Version May 2024
INTRODUCTION — Conduct disorder is a disorder defined by various forms of aggressive and rule-breaking behaviors in which the basic rights of others or age-appropriate societal norms are violated. Symptoms frequently lead to conflicts with adults (eg, parents, teachers, and other authority figures) or peers, and may include involvement with the legal system. Conduct disorder is often, but not always, preceded in early childhood by the development of attention deficit hyperactivity disorder (ADHD) or oppositional defiant disorder (ODD). Symptoms of conduct disorder typically begin either in childhood or adolescence and may often persist into adulthood, at times developing into antisocial personality disorder.
This topic describes the epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis of conduct disorder. Another topic describes the epidemiology, pathogenesis, clinical manifestations, course, assessment, and diagnosis of ODD. Treatment of ODD and conduct disorder are discussed separately. (See "Oppositional defiant disorder: Epidemiology, clinical manifestations, course, and diagnosis" and "Treatment of oppositional defiant and conduct disorders".)
EPIDEMIOLOGY, COMORBIDITY, AND PATHOGENESIS
Prevalence — The reported worldwide age-standardized prevalence rate of conduct disorder from age 5 to 19 is approximately 5 percent [1]. In a large, representative United States sample of 3199 individuals from the National Comorbidity Survey Replication Study, the lifetime prevalence of conduct disorder was estimated as 9.5 percent (males 12 percent; females 7 percent) [2]. This sex difference is consistent across studies [1,2].
Comorbidity — Conduct disorder is comorbid with other disorders, particularly attention deficit hyperactivity disorder (ADHD) and oppositional defiant disorder (ODD). Other comorbid disorders include impulse control disorders, substance use disorders, bipolar disorder, anxiety disorders, and major depression [2,3]. In addition to its comorbidity with other disorders, conduct disorder may be accompanied by callous-unemotional traits, including lack of remorse, shallow emotions, and callousness [4].
In the National Comorbidity Study Replication comorbidities with conduct disorder included [2]:
●ODD (odds ratio 12.1, 95% CI 9.3-15.8)
●Any impulse control disorder (odds ratio 7.7, 95% CI 5.9-10)
●Any substance use disorder (odds ratio 5.9, 95% CI 4.3-8.2)
●Bipolar disorder (odds ratio 5.0, 95% CI 3.6-7)
●ADHD (odds ratio 4.9, 95% CI 3.7-6.5)
●Panic disorder (odds ratio 3.5, 95% CI 2.4-5)
●Any anxiety disorder (odds ratio 3.0, 95% CI 2.3-3.8)
●Major depressive disorder (odds ratio 1.6, 95% CI 1.2-2.1)
Male-female differences have been found in comorbidity, such that females with conduct disorder tend to show higher rates of current major depression, anxiety disorders, PTSD, and borderline personality disorder, whereas males with conduct disorder show higher rates of current ADHD [5].
Genetic and environmental factors — Twin and adoption studies support a moderate heritability for conduct disorder.
Genetic influence may be higher for conduct disorder, specifically, than for antisocial behavior in general. For example, in a meta-analysis of 51 twin and adoption studies estimating the genetic and environmental influences on general antisocial behavior, genetic influences accounted for 41 percent of the variance, shared environmental influences accounted for 16 percent, and nonshared environmental influences accounted for 43 percent [6]. In the same study, analyses of these influences on conduct disorder found a higher heritability of 50 percent, shared environmental influences of 11 percent, and nonshared environmental influences of 39 percent [6].
However, these influences appear to vary depending on the predominant symptoms present. As examples:
●Heritability appears to be higher for those with aggressive symptoms as compared with those with primarily rule-breaking symptoms (65 versus 48 percent). Furthermore, shared environmental influence are lower for the aggressive symptoms as compared with those with primarily the rule breaking symptoms (5 versus 18 percent) [7,8].
●Heritability appears to be higher in individuals with callous-unemotional traits and environmental influence appears to be lower in individuals with callous-unemotional traits as compared with those without the presence of callous-unemotional traits [9,10].
Despite its importance, fewer behavior genetic studies have examined differences in heritability and environmental influences on conduct disorder as a function of age of onset, with one study showing no difference in heritability, and no evidence for shared environmental influences, on child- versus adolescent-onset conduct disorder [11].
There are only a few genome-wide studies of conduct disorder. Early genome-wide studies using linkage analysis and genome-wide association studies found no replicable results [12-15].
Neuroimaging — Structural and functional neuroimaging studies of conduct disorder have found evidence of structural abnormalities (small size, cortical thinning, folding deficits) and areas of decreased activity in brain regions associated with emotion-processing, aggression, problem solving, and impulse control [16-21]. The pattern of these changes are different than those observed in other disorders such as ADHD [18].
For example, in a meta-analysis of 29 studies examining structural and functional neuroimaging, a diagnosis of either ODD or conduct disorder was associated with smaller brain structures and lower brain activity in the bilateral amygdala, bilateral insula, right striatum, left medial/superior frontal gyrus, and left precuneus as compared with control [16]. These areas are associated with emotion-processing, error-monitoring, problem solving, and self-control and are thought to play a role in the neurocognitive and behavioral deficits implicated in ODD/conduct disorder. Evidence suggests that the abnormalities in the amygdala are specific to ODD/conduct disorder, irrespective of the presence of ADHD.
Sociodemographic correlates — Conduct disorder has been associated with a wide variety of sociodemographic correlates. In the National Comorbidity Survey Replication Study [2], a large, representative United States sample of 3199 individuals, a lifetime diagnosis of conduct disorder was associated with the following:
●Male gender (odds ratio 2.0)
●Lower educational attainment, 0 to 11 years of education (odds ratio 4.6, 95% CI 2.7-7)
●Lower educational attainment, 12 years of education (odds ratio 2.7, 95% CI 1.7-4.3)
●Separated or divorced (odds ratio 1.9, 95% CI 1-3.6)
●Residing in large urban settings (odds ratio 7.1, 95% CI 4.2-12)
●Hispanic (odds ratio 0.5, 95% CI 0.3-0.8)
CLINICAL PRESENTATION — The prominent feature of conduct disorder is a repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by three or more aggressive and/or rule-breaking symptoms over the past year, with at least one symptom presenting in the past six months [22]. Youth presenting such symptoms often come to the attention of the school system, as well as family members and, if sufficiently severe, the legal system.
The symptoms of conduct disorder are heterogenous with behaviors falling into four main groupings: aggressive symptoms or threats of harm to people and animals, nonaggressive conduct that causes property loss or damage, deceitfulness or theft, and serious rule violations. Onset may be seen in childhood or adolescence. The disturbance in behavior is associated with distress in the individual or others (family, peer group), often impacts negatively upon social/interpersonal, educational, occupational, or other areas of functioning, and can include involvement with the legal system. (See 'Diagnostic criteria' below.)
Other characteristics (eg, the presence of limited prosocial emotions, lack of remorse or guilt, callousness/lack of empathy, or shallow or deficient emotions) are indicated in specifiers. Conduct disorder accompanied by such callous-unemotional traits (or “limited prosocial emotions,” as designated in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition [DSM-5]) appears to show higher heritability [23], somewhat different patterns of neuroimaging findings [24-26], worse short- and long-term outcomes [27,28], and may adversely affect treatment outcome [29].
COURSE — The median age of onset is 11.6 years [30]. Conduct disorder is often, but not always, preceded in early childhood by the development of attention deficit hyperactivity disorder (ADHD) or oppositional defiant disorder (ODD).
The course of conduct disorder is heterogenous with some cases being limited to childhood only, some limited to adolescence only, and some extending from childhood or adolescence into adulthood [31].
●In a subsample of 672 participants from the Dunedin longitudinal study, 12 percent were characterized as having life-course-persistent (LCP) antisocial behavior, 23 percent as having adolescence-limited (AL) antisocial behavior, and 66 percent as having low antisocial behavior [32].
●In a set of large (n = 20,130) United States population-based nationally representative surveys known as the Collaborative Psychiatric Epidemiology Studies, for females the prevalence of LCP and AL conduct disorder was 0.5 and 4.6 percent, whereas for males these were 1.9 and 5.1 percent, respectively [33].
●Up to 50 percent of youth with conduct disorder have been found to develop antisocial personality disorder as adults [34].
Children and adolescents with conduct disorder are at increased risk of functional impairments in relationships, education, workplace, and involvement with the legal system in adulthood. Additionally, the disorder is associated with externalizing psychopathology (such as impulse control disorders and substance misuse) and internalizing psychopathology (such as anxiety and mood disorders), especially if their conduct disorder is more severe and/or persistent [34-38]. Conduct disorder is a stronger predictor of adult externalizing psychopathology in males, but a stronger predictor of adult internalizing psychopathology in females [39].
DIAGNOSIS
Assessment — We consider a diagnosis of conduct disorder in all youth who present with persistent behavior problems affecting academic performance, work performance, or causing psychosocial disruption. We assess interpersonal or relationship problems, school or work-related problems, and legal problems across multiple situations and settings. We do this by obtaining history from caregivers and teachers. Children under the age of 10 are rarely used as informants given the lack of reliability and validity of the child's reports of their conduct disorder symptoms. However, children’s reports are an important source of symptom information once they are in late childhood and are approaching adolescence.
We often use parent, caregiver, and teacher questionnaires such as the Emory Combined Rating Scale [40] as an alternative or supplement to structured or semistructured interviews. These rating scales are relatively quick and easy for parents or teachers to complete [40,41].
Other options that we occasionally use for diagnostic purposes are structured or semistructured interviews including the Diagnostic Interview Schedule for Children [42], the Diagnostic Interview Schedule for Children and Adolescents [43] the Kiddie-Schedule for Affective Disorders and Schizophrenia [44]. Our choice from among these diagnostic scales is based on practitioner preference.
Diagnostic criteria — To diagnose conduct disorder, the following criteria must be met [22]:
"A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated, as manifested by the presence of 3 (or more) of the following 15 criteria in the past 12 months from any of the categories below, with at least 1 criterion present in the past 6 months:
Aggression to people and animals:
●1. Often bullies, threatens, or intimidates others
●2. Often initiates physical fights
●3. Has used a weapon that can cause serious physical harm to others (eg, a bat, brick, broken bottle, knife, gun)
●4. Has been physically cruel to people
●5. Has been physically cruel to animals
●6. Has stolen while confronting a victim (eg, mugging, purse snatching, extortion, armed robbery)
●7. Has forced someone into sexual activity
Destruction of property:
●8. Has deliberately engaged in fire setting with the intention of causing serious damage
●9. Has deliberately destroyed others’ property (other than by fire setting)
Deceitfulness or theft:
●10. Has broken into someone else’s house, building, or car
●11. Often lies to obtain goods or favors or to avoid obligations (ie, ‘cons’ others)
●12. Has stolen items of nontrivial value without confronting a victim (eg, shoplifting, but without breaking and entering; forgery)
Serious violations of rules:
●13. Often stays out at night despite parental prohibitions, beginning before age 13 years
●14. Has run away from home overnight at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period)
●15. Is often truant from school, beginning before age 13 years
B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
C. If the individual is age 18 years or older, criteria are not met for antisocial personality disorder.” (See "Antisocial personality disorder: Epidemiology, clinical manifestations, course, and diagnosis", section on 'Clinical manifestations' and "Antisocial personality disorder: Epidemiology, clinical manifestations, course, and diagnosis", section on 'Course'.)
“Specifiers are given based on age of onset, presence or absence of limited prosocial emotions, and for severity of symptoms:
●Conduct disorder, childhood-onset type – Individuals show at least one symptom characteristic of conduct disorder prior to age 10 years
●Conduct disorder, adolescent-onset type – Individuals show now symptom characteristic of conduct disorder prior to age 10 years
●Conduct disorder, unspecified onset – Criteria for a diagnosis or conduct disorder are met, but there is not enough information available to determine whether the onset of the first symptom was before or after age 10 years.
Presence or absence of prosocial emotions:
●With limited prosocial emotions – To qualify for this specifier, an individual must have displayed at least two of the following characteristics persistently over at least 12 months and in multiple relationships and setting. These characteristics reflect the individual’s typical pattern of interpersonal and emotional functioning over this period and not just occasional occurrences in some situations. Thus, to assess the criteria for the specifier, multiple information sources are necessary. In addition to the individual’s self-report, it is necessary to consider reports by others who have known the individual for extended periods of time (eg, parents, teachers, coworkers, extended family members, peers).
•Lack of remorse or guilt – Does not feel bad or guilty when he/she does something wrong (excluding remorse when expressed only when caught and/or facing punishment). The individual shows a general lack of concern about the negative consequences of their actions. For example, the individual is not remorseful after hurting someone or does not care about the consequences of breaking rules.
•Callous lack of empathy – Disregards and is unconcerned about the feelings of others. The individual is described as cold and uncaring. The person appears more concerned about the effects of their actions on themselves, rather than their effects on others, even when they result in substantial harm to others.
•Unconcerned about performance – Does not show concern about poor/problematic performance at school, work, or in other important activities. The individual does not put forth the effort necessary to perform well, even when expectations are clear, and typically blames others for their poor performance.
•Shallow or deficient affect – Does not express feelings or show emotions to others, except in ways that seem shallow, insincere, or superficial (eg, actions contradict the emotion displayed; can turn emotions ‘on’ or ‘off’ quickly) or when emotional expressions are used for gain (eg, emotions displayed to manipulate or intimidate others).
Current severity:
●Mild – Few if any conduct problems in excess of those required to make the diagnosis are present, and conduct problems cause relatively minor harm to others (eg, lying, truancy, staying out after dark without permission, other rule breaking).
●Moderate – The number of conduct problems and the effect on others are intermediate between those specified in ‘mild’ and those in ‘severe’ (eg, stealing without confronting a victim, vandalism).
●Severe – Many conduct problems in excess of those required to make the diagnosis are present, or conduct problems cause considerable harm to others (eg, forced sex, physical cruelty, use of a weapon, stealing while confronting a victim, breaking and entering).”
Differential diagnosis — For each patient being evaluated we specifically consider the following diagnosis. These may be comorbid or alternative diagnosis:
●Oppositional defiant disorder (ODD) – The behaviors occurring in ODD are typically less severe than those in conduct disorder. Conduct disorder includes aggression towards people or animals, or destruction of property while these are not described in ODD. Emotional dysregulation (eg, irritability, anger) is often seen in ODD though not necessarily in conduct disorder. Additionally, while ODD symptoms include “often losing temper” and “is often angry or resentful” they do not include the more serious, overt forms of aggression that constitute symptoms of conduct disorder. Finally, ODD does not include the various forms of rule-breaking symptoms that are part of conduct disorder. When criteria are met for both disorders, both diagnoses can be given. (See "Oppositional defiant disorder: Epidemiology, clinical manifestations, course, and diagnosis".)
●Adjustment disorder – Aggressive and rule-breaking behaviors may be a reaction to psychosocial stressors or a symptom of conduct disorder. In individuals whose symptoms are temporally related to a psychosocial stressor and are present for up to six months, we diagnosis adjustment disorder.
●Attention deficit hyperactivity disorder (ADHD) – ADHD is often comorbid with conduct disorder. Individuals with ADHD may show symptoms of conduct disorder (eg, various forms of aggression) in situations that instill frustration, such as demanding sustained effort or demanding that the individual sit still. The aggressive behaviors in conduct disorder are more pervasive than those in ADHD. In addition, although ADHD and conduct disorder are moderately to highly comorbid, ADHD almost always developmentally precedes the onset of conduct disorder. (See "Attention deficit hyperactivity disorder in children and adolescents: Clinical features and diagnosis".)
●Posttraumatic stress disorder (PTSD) – Behaviors in children with PTSD may manifest as various forms of aggression and rule breaking. In PTSD, these behaviors would be associated with a prior traumatic event. Furthermore individuals with PTSD often manifest with intrusion symptoms, avoidance of stimuli that arouse recollections of the traumatic event, and decreased interest or participation in activities or persistent reduction in expression of positive emotions (in children under six). (See "Posttraumatic stress disorder in children and adolescents: Epidemiology, clinical features, assessment, and diagnosis".)
●Mood disorders – Both mood disorders and conduct disorder can have some features in common, including various aspects of disinhibited behavior that may lead to aggression and rule breaking. (See "Pediatric unipolar depression: Epidemiology, clinical features, assessment, and diagnosis" and "Pediatric bipolar disorder: Clinical manifestations and course of illness".)
In mood disorder, these symptoms typically occur during periods of mood elevation or depression, whereas the symptoms occur across many contexts in conduct disorder.
●Disruptive mood dysregulation disorder – Individuals with disruptive mood dysregulation disorder manifest severe and frequent recurrent outbursts, which may include aggression, with a persistent disruption in mood between outbursts. Persistent disruption in mood is not typically present in conduct disorder.
●Intermittent explosive disorder – Individuals with intermittent explosive disorder show aggression towards others, which is part of the criteria for conduct disorder. However, in contrast with the aggression in conduct disorder, the aggression in intermittent explosive disorder is often not premeditated or to achieve a tangible benefit.
●Antisocial personality disorder – As stated in the diagnostic criteria above, if the individual is age 18 years or older, criteria are not met for antisocial personality disorder. (See "Overview of personality disorders" and "Antisocial personality disorder: Epidemiology, clinical manifestations, course, and diagnosis".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Anxiety and trauma-related disorders in children" and "Society guideline links: Attention deficit hyperactivity disorder" and "Society guideline links: Trauma-related psychiatric disorders in adults".)
SUMMARY AND RECOMMENDATIONS
●Conduct disorder – Conduct disorder is defined by various forms of aggressive and rule-breaking behaviors in which the basic rights of others or age-appropriate societal norms are violated. Symptoms frequently lead to conflicts with adults (eg, parents, teachers, and other authority figures) or peers, and may include involvement with the legal system. (See 'Introduction' above.)
●Sociodemographic correlates – Conduct disorder has been associated with various sociodemographic correlates, including younger age, male gender, lower educational attainment, lower income, being separated or divorced, residing in large urban settings, and self-identification as non-Hispanic White compared with Hispanic. (See 'Sociodemographic correlates' above.)
●Clinical presentation – The prominent feature of conduct disorder is a pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules are violated. This is manifested by three or more aggressive and/or rule-breaking symptoms over the past year with at least one symptom presenting in the past six months.
The symptoms of conduct disorder are heterogenous with behaviors falling into four main groupings: aggressive symptoms or threats of harm to people and animals, nonaggressive conduct that causes property loss or damage, deceitfulness or theft, and serious rule violations. (See 'Clinical presentation' above.)
●Course – The course of illness is heterogeneous with a median age of onset at 12 years. Conduct disorder is often, but not always, preceded in early childhood by the development of attention deficit hyperactivity disorder (ADHD) or oppositional defiant disorder (ODD). Symptoms may persist into adulthood, in some patients, developing into antisocial personality disorder.
Children and adolescents with conduct disorder are at increased risk of functional impairments in adulthood (eg, in relationships, education, the workplace, and involvement with the legal system) and other psychopathology such as impulse control, substance misuse, anxiety, and mood disorders, especially if their conduct disorder is more severe and/or persistent. (See 'Course' above.)
●Assessment – We consider a diagnosis of conduct disorder in all youth who present with persistent behavior problems affecting academic performance, work performance, or causing psychosocial disruption. We assess interpersonal or relationship problems, school- or work-related problems, and legal problems across multiple situations and settings. We rarely use children under age 10 as reliable informants. We often use parent, caregiver, and teacher questionnaires as a supplement or alternative to structured or semistructured interviews. (See 'Assessment' above.)
●Differential diagnosis – We differentiate conduct disorder from other disorders with similar or overlapping presentations by detailed history and assessment. These other disorders include ODD, ADHD, adjustment disorder, posttraumatic stress disorder, mood disorders, disruptive mood dysregulation disorder, intermittent explosive disorder, and antisocial personality disorder. (See 'Differential diagnosis' above.)
آیا می خواهید مدیلیب را به صفحه اصلی خود اضافه کنید؟
