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Conduct Disorder

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Overview

Conduct disorders are defined as persistent behaviour problems across multiple settings that range from markedly and persistently defiant, disobedient, provocative, or spiteful that violate the basic rights of others or major age-appropriate societal norms, rules or laws.

ICD-11 updated the term ‘Conduct Disorders’ with ‘Disruptive Behaviour or Dissocial Disorders). These include:

  • Oppositional defiant disorder
  • Conduct-dissocial disorder
  • Other disruptive behaviour or dissocial disorders that share common clinical features with the above two but do not meet their diagnostic criteria 

It is essential to screen for maltreatment in children where a conduct disorder is suspected.

Epidemiology

  • Around 5% of people aged 5-19 years old had a behavioural or conduct disorder in 2017
  • Initial symptoms of oppositional defiant disorder typically appear in preschool children
  • Around 40% of children who are in foster homes/children’s homes, who have been abused, or who are on the child protection/safeguarding register met the criteria for conduct disorders

Risk Factors

  • Characteristics:
  • Familial risks:
    • Family history of conduct disorder
    • Parents with poor mental health
    • Frequent changes in caregivers or early institutional living
    • Physical or sexual abuse
    • Rejected by parents or experiencing permissive, harsh, neglectful, or inconsistent parenting
    • Exposure to domestic violence and/or marital conflict
    • Poverty
    • Maternal smoking during pregnancy
  • Risks outside of the family:
    • Being bullied
    • Physical/sexual abuse
    • Substance misuse
    • Involvement with other difficult young people

Presentation

Oppositional defiant disorder

Oppositional defiant disorder describes persistent and marked defiant, disobedient, provocative, or spiteful behaviours that occur more often than expected in those of comparable age, developmental level, gender, and sociocultural context.

Its diagnostic criteria include the following which must be persistent:

  • Difficulty getting along with others, arguing with authority figures, actively defying or refusing to comply with requests/rules/directives, intentionally annoying others, blaming others for mistakes or misbehaviour
  • Provocative, spiteful, or vindictive behaviour
  • Extreme anger/irritability
  • The behaviours have been ongoing for at least 6 months and are not better explained by relational problems between the person and a specific authority figure
  • These behaviours cause significant impairment in personal, familial, social, educational, or other important areas of functioning

Conduct-dissocial disorder

Conduct-dissocial disorder is described as repetitive and persistent behaviours that violate the basic rights of others or major age-appropriate societal norms, rules, or laws.

Its diagnostic criteria include the following which must be recurrent and persist for at least a year:

  • Aggression towards people/animals
  • Destruction of property
  • Deceitfulness/theft
  • Serious violations of rules (e.g. running away from home, skipping school, staying out all night despite parental prohibitions)
  • These behaviours cause significant impairment in personal, familial, social, educational, or other important areas of functioning

Conduct-dissocial disorder may present in childhood (<10 years, present and persist into adolescence) or in adolescence (>10 years, where none of the features were present before adolescence).

Referral

Assessment and consent

When making a referral, all information gathered from an assessment should be included. An assessment should be made with information from families, schools, and other caregivers.

  • Remember to seek permission from young people who are Gillick competent or from parents/guardians before contacting a school or nursery for more information or before passing on confidential information (e.g. family problems)

Referral

Children with a suspected conduct disorder should be referred for a specialist assessment by Child and Adolescent Mental Health Services (CAMHS) if any of the following complicating factors are present:

  • Coexisting mental health problems (e.g. depression or post-traumatic stress disorder)
  • Neurodevelopmental condition (e.g. ADHD or autism)
  • Learning disability or difficulty
  • Substance misuse

If no complicating factor is present, refer directly for an intervention such as parent training, child-focused programmes, or a multimodal intervention.

Prognosis

  • Adolescent-onset conduct disorders have a better prognosis and around 85% will have no antisocial behaviour by their early 20s
  • Around half of those with childhood-onset conduct disorders have serious problems that persist into adulthood such as:
    • Committing crimes
    • Psychiatric problems such as alcohol and drug abuse, anxiety, depression, and self-harm
    • Poorer school performance
    • Unemployment
    • Relationship problems

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