Conduct disorder is a mental health condition that affects children and teens. People with this condition persistently display severely antisocial and aggressive behaviors. They may bully others, be abusive to small animals, lie, steal, drink alcohol, use drugs, or skip school, often before their teenage years. They often experience little guilt about their actions or empathy toward others. Some are indifferent to the punishments that they receive for their actions.
It’s estimated that up to 3% of children and teens in the United States have conduct disorder. The condition is twice as common among males than females and is more common among those with attention deficit hyperactivity disorder (ADHD).
Conduct disorder typically arises during late childhood or early adolescence. Many with the condition were previously diagnosed with oppositional defiant disorder, a mental health condition in which children are angry or irritable and defiant toward their parents and teachers.
When a child or teen’s symptoms begin before age 10, their condition is considered child-onset conduct disorder. If symptoms arise after age 10, it’s known as adolescent-onset conduct disorder. Child-onset conduct disorder is associated with more physical aggression and violence. Those with child-onset conduct disorder tend to have worse outcomes than those with adolescent-onset conduct disorder.
Treatments for conduct disorder are most effective when started while the child or teen is relatively young. People can overcome conduct disorder with treatment. However, when conduct disorder is not adequately addressed, it may lead to problematic behaviors in adulthood, including drug use, criminal behavior, or suicidal thoughts or behaviors.
What is conduct disorder?
Conduct disorder is the mental health condition that is diagnosed when children or teens exhibit serious aggressive and antisocial behaviors that violate rules or rights of others, with little to no guilt or concern regarding their actions. Children and teens with this condition frequently break rules set for them by parents, teachers, and other authority figures, acting in ways that are not age-appropriate. To meet criteria for the diagnosis, symptoms must be present for at least one year and cause significant impairment in the child’s life and functioning.
People with conduct disorder act out at home, at school, and in other situations. They may be physically aggressive to other children or adults. They may heavily use drugs or alcohol, although they are underage. They may threaten, intimidate, or bully others. They may steal, light things on fire, run away from home, or exhibit other behaviors that are severely atypical for children or teens their age.
A number of influences may cause a child to exhibit symptoms of conduct disorder, including psychological factors, neurodevelopmental factors, socioeconomic factors, their home environment, how the parents interact with the child, and more. The combination of these factors may create circumstances that enable allow conduct disorder to develop.
What causes conduct disorder?
It’s unknown why conduct disorder develops, but doctors believe that the condition may have many causes, including genetic, environmental, and biological factors.
Possible causes include:
- Exposure to smoking, alcohol, or poor diet while developing in utero
- Growing up in a hostile home environment or one that lacks structure and guidance
- Having parents whose discipline styles are either hostile or ineffective
- Being exposed to parents’ negative habits, such as drug or alcohol use or domestic violence
- Experiencing poverty and its associated stressors during childhood
- Atypical neurodevelopment, possibly caused by abnormal electrical activity in the brain, developmental delays, seizures, or traumatic brain injury
- Inheriting genes that are associated with conduct disorder, including those that relate to aggression and rule-breaking behaviors, with little concern for possible punishment
What are the symptoms of conduct disorder?
The current diagnostic system includes 15 possible symptoms and meeting criteria for 3 out of 15 symptoms is one of the requirements for the diagnosis.
People with conduct disorder may exhibit behaviors such as:
- Destroying property
- Setting fires
- Skipping school
- Disregarding their parents’ rules
- Threatening or intimidating others
- Bullying others
- Being cruel to animals
- Possessing or using weapons
- Forcing others to perform sexual acts
- Running away from home
- Becoming engaged in promiscuous sexual behavior
- Using illegal drugs
- Drinking alcohol
- Experiencing academic difficulties in school
What are the risk factors for conduct disorder?
Children and teens who are at increased risk of conduct disorder include those who:
- Experienced child abuse or severe adversity
- Have parents who abuse drugs and/or alcohol
- Have parents with psychiatric disorders, such as bipolar disorder, schizophrenia, attention deficit hyperactivity disorder (ADHD), or conduct disorder
- Have been diagnosed with ADHD
- Have been diagnosed with oppositional defiant disorder
- Are exposed to domestic violence or neighborhood violence
- Live in poverty
- Were exposed to alcohol or tobacco in utero
- Have an association with delinquent peer groups
How is conduct disorder diagnosed?
Conduct disorder is diagnosed after a patient receives a psychiatric assessment. The condition has no physical symptoms, and no diagnostic tests can confirm the presence of conduct disorder.
In some cases, doctors perform bloodwork to rule out other medical conditions.
To make an accurate diagnosis, doctors need to learn about a patient’s medical history. Doctors will want to know if the patient has been diagnosed with ADHD, oppositional defiant disorder, mood disorders, schizophrenia, or another mental health condition. They should also ask about the child’s home and school environment to determine if there is neglect or abuse or if parents drink or use drugs around the children. It’s also helpful when parents, teachers, caregivers, and other adults can provide insights into the child’s or teen’s history or behaviors, typically by completing assessment forms or questionnaires.
During a psychiatric assessment, a mental health professional looks for behaviors that are so significant they infringe on other people’s rights and neglect social norms. These behaviors typically interfere with the child’s or teen’s relationships at home, school, work, or other social settings.
To be diagnosed with conduct disorder, a patient must have exhibited three or more symptoms under the following four categories during the previous 12 months and at least one symptom during the previous six months. As noted above, there are 15 possible symptoms of conduct disorder and they are grouped into four categories:
- Aggressive behavior toward people or animals
- Destroying property
- Lying, deception, or stealing
- Significantly disregarding the rules that parents have set
The Diagnostic and Statistical Manual of Mental Disorders, fifth edition, or DSM-5, the diagnostic tool used by the American Psychiatric Association, provides specific examples of activities related to the categories mentioned above.
If the symptoms began before the child was 10, they may be diagnosed with child-onset conduct disorder. If the symptoms began at age 10 or after, they may be diagnosed with adolescent-onset conduct disorder.
Other diagnostic criteria require that the symptoms have an onset before 18 years of age, last for at least 12 months, and cause significant impairment in functioning.
Children and teens suspected of having conduct disorder should also receive an academic assessment to determine if they have learning disabilities.
How is conduct disorder treated?
Treatments for conduct disorder are designed to help patients become less aggressive and more emotionally regulated. Treatment is most successful if it begins early, especially if parents and other family members are involved in the process.
- Parent management training. This approach teaches adults how to change their parenting techniques to encourage more positive behaviors from their children. Parents are taught to provide frequent positive feedback that recognizes good behavior rather than focusing on, and punishing, negative behavior. They are advised to give children specific instructions about tasks they are required to do rather than vague guidelines. When discipline is needed, parents are taught to give appropriate punishments rather than punishments that are too harsh for the circumstances.
- Multi-systemic therapy. This therapy helps patients with conduct disorder achieve improvements at home, at school, and in other venues. Doctors determine a patient’s individual needs to help them manage conduct disorder and any associated health conditions, such as ADHD. Treatments may include solutions to improve family dynamics, educational assistance to help improve school performance, anger management training, social skills training, problem-solving skills training, and more.
- Psychotherapy. Individual therapy for children or teens may include cognitive behavioral therapy (CBT), which helps patients focus on the ways that their thought process impacts their behaviors, to help them learn to make more positive choices, or skills training, which may help patients gain coping skills for interactions with peers and family members.
- Medication. Patients with conduct disorder with other conditions, such as ADHD or depression, may benefit from medication that helps manage those conditions. Medication management may help to improve a patient’s self-esteem and/or self-control, which may reduce symptoms of conduct disorder. Risperidone, an antipsychotic medication, may help some patients with conduct disorder decrease their aggression.
What is the outlook for people with conduct disorder?
Children who are treated early and complete treatment can often overcome conduct disorder.
Children with multiple risk factors and severe symptoms who don’t complete treatment may not overcome the behavioral problems associated with conduct disorder. They may develop other mental health conditions, such as depression or bipolar disorder as teenagers.
When children with unaddressed or untreated conduct disorder become adults, they are more likely to develop a personality disorder, such as antisocial personality disorder. Their involvement with drugs may develop into a substance use disorder. They may be violent toward other people and/or adopt criminal behaviors. They may also be at risk of suicide as adults if conduct disorder wasn’t treated during childhood.
What makes Yale unique in its treatment of conduct disorder?
“At Yale Medicine, we offer comprehensive treatment that focuses on early risk factors of conduct disorder and provides state-of-the-art care that includes family-based psychological interventions and medication management if needed,” says Denis Sukhodolsky, PhD, a clinical psychologist in the Yale Child Study Center who treats children and adolescents with neurodevelopmental disorders. “The treatment is provided by teams of child psychiatrists, psychologists, social workers, and nurse practitioners. The goals of treatment are to improve quality of life and functioning of children and their families and to prevent an escalation of symptoms.”