Conduct Disorder

Published - Written by Carla Rothaus

Children with repetitive rule-breaking, aggression, and disregard for others are at increased risk for substance abuse, educational disruption, and criminal behavior. Progress is being made toward understanding the clinical and neurocognitive features of youth conduct disorders.  Read the new review article on this topic.

The term “conduct problems” refers to a pattern of repetitive rule-breaking behavior, aggression, and disregard for others. Youth conduct problems are predictive of an increased risk of substance abuse, criminal behavior, and educational disruption; they also incur a considerable societal burden from interpersonal suffering and financial costs.

Clinical Pearls

When does youth conduct disorder present clinically?

For children with long-term behavioral problems, signs of conduct disorder often arise by early school age, but few children meet the full criteria for the disorder before 10 years of age. These early signs involve aggressive tendencies, impulsivity, and failure to comply with requests, which are features of attention deficit-hyperactivity disorder (ADHD) and oppositional-defiant disorder. Prospective data show a trajectory of behavioral problems, with progression from ADHD  behavioral problems in early school years to oppositional-defiant disorder in subsequent years, followed by conduct disorder as children approach adolescence. Although this developmental pattern is common, it is not typical in children who have early behavioral problems — that is, conduct disorder does not develop in most children with ADHD or oppositional-defiant disorder, and successful treatment of these two conditions may reduce the risk of progression.

Figure 1. Overlap among Six Clinical Entities. 

What are features of youth conduct disorder with associated callous-unemotional traits?

Callous-unemotional traits, which occur in fewer than half of young persons with conduct disorder, identify a subgroup with distinctive clinical features and neurocognitive perturbations. As compared with youth with conduct disorder who show remorse, empathy, and concern about school performance, those with callous-unemotional traits have a poorer prognosis and treatment response. Like ADHD and oppositional-defiant disorder, callous-unemotional traits are expressed early. Such traits have been identified in children as young as 2 years of age, and among young children with conduct problems, they predict a particularly early onset of a severe, persistent variant of conduct problems. In youth with conduct disorder, the presence of callous-unemotional traits predicts a poor response to typical socialization practices.

Morning Report Questions

Q: What is the prognosis of youth conduct disorder?

A: Once the diagnosis of conduct disorder is established, the prognosis is usually considered to be poor, though the outcome varies. Antisocial personality disorder, which has a particularly poor prognosis, develops in slightly less than 50% of patients with conduct disorder; however, youth with conduct disorder in whom antisocial personality disorder does not develop typically have other long-term problems. Thus, persistent psychopathology is the rule, though its nature can vary.

Q: Are there effective treatments for youth conduct disorder?

A: Currently available treatments target symptoms rather than underlying mechanisms, since the latter are, as yet, unknown. Most important, currently available treatments are only moderately effective. Two types of psychosocial intervention are effective in reducing conduct problems. One targets diverse behaviors with the use of multiple treatment components, including components that rely on principles from cognitive behavioral therapy to address anxiety and related emotional problems. The other form of effective psychosocial intervention facilitates proper child-rearing practices. Two pharmacologic interventions also show promise, but concerns about adverse effects should lead to judicious use. First, antipsychotic medications reduce irritability and aggression in children, although the usefulness of these drugs is limited by short-term adverse effects, such as sedation, and long-term adverse effects from disrupted metabolic and neurologic functions. Second, data also show benefits of psychostimulant medications. In general, psychostimulants are preferable to antipsychotic agents owing to fewer adverse effects. Nevertheless, stimulants can exacerbate anxiety and cause agitation.