Conduct Disorder

Key Takeaways

• Conduct disorder (CD) is a behavioral health diagnosis identified by persistent, ongoing behaviors of an aggressive or disrespectful nature.

• Without treatment, conduct disorder can have far-reaching effects. This condition is known to negatively impact a person’s occupational, social, and academic functioning.

• Children with conduct disorder typically undergo family therapy and behavior modification, whereas adults with this condition may benefit from Cognitive Behavioral Therapy (CBT) and medication management.

Understanding Conduct Disorder

Conduct disorder is a behavioral health condition that typically evolves during childhood or adolescence. Individuals with this condition are known to continually violate laws and setting-specific rules, disregard social norms, and ignore personal boundaries in a way that is inappropriate for their age. Conduct disorder also involves the demonstration of aggressive, harmful, and turbulent behaviors, which is why the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) categorizes it as a disruptive behavior disorder. The exact presentation of someone with conduct disorder will vary based on the severity of the condition and the exact symptoms they are living with.

How common is it?

Most sources place the lifetime prevalence rate of conduct disorder somewhere between 2% and 10%.^[1] This means between 2% and 10% of the population will develop this condition at some point during their life. The most recently recorded worldwide prevalence of conduct disorder is at the lower end of this range, at 2.5%.^[2] Conduct disorder is known to affect around 3% of all school-aged children.^[3] There are no major patterns noted across various ethnic or racial groups. Conduct disorder is twice as common in males as in females.

Symptoms of Conduct Disorder

Individuals living with this condition are likely to display a range of conduct disorder symptoms. These symptoms will fall under four categories: manipulative behaviors or lying; violations of another individual’s rights; physical aggression or violence; and errant behaviors. Specific behaviors include:

• Committing arson.

• Cheating.

• Lying to others.

• Stealing.

• Vandalizing property.

• Trespassing on others’ property.

• Breaking curfew.

• Running away from home.

• Skipping school.

• Bullying or otherwise threatening their peers.

• Being physically aggressive or cruel to animals or people.

• Being emotionally abusive to people.

Conduct disorder in children may cause aggression in the form of biting, hitting, pushing, and kicking others. During adolescence and the teenage years, this aggression shifts to harming animals, physically fighting with others, habitually lying, bullying peers, stealing, destroying property, and committing arson.^[1]

It is important to note that some of the more minor signs above (such as lying or breaking curfew) are not an indication of conduct disorder or other behavioral health concerns on their own. If children or adolescents engage in just one or two of these symptoms, there is the potential for those acts to simply be age-appropriate rebellion.

What sets conduct disorder apart from simply being troublesome is the nature in which these acts are carried out. Since conduct disorder involves coldness and disregard toward the needs and rights of other individuals, someone with this condition who engages in the above behaviors will not do so accidentally.^[5] It is common for individuals with conduct disorder to find pleasure in behaviors that involve deceiving, manipulating, and aggressing against others. Apart from these instances of enjoyment, individuals with conduct disorder struggle to express normal emotions such as remorse for their actions and empathy for others.

In some cases, conduct disorder symptoms may stem from an inability to properly read other people or adhere to social norms. For example, someone with conduct disorder may misread another person’s actions as being aggressive. This might lead them to respond aggressively, even though violence is frowned upon in most societies.

Severity of conduct disorder symptoms

In order to be classified as conduct disorder, someone must engage in these behaviors frequently and on an ongoing basis, so much so that these actions become a pattern for the individual. The severity of these behaviors must also be taken into account and can be determined based on how much difficulty a person with the condition has.^[5] For a teenager with conduct disorder, lying may not take the form of simple fibs to get them out of trouble with their parents. Rather, these individuals may lie to law enforcement officers to avoid being arrested.

Conduct disorder in children

As we mentioned earlier, professionals and families may have more difficulty identifying conduct disorder in children, as the condition can initially appear similar to rebellious behaviors. Conduct disorder symptoms can emerge as young as 3 years old, though it is more common for a child to be diagnosed with conduct disorder between 8 and 16 years of age.^[4]

During childhood, it is common for those with conduct disorder to also be diagnosed with Attention-Deficit/Hyperactivity Disorder (ADHD). It is estimated that 16 to 20% of children who have conduct disorder are also living with ADHD.^[6] This can further complicate a child’s clinical presentation as well as the treatment process for conduct disorder. However, treatment is essential for the health and safety of children with this condition. Research shows that children with conduct disorder are three times as likely to experience premature death.^[2] This can likely be attributed to their engagement in reckless and risky behaviors.

Causes

As with many mental health concerns, conduct disorder develops from both genetic and environmental factors. However, research indicates that genetics plays less of a role in the development of conduct disorder in females and more of a role in males.^[7]

Studies show that smaller amounts of grey matter in the insula, amygdala, and orbitofrontal cortex can all disrupt emotion processing, which can lead to aggressive behaviors.^[3] There is also a link between aggression and neurological injuries, such as seizures and traumatic brain injuries, early in life.^[1] These injuries can lead to impaired judgment, executive functioning (such as planning and organization), verbal expression, and difficulty responding to a crisis, all of which are common with conduct disorder.

Risk Factors

Some of the following risk factors increase the likelihood of someone developing conduct disorder:

• A history of being abused, neglected, or bullied, or being exposed to these situations.

• Living with other psychiatric conditions.

• A difficult temperament.

• Having parents with substance use disorder, bipolar disorder, schizophrenia, depression, or ADHD.

• Lacking proper nutrition.

• Difficulty learning proper social skills.

• Having a low socioeconomic status.

• Being raised with parents who don’t reward good behavior, are overly critical, or are too flexible.

• Spending time with peers who also have behavioral concerns.

Complications

Without treatment, conduct disorder stands to negatively affect many areas of someone’s life. The exact complications of this condition depend on the person’s age. Conduct disorder in children can lead to difficulty performing academically, socializing with peers, and abstaining from substances. Adults with this condition may experience social isolation due to unstable relationships, have difficulty holding a job, frequently get evicted from housing complexes, get arrested multiple times, and consume substances frequently.

Diagnosing Conduct Disorder

To receive a diagnosis of conduct disorder, someone must receive a thorough evaluation from a qualified mental health professional. This professional will first rule out comorbid conditions (such as ADHD and depression) as the source of difficult behaviors. A thorough assessment will cover all relevant contexts where someone interacts with others. For adults, this can include community, work, and social settings. Conduct disorder in children requires assessment of the home, school, community, and social settings.

Professionals should be sure to receive information from caregivers, teachers, coaches, and other relevant parties when assessing a child for conduct disorder. The evaluation should also delve into potential learning difficulties that may be present as a result of or alongside conduct disorder. For children, family dynamics and their relationship to habitual behaviors will also play a large part in exploring this mental health diagnosis.

According to the DSM, there are several types of conduct disorder someone may be diagnosed with. These subtypes are assigned based on when the condition first developed:

• Childhood-Onset Type: This subtype is diagnosed when conduct disorder symptoms arise before the age of 10. Individuals with this form usually have poorer long-term outcomes and more physical aggression than others with the condition.

• Adolescent-Onset Type: This type is diagnosed during adolescence (between 10 and 19 years old). Individuals whose conduct disorder develops in adolescence are known to have lower levels of aggression along with a better prognosis.

• Unspecified-Onset Type: Unspecified-onset type is intended for individuals who meet all the criteria for conduct disorder, but it is unknown when the condition first began.

Treatment Options

The most effective methods are multimodal in nature, meaning they combine various pharmacological and psychotherapy approaches.

In terms of medication, mental health professionals may recommend mood stabilizers and second-generation antipsychotics for conduct disorder symptoms. The latter of these two has proven especially effective for individuals with conduct disorder and ADHD.^[3] Pharmacological treatment for comorbid conditions is also necessary. Recommendations may include stimulants for ADHD, antidepressants for mood disorders, and mood stabilizers for bipolar disorder or unspecified aggression.^[1]

Psychotherapy may utilize approaches such as Cognitive Behavioral Therapy (CBT) to address anger management, problem-solving skills, assertiveness, and interpersonal effectiveness. For children with the condition, inclusion of family members, connections to community resources, and the provision of community-based treatment are all associated with improved outcomes.^[1] By including family members, mental health professionals can offer parent management training to mitigate difficult behaviors.

Living with Conduct Disorder

While conduct disorder does not go away, it is possible to live a happy life with this condition. Early diagnosis (and subsequent treatment) is important to experience positive outcomes in academic, employment, and social settings. Resources such as community-based treatment, parent management training, and family therapy can be very effective for children with conduct disorder. Adults with the condition benefit more from peer group therapy, CBT, and interpersonal therapy to strengthen their relationships. In order to start the diagnostic process, contact a qualified mental health professional with experience in treating conduct disorder and other disruptive behavior disorders.