Conduct disorders

ALSO KNOWN AS: Disruptive behavior disorders; juvenile delinquency

DEFINITION: Conduct disorders are psychiatric disorders based on different types of callous and aggressive behaviors: physical harm to others, substantial damage to property, pervasive dishonesty or stealing, and breaking rules or defying authority. Substantial evidence suggests that conduct disorders have both neurobiological and environmental causes.

Background

Conduct disorder (CD) is characterized by pervasive dishonesty, aggression, and callous disregard for others and rules. These behaviors are more intense and longer-lasting than the occasional rule-breaking behavior associated with young people, for example. An average of 9.5 percent of the United States (US) population could have CD at some time. The condition is more prevalent in boys than girls, with 12 percent of males having CD compared to 7.1 percent of females.

The disorder is on the spectrum of disruptive behavior disorders (DBD) and exists in a continuum with two closely related disorders, one of which—oppositional defiant disorder (ODD)—tends to appear in younger children and the other of which—antisocial personality disorder—is not strictly diagnosable until adulthood. It is believed that some children with ODD “grow into” CD in their teenage years; later, some teens with CD demonstrate an antisocial personality when they become adults.

In practical terms, some children with high levels of irritability, developmentally inappropriate tantrum-like behaviors, and defiance of adults may demonstrate (as they age) a continuing lack of empathy, increasing callousness, and difficulty in restraining from cruel impulses. If these tendencies manifest in three or more types of serious misbehavior repeated multiple times for more than one year, clinicians may consider a diagnosis of CD. Even in this case, the behaviors must be substantially worse than occasional acts of petty cruelty or vandalism, and the behaviors cannot be caused by underlying mood problems, attention deficit hyperactivity disorder (ADHD), or post-traumatic stress disorder. Usually, the earlier the problem behaviors appear, the more severe the disorder is likely to be. However, ADHD, depression, learning disorders, and other psychiatric conditions are commonly seen in those with CD.

Causes

Most mental illnesses emerge from the interaction of internal and external causes. Traditionally, some internal causes for aggressive behavior are believed to be low self-esteem, aberrant moral judgment, low frustration tolerance, low Intelligence Quotient (IQ), and concomitant low school achievement. CD is highly heritable. A person with a sibling or parent with conduct, hyperactivity, or substance abuse problems is more likely to have a CD.

Other studies have pointed to neurological dysfunctions as important in CD. One study of extremely violent men has offered evidence that the neural pathways associated with recognizing and interpreting facial cues are not particularly effective in these men. Although the data are arguable, it is possible that persons with CD may be similarly unable to interpret facial cues correctly and are, therefore, more likely to believe that neutral persons are hostile.

Other neurologic studies suggest that the brains of antisocial persons experience difficulty with regulating stress and maintaining appropriate levels of certain neurotransmitters, including serotonin and norepinephrine. Low levels of these brain chemicals have been associated with depression. Persons who experience increased levels of serotonin and norepinephrine after engaging in risky behaviors may increasingly seek out those behaviors to avoid low moods. Other studies have examined problems in neural pathways linking those parts of the brain responsible for overall decision-making with other parts of the brain associated with rewards and with learning.

Individuals prone to aggression or dishonesty may not demonstrate significant behavioral problems without environmental stress. Among the more commonly accepted environmental contributors to CD are inferior or absentee parenting, especially ineffective monitoring or inappropriate discipline; family problems, including conflict between parents or other disruptions in family life; economic problems like family poverty and poor and crime-ridden neighborhoods; and school problems, including schools that are plagued with high rates of criminal or deviant behavior among students. Not all who experience these environmental issues demonstrate conduct problems, however.

Typically, a diagnosis of CD will be based on extensive problems with aggression, property destruction, dishonesty, and rule-breaking behaviors. These problems are discussed here.

Types

Aggression Toward People and Animals. The first group of behaviors associated with CD has to do with repetitive viciousness toward people and animals. These behaviors indicate deep unconcern with the basic rights of others to be safe from physical harm. Hence, persons with CD may enjoy bullying or threatening. Beyond just threats, however, many will start fights and may use whatever weapons are available to wound or kill others. Other vicious behaviors in this group include the perpetration of other serious criminal acts in the course of physically harming or threatening others. Armed robbery, rape, and extortion are some examples.

Destruction of Property. Those with little regard for others’ physical well-being frequently demonstrate even less respect for others’ property. This second group of behaviors associated with CD involves arson, vandalism, and other forms of property destruction. However, this group does not include vandalism, which is better explained as thrill-seeking behavior; instead, it includes vandalism for the purpose of destruction and to deprive others.

Dishonesty and Stealing. When confronted with their behavior, many with CD either minimize the severity of their actions or project the blame onto the victim. This basic dishonesty characterizes the third group of behaviors used to diagnose CD. These behaviors include house-breaking, lying, forgery, writing worthless checks, and stealing when victims are not present.

Rule-Breaking Behaviors. As the previous sets of behaviors demonstrate, someone diagnosed with CD may often perceive others as unimportant, so rules developed in society to protect others will be likewise unimportant. However, this fourth group of diagnostically significant behaviors involves the transgression of rules designed to maintain the safety of the young person with CD themselves. These behaviors include eloping from school or from home multiple times, especially overnight and often before age thirteen years.

There are other deviant or dangerous behaviors associated with CD that are not diagnostically definitive but nonetheless important. Persons with CD are more likely to engage in several risky behaviors, including risky sexual behaviors, substance abuse, and other criminal behaviors.

Treatment

Persons with CD do not appear to respond well to medications. At its most basic level, no medication can help someone who refuses to take it, and with persons who have problems with honesty, compliance can be difficult to determine. Moreover, although they may help with mood lability or poor impulse control, medications are unlikely to help a person unlearn aberrant behavior patterns.

The more effective forms of treatment for children or adolescents with CD involve the entire family. Parents or other caregivers are taught to set appropriate limits, to encourage and reward good choices, and to use sensible and consistent discipline. Sometimes caregivers are taught the importance of spending more time with their children with CD, involving them in socially appropriate activities to lessen the amount of time they can spend with bad influences. Other therapies emphasize the importance for the person with CD of learning impulse control and stress management skills.

Progress has been made in the twenty-first century in understanding the causes of CD and developing treatments for it. Research has indicated that the complex interaction of several factors, including genetic, environmental, and psychological factors, often causes CD. CD is often diagnosed in individuals whose parents struggled with similar behavioral disorders, who grew up in unstable homes with inconsistent parental discipline, and who have difficulty processing social information. Psychosocial interventions remain the first line of treatment for patients who have been diagnosed with CD. These include but are not limited to cognitive-behavioral therapy (CBT), family therapy, and multi-systemic therapy. No medications exist solely for the treatment of CD. However, treating comorbid disorders with pharmacological solutions may lessen the behaviors related to CD. Early intervention through programs that offer parental training and support, teach social skills, and offer academic support have proven successful in treating CD. 

Bibliography

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