Continuing Education Activity

Conduct disorder (CD) lies on a spectrum of disruptive behavioral disorders, which also include oppositional defiant disorder (ODD). In some cases, ODD is a precursor to CD. CD is characterized by a pattern of behaviors that demonstrate aggression and violation of the rights of others and evolves over time. Conduct disorder often occurs comorbidly with other psychiatric conditions, including depression, attention deficit hyperactivity disorder (ADHD), and learning disorders. Thus, a thorough psychiatric evaluation is required before initiating an appropriate treatment plan. This activity examines the presentation, evaluation, and management of conduct disorder and the role of an interprofessional team approach to the care of affected patients.

Objectives:

• Describe conduct disorder.
• Summarize the history and exam of a patient with conduct disorder.
• Review strategies for managing conduct disorder.
• Outline the clinical evaluation of conduct disorder and explain the role of the health professional team in coordinating the care of patients with this condition.

Introduction

Conduct disorder (CD) is classified in the spectrum of disruptive behavior disorders, which also includes the diagnosis of oppositional defiant disorder (ODD). Disruptive behavior disorders (DBD) are frequently comorbid with attention deficit hyperactivity disorder (ADHD). It is to be noted that ADHD was previously listed in the DBDs spectrum in DSM-IV-TR, but DSM V has moved the diagnosis of ADHD to Neurodevelopmental disorders. ODD can be seen as a precursor to CD. CD is characterized by a pattern of behaviors that demonstrates aggression and violation of the rights of others and evolves over time. Conduct disorder is comorbid with many other psychiatric conditions, including depression, ADHD, learning disorders, and thus a thorough psychiatric evaluation is required to understand the psychopathology before initiating an appropriate treatment plan (American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Washington, DC: American Psychiatric Association; 2013; Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Washington, DC: American Psychiatric Association; 1994).[1][2][3][4]

Etiology

The etiology of CD is complex and results from an interaction between multiple biological and psychosocial factors.

Biological

• Various studies indicate a moderate degree of heritability for antisocial behavior, impulsivity, temperament, aggression, and insensitivity to punishment. 
• Evidence for low levels of plasma dopamine beta-hydroxylase supports the finding of decreased activity of the noradrenergic system in the CD.
• Low levels of 5-Hydroxy Indole acetic acid (5-HIAA) levels in CSF correlate with aggression and violence in adolescence.
• High testosterone levels are also associated with aggression

Parental and Family

• A home environment that lacks structure and adequate supervision with frequent marital conflicts between parents, inconsistent discipline leads to maladaptive behavior.
• Harsh parenting with verbal and physical aggression towards children
• Children exposed to frequent domestic violence
• The family history of criminality and disruptive behaviors in caregivers.
• Substance abuse, particularly alcohol dependence in parents
• Living in low social, economic conditions with overcrowding and unemployment leads to economic and social stress with lack of adequate parenting.

Neurological

•  Some studies suggest a correlation between resting frontal brain electrical activity (EEG) and aggression in children.
• Neuropsychological insults to the brain in early life can cause deficits in language, memory, and executive functioning leading to poor judgment and inability to plan and problem solve in crisis situations.
• Developmental delays cause poor social skills, learning disability, below-average intellectual capacity, thus contributing to difficulties in learning, academic difficulties, low self-esteem, and the tendency for children to engage in disruptive behaviors.
• Any traumatic brain injury, seizures, and neurological damage can contribute to aggression.

School

• School environment with large classroom size increased ratio of children to teachers, lack of positive feedback from teachers.
• Lack of supportive staff and counseling to address socio-economic difficulties in children
• Exposure to increased gang violence in the community

Protective 

• A positive role model in life
• Affectionate parenting
• Ability to regulate emotions with self-soothing
• Early intervention and adequate parenting

Comorbid Conditions

• Children with a difficult temperament that demonstrate poor adaptability and frequent negative emotions.
• Attention deficit hyperactivity disorder (ADHD): Almost one-third of children with ADHD have symptoms of conduct disorder and other central nervous system dysfunction or damage.
• Trauma-related disorders, particularly repeated physical and sexual abuse with maltreatment in children, can lead to a diagnosis of post traumatic stress disorder (PTSD) and other anxiety disorders.
• Mood disorders that include depression and bipolar disorder
• Developmental disorders

Epidemiology

It is important to note that occasional rebellious behavior and tendency to be disrespectful and disobedient towards authority figures can present commonly during childhood and adolescent periods. The signs and symptoms that lead to the diagnosis of CD demonstrate a pervasive and repetitive pattern of aggression towards people, animals, with the destruction of property and violation of rules. Conduct disorder is more common in boys than girls, and the ratio could range from 4:1 as much as 12:1. The lifetime prevalence rate in the general population could range from anywhere between 2 to 10% and is consistent among different race and ethnic groups. Children with conduct disorder are often categorized as antisocial personality different disorder in adult life. Early-onset of conduct disorder in childhood years could lead to a worse prognosis of the condition. Multiple socioeconomic factors contribute to a higher incidence of CD in children and adolescents, which includes substance abuse disorders and criminal problems in parents of these children.

Evaluation

Diagnosis

DSM-V Criteria

Exhibits a pattern of behavior that violates the rights of others and disregards social norms

Dysfunction in the Following Areas

• Aggression to people and animals: bullying, threatening, initiating fights, using weapons, physically cruel to people and animals,
• Destruction of property: deliberately causing damage to property, setting fire
• Deceitfulness and theft: often lies, breaks into other’s house, car, shoplifting, forgery
• Serious violation of rules: stays out late at night, frequent running away from home, school truancy.

CD, Childhood-Onset Type

• The onset of problems before age ten
• More common in males
• More physical aggression, Worse prognosis

CD, Adolescent-Onset Type

• Lack of problems before age ten
• Less physical aggression, better prognosis

CD, Unspecified-Onset Type

• Age of onset is unknown

Diagnostic Evaluation

• Complete psychiatric assessment with appropriate history taking for uncovering psychiatric comorbidities like ADHD, Mood disorders
• Assessment should be made in multiple settings with proper collateral information from school families and other significant caregivers.
• Thorough academic assessment with uncovering difficulties in the school environment with possible learning disorders
• Functional behavioral analysis of the patterns of repetitive behaviors and understanding complex family dynamics

Treatment / Management

Basic laboratory investigation, including urine drug screen, is necessary to rule out any comorbid medical problems or substance abuse disorders. Multimodal treatments that target family and community resources have improved outcomes.[5][6][7][8]

Evidence-based Psychosocial Treatments

• Parent management training with the goal to train parents to set consistent discipline with proper rewarding of positive behaviors and promote prosocial behaviors in children.
• Multisystemic therapy that targets family, school, individual, with a focus on improving family dynamics, academic functioning, and improving the child’s behavior in the context of multiple systems
• Anger management training
• Individual psychotherapy that targets developing problem-solving skills strengthens relationships by resolving interpersonal conflicts, learn assertive skills to decline negative influences in the community.
• Community-based treatment: Targets development of therapeutic schools and residential treatment centers that can provide a structured program to reduce disruptive behaviors

Pharmacotherapy

• Targets treating psychiatric comorbidities with appropriate medications such as stimulants and non-stimulants for the treatment of ADHD, antidepressants for the treatment of depression, mood stabilizers for the treatment of aggression, mood dysregulation, and bipolar disorder;
• Mood stabilizers include conventional mood stabilizers like AEDs (antiepileptic drugs) and second-generation antipsychotics. 

Differential Diagnosis

Differential diagnoses include new onset of a mood disorder or psychotic disorder that precipitate excessive indulgence in negative behaviors and hostility toward others. CD should be excluded if the problems occur only during episodes of mood or psychotic disorder.

Furthermore, untreated depressive disorder or ADHD leads to substance abuse and can be the precursor to CD.

Prognosis

Prognosis is variable and depends on the presence of subtle psychiatric comorbidities and the initiation of early interventions.

Low intelligence capacities and a dysfunctional family environment with persistent criminality in parents predict a poor prognosis. Adequate treatment of ADHD, proper school placements with assistance for difficulties in learning, higher verbal intelligence, and positive parenting contribute to a better prognosis.

Enhancing Healthcare Team Outcomes

While the definitive diagnosis of a conduct disorder is made by a mental health expert, the follow-up is usually done by the primary care provider and nurse practitioner. The management of these patients is difficult because of low compliance. A variety of treatments have been devised depending on the age of the patient and comorbidity, but relapse rates are high. Pharmacological therapy is often used to manage mood and aggression, but again these patients never remain compliant. Many get into trouble with the law and are then forced into treatment. [Level 5]