All rights reserved.
Mark Hutten, M.A.
Re: Conduct Disorder

What is conduct disorder?

Conduct disorder is a repetitive and persistent pattern of behavior in kids and teenagers in which the rights of others
or basic social rules are violated. The child or teenager usually exhibits these behavior patterns in a variety of
settings—at home, at school, and in social situations—and they cause significant impairment in his or her social,
academic, and family functioning.

Kids with conduct disorder repeatedly violate the personal or property rights of others and the basic expectations of
society. A diagnosis of conduct disorder is likely when symptoms continue for 6 months or longer. Conduct disorder is
known as a "disruptive behavior disorder" because of its impact on kids and their families, neighbors, and schools.

Another disruptive behavior disorder, called oppositional defiant disorder, may be a precursor of conduct disorder. A
youngster is diagnosed with oppositional defiant disorder when he or she shows signs of being hostile and defiant for
at least 6 months. Oppositional defiant disorder may start as early as the preschool years, while conduct disorder
generally appears when kids are older. Oppositional defiant disorder and conduct disorder are not co-occurring
conditions.

What are the signs of conduct disorder?

Symptoms of conduct disorder include:

•        Aggressive behavior that harms or threatens other people or animals
•        Destructive behavior that damages or destroys property
•        Early tobacco, alcohol, and substance use and abuse
•        Lying or theft
•        Precocious sexual activity
•        Truancy or other serious violations of rules

Kids with conduct disorder or oppositional defiant disorder also may experience:

•        Academic difficulties
•        Difficulty staying in adoptive, foster, or group homes
•        Higher rates of depression, suicidal thoughts, suicide attempts, and suicide
•        Higher rates of injuries, school expulsions, and problems with the law
•        Poor relationships with peers or adults
•        Sexually transmitted diseases

Many children with conduct disorder may have trouble feeling and expressing empathy or remorse and reading social
cues. These children often misinterpret the actions of others as being hostile or aggressive and respond by escalating
the situation into conflict. Conduct disorder may also be associated with other difficulties such as substance use, risk-
taking behavior, school problems, and physical injury from accidents or fights.
How common is conduct disorder?

Conduct disorder affects 1 to 4 percent of 9- to
17-year-olds, depending on exactly how the disorder
is defined (U.S. Department of Health and Human
Services, 1999). Conduct disorder is more common
among boys than girls, with studies indicating that the
rate among boys in the general population ranges from
6% to 16% while the rate among girls ranges from 2% to
9%. Conduct disorder can have its onset early, before
age 10, or in adolescence. Kids who display early-onset
conduct disorder are at greater risk for persistent
difficulties, however, and they are also more likely to
have troubled peer relationships and academic
problems. Among both boys and girls, conduct disorder
is one of the disorders most frequently diagnosed in
mental health settings.
Who is at risk for conduct disorder?

Research shows that some cases of conduct disorder begin in early childhood, often by the preschool years. In fact,
some infants who are especially "fussy" appear to be at risk for developing conduct disorder. Other factors that may
make a youngster more likely to develop conduct disorder include:

•        Abuse or violence
•        Crowding
•        Early institutionalization
•        Early maternal rejection
•        Family neglect
•        Large family size
•        Parental marital discord
•        Parental mental illness
•        Poverty
•        Separation from moms and dads, without an adequate alternative caregiver

Will a child with Conduct Disorder end up as a criminal?

A closely linked behavior is juvenile delinquency. This term refers to an adolescent's tendency to break the law or to
engage in illicit behavior, a broad concept that ranges from littering to murder. According to U.S. government statistics,
eight of ten cases of juvenile delinquency involve males. However, in the last two decades there has been a greater
increase in female than male delinquency.

Juvenile delinquency has been found to vary among cultures. Delinquency rates among minority groups and lower-
socioeconomic-status-youth are especially high in proportion to the overall population of these groups. However,
such groups have less influence over the judicial decision-making process in the United States and may be judged
delinquent more readily than their white counterparts and those of higher socioeconomic status. Some suggested
causes of delinquency are heredity, identity problems, community influences, and family experiences.

Although delinquency is less exclusively a phenomenon of lower socioeconomic status than it has been in the past,
some characteristics of lower-socioeconomic-class cultures may promote delinquency. It is a complex problem, but
psychologists have found factors which may predict whether a child is likely to turn violent. Violent children are
overwhelmingly male and driven by feelings of powerlessness. Ill-directed drives for power often motivate children
especially toward acts of violence.

Some scholars have proposed that lack of empathy and empathic concern (callous disregard for the welfare of
others) is an important risk factor for conduct disorder. Developmental psychologists and social neuroscientists have
hypothesized that empathy and sympathetic concern for others are essential factors inhibiting aggression toward
others.

The propensity for aggressive behavior has been hypothesized to reflect a blunted empathic response to the suffering
of others.  Such a lack of empathy in aggressive individuals may be a consequence of a failure to be aroused by the
distress of others. Similarly, it has been suggested that aggressive behavior arises from abnormal processing of
affective information, resulting in a deficiency in experiencing fear, empathy, and guilt, which in normally developing
individuals inhibits the acting out of violent impulses.

Recently, a functional magnetic resonance imaging (fMRI) study conducted by neuroscientist Jean Decety and
colleagues at the University of Chicago reported that children with aggressive conduct disorder (who have
psychopathic tendencies) have a different hemodynamic brain response when confronted with empathy-eliciting
stimuli.  In the study, researchers compared 16- to 18-year-old boys with aggressive conduct disorder to a control
group of adolescent boys with no unusual signs of aggression.

The children with the conduct disorder had exhibited disruptive behavior such as starting a fight, using a weapon and
stealing after confronting a victim. The children were tested with fMRI while looking at video clips in which people
endured pain accidentally, such as when a heavy bowl was dropped on their hands, and intentionally, such as when a
person stepped on another's foot. Results show that the aggressive children activated the neural circuits underpinning
pain processing to the same extent, and in some cases, even more so than the control participants without conduct
disorder.

However, aggressive teenagers showed a specific and very strong activation of the amygdala and ventral striatum
(an area that responds to feeling rewarded) when watching pain inflicted on others, which suggested that they enjoyed
watching pain. Unlike the control group, the children with conduct disorder did not activate the areas of the brain
involved in understanding social interaction and moral reasoning (i.e., the paracingulate cortex and temporoparietal
junction).
What does the research say about Conduct Disorder?

Recent research on Conduct Disorder has been very
promising. For example, research has shown that most kids
and teenagers with conduct disorder do not grow up to have
behavioral problems or problems with the law as adults; most
of these children do well as adults, both socially and
occupationally. Researchers are also gaining a better
understanding of the causes of conduct disorder, as well as
aggressive behavior more generally. Conduct disorder has
both genetic and environmental components. That is,
although the disorder is more common among the kids of
adults who themselves exhibited conduct problems when they
were young, there are many other factors which researchers
believe contribute to the development of the disorder. For
example, children with conduct disorder appear to have
deficits in processing social information or social cues, and
some may have been rejected by peers as young kids.
Despite early reports that treatment for this disorder is ineffective, several recent reviews of the literature have identified
promising approaches treating kids and teenagers with conduct disorder. The most successful approaches intervene as
early as possible, are structured and intensive, and address the multiple contexts in which kids exhibit problem behavior,
including the family, school, and community. Examples of effective treatment approaches include functional family
therapy, multi-systemic therapy, and cognitive behavioral approaches which focus on building skills such as anger
management. Pharmacological intervention alone is not sufficient for the treatment of conduct disorder.

Conduct disorder tends to co-occur with a number of other emotional and behavioral disorders of childhood, particularly
Attention Deficit Hyperactivity Disorder (ADHD) and Mood Disorders (such as depression). Co-occurring conduct
disorder and substance abuse problems must be treated in an integrated, holistic fashion.

Why are assessment and treatment important?

Assessment and diagnosis of conduct disorder—or any emotional or behavioral disorder of childhood—should be done
by a mental health professional, preferably one who is trained in kids’s mental health. Any diagnosis must be made in
consultation with the youngster’s family. The assessment process should include observation of the youngster,
discussion with the youngster and family, the use of standardized instruments or structured diagnostic interviews, and
history-taking, including a complete medical and family / social history. When assessing and diagnosing any childhood
emotional or behavioral disorder, the mental health professional should consider the social and economic context in
which a youngster’s behavior occurs.

Accurate assessment and appropriate, individualized treatment will assure that all kids are equipped to navigate the
developmental milestones of childhood and adolescence and make a successful adaptation to adulthood. Treatment
must be provided in the least restrictive setting possible.

What help is available for families?

Although conduct disorder is one of the most difficult behavior disorders to treat, young people often benefit from a
range of services that include:

•        Community-based services that focus on the young person within the context of family and community influences.
•        Family therapy.
•        Training for moms and dads on how to handle youngster or teenager behavior.
•        Training in problem solving skills for kids or teenagers.

What can parents do?

Some youngster and teenager behaviors are hard to change after they have become ingrained. Therefore, the earlier
the conduct disorder is identified and treated, the better the chance for success. Most kids or teenagers with conduct
disorder are probably reacting to events and situations in their lives. Some recent studies have focused on promising
ways to prevent conduct disorder among at-risk kids and teenagers. In addition, more research is needed to determine if
biology is a factor in conduct disorder.

Moms and dads or other caregivers who notice signs of conduct disorder or oppositional defiant disorder in a youngster
or teenager should:

•   Consult with a mental health professional, preferably one who is trained in kids’s mental health.
•   Explore the treatment options available. Treatment must be individualized to meet the needs of each youngster and
should be family-centered and developmentally and culturally appropriate.
•   Find a family support group or organization in your community.
•   Get accurate information from libraries, hotlines, or other sources.
•   If necessary, talk with a mental health or social services professional, such as a teacher, counselor, psychiatrist, or
psychologist specializing in childhood and adolescent disorders.
•   Learn more about conduct disorder, including recent research on effective treatment approaches. Contact NMHA for
additional resources on conduct disorder or other emotional or behavioral disorders of childhood.
•   Pay careful attention to the signs, try to understand the underlying reasons, and then try to improve the situation.
•   Talk to other families in their communities.

People who are not satisfied with the mental health services they receive should discuss their concerns with their
provider, ask for more information, and/or seek help from other sources.