Conduct disorder is a common childhood psychiatric problem that has an increased incidence in adolescence. The primary diagnostic features of conduct disorder include aggression, theft, vandalism, violations of rules and/or lying. For a diagnosis, these behaviors must occur for at least a six-month period. Conduct disorder has a multifactorial etiology that includes biologic, psychosocial and familial factors. The differential diagnosis of conduct disorder includes oppositional defiant disorder, attention-deficit/hyperactivity disorder (ADHD), mood disorder and intermittent explosive disorder.

Etiology

The etiology of conduct disorder involves an interaction of genetic/constitutional, familial and social factors. Children who have conduct disorder may inherit decreased baseline autonomic nervous system activity, requiring greater stimulation to achieve optimal arousal. This hereditary factor may account for the high level of sensation-seeking activity associated with conduct disorder.  Current research focuses on defining neurotransmitters that play a role in aggression, with serotonin most strongly implicated.

Parental substance abuse, psychiatric illness, marital conflict, and child abuse and neglect all increase the risk of conduct disorder. Exposure to the antisocial behavior of a caregiver is a particularly important risk factor. Children with conduct disorder, while present in all economic levels, appear to be overrepresented in lower socioeconomic groups.  Another common feature appears to be inconsistent parental availability and discipline.  As a result, children with conduct disorder do not experience a consistent relationship between their behavior and its consequences.

Clinical Features of Conduct Disorder

Four types of symptoms of conduct disorder are recognized:

(1) Aggression or serious threats of harm to people or animals;

(2) Deliberate property damage or destruction (e.g., fire setting, vandalism);

(3) Repeated violation of household or school rules, laws, or both; and

(4) Persistent lying to avoid consequences or to obtain tangible goods or privileges

Subtypes of Conduct Disorder

Conduct disorder has two subtypes: childhood onset and adolescent onset. Childhood conduct disorder, left untreated, has a poorer prognosis. Behaviors that are typical of childhood conduct disorder include aggression, property destruction (deliberately breaking things, setting fires) and poor peer relationships. In about 40 percent of cases, childhood onset conduct disorder develops into adult antisocial personality disorder. Adolescent conduct disorder should be considered in social context. Adolescents exhibiting conduct disorder behavior as a part of gang culture or to meet basic survival needs (e.g., stealing food) are often less psychologically disturbed than those with early childhood histories of behavior disorders. Additionally, new-onset conduct disorder behavior, such as skipping school, shoplifting or running away, in the context of a family stressor, often remits if appropriate structure and support are provided.

Intervention

Family physicians are often the first professionals who are consulted by families of children with conduct disorder. During these visits, physicians should emphasize the seriousness of the patient’s behavior and the possibility of a poor long-term prognosis if there is no significant parental intervention. Parents of children with conduct disorder are more likely to exhibit depression, substance abuse and/or antisocial personality traits. These parental disorders influence children’s behavior problems associated with inconsistency, harsh discipline, impaired attachment and minimal supervision. While parents of children with conduct disorder often have legal and social difficulties of their own, they usually do not want their children to have a similar life course.

Practical Interventions for Management of Patients with Conduct Disorder

• Assess severity and refer for treatment with a subspecialist as needed.
• Treat co morbid substance abuse first.
• Describe the likely long-term prognosis without intervention to caregiver.
• Structure children’s activities and implement consistent behavior guidelines.
• Emphasize parental monitoring of children’s activities (where they are, who they are with). Encourage the enforcement of curfews.
• Encourage children’s involvement in structured and supervised peer activities (e. organized sports, Scouting).
• Discuss and demonstrate clear and specific parental communication techniques.
• Help caregivers establish appropriate rewards for desirable behavior.
• Help establish realistic, clearly communicated consequences for noncompliance.
• Help establish daily routine of child-directed play activity with parent(s).
• Consider pharmacotherapy for children who are highly aggressive or impulsive, or both, or those with mood disorder