Conduct Disorder in Children

Definition

• Conduct Disorder (CD) is a disruptive behavior disorder characterized by a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated.
• Diagnosis requires the presence of at least three criteria in the past 12 months, with at least one criterion present in the past 6 months (DSM-5).

Etiology and Risk Factors

• Biological: Genetic predisposition; functional abnormalities in the amygdala and prefrontal cortex; reduced basal autonomic nervous system reactivity.
• Environmental/Psychosocial: Maltreatment, physical/sexual abuse, harsh or inconsistent discipline, parental criminality or substance abuse, poverty, and peer rejection.
• Comorbidities: High rates of co-occurring Attention-Deficit/Hyperactivity Disorder (ADHD), specific learning disorders, and substance use disorders.

Clinical Features

Symptoms are categorized into four primary domains:

1. Aggression to People and Animals

• Bullies, threatens, or intimidates others.
• Initiates physical fights or uses weapons that can cause serious harm.
• Exhibits physical cruelty to people or animals.
• Engages in forced sexual activity.

2. Destruction of Property

• Deliberately engages in fire setting with the intent to cause serious damage.
• Deliberately destroys others' property.

3. Deceitfulness or Theft

• Breaks into houses, buildings, or cars.
• Lies to obtain goods/favors or avoid obligations ("cons" others).
• Steals items of nontrivial value without confronting the victim (e.g., shoplifting).

4. Serious Violations of Rules

• Stays out at night despite parental prohibitions (beginning before age 13).
• Has run away from home overnight at least twice.
• Is often truant from school (beginning before age 13).

Subtypes

• Childhood-Onset Type: Onset of at least one symptom prior to age 10 years. Predominantly male, frequently aggressive, high risk for persistent criminality.
• Adolescent-Onset Type: No symptoms prior to age 10 years. More equal gender ratio, often less aggressive, better prognosis.
• Specifier: "With limited prosocial emotions" (callous-unemotional traits) indicates a lack of remorse, guilt, or empathy.

Evaluation

• Multi-informant clinical interviews involving the child, parents, and teachers.
• Standardized behavioral rating scales (e.g., Child Behavior Checklist).
• Comprehensive assessment for learning disabilities, ADHD, and substance use.

Management

• First-Line Psychosocial Interventions:
  • Parent Management Training (PMT) to improve discipline and positive reinforcement.
  • Multisystemic Therapy (MST) addressing family, school, and peer networks.
  • Cognitive Behavioral Therapy (CBT) focusing on anger management and problem-solving skills.
• Pharmacotherapy:
  • No FDA-approved medications specifically for CD.
  • Primary role is treating comorbidities (e.g., stimulants for ADHD).
  • Atypical antipsychotics (e.g., Risperidone) may be used off-label as adjuncts for severe, refractory, and dangerous aggression.

Prognosis

• High risk for school dropout, legal issues, and substance use disorders.
• The childhood-onset type carries a high likelihood of evolving into Antisocial Personality Disorder in adulthood.