Conduct Disorder in Children and Adolescents

 Conduct disorder is characterized by the following symptoms:

• Aggression to people and animals, which includes:
• Bullying, threatening, or intimidating others
• Initiating physical fights
• Using a weapon that can cause serious physical harm to others
• Being physically cruel to people or animals
• Stealing while confronting a victim (e.g., mugging)
• Forcing someone into sexual activity

• Destruction of property, which includes:
• Deliberate fire setting with the intention of causing serious damage
• Deliberate destruction of others’ property
• Deceitfulness or theft, which includes:
• Breaking into someone else’s house, building, or car
• Lying or “conning” to obtain goods or favors or to avoid obligations
• Stealing items of nontrivial value without confronting a victim (e.g., shoplifting).
• Serious violations of rules, which includes:
• Staying out at night despite parental prohibitions, beginning before age 13 years
• Running away from home overnight
• Being truant from school, beginning before age 13 years

Children and adolescents with this disorder have difficulty following rules and behaving in a socially acceptable way. Associated features of conduct disorder may include an inability to appreciate the importance of others' welfare and little guilt or remorse about harming others. Personality features of children and adolescents with conduct disorder may include trait negative emotionality and poor self-control, poor frustration tolerance, irritability, temper outbursts, suspiciousness, insensitivity to punishment, thrill seeking, and recklessness. Adolescents with conduct disorder often develop skills in outwardly verbalizing remorse to obtain favor or avoid punishment, but do not experience any apparent guilt. Children and adolescents are likely to show a variety of cognitive and attributional deficits and distortions including problem-solving skills, attributions of hostile intent to others, and resentment and suspiciousness. As a result, they may lash out preemptively, and aggression may appear unprovoked.

Very few children and adolescents with conduct disorder exhibit characteristics that qualify for the "with limited prosocial emotions" specifier. This specifier indicates that children and adolescents display limited prosocial emotions in multiple settings and relationships. They reflect the child or adolescent’s overall pattern of functioning, not just occasional occurrences in some situations. Children and adolescents who qualify for this specifier have been described as exhibiting callous and unemotional traits in research. Other personality features, such as thrill seeking, fearlessness, and insensitivity to punishment, may also distinguish those who fall under this specifier. Children and adolescents described in this specifier may be more likely than others with conduct disorder to engage in aggression that is planned for instrumental gain.

Conduct disorder is comprised of three subtypes- childhood onset, adolescent onset, and unspecified onset. Behaviors that are typical of childhood onset conduct disorder include physical aggression toward others, have disturbed peer relationships, may have had oppositional defiant disorder during early childhood, and usually have symptoms that meet full criteria for conduct disorder prior to age 10. Many children with this subtype also have concurrent attention-deficit/hyperactivity disorder (ADHD) or other neurodevelopmental difficulties. Individuals with adolescent-onset conduct disorder are less likely to display aggressive behaviors and tend to have more normative peer relationships.

Parental abuse, onset of problem behavior in early childhood, financial hardship and lack of supervision are all associated with more symptoms of conduct disorder. Childhood conduct disorder, left untreated, has a poorer prognosis. 40% of individuals with childhood-onset conduct disorder will develop antisocial personality disorder. Children and adolescents with conduct disorder are at risk for later mood disorders, anxiety disorders, posttraumatic stress disorder, impulse-control disorders, psychotic disorders, somatic symptom disorders, and substance abuse disorders as adults.

Children and adolescents with conduct disorder are likely to show academic deficiencies, as reflected in achievement level, grades, being left behind in school, early termination from school and deficiencies in specific skill areas. Youths with the disorder are likely to display poor interpersonal relations, as demonstrated in their diminished social skills in relation to peers and adults and higher levels of peer rejection. They may engage in other risky behaviors such as cigarette smoking, early sexual activity, and alcohol or drug use. Suicidal ideation, suicide attempts, and completed suicide occur at a higher rate in this population.

Familial risk factors include parental neglect, parent criminality, inconsistent child-rearing practices, harsh discipline, physical or sexual abuse, and early institutional living. Social risk factors include peer rejection, association with a delinquent peer group, and neighborhood exposure to violence. The disorder appears to also have a genetic component, as it is more common in children with a biological or adoptive parent or sibling with conduct disorder. However, having a genetic predisposition to conduct disorder does not necessarily mean that someone will develop conduct disorder.

Children who have conduct disorder may have decreased baseline autonomic nervous system activity, requiring greater stimulation to achieve optimal arousal. Some research suggests that the types and intensities of autonomic responses may increase or decrease susceptibility to form of family conflict. Thus, it is hypothesized that autonomic nervous systemic activity may increase vulnerability or provide protection against psychological maladjustment the context of family conflict. Structural and functional differences in brain areas associated with affect regulation and affect processing, particularly frontotemporal-limbic connections involving the brain's ventral prefrontal cortex and amygdala, have been noted in individuals with conduct disorder.

First Line Treatments

• Parent Training Program: training for parents to help them better handle aggressive and antisocial behavior. Parents are trained in how to effectively utilize reinforcement, punishment, and consequences to reduce aggressive behavior and increase prosocial and compliant behavior.
• Pharmacologic Intervention, which are thought to help by reducing aggression.
• Stimulants such as dextroamphetamine or methylphenidate

• Anticonvulsants such as lithium

• Antipsychotics such as haloperidol or risperidone

Second Line Treatments

In cases of nonresponse to first-line treatment, alternative treatments with reasonable evidence of efficacy include:

• Cognitive behavioral therapy: An intervention that combines cognitive and behavioral learning principles to shape and encourages desired behaviors. Clients are encouraged to change the way of thinking or acting out their problems and replace them with proactive solutions.
• Multi-systemic Intervention: community-based intervention that explicitly attempts to intervene in multiple real-life settings (e.g., home, school)
• Antidepressant medications such as bupropion and fluoxetine

Third Line Treatments

When patients do not respond adequately to the first- and second-line treatments described above, other strategies might include:

• Alpha-2 agonist medications such as clonidine