Conduct Disorder is a pervasive childhood and adolescent disorder characterized by violating the rights of others and disregard for developmentally appropriate societal norms. The disorder has three sub-types based upon age of onset: childhood-onset type, adolescent-onset type and unspecified onset-type. There is also a diagnostic specifier of “limited prosocial emotions” given to those displaying unemotionality and callousness.
Diagnosis of or evidence of Conduct Disorder is a necessary precursor for diagnosis of antisocial personality disorder in adulthood.1
What Is Conduct Disorder?
Conduct disorder is classified with other disruptive behavioral disorders and is conceptualized into four categories: aggression, property destruction, deceitfulness and violation of rules. The disorder is diagnosed using criteria from the fifth edition of the Diagnostics and Statistical Manual (DSM-5). There are no age limitations on receiving a conduct disorder diagnosis.
However, conduct disorder is rarely diagnosed after the age of 16 and typically when similar symptoms present over the age of 18, it is diagnosed as antisocial personality disorder. If criteria for a personality disorder in teens or children are met, conduct disorder is no longer the appropriate diagnosis.
To meet criteria a person must present with at least three of the following criteria over the past 12 months and it must cause significant impairment to the person’s functioning:1,2
Aggression to people and animals:
- Bullying, threatening, intimidating others
- Starting physical fights
- Use of weapon that can cause physical harm
- Physically cruel to people
- Physically cruel to animals
- Stealing property while confronting victim
- Forcing someone into sexual activity
Property destruction:
- Engaged in fire setting with intent to cause damage
- Property destruction other than fire setting
Deceitfulness or theft:
- Has broken into someone else’s house, building or car
- Lies to gain favors, obtain goods or to avoid obligations
- Has stolen trivial items without confronting victim such as shoplifting
Serious Violations of Rules:
- Staying out at night despite rules prohibiting such behavior beginning before 13 years old.
- Running away from home at least twice or once for long period of time
- Truancy from school, beginning before the age of 131
Signs of Conduct Disorder: What It Looks Like
A child or teen with conduct disorder will exhibit troubling behaviors that draw negative attention from family members, school authorities, and law enforcement. They will constantly be in trouble at home, school and in most aspects of their life. Often, they will bully and initiate fights, display hostility and aggression towards others. They will frequently manipulate people for personal gain, and they will exhibit cunning and deceitful behaviors; they will likely not understand right and wrong and may have difficulty feeling remorse.
These maladaptive behaviors extend well beyond developmentally appropriate rebellion and often cause the child or teen to drop out of school, become incarcerated, get seriously injured and even socially shunned by peers and authority figures.2,3 Adults and seniors with conduct disorder will likely be diagnosed with antisocial personality disorder. Rarely does conduct disorder develop after the age of 16 and to be diagnosed with antisocial personality disorder, there must be evidence of conduct disorder in childhood.
Typically, antisocial personality disorder is viewed as a progression of conduct disorder or a precursor to antisocial personality disorder into adulthood, particularly when the behavioral issues continue or worsen. However, if an adult meets criteria for Conduct Disorder and not antisocial personality disorder they may be diagnosed with conduct disorder or carry on their conduct disorder diagnosis from childhood.
Adults with conduct disorder typically have an increased risk of incarceration and are more likely to commit violent crimes. As stated earlier due to the rarity of this, most people consider conduct disorder a childhood/adolescent disorder.2,3
Symptoms of Conduct Disorder
Symptoms of conduct disorder vary depending on severity of presentation and age of the child or teen. Common subjective symptoms of conduct disorder are anger, rage, low self-esteem, irritability, and difficulty feeling remorse.
Symptoms of conduct disorder that draw attention to the child or teen are:
- Tantrums, losing composure easily
- Hostility and aggression towards others including animals
- Pathological lying
- Truancy
- Stealing
- Sexual abuse/assault
- Destroying property
- Setting fires
- Substance abuse1,2
Causes of Conduct Disorder
Conduct disorder is caused by a combination of biological and environmental factors that differs among individuals; there is no identified singular causation of conduct disorder. Authoritarian or high-discipline, low-affection parenting style and permissive parenting, which are low on discipline and low on child engagement, have been shown to be correlated with an increased risk of conduct disorder development. Traumatic experiences and generational trauma are also commonly identified correlates in the development of conduct disorder.
Other common risk factors for developing conduct disorder include:
- Male gender
- Parents that abuse drugs and alcohol
- Brain injury, impaired frontal lobe, neurological abnormality
- Co-occurring substance abuse and mental illness
- Genetic connection such as having family members with mental illness
- Dysfunctional family life
- Childhood abuse and neglect
- Poverty
- Not being accepted by peer groups, social rejection
- Cognitive processing issues
- Difficulty with moral awareness
- Low empathy, callousness
- Traumatic events
- Exposure to gang activity
- Large classroom sizes, unsupportive school staff and environment
- Authoritarian or permissive parenting styles1,3
How Is Conduct Disorder Diagnosed?
Conduct disorder is diagnosed by a mental health care professional or medical provider. A child or teen will likely be referred for evaluation to seek remedy for their problematic behavior, often by schools, medical providers or if the youth have involvement in the criminal justice system by lawyers or judges. A trained mental health professional will use DSM-5 criteria with a structured or semi-structured clinical interview to assess the child or teen.
They may also want to observe the child in their natural environment such as at school or home. Interviewing of parents, family members, teachers may also help determine proper diagnosis and help identify contributing factors to the maladaptive behavior. They will also look at behavior across different settings and contexts to look for variations in behavior.
For instance, if the child is relatively well behaved at school but disruptive at home, this could be indicative of parental or environmental issues at home that are exacerbating the youth’s behavior. Conversely, if the child’s behavior is consistent in most contexts and has been present for most of their life, this could indicate more severe and persistent causes of disorder such as personality, temperament or biological origins.8
Treatment of Conduct Disorder
Common treatment modalities for conduct disorder are cognitive behavioral therapy (CBT), parent management training (PMT), individual therapy, family therapy, and social skills training. School based treatment programs including residential treatment may work on academic performance and improve self-esteem. Ongoing medical, emotional, education and social supports are required for many years with severe forms of Conduct Disorder in order to help them become productive adults. A parent or guardian should expect long-term treatment to successfully reduce Conduct Disorder signs and symptoms.
The cost of conduct disorder treatment varies depending on health insurance coverage, form of treatment and access to providers and resources. Inpatient treatment is significantly more costly than outpatient treatment, however if symptoms are severe it may be the best indicated treatment modality.
If the youth is incarcerated, there may be group and individual therapy treatments included as part of the rehabilitation process, often targeting interpersonal skills training, emotion regulation and substance abuse treatment. Common treatment modalities for incarcerated youth reintegrating back to home or youth at risk are: multisystemic therapy (MST), multidimensional family therapy (MDFT), and functional family therapy (FFT). These interventions have shown to be effective in reducing delinquency and substance abuse in juveniles. Therapies that target interpersonal skills training
There is currently no Food and Drug Administration (FDA)-approved medication for conduct disorder, however treating with medication any co-occurring disorders such as mood disorders, ADHD are common practice. Without treatment, escalations of violent and aggressive behaviors are probable. Risk of the developing of antisocial personality disorder, psychopathy and being incarcerated is also more likely in youth diagnosed with conduct disorder.1,9,10,11
How to Get Help for Conduct Disorder
Positive parenting styles, generally defined as those that are supportive, affectionate, promote growth and resilience and communication of clear expectations with regards to behavior and consequences or discipline when not. This high affection, high structure may help reduce the chances a child with certain risk factors will go on to develop conduct disorder.
Permissive parenting styles which are characterized by little to no authority or discipline over their children, leading them to not regulate or change bad behaviors, are positively correlated with an increase in conduct disorders in boys but not in girls. Authoritarian parenting styles which are indicative of low affection and high discipline are also correlated to the development of conduct disorder.5,6,7
- Obtain formal diagnoses, medical treatment, psychiatric treatment
- Rule out learning disorders and developmental delays
- Rule out neurological causes
- Foster healthy relationships, particularly with peer groups
- Improve communication skills, learn to add praise and minimize negative messaging
- Model empathy, encourage volunteering
- Self-care for entire family
- Educate yourself on the disorder9
Helping Your Child Cope With Conduct Disorder
Supporting your child or teen with conduct disorder can be challenging and exhausting, however there are strategies that can help improve daily life for the child and family members and improve long-term positive outcomes.
The following tactics are useful in helping your child cope with conduct disorder:
Praise Your Child
When they do something positive, praise your child, be specific and genuine. Telling your child something as simple as, “Thank you for making your bed today,” reinforces positive behavior and lets them know you are paying attention to their efforts in improving.
Set Boundaries
Once boundaries are set, stick to them. Be clear and consistent with rules in your home, avoid power struggles.
Assign Chores
Give responsibilities to your child. This will help your child feel responsible and develop a sense of agency within them.
Set a Good Example
Model the behaviors you want to see in your child. Interacting effectively with people and behaving in a pro-social way models the kind of behavior you want to see in your child or youth. Modeling is a powerful form of learning, especially in the youth’s formative years.
Establish Routine
Creating a consistent schedule for your child or teen will help foster stability and structure in the household and in their daily life.
Make Time for Your Child
Spend meaningful time together. Engage your child in conversations. Listen to your child and engage in activities with them. Show them that they matter!
Communicate
Get everyone in the family on the same page. As restructuring of the household may occur, get everyone in the family to participate so as to avoid reverting back to prior ineffective family dynamics and behaviors.
Be Patient
The process of change won’t happen overnight. Your child and even other family members may resist the idea of change and it may take time. Think of this process as a marathon and not a sprint. Also, remember to practice self-care and check in with your support system when difficulties and stressors arise.9,12
What Is the Long-Term Outlook for a Child with Conduct Disorder?
Conduct disorder in children predicts an increased rate of psychiatric disorders throughout the lifespan. Certain disorders combined with conduct disorder can produce more complex and severe clinical presentations of conduct disorder. Substance abuse disorders, schizophrenia, and bipolar related disorders have been identified as more likely to predict future antisocial personality disorder, criminality, and early death. In males, conduct disorder is more predictive of externalizing disorders such as substance abuse disorders, impulse control disorders and criminality.
Conduct disorder in females has been shown to be more predictive of internalizing disorders such as depression, social withdrawal, anxiety, and low self-esteem.It also often predicts poor educational and vocational performance. The importance of early identification and treatment of conduct disorder in conjunction with protective factors such as positive role models, affectionate parents and ability to regulate emotions are important in predicting better long-term outcomes for youth diagnosed.4,17,19
Conduct Disorder Statistics
Consider the following statistics about conduct disorder:
- The United States prevalence rates of conduct disorder have been found to be 2% to 10% according to the DSM-5, whereas other studies have shown rates as high as 16%.
- Conduct disorder is more common in males than females
- Prevalence rates for males vary from 6% to 16%
- Prevalence rates for females vary from 2% to 9%
- It is estimated that 40%of youth with conduct disorder go on to develop a personality disorder
- It is estimated that 25% of children diagnosed with ADHD will also have conduct disorder and 45% of adolescents will be diagnosed with both disorders.1,10
Conduct Disorder vs Other Disorders
Conduct disorder is commonly found in combination with other disruptive disorders such as oppositional defiance disorder (ODD), intermittent explosive disorder (IED) and attention deficit hyperactivity disorder (ADHD). These disorders should be considered during differential diagnosis of a youth. Some people view ODD and conduct disorder as separate disorders while others view them on a spectrum with Conduct Disorder being a more severe form of same psychopathology.
Post-traumatic stress disorder, substance abuse disorder and anxiety disorders are also commonly found with conduct disorder. For mood disorders such as depression and bipolar disorder, the symptoms of aggression and impulsivity that are seen in conduct disorder can be present even when the mood disorder is not active. There needs to be consistency in the presentation of conduct disorder to help distinguish it from the features of other disorders for proper diagnosis.1,14
Conduct Disorder vs ADHD
It is estimated that 25% of children diagnosed with ADHD will also have conduct disorder, and a surprising 45% of teens will be diagnosed with both disorders. Research also suggests that there may be a common pathological spectrum associated with ADHD, conduct disorder and oppositional defiant disorder (ODD) as they are commonly comorbid, share similar symptoms and developmental pathways. Youth with both conduct disorder and ADHD diagnoses show less successful treatment outcomes.1,10,11
Conduct Disorder vs Oppositional Defiant Disorder
While conduct disorder is characterized by aggression to people, animals, theft and destruction of property, ODD is diagnosed by exhibiting at least four symptoms of the following DSM-5 criteria and having it functionally impair social interactions, education or occupational goals:
Angry and irritable mood:
- Losing one’s temper frequently
- Easily annoyed
- Feeling resentful and angry.
Argumentative/defiant behavior:
- Arguing with people
- Defying rules
- Annoying people deliberately,
- Blaming others for mistakes and
Vindictiveness:
- Spiteful and vindictive behavior
ODD in combination with conduct disorder predicts worse outcomes for youth.1,14
Reactive Attachment Disorder (RAD) & Conduct Disorder
Children with reactive attachment disorder (RAD) display strong unemotional and callousness, traits commonly associated with conduct disorder. RAD and conduct disorder are commonly comorbid disorders among behavioral and trauma-related disorders.15,16
Conduct Disorder & Substance Abuse Disorders
Conduct disorder diagnosis increases risk for substance abuse disorders, research has found no significant differences between genders in risk of developing substance abuse disorders.1,17
Conduct Disorder Tests, Quizzes, & Self-Assessment Tools
Each mental health provider may utilize different screening and assessment tools and will approach the clinical interview in varying ways; however certain methodologies and practices have more research validity and reliability.
To assess for conduct disorder, it is common to utilize the Kiddie Schedule for Affective Disorders and Schizophrenia (KSADS) semi-structured clinical interview. This tool helps assess for commonly comorbid disorders and is often praised for its flexibility of structure and applicability. The Delinquent Activities Scale (DAS) is also a tool used to measure severity of conduct disorder and is commonly used in forensic settings to determine risk level.
The Childhood Behavior Checklist is also frequently given to parents/guardians of children to assess for emotional and behavioral issues. It is self-administered by computer or by paper, and is often provided by medical or mental health providers. It is also accessible for purchase at the Achenback System of Empirically Based Assessment (ASEBA). A single time use purchase is currently $295.8,17
Assessments are to be conducted by trained mental health professionals such as therapists, forensic evaluators, psychologists, and psychiatrists. It is preferable that the mental health professional specializes in children’s disorders or behavioral and impulse-control disorders. The clinical considerations when assessing for conduct disorder are: client deceitfulness, reliability of parents/guardians and teachers, diagnostic comorbidities, issues with counseling counter-transference and relevant cultural considerations.1,8
For non-professional, self-administered screening, The Parent Test is a questionnaire at Mental Health America website that measures a youth’s behaviors to see if further professional evaluation may be warranted. When in doubt, always consult a mental health professional; it can often be confusing as a parent or guardian to know just what is normal developmentally and what is not. Visit the Mental Health America website for more information.
For Further Reading
The following are helpful resources for anyone impacted by Conduct Disorder:
