111 Conduct Disorder (CD), Childhood-Onset Type (312.81)

• Classified as an externalizing disorder. More severe than operational defiant disorder.

Children with Conduct Disorder (CD) are usually rejected by their peers and usually have a hard time making friends.

DSM-IV-TR criteria

• Conduct disorder is a more extreme form of ODD and involves more serious incidents of aggression and defiance.
• A repetitive and persistent pattern of behavior in which the basic rights of others or major age-appropriate societal norms or rules that are violated, as manifested by the presence of three (or more) of the following criteria in the past 12 months, with at least one criterion present in the past 6 months.
  • Aggressive conduct that threatens physical harm.
  • Nonaggressive conduct that causes property damage.
  • Deceitfulness or theft.
  • Serious violations of rules.

• The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.
• If the individual is age 18 years or older, criteria are not met for Antisocial Personality Disorder.
• Coding note: Onset of at least one criterion characteristic of Conduct Disorder (CD) prior to age 10 years.
• Aggression to People and Animals:
  • Often bullies, threatens, or intimidates others.
  • Often initiates physical fights.
  • Has used a weapon that can cause serious physical harm to others.
    • A bat, brick, broken bottle, knife, gun
  • Has been physically cruel to people.
  • Has been physically cruel to animals.
  • Has stolen wile confronting a victim.
    • Mugging, purse snatching, extortion, armed robbery
  • Has forced someone into sexual activity.

CD Subtypes

• Child-Onset Type:
  • Onset of at least one criteria before age 10.
• Adolescent-Onset Type:
  • Absence of any criteria before age 10.
• Unspecified Onset
• Code Severity:
  • Mild, Moderate, and Sever.

Associated features

Children with Conduct Disorder (CD) show acts of aggression towards others and animals. Children with conduct disorder (CD) usually show little to no compassion or concern for others or their feelings. Also, concern for the well-being of others is at a minimum. Children also perceive the actions and intentions of others as harmful and threatening than they actually are and respond with what they feel is reasonable and justified aggression. They may lack feelings of guilt or remorse. Since these individuals learn that expressing guilt or remorse may help in avoiding or lessening punishment, it may be difficult to evaluate when their guilt or remorse is genuine. Individuals will also try and place blame on others for the wrong doings that they had committed. Children with conduct disorders (CD) tend to have lower levels of self-esteem. Children diagnosed with conduct disorders (CD) are typically characterized as being easily irritable and often reckless, as well as having many temper tantrums. These children may force sexual activity and theft while confrontion (e.g. mugging).

Individuals may have low self-esteem despite their projected “tough” image portrayed to society. Conduct Disorder (CD) often accompanies early onset of sexual behavior, drinking, smoking, use of illegal drugs, and reckless acts. Illegal drug use may increase the risk of the disorder persisting. The disorder may lead to school suspension or expulsion, problems at work, legal difficulties, STD’s, unplanned pregnancy, and injury from fights or accidents. Suicidal ideation and attempts occur at a higher rate than expected.

They show aggressive conduct that threatens physical harm, and non-aggressive conduct that causes property damage. They display deceitfulness or theft, and serious rule violations. Rule violations sometimes include staying out all night, running away, and frequently playing truant. There are behavior problems that cause significant impairment in social, academic, or occupational functioning. There is a deliberate engagement in fire setting, with the intention of causing serious damage. They have deliberately destroyed others’ property by means other than fire setting. Often children with this disorder will lose their temper easily, argue with adults, and deliberately annoy others.

Conduct Disorder (CD) may be accompanied by a lower-than-average intelligence, particularly regarding verbal IQ. Attention-Deficit/Hyperactivity Disorder (ADHD) is common in individuals with this disorder, and the disorder may be comorbid with Learning Disorders (LD), Anxiety Disorders, Mood Disorders, and Substance-Related Disorders.

Research has suggested that parents of children with conduct disorder (CD) frequently lack several important parenting skills. Parents have been reported to be more violent and critical in their use of discipline, more inconsistent, erratic, permissive, less likely to monitor their children, as well as more likely to punish pro-social behaviours, and to reinforce negative behaviours. A coercive process is set in motion during which a child escapes or avoids being criticised by his or her parents through producing an increased number of negative behaviours. These behaviours lead to increasingly aversive parental reactions which serve to reinforce the negative behaviours (Duff, 2005).
Differences in affect have also been noted in conduct disordered (CD) in children. In general their affect is less positive, they appear to be depressed, and are less reinforcing to their parents. These attributes can set the scene for the cycle of aversive interactions between parents and children (Duff, 2005).

Child vs. adult presentation

The presentation of symptoms differ among age. As the individual matures, behaviors intensify and become more physical. Less severe behaviors tend to appear first while others emerge later. The most severe appear last. In comparison, childhood-onset presentation involves more behavioral problems. Lying, shoplifting, and burglary are just a few examples of symptoms present among adults.

Gender and cultural differences in presentation

Boys tend to display behavioral problems that are associated with conduct disorders than girls. Studies show findings that there is a 4:1 prevalence ratio of CD in boys to girls. However, this ratio may fluctuate throughout the child’s development. For example, the difference in prevalence among boys and girls may be small to nonexistent in preschool children, but the difference usually becomes more dramatic throughout childhood. The ration then seems to drops to 2:1 (males to females) during adolescence. There is a bit of controversy about the difference in prevalence rates among boys and girls. Some argue that girls are less likely to be diagnosed with CD because they may exhibit more indirect or relational aggression. Others argue that girls showing possible symptoms of CD should be diagnosed using more lenient criteria that compares a girl to other girls, instead of a sample of both girls and boys.

There is some research that has indicated that certain social factors can influence the development of this disorder. For example, the high rate of violence in the United States (compared to other industrialized nations), and the marginalization of ethnic minorities have been noted to increase the risk of delinquent and antisocial behavior among those without the means to obtain goods through socially accepted methods. However, the findings of these studies are not conclusive.

Boys diagnosed with CD tend to display more serious acts such as vandalism and theft. Whereas girls tend to display acts such as running away, truancy, and prostitution.

Epidemiology

The diagnosis range of individuals with conduct disorder are anywhere from 1% to no more than 10%. Also, conduct disorder (CD) ranges in 9 to 17 year old kids at about 1% to 4%.The prevalence rate of males is higher than that of females. Research has showed that the prevalence of CD has increased.

Onset may occur as early as preschool, but the most significant symptoms usually appear from middle childhood through middle adolescence. Oppositional Defiant Disorder (ODD) is a common precursor to Conduct Disorder (CD). Onset after 16 years of age is rare. The course varies; in the majority of individuals, it remits by adulthood. A large portion continues to show that meet criteria for Antisocial Personality Disorder. Many achieve adequate social and occupational adjustment as adults. Early onset predicts a worse prognosis and an increased risk for Antisocial Personality Disorder and Substance-Related Disorders. Those with Conduct Disorder (CD) are at risk for Somatoform Disorders, Mood Disorders, and Anxiety Disorders as well.

Etiology

The etiology of conduct disorders (CD) is thought to be mostly family influenced and morally developed. Studies have shown that there is a high incidence rate of deviant behavior among families of children with conduct disorder. Also, moral development relates to the violating of rules and norms that is portrayed among conduct disorder. These behavioral characteristics pertain to moral development.

Social problems and peer group rejection have been found to contribute to delinquency. Low socioeconomic status has been associated with conduct disorders. Children and adolescents exhibiting delinquent and aggressive behaviors have distinctive cognitive and psychological profiles when compared to children with other Mental Health Disorders problems and control groups.

A decrease of activity in frontal lobe functioning has been associated with poor ability to inhabit behavioral responses. This also leads to a weakness in planning ability.

Empirically supported treatments

Educating the parents of children with conduct disorders (CD) and providing them with information on the disorder are well-established treatments. Also, modifying the behavior in the classroom can be an effective treatment modality in children with conduct disorder (CD).

Certain cognitive-behavioral approaches have been proven to be effective when working with children that have CD. It has been documented that children with CD have problems processing social information. This may include difficulty encoding social cues, interpreting these cues, developing social goals, and developing appropriate social responses. These cognitive-behavioral techniques are designed specifically to help children overcome these deficiencies in social cognition and social problem solving.

Family therapy helps families gain an understanding of the problems with conduct disorder and how they can be corrected. Therapists evaluate how different family members interact in a therapy type environment. Typically, family therapy is directed towards helping parents work together as a whole, help them cope more efficiently, and to equip parents with better disciplinary skills.

Note: CD with choldhood-onset-type applies if at least one criterion symptom was present prior to 10 years of age, while CD with adolescent-onset-type is used if no symptoms were evident prior to 10 years of age.

Summary

Conduct disorder (CD) is very common among children and adolescents in our society. This disorder not only affects the individual, but his or her family and surrounding environment. Conduct disorder (CD) appears in various forms, and a combination of factors appear to contribute to its development and maintenance. A variety of interventions have been put forward to reduce the prevalence and incidence of conduct disorder (CD). The optimum method appears to be an integrated approach that considers both the child and the family, within a variety of contexts throughout the developmental stages of the child and family’s life (Duff, 2005).