Conduct Disorder

The etiology underlying conduct disorder is likely a complex interplay of genetic and environmental factors. One meta-analysis indicated that environmental factors may be slightly more influential in determining antisocial behaviors than genetic factors, with no significant sex-based etiologic differences identified in studies including both males and females (1). Genome-wide association studies have not found consistently replicable candidate genes or single nucleotide polymorphisms implicated in its pathogenesis (2). Reduced amygdala responsiveness to distress cues and dysfunction in the ventromedial prefrontal cortex and striatum may lead to deficits in decision-making in such children and adolescents. Racial and sex disparities have been identified in the prevalence of conduct disorder (3).

Parents of adolescents with conduct disorder often have engaged in substance use and antisocial behaviors and frequently have been diagnosed with attention-deficit/hyperactivity disorder (ADHD), mood disorders, schizophrenia, or antisocial personality disorder. Tetrahydrocannabinol (THC) has been reported to be a risk factor for physical violence even when socioeconomic factors and other substance use are accounted for (4). Urban residence, lower parental socioeconomic status, and having divorced parents are associated with conduct disorder. However, conduct disorder can occur in children from high-functioning, healthy families.

Children or adolescents with conduct disorder lack sensitivity to the feelings and well-being of others and sometimes misperceive the behavior of others as threatening. They may act aggressively, by bullying and making threats, brandishing or using a weapon, committing acts of physical cruelty, or forcing someone into sexual activity, and have few or no feelings of remorse. Sometimes their aggression is directed at animals. Children or adolescents with conduct disorder may destroy property, lie, and steal. They tolerate frustration poorly and are commonly reckless, violating rules and parental prohibitions (eg, by running away from home, being frequently truant from school).

Aberrant behaviors differ between the sexes: Boys tend to fight, steal, and vandalize; girls are likely to lie, run away, and engage in prostitution. Both sexes are likely to use illicit drugs and have academic difficulties in school. Suicidal ideation is common, and suicide attempts must be taken seriously.

• Psychiatric assessment

• Diagnostic and Statistical Manual of Mental Disorders, Fifth edition, Text Revision (DSM-5-TR) criteria

Conduct disorder is diagnosed in children or adolescents who have demonstrated ≥ 3 of the following behaviors in the previous 12 months plus at least 1 in the previous 6 months (1):

• Aggression toward people and animals

• Destruction of property

• Deceitfulness, lying, or stealing

• Serious violations of parental rules

Symptoms or behaviors must be significant enough to impair functioning in relationships, at school, or at work. Callous-unemotional traits (eg, reduced guilt, callousness, uncaring behavior, and reduced empathy) has been added as a DSM-5-TR criterion specifier (ie, a term that describes the nature of the condition) for the diagnosis of conduct disorder.

• Medications to treat comorbid disorders

• Psychotherapy

• Sometimes placement in a residential center

Conduct disorder presents significant treatment challenges because of potential difficulty in appropriately engaging patients, patient's lack of self-awareness and/or guilt, and the presence of concurrent comorbidities and environmental factors. A combination approach encompassing pharmacotherapy and psychotherapy is often advised for optimizing treatment outcomes. Treating comorbid disorders with medications and psychotherapy may improve self-esteem and self-control and ultimately improve control of conduct disorder.

Medications may include stimulants such as methylphenidate, which have been known to decrease emerging substance use and criminality (may include stimulants such as methylphenidate, which have been known to decrease emerging substance use and criminality (1, 2). Stimulants may also decrease criminal activity. Mood stabilizers and atypical antipsychotics, especially short-term use of risperidone may also be helpful. However, its use in boys can be limited by adverse effects including gynecomastia (). Stimulants may also decrease criminal activity. Mood stabilizers and atypical antipsychotics, especially short-term use of risperidone may also be helpful. However, its use in boys can be limited by adverse effects including gynecomastia (3). Lower-quality evidence supports the use of other agents such as aripiprazole, ziprasidone, and quetiapine (). Lower-quality evidence supports the use of other agents such as aripiprazole, ziprasidone, and quetiapine (4). If there is a concurrent mood disorder, selective serotonin reuptake inhibitors (SSRIs) may also be necessary (eg, citalopram).). If there is a concurrent mood disorder, selective serotonin reuptake inhibitors (SSRIs) may also be necessary (eg, citalopram).

Psychotherapy, including approaches such as cognitive behavioral therapy, family therapy, behavioral modification, and parental therapy, is a key component in treating conduct disorder. Psychotherapy helps individuals learn problem-solving skills, improve social interactions, manage anger, and modify disruptive behaviors. Therapeutic goal-setting may improve symptom resolution. Moralization and dire admonitions are ineffective and should be avoided.

Often, seriously disturbed children and adolescents may have to be placed in residential centers where their behavior can be managed appropriately, thus separating them from the environment that may contribute to their aberrant behavior.

Future research should focus on identifying factors that contribute to disparities in conduct disorder; cultural biases and structural racism are important factors.

Usually, disruptive behaviors stop during early adulthood, but they may also persist through the life course. Many of these cases meet the criteria for antisocial personality disorder, which may occur in as many as 50% of affected youth (1). Early onset is associated with a poorer prognosis. Children with callous-unemotional traits exhibit reduced empathy and guilt, and often have a poor prognosis and treatment response.

Children and adolescents with conduct disorder tend to have higher rates of comorbid general medical and other psychiatric disorders. Some children and adolescents subsequently develop mood or anxiety disorders, somatic symptom or related disorders, substance-related disorders, or early adult–onset psychotic disorders.