Conduct disorder
Conduct disorder is a mental disorder diagnosed in childhood or adolescence that presents itself through a repetitive and persistent pattern of behavior that includes theft, lies, physical violence that may lead to destruction, and reckless breaking of rules, in which the basic rights of others or major age-appropriate norms are violated. These behaviors are often referred to as "antisocial behaviors", and is often seen as the precursor to antisocial personality disorder; however, the latter, by definition, cannot be diagnosed until the individual is 18 years old. Conduct disorder may result from parental rejection and neglect and in such cases can be treated with family therapy, as well as behavioral modifications and pharmacotherapy. It may also be caused by environmental lead exposure. Conduct disorder is estimated to affect 51.1 million people globally
Signs and symptoms
One of the symptoms of conduct disorder is a lower level of fear. Research performed on the impact of toddlers exposed to fear and distress shows that negative emotionality predicts toddlers' empathy-related response to distress. The findings support that if a caregiver is able to respond to infant cues, the toddler has a better ability to respond to fear and distress. If a child does not learn how to handle fear or distress the child will be more likely to lash out at other children. If the caregiver is able to provide therapeutic intervention teaching children at risk better empathy skills, the child will have a lower incident level of conduct disorder.The condition is also linked to a rise in violent and antisocial behaviour; examples may range from pushing, hitting and biting when the child is young, progressing towards beating and inflicted cruelty as the child becomes older. Additionally, self-harm has been observed in children with conduct disorder. A predisposition towards impulsivity and lowered emotional intelligence have been cited as contributing factors to this phenomenon. However, in order to determine direct causal links further studies must be conducted.
Conduct disorder can present with limited prosocial emotions, lack of remorse or guilt, lack of empathy, lack of concern for performance, and shallow or deficient affect. Symptoms vary by individual, but the four main groups of symptoms are described below.
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
- Has been physically cruel to people
- Has been physically cruel to animals
- Has stolen while confronting a victim
- Feels no remorse or empathy towards the harm, fear, or pain they may have inflicted on others
Destruction of property
- Has deliberately engaged in fire setting with the intention of causing serious damage
- Has deliberately destroyed others' property
Deceitfulness or theft
- Has broken into someone else's house, other building, car, other vehicle, etc
- Often lies to obtain goods or favors or to avoid obligations
- Has stolen items of nontrivial value without confronting a victim
Serious violations of rules
- Often stays out at night despite parental prohibitions, beginning before age 13
- Has run away from home overnight at least twice while living in parental or parental surrogate home
- Is often truant from school, beginning before age 13
Developmental course
Currently, two possible developmental courses are thought to lead to conduct disorder. The first is known as the "childhood-onset type" and occurs when conduct disorder symptoms are present before the age of 10 years. This course is often linked to a more persistent life course and more pervasive behaviors. Specifically, children in this group have greater levels of ADHD symptoms, neuropsychological deficits, more academic problems, increased family dysfunction and higher likelihood of aggression and violence.There is debate among professionals regarding the validity and appropriateness of diagnosing young children with conduct disorder. The characteristics of the diagnosis are commonly seen in young children who are referred to mental health professionals. A premature diagnosis made in young children, and thus labeling and stigmatizing an individual, may be inappropriate. It is also argued that some children may not in fact have conduct disorder, but are engaging in developmentally appropriate disruptive behavior.
The second developmental course is known as the "adolescent-onset type" and occurs when conduct disorder symptoms are present after the age of 10 years. Individuals with adolescent-onset conduct disorder exhibit less impairment than those with the childhood-onset type and are not characterized by similar psychopathology. At times, these individuals will remit in their deviant patterns before adulthood. Research has shown that there is a greater number of children with adolescent-onset conduct disorder than those with childhood-onset, suggesting that adolescent-onset conduct disorder is an exaggeration of developmental behaviors that are typically seen in adolescence, such as rebellion against authority figures and rejection of conventional values. However, this argument is not established and empirical research suggests that these subgroups are not as valid as once thought.
In addition to these two courses that are recognized by the DSM-IV-TR, there appears to be a relationship among oppositional defiant disorder, conduct disorder, and antisocial personality disorder. Specifically, research has demonstrated continuity in the disorders such that conduct disorder is often diagnosed in children who have been previously diagnosed with oppositional defiant disorder, and most adults with antisocial personality disorder were previously diagnosed with conduct disorder. For example, some research has shown that 90% of children diagnosed with conduct disorder had a previous diagnosis of oppositional defiant disorder. Moreover, both disorders share relevant risk factors and disruptive behaviors, suggesting that oppositional defiant disorder is a developmental precursor and milder variant of conduct disorder. However, this is not to say that this trajectory occurs in all individuals. In fact, only about 25% of children with oppositional defiant disorder will receive a later diagnosis of conduct disorder. Correspondingly, there is an established link between conduct disorder and the diagnosis of antisocial personality disorder as an adult. In fact, the current diagnostic criteria for antisocial personality disorder require a conduct disorder diagnosis before the age of 15. However, again, only 25–40% of youths with conduct disorder will develop an antisocial personality disorder. Nonetheless, many of the individuals who do not meet full criteria for antisocial personality disorder still exhibit a pattern of social and personal impairments or antisocial behaviors. These developmental trajectories suggest the existence of antisocial pathways in certain individuals, which have important implications for both research and treatment.
Associated conditions
Children with conduct disorder have a high risk of developing other adjustment problems. Specifically, risk factors associated with conduct disorder and the effects of conduct disorder symptomatology on a child's psychosocial context have been linked to overlapping with other psychological disorders. In this way, there seems to be reciprocal effects of comorbidity with certain disorders, leading to increased overall risk for these youth.Attention deficit hyperactivity disorder
is the condition most commonly associated with conduct disorders, with approximately 25–30% of boys and 50–55% of girls with conduct disorder having a comorbid ADHD diagnosis. While it is unlikely that ADHD alone is a risk factor for developing conduct disorder, children who exhibit hyperactivity and impulsivity along with aggression is associated with the early onset of conduct problems. Moreover, children with comorbid conduct disorder and ADHD show more severe aggression.Oppositional defiant disorder
ODD is a mental disorder characterized by angry, argumentative, and resentful behavior. ODD and CD both fall under the umbrella of Disruptive Behavior Disorders. The main difference is in severity. While ODD is based on verbal hostility, CD is more severe in that it includes aggression and violence towards other people and animals, theft, deceit, and breaking of rules. ODD has also been found to be a precursor for CD. The chances of developing CD is four times higher in children who previously had ODD than in children who do not have a history of ODD.
Substance use disorders
Conduct disorder is also highly associated with both substance use and abuse. Children with conduct disorder have an earlier onset of substance use, as compared to their peers, and also tend to use multiple substances. Studies have shown that a diagnosis of conduct disorder during early adolescence was a significant predictor of substance abuse by the age of 18. However, substance use disorders themselves can directly or indirectly cause conduct disorder-like traits in about half of adolescents who have a substance use disorder. As mentioned above, it seems that there is a transactional relationship between substance use and conduct problems, such that aggressive behaviors increase substance use, which leads to increased aggressive behavior. Notably, while older studies may have failed to find a correlation between hyperactivity or impulsivity as a predictor of conduct disorder, more recent studies have found that even a single symptom of ADHD or conduct disorder is associated with increased risk of substance abuse.Substance use in conduct disorder can lead to antisocial behavior in adulthood.