problem because youth with conduct disorder not only inflict serious physical and psychological harm on others, but they are at greatly increased risk for incarceration, injury, depression, substance abuse, and death by homicide and suicide. After the age of 18, a conduct disorder may develop into antisocial personality disorder, which is related to psychopathy.^[2]

Contents 1 Diagnosis 2 Causation 3 Lack of empathy 4 See also 5 References 6 Further reading 7 External links

Diagnosis

The diagnostic criteria for Conduct Disorder (codes 312.xx, with xx representing digits which vary depending upon the severity, onset, etc. of the disorder) as listed in the DSM-IV-TR are as follows:

1. A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past 6 months:
   1. Aggression to people and animals
      1. often bullies people, threatens, or intimidates others
      2. often initiates physical fights
      3. has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun) (except for activities such as archery and hunting)
      4. has been physically cruel to people
      5. has been physically cruel to animals
      6. has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery)
      7. has forced someone into sexual activity
   2. Destruction of property
      1. has deliberately engaged in fire setting with the intention of causing serious damage.
      2. has deliberately destroyed others' property (other than by fire).
   3. Deceitfulness or theft
      1. has broken into someone else's house, building, or car
      2. often lies to obtain goods or favors or to avoid obligations (i.e., "cons" others)
      3. has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery)
   4. Serious violations of rules
      1. often stays out at night despite parental prohibitions, beginning before age 13 years
      2. has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period)
      3. is often truant from school, beginning before age 13 years
2. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
3. If the individual is age 18 years or older, criteria are not met for Antisocial personality disorder.

Causation

At one time or another most children and adolescents act out or do things that are destructive or troublesome to themselves or others. Only if such behavior persists is it indicative of conduct disorder. This disorder is much more common among boys than girls. As many as 50 percent of parents of 4- to 6-year-old children report that their child has exhibited some such behavior, but most such children show a decrease in antisocial behavior within the next couple of years.

Those in whom this behavior persists may be candidates for psychological help. It is estimated that 5 percent of children show serious conduct problems, being described as impulsive, overactive, and aggressive and engaging in delinquent behavior. Some motives for such behavior are genetic inheritance of a difficult temperament, ineffective parenting, and living in a neighborhood in which violence is common. There is a lack of consensus on what actually works, despite considerable efforts made to help children with conduct disorders.^[3]

A closely linked behavior is juvenile delinquency. This term refers to an adolescent's tendency to break the law or to engage in illicit behavior, a broad concept that ranges from littering to murder. According to U.S. government statistics, eight of ten cases of juvenile delinquency involve males. However, in the last two decades there has been a greater increase in female than male delinquency.

Juvenile delinquency has been found to vary among cultures. Delinquency rates among minority groups and lower-socioeconomic-status-youth are especially high in proportion to the overall population of these groups. However, such groups have less influence over the judicial decision-making process in the United States and may be judged delinquent more readily than their white counterparts and those of higher socioeconomic status. Some suggested causes of delinquency are heredity, identity problems, community influences, and family experiences.

Although delinquency is less exclusively a phenomenon of lower socioeconomic status than it has been in the past, some characteristics of lower-socioeconomic-class cultures may promote delinquency. It is a complex problem, but psychologists have found factors which may predict whether a youth is likely to turn violent. Violent youths are overwhelmingly male and driven by feelings of powerlessness. Ill-directed drives for power often motivate youth especially toward acts of violence.^[3]

Lack of empathy

Some scholars have proposed that lack of empathy and empathic concern (callous disregard for the welfare of others) is an important risk factor for conduct disorder.^{[4] [5]}

When youth with aggressive conduct disorder watch an individual intentionally hurting another (like closing a piano lid), regions of the brain that process painful information are activated, as are the amygdala and ventral striatum (part of the neural circuit involved in reward processing (Decety, Michalska, Akitsuki & Lahey, 2009).

Developmental psychologists and social neuroscientists have hypothesized that empathy and sympathetic concern for others are essential factors inhibiting aggression toward others.^{[6] [7]}

The propensity for aggressive behavior has been hypothesized to reflect a blunted empathic response to the suffering of others.^[8] Such a lack of empathy in aggressive individuals may be a consequence of a failure to be aroused by the distress of others.^[9] Similarly, it has been suggested that aggressive behavior arises from abnormal processing of affective information, resulting in a deficiency in experiencing fear, empathy, and guilt, which in normally developing individuals inhibits the acting out of violent impulses.^[10]

Recently, a functional magnetic resonance imaging (fMRI) study conducted by neuroscientist Jean Decety and colleagues at the University of Chicago reported that youth with aggressive conduct disorder (who have psychopathic tendencies) have a different hemodynamic brain response when confronted with empathy-eliciting stimuli.^[11] In the study, researchers compared 16- to 18-year-old boys with aggressive conduct disorder to a control group of adolescent boys with no unusual signs of aggression.

The youth with the conduct disorder had exhibited disruptive behavior such as starting a fight, using a weapon and stealing after confronting a victim. The youth were tested with fMRI while looking at video clips in which people endured pain accidentally, such as when a heavy bowl was dropped on their hands, and intentionally, such as when a person stepped on another's foot. Results show that the aggressive youth activated the neural circuits underpinning pain processing to the same extent, and in some cases, even more so than the control participants without conduct disorder.^[12]

However, aggressive adolescents showed a specific and very strong activation of the amygdala and ventral striatum (an area that responds to feeling rewarded) when watching pain inflicted on others, which suggested that they enjoyed watching pain. Unlike the control group, the youth with conduct disorder did not activate the areas of the brain involved in understanding social interaction and moral reasoning (i.e., the paracingulate cortex and temporoparietal junction).

See also

• Antisocial personality disorder
• Bullying
• Challenging behavior
• Child pyromaniac
• Empathy
• Empathic concern
• Oppositional defiant disorder
• Psychopathy

References

1. ^ Loeber, R., Farrington, D.P., Stouthamer-Loeber, M., & Van Kammen, W.B. (1998). Antisocial behavior and mental health problems: Explanatory factors in childhood and adolescence. Mahwah, NJ: Lawrence Erlbaum Associates.
2. ^ Lahey, B.B., Loeber, R., Burke, J.D., & Applegate, B. (2005). Predicting future antisocial personality disorder in males from a clinical assessment in childhood. Journal of Consulting and Clinical Psychology, 73, 389-399.
3. ^ ^{a b} Santrock, J. W. (2008). A Topical Approach to Life-Span Development. Moral Development, Values, and Religion: Antisocial Behavior (pp. 491-495). Boston, Massachusetts: McGraw-Hill.
4. ^ Frick, P.J., Stickle, T.R., Dandreaux, D.M., Farrell, J.M., & Kimonis, E.R. (2005). Callous-unemotional traits in predicting the severity and stability of conduct problems and delinquency. Journal of Abnormal Child Psychology, 33, 471-487.
5. ^ Lahey, B.B., & Waldman, I.D. (2003). A developmental propensity model of the origins of conduct problems during childhood and adolescence. In B.B. Lahey, T.E. Moffitt, & A. Caspi (Eds.), Causes of conduct disorder and juvenile delinquency (pp. 76-117). New York: Guilford Press.
6. ^ Eisenberg, N. (2005). Age changes in prosocial responding and moral reasoning in adolescence and early adulthood. Journal of Research on Adolescence, 15, 235-260.
7. ^ Decety, J., & Meyer, M. (2008). From emotion resonance to empathic understanding: A social developmental neuroscience account. Development and Psychopathology, 20, 1053-1080.
8. ^ Blair, R.J.R. (2005). Responding to the emotions of others: Dissociating forms of empathy through the study of typical and psychiatric populations. Consciousness and Cognition, 14, 698-718.
9. ^ Raine, A., Venables, P., & Mednick, S. (1997). Low resting heart rate at age three years predisposes to aggression at age 11 years: Evidence from the Mauritius Child Health Project. Journal of the Academy of Child and Adolescent Psychiatry, 36, 1457-1464.
10. ^ Herpertz, S.C., & Sass, H. (2000). Emotional deficiency and psychopathy. Behavioral Science and Law, 18, 317-323.
11. ^ Decety, J., Michalska, K.J., Akitsuki, Y., & Lahey, B. (2009). Atypical empathic responses in adolescents with aggressive conduct disorder: a functional MRI investigation. Biological Psychology, 80, 203-211.
12. ^ Decety, J., Michalska, K.J., & Akitsuki, Y. (2008). Who caused the pain? A functional MRI investigation of empathy and intentionality in children. Neuropsychologia, 46, 2607-2614.

Further reading

• Decety, J., & Moriguchi, Y. (2007). The empathic brain and its dysfunction in psychiatric populations: implications for intervention across different clinical conditions. BioPsychoSocial Medicine, 1, 22-65.
• Lahey, B.B., Moffitt, T.E.,& Caspi, A. (Eds.). Causes of conduct disorder and juvenile delinquency. New York: Guilford Press.
• Raine, A. (2002). Biosocial Studies of Antisocial and Violent Behavior in Children and Adults: A Review. Journal of Abnormal Child Psychology, 30, 311-326.
• Van Goozen, S.H.M., & Fairchild, G. (2008). How can the study of biological processes help design new interventions for children with severe antisocial behavior? Development and Psychopathology, 20, 941-973.

External links

• Bullying tendency wired in brain from the BBC News.
• Bullies may enjoy seeing others in pain National Science Foundation

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