9 Child and adolescent psychiatry9.7 Disorders in childhood and adolescence
9.7.10 Conduct disorder
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Written by Resident Doctor Committee · Published
Conduct disorder and oppositional defiant disorder
Conduct disorder is persistent violation of the rights of others or of major age-appropriate norms. Oppositional defiant disorder (ODD) is confined to angry mood, argumentative defiance and vindictiveness.
Feature | Conduct disorder | ODD |
|---|---|---|
Behaviours | Aggression to people or animals, destruction of property, deceit or theft, serious rule violation | Irritable mood, argumentativeness, defiance, vindictiveness, with no aggression, property destruction, deceit or serious rule breaking |
Duration | Typically 12 months or more | Six months or more |
Usual onset | Childhood or adolescence | About 3 to 8 years, from around age 3, rarely after early adolescence |
Serious rule violation alone is enough for conduct disorder, even without aggression, theft or destruction: staying out at night, running away and truancy all count.
ODD shows most reliably at home and with familiar people, and it may be absent at school, with other adults or with peers.
ODD may come before conduct disorder, but children do not inevitably progress from one to the other.
Defiance is more linked to later conduct problems, and persistent irritability is more linked to later emotional disorders.
Classification
Feature | ICD-11 |
|---|---|
Name | Conduct-dissocial disorder |
Grouping | Disruptive behaviour or dissocial disorders, with ODD |
Threshold | Repetitive, persistent, enduring dissocial pattern, typically 12 months or more |
Subtypes | Childhood or adolescent onset |
Under ICD-11, isolated or time-limited dissocial acts do not qualify.
ICD-11 uses childhood-onset and adolescent-onset subtypes.
Personality disorder can be diagnosed in adolescence when its enduring requirements are met; conduct-dissocial disorder is not an automatic substitute based on age.
Onset subtypes and limited prosocial emotions
Childhood onset means at least one characteristic symptom before age 10. Adolescent onset means none before 10, not simply a later diagnosis.
Feature | Childhood onset | Adolescent onset |
|---|---|---|
Sex ratio | Greater male predominance | More even |
Neurodevelopmental problems | More ADHD, language and executive difficulties | Less prominent |
Aggression | More severe | More rule breaking than aggression |
Course | Greater risk of persistence | More often improves |
Moffitt's life-course-persistent and adolescence-limited pathways are research models, not exact equivalents of the onset subtypes.
The ICD-11 limited prosocial emotions specifier describes several persistent features: limited empathy, little remorse, unconcern about performance and shallow affect, across relationships and settings, typically for at least a year.
These traits, formerly called callous-unemotional, go with reduced sensitivity to others' distress and a more persistent course.
Clinicians should use several informants and never infer the specifier from one offence or from interview manner.
Epidemiology
Age (UK national survey) | Boys | Girls |
|---|---|---|
5 to 10 | About 7% | About 3% |
11 to 16 | About 8% | About 5% |
Prevalence is higher at 11 to 16 because adolescent-onset cases add to persisting childhood-onset cases.
Conduct disorder is about twice as common in males (2:1), and this ratio holds across world regions.
Rates are higher in deprived communities, care populations and youth justice samples, so these selected samples do not represent the general population.
Comorbidity and differential diagnosis
Attention deficit hyperactivity disorder (ADHD), depression, reading and learning difficulties and substance misuse commonly accompany conduct disorder, while overcontrolled internalising conditions are the least associated.
Clinicians should look actively for ADHD, because impulsivity and poor regulation may respond to ADHD treatment.
Threat-driven aggression after trauma or maltreatment can resemble conduct disorder, and the two may coexist.
Depression, autism, intellectual disability and substance intoxication or withdrawal can each explain disruptive behaviour and need to be considered.
Aetiology and risk
Patterson's coercive family model describes reciprocal reinforcement: the child's escalation ends an unwanted demand, and the adult's withdrawal ends the conflict, so both responses grow more likely.
Coercive, hostile or inconsistent parenting is a risk factor, whereas warm, firm, consistent and supervising parenting is protective.
Harsh, punitive parenting is the strongest predictor of progression from childhood conduct problems to adolescent offending, ahead of low IQ and poor attainment.
Low cerebrospinal fluid 5-HIAA, reflecting reduced central serotonergic activity, is the neurochemical correlate of impulsive aggression.
Other contributors are temperament, maltreatment, peer rejection, antisocial peers, school exclusion, deprivation and community violence.
The Cambridge Study in Delinquent Development (Farrington) named predictors at age 8 to 10 of later convictions.
The child's own predictors were antisocial behaviour, hyperactivity, impulsivity and attention deficit, and low intelligence and attainment.
The family predictors were family criminality, family poverty and poor child-rearing.
Resilience cohorts such as Werner's Kauai study found that a close bond with one caregiver protects children exposed to heavy adversity from conduct problems.
Assessment
Clinicians gather information from home, school and community, since differences between accounts can reveal triggers or supports.
Assessment covers the antecedents, function and consequences of behaviour, along with development, learning, family stress and substances.
Weapons, sexual aggression and dangerous fire setting need urgent risk assessment, alongside self-harm, suicide and vulnerability to criminal or sexual exploitation.
Management
The National Institute for Health and Care Excellence matches psychosocial treatment to the child's age, starting with parent training for younger children.
Group | Intervention | Details |
|---|---|---|
Pregnancy onwards | Family Nurse Partnership | Nurse home visiting before any child has shown a problem |
Age 3 to 11 | Group-based parent training | First line, before any medication however severe the aggression; 10 to 16 weekly sessions of praise, clear commands, consistent limits and time out |
Age 3 to 11, parent cannot join a group or needs are too complex | Individual parent training | Same methods, one family |
Age 3 to 11 with foster carers | Foster carer training programme | Same methods adapted to looked-after status |
Age 9 to 14 | Group social and cognitive problem-solving for the child | Targets hostile attribution bias and a stepwise response to provocation |
Age 11 to 17 | Multimodal intervention, such as multisystemic therapy | Round-the-clock availability, small caseloads, three to five months, across family, school, peers and community |
In the 9 to 11 overlap, parent training is chosen when the child lacks emotional maturity and insight and inconsistent parenting drives the difficulties.
Functional family therapy is brief, reframes blame to engage the family, then works on communication, consistent rules and agreed consequences.
Triple P is parent management training with versions from young children to adolescence (Teen Triple P), deliverable to individual families.
The UK START trial found no advantage of multisystemic therapy over usual management for out-of-home placement at 18 months.
Group interventions need monitoring, because antisocial behaviour can be reinforced within peer groups.
For limited prosocial emotions, clinicians emphasise warmth, praise and consistent rewards and do not assume punishment will help.
Medication
Drugs are not prescribed routinely.
Short-term risperidone may be considered for severe aggression with explosive anger and marked emotional dysregulation that psychosocial treatment has not settled.
A specialist starts it, reviews it at 3 to 4 weeks and stops it by six weeks if there is no clinically important response.
Baseline and ongoing checks cover growth, weight and body mass index, pulse, blood pressure, glucose or HbA1c, lipids, prolactin and movement symptoms.
Outcome
Earlier onset, severe aggression, limited prosocial emotions and continuing adversity increase the risk of persistence.
Estimates of adult antisocial personality disorder vary: about half (40 to 50%), or about one third (a quarter to two fifths) as the forward rate.
Looking back, nearly all adults with antisocial personality disorder had childhood conduct disorder.
Diagnosis alone cannot predict an individual's outcome, so the adult presentation is reassessed at transition.