Conduct Disorder

Conduct disorder (CD) refers to a broad spectrum of potentially enduring behaviors that violate social norms. The behaviors and symptoms of CD vary, with diagnostic criteria clustered into one of four broad categories: (a) aggressive behavior; (b) nonaggressive misbehavior; (c) deceitfulness or theft; and (d) a serious infraction of established rules.

Aggressive conduct is that which threatens or causes physical harm to people or animals and typically involves acts such as initiating fights, bullying, intimidating, overt aggression, and physical cruelty. Nonaggressive conduct is characterized by vandalism or intentional destruction of property. Common manifestations of deceitfulness include stealing, persistent lying, and fraudulent behavior. Lastly, rule violation entails deeds that defy or circumvent social convention. The severity of observed behaviors is rated as mild, moderate, or severe, depending upon the number and seriousness of acts committed and the extent to which others are harmed.

Reported rates of the disorder have increased over several decades, with 6 to 16 percent of males and 2 to 9 percent of females under the age of 18 fulfilling diagnostic criteria (American Psychiatric Association 1994). These results are generally consistent across cultures. Epidemiological data indicate that the prevalence rates for CD are generally greater for males than females. However, some researchers are concerned that the current diagnostic protocol overemphasizes behaviors that are more typical of male than female problem behavior.

To receive a diagnosis of CD, three or more behaviors in any of the four categories must occur within the last twelve months, with at least one of these behaviors persisting during the previous six months. Noncompliance with adults (parents, teachers, or both) typically marks the beginning of a behavior pattern that often culminates in the youth engaging in acts consistent with CD. In general, the early onset of problem behavior in multiple settings and variability of observed problem behavior are associated with more serious psychosocial disruption, escalation to more serious problem behaviors in adolescence (Loeber and Dishion 1983), and ultimately, continuity of adjustment problems into adulthood (e.g., antisocial personality disorder, chronic offending, substance use, marital problems, employment difficulties).

Children and adolescents diagnosed with CD also tend to suffer from elevated rates of hyperactivity and emotional difficulties. Many individuals with behavior problems experience clinical levels of attention deficit hyperactivity disorder (ADHD), depression, and anxiety. Research suggests that youth with both ADHD and CD experience high levels of peer rejection, academic problems, psychosocial hardship, conflict with parents, and parental psychopathology (see Angold and Costello 2001, for a review). The prognosis for persons with both ADHD and behavioral maladjustment also tends to be worse than for those with either diagnosis alone. Combined with depression, CD is generally a marker for more severe psychosocial disruption and heightens the risk for suicide and other adjustment problems in young adulthood. Children with CD often do not simply outgrow their problem behavior (Robins 1966).

A Model of Conduct Problems

Given the magnitude and breadth of difficulties experienced by children fitting the CD diagnosis, coupled with the costs of adolescent problem behavior to families, community, and society, there have been hundreds of studies of CD. Findings from carefully controlled intervention research combined with those of longitudinal investigations provide the best evidence of causality and offer suggestions regarding promising intervention strategies. Figure 1 summarizes a model that synthesizes the results of a several longitudinal and intervention studies.

A crucial issue that emerges from research on child and adolescent socialization is that the development of a behavioral repertoire is determined by a variety of interrelated factors. Multidirectional transactions between child genes, family environment, and the broader social and cultural ecology create a history of experience through which anti-social behavior is successively manifested and reinforced. Figure 1 illustrates this complexity, with bold arrows indicating effects demonstrated in both longitudinal and experimental intervention research.

Biological Factors

Certain neuropsychological indicators (influences in the brain that are linked to psychological functioning) are linked with aggression. Aggression and impulsiveness are associated with structural abnormalities related to thought processing and inhibition of behavior. Deficits in certain neurochemicals, including serotonin and norepinephrine, are also linked to behavior problems. Reductions in the functioning of the autonomic nervous system, which is responsible for the regulation of bodily processes, is also linked to chronic conduct problems. In particular, low-resting heart rate and low-skin conductance are frequently present in individuals with persistent behavior problems. These deficits and resultant reductions in behavioral inhibition are characteristic of both CD and ADHD.

Contemporary theories accentuate a dynamic interplay between biological and environmental factors and propose that most of the effects of a person's biological constitution on CD are mediated through disrupted parenting and peer environments (Deater-Deckard and Bullock, in press). There is some evidence that child-onset CD, characterized by antisocial behavior and hyperactivity, may have stronger biological underpinnings than later-onset CD. Exploration of reciprocal transactions between genes and the environment suggests that children may evoke reactions from parents and others that contribute to antisocial behavior (Rutter et al. 1997).

Individual differences in infant temperament are also directly implicated in behavioral development, with mothers' ratings of children's difficult and hyperpersistent temperament at six months predicting later teacher ratings of conduct difficulties. Studies of adoptees at genetic risk for conduct problems also indicate that genetically compromised children are more likely to experience harsh, negative parenting in their adoptive families, compared to children without a liability for problem behavior (Ge et al. 1996).

Some theorists propose that individuals actively select environments and relationships consistent with their genetic disposition (Scarr and McCartney 1983), with antisocial youth selecting peers who reinforce deviance. Although little research focuses on the biological characteristics that contribute to the influence of deviant peers in early adolescence, the ability of individuals to regulate their behavior and emotions seems to be a promising candidate. Many other biologically oriented constructs have been proposed, but none have clarified whether such constructs are causally unique or simply by-products of being raised in a harsh family environment from an early age.

Family Management

Parenting behavior is also mediated by genetic influence. Individuals prone to aggression, impulsiveness, and antisocial acts are more inclined to create harmful rearing environments characterized by harsh parenting, hostile relationships, and little supervision. Inconsistent harsh discipline, insufficient monitoring, coercive parenting, and child abuse and neglect have long been associated with child-conduct problems and adult criminal behavior.

Parental behaviors directed to one or more siblings may further contribute to the development of deviance. A recent investigation of differential parenting and adjustment revealed that parent-directed behaviors toward each sibling were strongly correlated with individual levels of adolescent problem behavior. Youths with a negatively treated sibling had better outcomes, suggesting that harsh behavior directed toward a fellow sibling may serve a protective function (O'Connor, Hetherington, and Reiss 1998). These findings suggest that children's interpretation of the dynamics of their rearing environment influences the manner in which they respond to future parent attempts to socialize.

Parent behavior may vary greatly for individuals of different ethnic or cultural backgrounds. Physical discipline is known to exert a differential impact on outcomes for European-American children in contrast to their African-American counterparts (Deater-Deckard et al. 1996). A recent report suggests that physical discipline is associated with higher scores of conduct problems only among European-American children. It is hypothesized that physical discipline may be perceived as being more normative and less destructive or deviant by African-American children. Thus, the effectiveness of particular parenting techniques may be mediated by cultural factors and universal statements regarding parenting behavior are ill advised.

Peer Deviance

As development progresses, children become more involved in choosing and shaping their environments. In particular, adolescents are more active in shaping the constituency of their peer environment, and unfortunately may select settings with greater prevalence of problem behavior and substance use. Parent involvement and monitoring of adolescent activities can be an important counteractive force in the drift to deviant peers.

Evidence is compelling that the peer group can cause escalations in drug use, delinquency, and violent behavior in adolescence (Dishion, Spracklen, and Andrews 1996). Problem behavior becomes a mechanism for making friends and eventually in selecting relationship partners with similar values. When peers encourage deviance, youngsters may become especially difficult to monitor and display more resistance to parenting efforts.

Contextual Influences

An ecological framework for understanding development promotes research linking contextual influences with basic socialization processes in the emergence of competence and dysfunction (Bronfenbrenner 1989). Child relationships with teachers and other school officials, as well as influences that arise from factors including poverty and social disadvantage, all interact to create an intricate developmental tapestry that potentially supports maladaptive behavior.

Contextual conditions that can affect the development of antisocial behavior include divorce, marital transitions, poverty, and unemployment. Consistent with an ecological emphasis, it seems that these factors influence CD by disrupting family and peer environments. In a classic study, Glen Elder, Tri Van Nguyen, and Avshalom Caspi (1985) showed that poverty associated with the Great Depression disrupted parent-child interactions and was a factor in behavior problems in children.

For some children, the climate at school is reminiscent of their own family context in that relationships with teachers and peers can be experienced as conflictual, coercive, and embedded in spirals of negative interactions. This elevates the likelihood of child disengagement from the learning process. Academic failure is well documented to be strongly linked to aggressive, impulsive, antisocial behavior and criminality. In addition, studies of school environments suggest that classroom aggression may also influence the development of conduct problems. A study of first grade children revealed that individually aggressive boys in highly aggressive classes are at increased risk of being rated aggressive by sixth grade teachers (Kellam et al. 1998), confirming that experiences across multiple domains influence the development of conduct problems.

Cross-Cultural Research

Comprehensive reviews of the literature on the development of antisocial behavior and conduct problems suggest that prevalence and incidence is highest among children and adolescents within the United States (Dishion, French, and Patterson 1995). However, several longitudinal studies have been conducted outside of the United States that are integral to the development of theory, for example, in London (West and Farrington 1977), Finland (Pulkkinen 1996), Norway (Olweus 1979), New Zealand (Fergusson and Horwood 2002), and Sweden (Stattin and Magnusson 1991). Although prevalence rates vary, the major models of etiology, symptom clustering, stability, and longitudinal course over the lifetime show a high level of convergence across international contexts.

Implications for Treatment

The pioneering work of Gerald Patterson, Rex Forehand, and Bob Wahler brought family management to the fore as a critical component of systematic parent-training programs. These programs often produced observable changes in parenting strategies, which, in turn, positively affected child behavior. Interventions that improve school organization and support teachers' proactive behavior management also show promise in preventing antisocial behaviors at school, which are highly relevant to CD.

In general, interventions that encourage adults to manage the family context, promote prosocial classroom norms, and foster proactive supervision of school behavior generate reductions in antisocial behavior. Reviewers of the treatment literature on CD concur that interventions emphasizing family management practices are among the most effective strategies to date (Kazdin 1993).

Intervention research also addresses the power of the peer group in contributing to CD. Random assignment studies show that treatments that combine youth into groups lead to escalations in drug use, increased problem behavior at school, and long-term negativity. In one study, assignment of high-risk children to summer camps was associated with a ten-fold increase in risk for thirty-year negative outcomes (Dishion, McCord, and Poulin 1999). Treatment strategies that combine high-risk youth run the risk of exacerbating the problem behavior, with less-supervised intervention groups being more likely to produce iatrogenic or negative effects. This finding is disturbing, given that aggregating high-risk youth into treatment groups is a frequently employed therapeutic approach. Reviews of the literature also indicate that 29 percent of reported outcome analyses yield negative effects for youth with behavior problems (Lipsey 1992). Given that most evaluations of interventions with negative effects are unpublished, this is likely an underestimate of iatrogenic treatment effects, particularly for youth with CD.

Intervention Process

Clearly, professional skills are critical to the success of interventions, especially those that target parenting practices (Patterson 1985). Parents and other adults can develop negative attributions and expectations toward children with CD. Those issues must be sensitively addressed before interventions can move forward. Therapist skills in supporting and validating negative parenting experiences, while simultaneously encouraging proactive behavior management strategies, are especially important.

An exemplary parenting intervention designed to address conduct issues in young children utilizes videotaped modeling and collaborative group process to encourage change in parenting (Webster-Stratton 1990). For adolescents with more serious CD symptoms, Scott Henggeler and colleagues (1998) conducted parenting interventions in the home, expanding the array of issues addressed to include contextual, peer, and other systemic barriers to change. Thus, youth with extreme CD symptoms that warrant removal from the home may be effectively treated within a family-centered model.

Mark Eddy and Patti Chamberlain (2000) report that training foster parents in proactive behavior management skills and monitoring reduces serious delinquent behavior, compared to invoking group-home interventions. Though conduct problems may appear to be intractable, interventions that engage parents and buttress their efforts to improve family management skills can be effective in mitigating antisocial behavior.

Conclusion

Research regarding the origins of CD suggests that environmental and biological risk factors are primarily mediated through parenting and peer environments. Intervention research confirms the importance of promoting family management, attending to peer dynamics, and addressing self-regulation to reduce problem behavior in youth with CD.

Successful interventions are those that are flexible in delivery, promote a collaborative process with related individuals, and involve proactive behavior management. The prevalence of conduct disorder within a family can profoundly affect individual and collective functioning and initiate a cycle of frustration, negativity, and escalating behavior problems. It is important to engage families in processes that will mitigate the development of CD symptoms and promote positive and sustainable change in both parent and child behavior.

See also:Attention Deficit Hyperactivity Disorder (ADHD); Child Abuse: Physical Abuse and Neglect; Child Abuse: Psychological Maltreatment; Child Abuse: Sexual Abuse; Childhood, Stages of: Adolescence; Children of Alcoholics; Depression: Children and Adolescents; Development: Moral; Developmental Psychopathology; Discipline; Divorce: Effects on Children; Family Diagnosis/DSM-IV; Interparental Conflict—Effects on Children; Interparental Violence—Effects on Children; Juvenile Delinquency; Oppositionality; Parenting Education; Parenting Styles; Peer Influence; Runaway Youths; Spanking; Substance Abuse; Substitute Caregivers; Temperament

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bernadette marie bullock

thomas j. dishion

Conduct disorder

Definition

Conduct disorder is a childhood behavior disorder characterized by aggressive and destructive activities that cause disruptions in the child's natural environments such as home, school, church, or the neighborhood. The overriding feature of conduct disorder is the repetitive and persistent pattern of behaviors that violate societal norms and the rights of other people. It is one of the most prevalent categories of mental health problems of children in the United States, with rates estimated at 9% for males and 2% for females.

Description

The specific behaviors used to produce a diagnosis of conduct disorder fall into four groups: aggressive conduct that causes or threatens physical harm to other people or animals, nonaggressive behavior that causes property loss or damage, deceitfulness or theft, and serious violations of rules. Two subtypes of conduct disorder can be delineated based on the age that symptoms first appear. Childhood-onset type is appropriate for children showing at least one of the behaviors in question before the age of 10. Adolescent onset type is defined by the absence of any conduct disorder criteria before the age of 10. Severity may be described as mild, moderate or severe, depending on the number of problems exhibited and their impact on other people.

Youngsters who show symptoms (most often aggression) before age 10 may also exhibit oppositional behavior and peer relationship problems. When they also show persistent conduct disorder and then develop adult antisocial personality disorder , they should be distinguished from individuals who had no symptoms of conduct disorder before age 10. The childhood type is more highly associated with heightened aggression, male gender, oppositional defiant disorder , and a family history of antisocial behavior.

The individual behaviors that can be observed when conduct disorder is diagnosed may be both common, problematic, and chronic. They tend to occur frequently and are distressingly consistent across time, settings, and families. Not surprisingly, these children function poorly in a variety of places. In fact, the behaviors clustered within the term "conduct disorder" account for a majority of clinical referrals, classroom detentions or other sanctions, being asked to stop participating in numerous activities, and can be extremely difficult (even impossible) for parents to manage.

The negative consequences of conduct disorder, particularly childhood onset, may include illicit drug use, dropping out of school, violent behavior, severe family conflict, and frequent delinquent acts. Such behaviors often result in the child's eventual placement out of the home, in special education and/or the juvenile justice system. There is evidence that the rates of disruptive behavior disorders may be as high as 50% in youth in public sectors of care such as juvenile justice, alcohol and drug services, schools for youths with serious emotional disturbances, child welfare, and mental health.

The financial costs of crime and correction for repeated juvenile offenses by youth with conduct disorder are extensive. The social costs include citizens' fear of such behavior, loss of a sense of safety, and disruptions in classrooms that interfere with other children's opportunity to learn. The costs to the child and his or her family are enormous in terms of the emotional and other resources needed to address the consequences of the constellation of symptoms that define conduct disorder.

Causes and symptoms

There is no known cause for conduct disorder. The frustrating behavior of youngsters with conduct disorder frequently leads to blaming, labeling, and other unproductive activities. Children who are "acting out" do not inspire sympathy or the benefit of the doubt. They are often ostracized by other children. Parents of such children are often blamed as poor disciplinarians or bad parents. As a result, parents of children with conduct disorder may be reluctant to engage with schools or other authorities. At the same time, there is a strong correlation between children diagnosed with conduct disorder and a significant level of family dysfunction, poor parenting practices, an overemphasis on coercion and hostile communication patterns, verbal and physical aggression and a history of maltreatment.

There is a suggestion of an, as yet, unidentified genetic component to what has generally been viewed as a behavioral disorder. One study with adopted children in the mid-1990s looked at the relationship between birth parents with antisocial personality disorder, and adverse adoptive home environments. When these two adverse conditions occurred, there was significantly increased aggressiveness and conduct disorder in the adopted children. That was not the case if there was no indication of antisocial personality disorder in the birth parents. This finding has important implications for prevention and intervention of conduct disorders and its associated conditions of substance abuse and aggressiveness.

Symptoms

The Diagnostic and Statistical Manual of Mental Disorders (also known as the DSM-IV-TR ) indicates that for conduct disorder to be diagnosed, the patient has repeatedly violated rules, age-appropriate social norms and the rights of others for a period of at least twelve months. This is shown by three or more of the following behaviors, with at least one having taken place in the previous six months: aggression to people or animals, property destruction, lying or theft, and serious rule violations.

Aggression to people or animals includes:

• engaging in frequent bullying or threatening
• often starting fights
• using a weapon that could cause serious injury (gun, knife, club, broken glass)
• showing physical cruelty to people
• showing physical cruelty to animals
• engaging in theft with confrontation (armed robbery, extortion, mugging, purse snatching)
• forcing sex upon someone

Property destruction includes:

• deliberately setting fires to cause serious damage
• deliberately destroying the property of others by means other than fire setting

Lying or theft includes:

• breaking into building, car, or house belonging to someone else
• frequently lying or breaking promises for gain or to avoid obligations (called "conning")
• stealing valuables without confrontation (burglary, forgery, shop lifting)

Serious rule violations include:

• beginning before age 13, frequently staying out at night against parents' wishes
• running away from parents overnight twice or more or once if for an extended period
• engaging in frequent truancy beginning before the age of 13

Mild severity would mean there are few problems with conduct beyond those needed to make a diagnosis AND all of the problems cause little harm to other people. Moderate severity means the number and effect of the conduct problems is between the extremes of mild and severe. Severe is indicated if there are many more conduct symptoms than are needed to make the diagnosis (more than three in the previous twelve months or more than one in the previous six months), or, the behaviors cause other people considerable harm.

Diagnosis

Conduct disorder is generally diagnosed when somebody, often a child in school, comes to the attention of authorities (school, law enforcement, and others) most often because of behavior. The person might then be referred to a psychiatrist or psychologist for assessment and diagnosis . It is unlikely that any sort of specific test is given; rather, the individual would have to meet the criteria in the DSM-IV-TR. Usually there is a history of acting out in school, neighborhood, home, and other social settings. Court-ordered treatment would likely occur if the person comes to the attention of the police and if a crime is involved. A judge might order treatment as an alternative to jail, or before a sentence is served.

Treatments

Earlier treatments of youth with conduct disorder relied on legal processes to declare a child in need of supervision or treatment and thus able to be placed in residential settings established for this purpose. While residential placements may still be used, recent treatment models have relied less on such restrictive procedures. The increased visibility and sophistication of the consumer movement, comprised of families of children and youth with mental health disorders, is bringing pressure to bear on treatment providers to stop blaming families, stop removing children from their families for services, focus instead on strengths and assets in both the child and his or her family, and to use community-based interventions in several domains in which the child and family live.

Community-based interventions are sometimes called wrap-around services to describe the intention that they will be brought to the child's natural environment in a comprehensive and flexible way. The idea is to target a range of child, parent, family and social system factors associated with a child's behavioral problems. This approach has been successful in modifying antisocial behavior, rates of restrictive placement, and in reducing the cost of services.

Another treatment that has been used with some success is the Child Cognitive Behavioral Treatment and Skills Training which trains children with conduct disorder in anger-coping, peer coping, and problem-solving skills.

Parent Management Training and family therapy are also used to treat conduct disorder. Parents learn to apply behavioral principles effectively, how to play with their children, and how to teach and coach the child to use new skills.

Medication is sometimes used and may be effective in controlling aggression. Generally, a variety of treatment modes are used to address such a complex disorder. Severe antisocial behavior on the part of the child and adverse parenting practices may suggest that the family will stop treatment before it can be effective, or before meaningful change can result.

Prognosis

Early identification and appropriate and innovative treatment will improve the course of conduct disorder and possibly prevent a host of negative outcomes that are often a consequence of the behaviors associated with it. Unfortunately, the stigma of treatment and the undiagnosed problems of many parents are still significant enough that families whose children could benefit from treatment never find their way to a treatment setting. Instead their children come into contact with the juvenile and criminal justice system.

Prevention

Prognosis may best be improved by prevention of conduct disorder before it becomes so resistant to treatment. Research is being conducted on what early interventions hold the greatest promise. The research incorporates several components such as child tutoring, classroom intervention, peer training, social-cognitive skills training, parent training, and family problem-solving.

Other studies have included early parent or family interventions, school-based interventions and community interventions. Again, these include a variety of elements as suggested before, including parent training that includes education about normal child development, child problem-solving, and family communication skills training. Research is still needed to determine where and when to target specific preventive interventions.

See also Cognitive-behavioral therapy; Cognitive problem-solving skills training

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association Publishing, Inc. 2000.

Kazdin, Alan E., ed. Encyclopedia of Psychology. Vol. 2. Washington, DC: Oxford University Press, 2000.

Morrison, James M.D. DSM-IV Made Easy:The Clinician's Guide to Diagnosis. New York, The Guilford Press, 1995.

PERIODICALS

Bennett, Kathryn J., PhD and David Offord, MD. "Screening for Conduct Problems: Does Predictive Accuracy of Conduct Disorder Symptoms Improve with Age?" Journal of the American Academy of Child and Adolescent Psychiatry 40, no. 12 (2001).

Biederman, Joseph M.D., Eric Mick, ScD, Stephen V. Faraone, PhD and Melissa Burback, B.A. "Patterns of Remission and Symptom Decline in Conduct Disorder: A four-Year Prospective Study of an ADHD Sample." Journal of the American Academy of Child and Adolescent Psychiatry 40, no. 3 (2001).

Cadoret, Remi J., MD, William R. Yates, MD, Ed Troughton, George Woodworth, PhD, and Mark A. Stewart, MD. "Genetic-Environmental Interaction in the Genesis of Aggressivity and Conduct Disorders." Archives of General Psychiatry 52, no. 11 (1995).

Garland, Ann F. PhD, Richard Hough, PhD, Kristen McCabe, PhD, May Yeh, PhD, Patricia Wood, MPH, MA, and Gregory Aarons, PhD. "Prevalence of Psychiatric Disorders in Youths Across Five Sectors of Care." Journal of the American Academy of Child and Adolescent Psychiatry 40, no. 4 (2001).

ORGANIZATIONS

American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Ave. NW, Washington, DC 20016. <http://www.aacap.org>.

Federation of Families for Children's Mental Health. 1101 King St., Suite 420, Alexandria, VA 22314. <http://www.ffcmh.org>.

Judy Leaver, M.A.

Conduct Disorder

Definition

Description

Causes

Diagnosis

Treatments

Prognosis

Prevention

Resources

Definition

Conduct disorder is a childhood behavior disorder characterized by aggressive and destructive activities that cause disruptions in the child’s natural environments such as home, school, church, or the neighborhood. The overriding feature of conduct disorder is the repetitive and persistent pattern of behaviors that violate societal norms and the rights of other people. It is one of the most prevalent categories of mental health problems of children in this country, with rates estimated at 9% for males and 2% for females.

Description

The specific behaviors used to produce a diagnosis of conduct disorder fall into four groups: aggressive conduct that causes or threatens physical harm to other people or animals, nonaggressive behavior that causes property loss or damage, deceitfulness or theft, and serious violations of rules. Two subtypes of conduct disorder can be delineated based on the age that symptoms first appear. Childhood-onset type is appropriate for children showing at least one of the behaviors in question before the age of 10. Adolescent onset type is defined by the absence of any conduct disorder criteria before the age of 10. Severity may be described as mild, moderate or severe, depending on the number of problems exhibited and their impact on other people.

A youngster who shows symptoms (most often aggression) before age 10 may also exhibit oppositional behavior and peer relationship problems. When they also show persistent conduct disorder and then develop adult antisocial personality disorder, they should be distinguished from an individual who had no symptoms of conduct disorder before age 10. The childhood type is more highly associated with heightened aggression, male gender, oppositional defiant disorder, and a family history of antisocial behavior.

The individual behaviors that can be observed when conduct disorder is diagnosed may be both common, problematic, and chronic. They tend to occur frequently and are distressingly consistent across time, settings, and families. Not surprisingly, these children function poorly in a variety of places. In fact, the behaviors clustered within the term “conduct disorder” account for a majority of clinical referrals, classroom detentions or other sanctions, being asked to stop participating in numerous activities, and can be extremely difficult (even impossible) for parents to manage.

The negative consequences of conduct disorder, particularly childhood onset, may include illicit drug use, dropping out of school, violent behavior, severe family conflict, and frequent delinquent acts. Such behaviors often result in the child’s eventual placement out of the home, in special education and/or the juvenile justice system. There is evidence that the rates of disruptive behavior disorders may be as high as 50% in youth in public sectors of care such as juvenile justice, alcohol and drug services, schools for youths with serious emotional disturbances, child welfare, and mental health.

The financial costs of crime and correction for repeated juvenile offenses by youth with conduct disorder are extensive. The social costs include citizens’ fear of such behavior, loss of a sense of safety, and disruptions in classrooms that interfere with other children’s opportunity to learn. The costs to the child and his or her family are enormous in terms of the emotional and other resources needed to address the consequences of the constellation of symptoms that define conduct disorder.

Causes

There is no known cause for conduct disorder. The frustrating behavior of youngsters with conduct disorder frequently leads to blaming, labeling and other unproductive activities. Children who are “acting out” do not inspire sympathy or the benefit of the doubt. They are often ostracized by other children. Parents of such children are often blamed as poor disciplinarians or bad parents. As a result, parents of children with conduct disorder may be reluctant to engage with schools or other authorities. At the same time, there is a strong correlation between children diagnosed with conduct disorder and a significant level of family dysfunction, poor parenting practices, an overemphasis on coercion and hostile communication patterns, verbal and physical aggression and a history of maltreatment.

There is a suggestion of an, as yet, unidentified genetic component to what has generally been viewed as a behavioral disorder. One study with adopted children in the mid-1990s looked at the relationship between birth parents with antisocial personality disorder, and adverse adoptive home environments. When these two adverse conditions occurred, there was significantly increased aggressiveness and conduct disorder in the adopted children. That was not the case if there was no indication of antisocial personality disorder in the birth parents. This finding has important implications for prevention and intervention of conduct disorders and its associated conditions of substance abuse and aggressiveness.

Diagnosis

The Diagnostic and Statistical Manual of Mental Disorders (also known as the DSM-IV-TR) indicates that for conduct disorder to be diagnosed, the patient has repeatedly violated rules, age-appropriate social norms and the rights of others for a period of at least twelve months. This is shown by three or more of the following behaviors, with at least one having taken place in the previous six months: agression to people or animals, property destruction, lying or theft, and serious rule violations.

Aggression to people or animals includes:

• engaging in frequent bullying or threatening
• often starting fights
• using a weapon that could cause serious injury (gun, knife, club, broken glass)
• showing physical cruelty to people
• showing physical cruelty to animals
• engaging in theft with confrontation (armed robbery, extortion, mugging, purse snatching)
• forcing sex upon someone

Property destruction includes:

• deliberately setting fires to cause serious damage
• deliberately destroying the property of others by means other than fire setting

Lying or theft includes:

• breaking into building, car, or house belonging to someone else
• frequently lying or breaking promises for gain or to avoid obligations (called “conning”)
• stealing valuables without confrontation (burglary, forgery, shop lifting)

Serious rule violations include:

• beginning before age 13, frequently staying out at night against parents’ wishes
• running away from parents overnight twice or more or once if for an extended period
• engaging in frequent truancy beginning before the age of 13

Mild severity would mean there are few problems with conduct beyond those needed to make a diagnosis and all of the problems cause little harm to other people. Moderate severity means the number and effect of the conduct problems is between the extremes of mild and severe. Severe is indicated if there are many more conduct symptoms than are needed to make the diagnosis (more than three in the previous twelve months or more than one in the previous six months), or, the behaviors cause other people considerable harm.

It is generally diagnosed when somebody, often a child in school, comes to the attention of authorities (school, law enforcement, and others) most often because of behavior. The person might then be referred to a psychiatrist or psychologist for assessment and diagnosis. It is unlikely that any sort of specific test is given; rather, the individual would have to meet the criteria in the DSM-IV-TR. Usually there is a history of acting out in school, neighborhood, home, and other social settings. Court-ordered treatment would likely occur if the person comes to the attention of the police and if a crime is involved. A judge might order treatment as an alternative to jail, or before a sentence is served.

Treatments

Earlier treatments of youth with conduct disorder relied on legal processes to either declare a child in need of supervision or treatment and thus able to be placed in residential settings established for this purpose. While residential placements may still be used, recent treatment models have relied less on such restrictive procedures. The increased visibility and sophistication of the consumer movement, comprised of families of children and youth with mental health disorders, is bringing pressure to bear on treatment providers to stop blaming families, stop removing children from their families for services, focus instead on strengths and assets in both the child and his or her family, and to use community-based interventions in several domains in which the child and family live.

Community-based interventions are sometimes called wrap-around services to describe the intention that they will be brought to the child’s natural environment in a comprehensive and flexible way. The idea is to target a range of child, parent, family and social system factors associated with a child’s behavioral problems. This approach has been successful in modifying antisocial behavior, rates of restrictive placement, and in reducing the cost of services.

Another treatment that has been used with some success is the Child Cognitive Behavioral Treatment and Skills Training which trains children with conduct disorder in anger-coping, peer coping, and problem-solving skills.

Parent Management Training and family therapy are also used to treat conduct disorder. Parents learn to apply behavioral principles effectively, how to play with their children, and how to teach and coach the child to use new skills.

Medication is sometimes used and may be effective in controlling aggression. Generally, a variety of treatment modes are used to address such a complex disorder. Severe antisocial behavior on the part of the child and adverse parenting practices may suggest that the family will stop treatment before it can be effective, or before meaningful change can result.

Prognosis

Early identification and appropriate and innovative treatment will improve the course of conduct disorder and possibly prevent a host of negative outcomes that are often a consequence of the behaviors associated with it. Unfortunately, the stigma of treatment and the undiagnosed problems of many parents are still significant enough that families whose children could benefit from treatment, never find their way to a treatment setting. Instead their children come into contact with the juvenile and criminal justice system.

Prevention

Prognosis may best be improved by prevention of conduct disorder before it becomes so resistant to treatment. Research is being conducted on what early interventions hold the greatest promise. It incorporates several components such as child tutoring, classroom intervention, peer training, social-cognitive skills training, parent training, and family problem solving.

Other studies have included early parent or family interventions, school based interventions and community interventions. Again, these include a variety of elements as suggested before, including parent training that includes education about normal child development, child problem solving, and family communication skills training. Research is still needed to determine where and when to target specific preventive interventions.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association Publishing, Inc. 2000.

Kazdin, Alan E., ed. Encyclopedia of Psychology. Vol. 2. Washington, D.C.: Oxford University Press, 2000.

Morrison, James M.D. DSM-IV Made Easy:The Clinician’s Guide to Diagnosis. New York, The Guilford Press, 1995.

PERIODICALS

Bennett, Kathryn J. PhD, and David Offord, MD. “Screening for Conduct Problems: Does Predictive Accuracy of Conduct Disorder Symptoms Improve with Age?” Journal of the American Academy of Child and Adolescent Psychiatry 40, no. 12 (2001).

Biederman, Joseph M.D., Eric Mick, ScD, Stephen V. Faraone, PhD, and Melissa Burback, B.A. “Patterns of Remission and Symptom Decline in Conduct Disorder: A four-Year Prospective Study of an ADHD Sample.” Journal of the American Academy of Child and Adolescent Psychiatry 40, no. 3 (2001).

Cadoret, Remi J., MD, William R. Yates, MD, Ed Troughton, George Woodworth, PhD, and Mark A. Stewart, MD. “Genetic-Environmental Interaction in the Genesis of Aggressivity and Conduct Disorders.” Archives of General Psychiatry 52, no. 11 (1995).

Garland, Ann F. PhD, Richard Hough, PhD, Kristen McCabe, PhD, May Yeh, PhD, Patricia Wood, MPH, MA, and Gregory Aarons, PhD. “Prevalence of Psychiatric Disorders in Youths Across Five Sectors of Care.” Journal of the American Academy of Child and Adolescent Psychiatry 40, no. 4 (2001).

ORGANIZATIONS

American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Ave. NW, Washington, DC 20016. <http://www.aacap.org>.

Federation of Families for Children’s Mental Health. 1101 King St., Suite 420, Alexandria, VA 22314. <http://www.ffcmh.org>.

Judy Leaver, M.A.

Conduct disorder

Definition

Conduct disorder (CD) is a behavioral and emotional disorder of childhood and adolescence . Children with conduct disorder act inappropriately, infringe on the rights of others, and violate the behavioral expectations of others.

Description

Children and adolescents with conduct disorder act out aggressively and express anger inappropriately. They engage in a variety of antisocial and destructive acts, including violence towards people and animals, destruction of property, lying, stealing, truancy , and running away from home. They often begin using and abusing drugs and alcohol and having sex at an early age. Irritability, temper tantrums , and low self-esteem are common personality traits of children with CD.

Demographics

Conduct disorder is present in approximately 6–16 percent of boys and 2–9 percent of girls under the age of 18. The incidence of CD increases with age. Girls tend to develop CD later in life (age 12 or older) than boys. Up to 40 percent of children with conduct disorder grow into adults with antisocial personality disorder .

Causes and symptoms

There are two subtypes of CD, one beginning in childhood (childhood onset) and the other in adolescence (adolescent onset). Research suggests that this disease may be caused by one or more of the following factors:

• poor parent-child relationships
• dysfunctional families
• inconsistent or inappropriate parenting habits
• substance abuse
• physical and/or emotional abuse
• poor relationships with other children
• cognitive problems leading to school failures
• brain damage
• biological defects

Difficulty in school is an early sign of potential conduct disorder problems. While the child's IQ may be in the normal range, he or she can have trouble with verbal and abstract reasoning skills and may lag behind classmates, and consequently feel as if he/she does not "fit in." The frustration and loss of self-esteem resulting from this academic and social inadequacy can trigger the development of CD.

A dysfunctional home environment can be another major contributor to CD. An emotionally, physically, or sexually abusive household member; a family history of antisocial personality disorder; or parental alcoholism or substance abuse can damage a child's self-perception and put him or her on a path toward negative or aggressive behavior . Other less obvious environmental factors can also play a part in the development of conduct disorder; several long-term studies have found an association between maternal smoking during pregnancy and the development of CD in offspring.

Other conditions that may cause or co-exist with conduct disorder include head injury , substance abuse disorder, major depressive disorder, and attention deficit hyperactivity disorder (ADHD). Fifty to seventy-five percent of children diagnosed with CD also have ADHD, a disorder characterized by a persistent pattern of inattention and/or hyperactivity.

CD is defined as a repetitive behavioral pattern of violating the rights of others or societal norms. Three of the following criteria or symptoms are required over the previous 12 months for a diagnosis of CD (one of the three must have occurred in the past six months):

• bullies, threatens, or intimidates others
• picks fights
• has used a dangerous weapon
• has been physically cruel to people
• has been physically cruel to animals
• has stolen while confronting a victim (for example, mugging or extortion)
• has forced someone into sexual activity
• has deliberately set a fire with the intention of causing damage
• has deliberately destroyed property of others
• has broken into someone else's house or car
• frequently lies to get something or to avoid obligations
• has stolen without confronting a victim or breaking and entering (e.g., shoplifting or forgery)
• stays out at night; breaks curfew (beginning before 13 years of age)
• has run away from home overnight at least twice (or once for a lengthy period)
• is often truant from school (beginning before 13 years of age)

When to call the doctor

When symptoms of conduct disorder are present, a child should be taken to his or her health care provider as soon as possible for evaluation and possible referral to a mental health care professional. If a child or teen diagnosed with conduct disorder reveals at any time that he/she has had recent thoughts of self-injury or suicide , or if he/she demonstrates behavior that compromises personal safety or the safety of others, professional assistance from a mental health care provider or care facility should be sought immediately.

Diagnosis

Conduct disorder may be diagnosed by a family physician or pediatrician, social worker, school counselor, psychiatrist, or psychologist. Diagnosis may require psychiatric expertise to rule out such conditions as oppositional defiant disorder, bipolar disorder , or ADHD. A comprehensive evaluation of the child should ideally include interviews with the child and parents, a full social and medical history, review of educational records, a cognitive evaluation, and a psychiatric exam.

One or more clinical inventories or scales may be used to assess the child for conduct disorder, including the Youth Self-Report, the Overt Aggression Scale (OAS), Behavioral Assessment System for Children (BASC), Child Behavior Checklist (CBCL), the Nisonger Child Behavior Rating Form (N-CBRF), Clinical Global Impressions scale (CGI), and Diagnostic Interview Schedule for Children (DISC). The tests are verbal and/or written and are administered in both hospital and outpatient settings.

Treatment

Treating conduct disorder requires an approach that addresses both the child and his/her environment. Behavioral therapy and psychotherapy can help a child with CD to control his/her anger and develop new coping techniques. Social skills training can help a child improve his/her relationship with peers.

Family group therapy may also be effective in some cases. Parents should be counseled on how to set appropriate limits with their child and be consistent and realistic when disciplining. A parental skills training program may be recommended. If an abusive home life is at the root of the conduct problem, every effort should be made to move the child into a more supportive environment.

For children with coexisting ADHD, substance abuse, depression, anxiety , or learning disorders , treating these conditions first is preferred, and may result in a significant improvement in behavior. In all cases of CD, treatment should begin when symptoms first appear. Several studies have shown methylphenidate (Ritalin) to be a useful drug for both ADHD and CD in some children.

When aggressive behavior is severe, mood stabilizing medication, including lithium (Cibalith-S, Eskalith, Lithobid, Lithonate, Lithotabs), and carbamazepine (Tegretol, Carbatrol, Epitol) may be an appropriate option for treating the aggressive symptoms. However, placing the child into a structured setting or treatment program such as a psychiatric hospital may be just as beneficial for easing aggression as medication.

Prognosis

Follow-up studies of conduct-disordered children have shown a high incidence of antisocial personality disorder, affective illnesses, and chronic criminal behavior in adulthood. However, proper treatment of coexisting disorders, early identification and intervention, and long-term support may improve the outlook significantly.

Conduct disorder that first occurs in adolescence is thought to have a statistically better prognosis than childhood-onset conduct disorder. Adolescents with CD tend to have better relationships with their peers and are less likely to develop antisocial personality disorder in adulthood than those with childhood-onset CD. There is also less of a gender gap in adolescent-onset conduct disorder, as girls approach boys in CD incidence. Childhood-onset CD is much more common among boys.

Prevention

A supportive, nurturing, and structured home environment is believed to be the best defense against conduct disorder. Children with learning disabilities and/or difficulties in school should get immediate and appropriate academic assistance. Addressing these problems when they first appear helps to prevent the frustration and low self-esteem that may lead to CD later on.

Parental concerns

A child with conduct disorder can have a tremendous impact on the home environment and on the physical and emotional welfare of siblings and others sharing the household. While seeking help for their child with CD, parents must remain sensitive to the needs of their other children and adjust household routines accordingly. This may mean avoiding leaving siblings alone together, getting assistance with childcare, or even seeking residential or hospital treatment for the conduct disordered child if the safety and well-being of other family members is in jeopardy.

KEY TERMS

Attention deficit hyperactivity disorder (ADHD) —A condition in which a person (usually a child) has an unusually high activity level and a short attention span. People with the disorder may act impulsively and may have learning and behavioral problems.

Major depressive disorder —A mood disorder characterized by profound feelings of sadness or despair.

See also Aggression; Oppositional defiant disorder.

Resources

BOOKS

Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR). Washington, DC: American Psychiatric Press, Inc., 2000.

Eddy, J. Mark. Conduct Disorders: The Latest Assessment and Treatment Strategies. Kansas City, MO: Compact Clinicals, 2003.

PERIODICALS

Black, Susan. "New Remedies for High School Violence." Education Digest. 69, no.3 (November 2003): 43.

"Conduct Disorder and Oppositional Defiant Disorder: Trends and Treatment." The Brown University Child and Adolescent Psychopharmacology Update. 6, no.8 (August 2004): 1+.

ORGANIZATIONS

The American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Ave., N.W., Washington, D.C. 20016. (202) 966–7300. Web site: <www.aacap.org>.

WEB SITES

Goodman, Robin and Anita Gurian. "About Conduct Disorder." NYU Child Study Center. Available online at: <www.aboutourkids.org/aboutour/articles/about_conduct.html> (accessed September 12, 2004).

Paula Ford-Martin

Conduct Disorder

Joe’s Story

What Is Conduct Disorder?

How Does Conduct Disorder Develop?

How Is Conduct Disorder Treated?

Resource

When a child or adolescent shows an ongoing pattern of behavior that violates the rights of others and breaks social rules, he or she may be said to have conduct disorder.

KEYWORDS

for searching the Internet and other reference sources

Antisocial behaviors

Disruptive behaviors

Antisocial personality disorder

Joe’s Story

Joe always seems to pick fights on the school bus. He intimidates and bullies others and has few friends. Serving detention does not seem to help Joe learn to behave. Last year, in fifth grade, he was always in trouble for writing graffiti on school property, and he was suspended once for throwing rocks at a school bus. Though he was never caught, Joe stole money from the teachers’ lounge and from the backpack of the girl who sat in front of him in English class. This year, he frequently cuts school. When he does not attend school, he hangs out behind the local convenience store smoking cigarettes he sneaks from his father’s car.

What Is Conduct Disorder?

While all children and adolescents misbehave on occasion, some seem to do so all the time. Conduct disorder refers to serious and frequent antisocial behavior* in young people. Conduct disorder describes behaviors such as aggression or cruelty toward people or animals, bullying, threatening, physical fights, using weapons to hurt others, destroying property, fire-setting, lying, stealing, running away, and school truancy*. Someone who is diagnosed with conduct disorder has demonstrated at least three or more of these serious behaviors over the past year.

* antisocial behavior

is behavior that differs significantly from the norms of society and is considered harmful to society.

* truancy

means staying out of school or work without permission.

Young people with conduct disorder may act alone or in groups. Many youth involved in gang violence or other criminal or delinquent* behaviors have conduct disorder. When caught violating rules of conduct, antisocial youth often deny their guilt and may shift blame onto others. They often lack remorse for the deeds they have done and lack feeling for people or animals they may have hurt.

* delinquent

is a legal term that refers to a juvenile (someone under the age of 18) who has committed an illegal act. Delinquent behavior includes any behavior that would be considered a crime if committed by an adult as well as specific behaviors that are illegal for youth, such as school truancy, violating curfew, or running away.

For some, conduct disordered behavior begins early in childhood. The earlier and more frequently the antisocial behavior occurs, the more likely it is to develop into more serious problems during adolescence. Others may not develop antisocial behaviors until adolescence; though still serious, their behavioral problems are sometimes more temporary. Most young people who have conduct disorder do not go on to have serious problems in adulthood, although for some it will lead to a lifelong problem with antisocial behavior. In adults, a pattern of aggressive and antisocial behavior that disregards the rights of others may be diagnosed as antisocial personality disorder. All adults who have antisocial personality disorder have had symptoms of conduct disorder in their youth.

How Does Conduct Disorder Develop?

There are many different theories about what causes conduct disorder. There is no one single cause, and a number of factors seem to contribute to its development. Conduct disorder and related antisocial behaviors tend to run in families. This may be due in part to inherited genes that affect behavioral development, but there is strong evidence that antisocial behavior is learned and modeled in the family environment.

Genetics and behavior

Many researchers have tried to determine how genetics and biology contribute to conduct disorder. Some studies have found that youth with conduct disorder may crave more stimulation, have trouble with self-awareness and with making goals, and lack skills for forethought and planning. Other studies have found that youth with conduct disorder have problems with social learning, which includes the skills needed to learn social rules and to interact well with others. Young people with conduct disorder also have less empathy than do others their age. Empathy is a type of emotional feeling for others; it involves the ability to see another person’s point of view and to understand how someone else might feel in a given situation.

Children who have deficiencies in empathy, social learning, planning, and self-awareness may have a harder time developing behavioral controls, good problem-solving skills, and respect for others. Because they have fewer skills to solve problems in socially acceptable ways, they may be more likely to develop conduct problems. However, to what extent these deficiencies are part of a person’s genetic make-up, or are tendencies that are learned by example and behavior in the family, remains unclear.

Learned behavior

There is convincing evidence that aggression, the main ingredient of conduct disorder, is a learned behavior. People who observe others behaving in aggressive ways (and this includes watching aggression and violence on television, movies, and video games) are more likely to demonstrate the aggressive behaviors they have witnessed. Children who witness aggressive behaviors at home, such as physical fighting, pushing, and shoving, are at increased risk for developing conduct disorder. Children with conduct disorder often live in families in which there is a high level of conflict that takes physical form.

Certain parenting practices increase the risk that a child will develop conduct disorder. For example, parents who fail to provide enough supervision, consistent rules for behavior, and discipline contribute to conduct disorder. Parents who use overly harsh or abusive discipline also contribute to the development of conduct disorder.

Peers can also influence a child’s behavior. Many young people with conduct disorder are rejected by their peers, which may make their conduct problems worse. Social rejection may also cause them to associate with other children with conduct problems; children and adolescents who have aggressive or delinquent peers are more likely to have conduct disorder.

How Is Conduct Disorder Treated?

Individual or group treatment for young people with conduct disorder often involves helping them to learn social skills they may be lacking, especially empathy and problem-solving skills. Good behaviors are rewarded and antisocial behaviors are punished. Parent training is an important ingredient in many treatment programs. It helps parents replace harsh and coercive parenting behaviors with consistent rules, appropriate consequences, and positive attention to children’s good behaviors. Studies have demonstrated that these treatment methods can be effective in reducing antisocial behavior in youth with conduct disorder. Treatment works best when it begins soon after the child or adolescent has started to show antisocial behaviors and is more effective when the family also participates. Medication may also be used in some cases.

Learning To Be Aggressive: Albert Bandura’s Experiments

In the 1960s, a social psychologist named Albert Bandura wanted to find out whether children would learn and perform aggressive behaviors simply by watching someone else behave in aggressive ways. Learning a certain behavior by watching someone else do it is called modeling, or observational learning. Bandura conducted a series of experiments that demonstrated that aggressive behavior is indeed learned simply by observation. Whether or not a child actually went on to behave aggressively depended on what happened to the person they observed. If a child saw that the other person was scolded or punished for acting aggressively, the child was not likely to perform the aggressive behavior, even though he or she had learned how. Children who saw that the other person’s aggressive behavior was met with no consequence were more likely to perform the aggressive behavior they had observed as well as other aggressive behaviors.

See also

Antisocial Personality Disorder

Bullying

Lying and Stealing

Oppositional Defiant Disorder

Peer Pressure

Personality

Personality Disorders

Resource

Book

Lewis, Barbara. What Do You Stand For? A Kid’s Guide to Building Character. Minneapolis: Free Spirit Publishing, 1997. Helps teens learn ways to practice honesty, and develop empathy, tolerance, and respect. Ages 11 and up.