Definition and common characteristics of conduct disorder
Conduct disorder is a disorder of impulse control which usually occurs in childhood and or adolescence and involves anti-social behaviour in which there 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" (Diagnostic and Statistical Manual, 4th Edition, of the American Psychiatric Association, DSM-IV).
The DSM-IV divides the antisocial behaviors into four types:
- Aggressive conduct that causes or threatens physical harm to other people or animals
- Non-aggressive conduct that causes property loss or damage
- Deceitfulness or theft
- Serious violation of social or family rules
According to the DSM-IV associated features of conduct disorder include "a lack of empathy and little concern for the feelings, wishes and well being of others. This poor capacity for empathy results in the individual with conduct disorder misperceiving the intentions of others, specifically to interpreting them more negatively than they really are.
This can result in inappropriate aggression by the person with conduct disorder. The deficit in empathy can also result in a lack of appropriate feelings of guilt or remorse after committing an anti-social act.
Difficulties in everyday functioning
Conduct disorder is often associated with a host of difficulties in everyday functioning including a precocious onset of sexual behavior, alcohol abuse, smoking, use of illegal substances, and reckless and risk-taking acts.
The lifetime prevalence for conduct disorder was found to be 9.5% in a large US epidemiological study (Kessler 2005) making it the most prevalent of the impulse control disorders.
It is followed in frequency of occurrence by oppositional defiant disorder 8.5% and attention deficit hyperactivity disorder at 8.1%. Intermittent explosive disorder is the least prevalent of the impulse control disorders having a lifetime prevalence of just 5.2%.
The prevalence of conduct disorder was not uniform over the entire continental US being higher in the western part of the country (Nock et 2006). It seems quite possible that there are national differences e.g. Singapore versus the US.
There is evidence that a variety of factors, individually or in a complex interaction), can be involved in the aetiology and maintenance of conduct disorder (Finch, Nelson, & Hart, 2006).
- Genetics. There is abundant evidence that genetics can play an important role in the causation of conduct disorder (Finch, Nelson, & Hart, 2006). Genetic causation seems to play a particularly strong role if the conduct disorder occurs along with attention deficit hyperactivity disorder and across the life-span (Comings, 2000).
- Family. Neglect, physical, emotional, or sexual abuse or rejection, inconsistent child rearing, or lack of supervision and love can all increase the risk of conduct disorder
- Peer interactions. Association with delinquent peer groups may contribute to the development of conduct disorder in vulnerable individuals.
- Community and neighbourhood factors e.g. poverty, discrimination of any type.
Transition of conduct disorder into antisocial personality disorder
There are important continuities (transitions, progressions) which frequently occur between childhood and or adolescent conduct disorder and anti-social personality disorder and oppositional defiant disorder (Steiner & Dunne, 1997).
For example, in a sample of adolescent substance abusers, 61% had progressed from conduct disorder to antisocial personality disorder 4 years after the initial diagnosis and treatment (Myers, Stewart, & Brown, 1998).
Nock et al 2006 state "However, it is also possible that CD (conduct disorder) has lasting negative consequences that persist even after the disorder has remitted (e.g. a criminal record), or that once remitted, CD may have been replaced with symptoms of related adult disorders such as antisocial personality disorder". Indeed the DSM-IV states that conduct disorder may be diagnosed in individuals older than age 18 but only if the criteria for antisocial personality disorder are not met.
Conduct disorder and the associated acting out of aggression, stealing, bullying, etc can result in serious consequences, such as arrest by the police. For this reason, conduct disorder is one of the most frequent reasons for the referrals of children and adolescents to mental health professionals.
The serious consequences for individuals with conduct disorder, the pain to their families, and the financial costs to society, are all reasons why this disorder quite rightfully deserves a lot of time and attention from mental health workers and financial support by various levels of the government.
Also, it is important that young persons with conduct disorder receive professional help to prevent the transition to anti-social personality disorder with all its associated problems e.g. problems with the police and legal system.
A variety of treatment approaches have been used for conduct disorder. In general, early treatment and prevention seem to be more effective than later intervention (Steiner & Dunne, 1997). Some of the approaches which have been used are:
Multisystemic. Because of the complex interaction of genetics, family dynamics, peer interactions, school performance, and community influences in the causation of this disorder, a multi - systemic approach has been advocated and used with demonstrated effectiveness (Finch, Nelson III, & Hart, 2006; Henggeler et al, 1997; Schaeffer & Borduin. 2005).
Multisystemic therapy involves an intensive, family-focused and community-based treatment program in which therapists visit the home, school and community so that the complete environment of the youth can be improved.
- Pharmacotherapy. David Cummings (2000) has discussed the genetics of conduct disorder. In particular he focused on the combination of conduct disorder with attention deficit hyperactivity (ADHD) and argues that the life-persistent form of comorbid conduct disorder and ADHD is "largely genetic" and poly genetically inherited.
Family therapy approaches. Keiley (2002) after reviewing relevant research has concluded that deficits in affect regulation and attachment strategies may be involved in the aetiology of conduct disorders in adolescence and that family therapists should focus on these two processes.
Kylie also presents preliminary evidence for the effectiveness of this approach in therapy involving multiple family groups of parents and their incarcerated adolescents.
- Community-based residential treatment for adolescents with conduct disorder (Chamberlin, 1996).
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders. (4th ed., text rev.) Washington, DC: Author.
Borduin C.M., Mann B.J., Cone L.T., Henggeler S.W., Fucci B.R., Blaske D.M., & Williams R.A. (1995). Multisystemic treatment of serious juvenile offenders: long-term prevention of criminality and violence. Journal of Consulting and Clinical Psychology. 63, 569–578.
Chamberlain, P. (1996). Community-based residential treatment for adolescents with conduct disorder. In T. H. Ollendick & R. J. Prinz (Eds.), Advances in clinical child psychology. Advances in clinical child psychology, Vol. 18, pp. 63-90). New York: Plenum Press.
Comings, D. E. (2000). The role of genetics in ADHD and conduct disorder —Relevance to the treatment of recidivistic antisocial behavior.
In The science, treatment, and prevention of antisocial behaviors: Application to the criminal justice system.(pp. 16-1-16-25)Kingston, NJ, US: Civic Research Institute. Fishbein, Diana H. (Ed), (2000). xiii, 27-25 pp.
Finch Jr., A. J., Nelson III, W. M., & Hart, K. J. (2006). Conduct Disorder : Description, Prevalence , and Etiology. In Conduct disorders: A practitioner's guide to comparative treatments.(pp. 1-13) New York, NY, US: Springer Publishing Co. Nelson, W. Michael, III (Ed); Finch, Alfred J., Jr. (Ed); Hart, Kathleen J. (Ed).
Henggeler, S., Melton, G., Brondino, M., Scherer, D., & Hanley, J. (1997). Multisystemic therapy with violent and chronic juvenile offenders and their families: The role of treatment fidelity in successful dissemination. Journal of Consulting and Clinical Psychology, 65(5), 821-833.
Keiley, M. K. (2002). Attach and affect regulation: A framework for family treatment of conduct disorder. Family Process, 41(3), 477-493.
Kessler, Ronald C., Berglund, Patricia, Demler, Olga, Jin, Robert, Merikangas, K. R., Walters, Ellen E., (2005). Lifetime Prevalence and Age-of-Onset Distributions of DSM-IV Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry, Vol. 62(6), 593-602.
Myers, M .G., Stewart, D.G., & Brown, S. A. (1998). Progression From Conduct Disorder to Antisocial Personality Disorder Following Treatment for Adolescent Substance Abuse American Journal of Psychiatry, 155:479-485.
Nock, M. K., Kazdin, A. E., Hiripi, E., & Kessler, R. C. (2006). Prevalence, subtypes, and correlates of DSM-IV conduct disorder in the National Comorbidity Survey Replication. Psychological Medicine: A Journal of Research in Psychiatry and the Allied Sciences, 36(5), 699-710.
Schaeffer, Cindy M. and Charles M. Borduin. “Long-Term Follow-Up to a Randomized Clinical Trial of Multisystemic Therapy With Serious and Violent Offenders.” Journal of Consulting and Clinical Psychology, 2005, Vol. 73, No. 3, pp. 445-453.
Steiner, H. & Dunne, J. E. (1997). Summary of the practice parameters for the assessment and treatment of children and adolescents with conduct disorder . Journal of the American Academy of Child & Adolescent Psychiatry. 36(10), 1482-1485.