Conduct disorders are behaviors in which a person violates the rights of others and consistently breaks basic social rules. They tend to occur in childhood or adolescence and affect boys more often than girls. Patients with conduct disorders struggle to behave in a socially acceptable fashion.
Conduct disorders are classified as either childhood-onset type (symptoms appear before age 10) or adolescent-onset type (symptoms appear after age 10). There are four major types:
- Aggressive conduct
- Nonaggressive conduct
- Deceitfulness or theft
- Serious violations of rules
Many of the behaviors associated with conduct disorders resemble typical childhood rebellion and trauma, but are much more severe. Patients may act aggressively toward others and engage in bullying behavior or pick fights. They may tend to lie, skip classes, run away from home or engage in substance abuse. Recklessness and risk-taking behavior are characteristic of patients with a conduct disorder.
Certain factors appear to be highly correlated with a diagnosis of a conduct disorder. These include conflict in the child’s family of origin, including abuse, neglect, marital problems between parents or caregivers and parental substance abuse problems.
If a physician suspects a conduct disorder, the child will likely be referred to a mental health professional. This expert will observe the child’s behavior. In addition, standard tests or other psychological assessment tools may be used. Particular criteria, established by the American Psychiatric Association, are used to make a diagnosis of a conduct disorder. Recent research indicates that a multi-pronged approach involving psychotherapy is often most effective in treating conduct disorders. The prognosis for patients with conduct disorders is mixed. In a majority of patients, conduct disorders resolve by adulthood. However, a substantial minority of patients continue to have problems as adults, developing conditions such as antisocial personality disorder.
About conduct disorders
Conduct disorders are a group of behaviors in which patients repeatedly violate the basic rights of others or transgress established major age-appropriate norms of society. They occur in childhood or adolescence and are more common among boys than girls. Patients may struggle in social, academic and family settings.
Many of the behaviors associated with conduct disorders resemble typical childhood rebellion and trauma, but are much more severe. Patients with conduct disorders typically have little regard for the feelings or well-being of others. They lack the capacity to empathize and frequently misjudge the intentions of others as being especially hostile or threatening. As a result, they often respond aggressively to these perceived threats and believe their behavior is justified.
Some patients with conduct disorders may have poor self-esteem, whereas others may have an inflated sense of self worth. Patients are often callous and feel little guilt or remorse, and even when they appear to acknowledge wrongdoing, it may simply be a tactic to avoid punishment.
Recklessness and risk-taking behavior are the typical characteristics of patients with conduct disorders. They may engage in sexual behavior at an early age, and may smoke, drink alcohol or use illegal drugs. They may get into legal troubles or have unplanned pregnancies.
In many cases, patients with a conduct disorder have lower-than-average intelligence and low academic performance. They may also have suicidal thoughts or may make suicide attempts. Recent research indicates that some children with a conduct disorder grow up to be healthy, well-adjusted and successful adults with normal levels of social functioning. However, others may go on to develop other disorders, such as antisocial personality disorder and substance abuse problems.
Types and differences of conduct disorders
Conduct disorders are among the most commonly diagnosed mental health disorders in boys and girls, according to the National Mental Health Association. There are four major types of conduct disorder:
- Aggressive conduct. Behavior that causes or threatens physical harm to people or animals.
- Nonaggressive conduct. Behavior that causes property loss or damage.
- Deceitfulness or theft. Behavior that involves lying to or manipulating other people or stealing others’ property.
- Serious violations of rules. Behavior that involves breaking established rules, such as skipping school or staying out past curfew.
In addition, conduct disorders are classified as either childhood-onset type (symptoms appear before age 10) or adolescent-onset type (symptoms appear after age 10). Patients with childhood-onset type tend to be boys who are frequently physically aggressive toward others and who may have poor peer relationships. They may also have a history of other disorders, such as oppositional defiant disorder or attention-deficit hyperactivity disorder (ADHD). The onset of a conduct disorder rarely occurs after age 16. Patients with adolescent-onset type are less likely to display aggressive behavior toward others and more likely to have normal peer relationships. They are also less likely to have persistent conduct disorder or to develop adult antisocial personality disorder than those who have childhood-onset type.
Risk factors and causes of conduct disorders
Certain factors appear to be highly correlated with a diagnosis of a conduct disorder. These include conflict in the child’s family, such as abuse, neglect, marital problems between parents and parental substance abuse problems.
Some research indicates that children who are especially fussy as infants may be at higher risk for developing conduct disorders later. Children with conduct disorders may have had oppositional defiant disorder in early childhood. Having a family history of mental health disorders such as attention-deficit hyperactivity disorder, schizophrenia, mood disorders and substance abuse also increases the risk, especially if a biological parent has one of these conditions. Research also shows that children who display aggressive or thrill-seeking behavior have an increased risk of developing a conduct disorder.
Other factors that may be associated with conduct disorders include:
- Brain damage
- Genetic problems
- History of maternal smoking during pregnancy
- Lack of adult supervision
- Peer rejection or association with delinquent peers
- Physical or sexual abuse
Conduct disorders are more likely to occur in boys than in girls. Between 6 and 16 percent of boys and 2 and 9 percent of girls may have a conduct disorder, according to the National Mental Health Association. Incidence levels of conduct disorders appear to be increasing and may be higher in urban areas than in rural areas.
Signs and symptoms of conduct disorders
Children and adolescents with conduct disorders tend to experience several different symptoms. Although patients of either gender many experience any of these symptoms, certain symptoms are more likely depending on the child’s gender.
Boys are more likely to act aggressively toward others and to engage in bullying behavior or to pick fights often. They may also be cruel to other people and to animals. Meanwhile, girls are more likely to lie, skip classes, run away, or engage in substance abuse or prostitution.
Symptoms associated with conduct disorders include:
- Cruelty to animals and other humans
- Verbally or physically abusive behavior
- Poor frustration tolerance
- Reckless behavior (e.g., early sexual intercourse, problems with the law)
- Substance abuse
- Temper outbursts
- Difficulty feeling or expressing empathy
The nature of the symptoms also determines whether or not conduct disorders are described as mild, moderate or severe:
- Mild. Symptoms are just enough to qualify for diagnosis of a conduct disorder, and cause relatively minor harm. Examples include lying, truancy and staying out past curfew.
- Moderate. Symptoms are greater in number than in a mild conduct disorder, and the behaviors affect others. Examples of such behaviors include stealing without confronting the victim and vandalism.
- Severe. Symptoms are far greater than the minimum necessary to diagnose a conduct disorder. In addition, behaviors cause considerable harm to others and may include physical cruelty, sexual assault, use of weapons, stealing while confronting a victim and breaking and entering.
In some cases, patients experience a conduct disorder that begins with mild symptoms, which progress to severe symptoms over time. Conduct disorders may also be associated with other mental health disorders, including:
- Anxiety disorders
- Attention-deficit hyperactivity disorderLearning disorders
- Communication disorder
- Mood disorders
- Substance abuse
Diagnosis methods for conduct disorders
Diagnosis of a conduct disorder may begin when parents bring a child to a family physician after the child has displayed particularly unruly behavior. Oftentimes, the referral occurs in response to a threatened or actual suspension from school. The physician will likely try to rule out any physical illness by performing a complete physical examination and compiling a thorough medical history.
If the physician suspects a conduct disorder or another psychological problem, the child will likely be referred to a mental health professional, such as a child and adolescent psychiatrist or psychologist.This expert will assess the patient’s motor, cognitive, academic and social competencies, as well as examine the child’s behavior in school, with peers, at home with family members, and in relation to the community. In addition, certain standard tests or other psychological assessment tools may be used. Urine and blood analyses may be ordered to reveal abused substances. The patient and family members will also likely be interviewed about any unusual behaviors.
Diagnosing conduct disorders can be difficult. Patients may withhold information about poor behaviors. Although the mental health professional may also interview caregivers or others to get a more subjective view of the child’s behavior, this information may be limited. Patients with conduct disorders may conceal their worst behavior from loved ones.
Conduct disorders are diagnosed in patients who display a repetitive and persistent pattern of behavior that violates the rights of others or transgresses major age-appropriate societal norms or rules. This behavior must cause significant difficulty in social, academic or occupational functioning.
In addition, three or more of the following criteria must be present within a 12-month period, and at least one criterion must be present within the past six months:
- Aggression toward people and animals. Bullying, threats or intimidation of others, including starting fights and using weapons that can harm others (e.g., guns, bats, broken bottles). These patients may be physically cruel to animals or humans, or may have stolen items when confronting a victim (e.g., mugging) or sexually assaulted another person.
- Destruction of property. Deliberately destroying another person’s property such as by setting it on fire. It also can include other types of behavior intended to destroy property such as vandalism.
- Deceitfulness or theft. Examples include breaking into someone’s house, building or car; lying to obtain goods or favors or to avoid obligations; and stealing items of value without confronting the victim (e.g., forgery, shoplifting).
- Serious violation of rules. Examples include staying out all night in defiance of parent’s orders, running away from home overnight more than twice while living in the caregiver’s home and repeatedly skipping school without permission.
Conduct disorders are not diagnosed in patients who are 18 or older if the symptoms better fit the criteria for antisocial personality disorder.
Treatment options for conduct disorders
Recent research indicates that a multi-pronged approach involving psychotherapy is often most effective in treating conduct disorders. Cognitive-behavioral therapy(CBT) may be used to help patients restructure negative thought processes and address emotions such as anger. In order for treatment to be successful, the patient’s entire family is urged to become involved. In addition, therapy should address the child’s behavior in the family, at school and in the community. However, if the child’s problems stem from physical or emotional abuse in the home, separation from the home may be necessary for the child.
During treatment, patients may learn to build skills such as anger management skills. Treatment may also focus on addressing associated disorders, such as attention-deficit hyperactivity disorder (ADHD). In some cases, medications may be used in conjunction with psychotherapy. Children with learning disabilities may require special education. Parents often need expert assistance in devising and carrying out special management and educational programs in the home and at school.
Medication treatment has been thought to be useful for treating comorbid problems such as ADHD and anxiety. Recent studies have demonstrated efficacy of the medication treatment in reducing aggression, oppositionalism and mood changes in patients with conduct disorders. Substance abuse problems should also be addressed and closely monitored.
There are some treatment methods for conduct disorders that may be advocated by outsiders to parents, yet are potentially harmful for the child. A “boot camp” style behavior modification program uses techniques such as confrontation that may harm the patient, and also end up worsening the disorder. Parents or caregivers are encouraged to consult mental health professionals for reliable and safe treatment options.
The prognosis for patients with conduct disorders is mixed. In some patients, conduct disorder resolves by adulthood. Early and long-term treatment may increase the odds that patients will successfully learn adaptive behaviors, and many patients grow up to be successful adults. However, a substantial minority of patients continue to have problems as adults, developing conditions such as antisocial personality disorder. Generally, the more significant the symptoms, the more difficult it is to treat the condition. Patients with associated mental health disorders also have a more uncertain prognosis.
Questions for your doctor on conduct disorders
Preparing questions in advance can help people to have more meaningful discussions with physicians about conditions. Parents may wish to ask the doctor the following questions related to conduct disorders:
- What are the signs that I should look for that might indicate conduct disorder in my child?
- How can I distinguish symptoms of conduct disorder from typical youthful behavior?
- If I suspect conduct disorder, what type of physician should my child see?
- How will you diagnose my child’s conduct disorder?
- What specific behaviors or other signs lead you to believe my child has a conduct disorder?
- What type of conduct disorder do you suspect in my child?
- What are my child’s treatment options?
- Who should be involved in my child’s treatment – other family members, school officials, etc.?
- What is my child’s likely prognosis? What can I do to improve that prognosis?
- How will I know whether or not my child is getting better?