Understanding
Conduct Disorder

What is conduct disorder?

Conduct disorder is a psychiatric syndrome that falls in the realm of behavioural disorders and which most commonly occurs during childhood and adolescence. It is characterised by antisocial behaviour which manifests as hostile and sometimes physically violent behaviour and a disregard for others. It boils down to repetitive, persistent violations of both the rights of others and of the norms set by society for the child’s age group. Although all children can act out from time to time, children with this disorder show persistent patterns of aggression toward people or animals, destruction of property, deceitfulness or theft, and serious violations of rules.

It is more prevalent in boys, and in the USA, the estimated lifetime prevalence is 9,5% for both genders with a life-time prevalence of 12% for boys and 7,1% for girls.

How do you know your child has conduct disorder?

Children with conduct disorder demonstrate a callous disregard for others. In addition, they are also aggressive toward other children or people. This aggression may manifest as pushing, hitting, and biting in early childhood to bullying, cruelty and violence in the teenage years. They may hurt animals, pick fights and steal from others. They are also prone to get involved in vandalism and arson.

These children seem to get a “kick” out of causing harm and show no regard or respect for the rights, feelings, or personal space of other people.

When to see a doctor

It is important to bear in mind that children who do not suffer from conduct disorder may also display some of the behaviours listed below, but in children with conduct disorder these behaviours happen more frequently whilst they also interfere with learning, school adjustment, and sometimes with the child’s relationships.

The following behaviour may be indicative of an underlying conduct disorder and thus a psychiatric or paediatric evaluation may be warranted:

  1. No regard for the feelings or rights of other people
  2. Frequent aggression toward other children, people, or animals
  3. Frequent fight-picking
  4. Guilty of trespassing
  5. Lying, cheating, or stealing frequently
  6. Vandalism or arson
  7. Emotionally or physically abusive behaviour (including wielding a weapon or forcing sex)

What causes conduct disorder?

Many factors may contribute to the development of conduct disorder. These include:

  • Brain damage
  • A traumatic event
  • Genes
  • Child abuse
  • Past school failure
  • Social problems

Some children with conduct disorder appear to have a problem in their frontal brain lobes (the part of the brain situated in front that regulates important skills, such as problem solving, memory and emotional expression and which is also home to one’s personality). This hinders the child’s ability to plan, stay away from harm, and learn from negative experiences. It is also possible that a serious of traumatic experiences should occur for a child to develop conduct disorder and that these negative experiences give rise to depressed mood, behavioural problems, and involvement in a deviant peer group.

Risk factors

The following risk factors for the development of conduct disorder have been identified:

  • Male gender
  • Maternal smoking during pregnancy
  • Living in poverty during childhood
  • Parents with substance use disorders or criminal behaviour
  • Family instability (with changes in parent or guardian figures)
  • Lower cognitive ability
  • Association with peers who use substances, are truant from school, or engage in criminal activity
  • Harsh discipline
  • Parents with a cruel or rejecting attitude
  • Poor health
  • Lack of engaging with other people who have children

Disadvantaged, dysfunctional, and disorganised homes may contribute to the development of conduct disorder. In addition, children with other mental health problems are more likely to have this disorder.

How is the diagnosis made?

The diagnosis is made by a psychiatrist, paediatrician, or other doctor in accordance with a set of criteria set out in a psychiatric textbook called the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). This textbook is used worldwide to assist doctors with the diagnosis of mental health problems, since special investigations such as scans or blood tests, are mostly of limited value when it comes to correctly diagnosing mental health disorders.

To make the diagnosis of conduct disorder, the DSM-5 firstly stipulates that there must be a repetitive and persistent pattern of behaviour in which the basic rights of others or major age-appropriate societal norms or rules are violated. It is important to note that this is a pattern of behaviour that is repeated – it is not a once-off incident in an otherwise well-adjusted child. Therefore, a child must meet 3 of 15 criteria over a preceding 12-month period with at least one criterion present in the previous 6 months. In addition, the disturbance in behaviour must be severe enough to significantly impair the child’s social, academic, or, if applicable, occupational functioning. The criteria are divided into 4 broad categories and to make the diagnosis, the child can meet any three criteria from any of the categories as listed below:

  1. Aggression to People and Animals
    • Often bullies, threatens, or intimidates others
    • Often initiates physical fights
    • Has used a weapon that can cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun)
    • Has been physically cruel to people
    • Has been physically cruel to animals
    • Has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed robbery)
    • Has forced someone into sexual activity
  2. Destruction of Property
  • Has deliberately engaged in fire setting with the intention of causing serious damage
  • Has deliberately destroyed others’ property (other than by fire setting)
  1. Deceitfulness and Theft
    • Has broken into someone else’s house, building, or car
    • Often lies to obtain goods or favours or to avoid obligations (i.e., “cons” others)
    • Has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but without breaking and entering; forgery)
  2. Serious Violations of Rules
  • Often stays out at night despite parental prohibitions, beginning before age 13 years
  • Has run away from home overnight at least twice while living in the parental or parental surrogate home, or once without returning for a lengthy period
  • Is often truant from school, beginning before age 13 years.

In addition to the above, doctors will also note whether the child demonstrates a lack of remorse or guilt, a lack of empathy (by disregarding or being unconcerned about others’ feelings), and whether he/she is unconcerned about his performance at school or in other important activities. With conduct disorder, a child may also fail to express feelings or show emotions, except in ways that come across as shallow, insincere, or superficial.

What treatment is available for conduct disorder?

Treatment for conduct disorder is complex and usually requires treatment of co-occurring conditions (known as comorbid conditions) as well as family support, psychosocial support (with the help of a psychologist) and sometimes medicines.

While conduct disorder is a challenging condition that may be difficult to overcome, it is important to know that help is available, and that the situation is not hopeless.  The disorder is manageable in situations where an effective support network of parental figures, teachers, and peers can be assembled.

The child’s age, symptoms, general health as well as the severity of the condition will all impact the treatment plan. The latter may include psychotherapy, family therapy, peer group therapy and, sometimes medicines.

Psychotherapy

One challenging aspect of treating conduct disorder is that the condition itself instils negative attitudes. Psychotherapy and behavioural therapy may thus have to be undertaken for extended periods. Apart from the patient, it is also important to involve the entire family and support network of the child. It is important to diagnose the condition early, because the earlier the condition is diagnosed, the more successful therapy will be. Psychotherapy provides the child with improved skills to interact with the world at large, while the family learns the best ways to communicate with him/her.

Medicines

Medicines are not often used to treat conduct disorders but may be required to treat symptoms of other disorders, such as Attention-deficit-hyperactivity disorder (ADHD).

While medication is usually only indicated for concurrent ADHD (or other mental health disorders), risperidone is sometimes recommended as a short-term treatment for severe aggression or explosive anger after comorbid ADHD has been treated (if applicable). In Canda, risperidone is used, if considered appropriate under the circumstances, to treat disruptive and aggressive behaviour in patient with an average IQ and conduct disorder, but can also be used, under certain circumstances, to treat children with a below average IQ.

Addressing other mental health problems

A child with conduct disorder may also suffer from other mental health disorders and it is important to recognise and treat these as well. ADHD and oppositional defiant disorder (ODD) most frequently co-occur with conduct disorder, but the child should also be screened for learning disorders, anxiety disorders, mood disorders (including both depressive and bipolar disorders) and substance use disorders.

 

Living with conduct disorder

It is important to seek help without delay should a child display symptoms of conduct disorder. Treatment is not only more successful if started early, but children or teenagers with conduct disorder are at risk of developing other mental disorders as adults if left untreated. Examples of such mental disorders include personality disorders, mood or anxiety disorders and as well as substance use disorders.

Although it is not possible to predict how a child will respond to treatment with outcomes varying greatly, early intervention may help to reduce the risk for incarcerations, mood disorders, and other comorbidities, such as substance abuse.

Early recognition of the condition and addressing symptoms when they appear may help to minimise distress to the child and family. It is important to note that a nurturing, supportive, and consistent home environment with a balance of love and discipline may help to reduce symptoms and prevent episodes of disturbing behaviour.

What to eat

It is always important to eat a healthy, balanced diet. Well-informed food choices may help parents to steer away from foods that may make matters worse for children with conduct disorder. Since conduct disorder is frequently accompanied by ADHD, parents may benefit from paying attention to the amount of diary in their child’s diet. Dairy is the most common food allergy among children, and for those who have ADHD, hyperactivity and dairy products seem to be associated with each other. This means that some children act out more than usual after consuming milk, cheese, yogurt, or other foods containing diary.

Apart from dairy, gluten found in wheat (and thus in bread, cereal, crackers, cakes, etc.) may also induce hyperactivity, irritability and aggressiveness in children who are gluten sensitive.

Food dyes are also well-known triggers of hyperactivity.

Parents are encouraged to include meat, nuts, and beans for protein as well as complex carbohydrates, which can be found in fresh fruits and vegetables, in their child’s diet. In addition, omega-3 fatty acids may also help with behavioural problems, and these can be sourced from salmon, tuna, walnuts, and olive oil.

 

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