Conduct Disorder

Conduct Disorder (CD) is the repetitive and persistent pattern of the violation of the rights of others or major age appropriate societal norms or rules are violated as seen in at least three areas as list in the DSM-IV. These areas include aggression to people or animals, destruction of property, deceitfulness or theft and serious violation of rules. In the manual, each of the aforementioned areas has a list of possible criterion that could constitute such violation of rules or norms. This disorder can sometimes be confused with Oppositional Defiant Disorder (ODD) as all the symptoms present in ODD are present in CD. ODD may be a less severe form of CD, but does not have the violation of others rights to such a significant degree. For example, while children with ODD may destroy others property, this usually occurs in the course of a tempter tantrum, rather than a deliberate and planned destruction of the property. ODD children may lie but this usually occurs in an attempt to escape punishment rather than a deliberate manipulation or “con” as is the case in CD.

Research shows that CD often develops in the presence of significant family problems including low SES, broken homes, family conflict, or alcoholic fathers. Further, because children tend to act out, children or adolescents with other disorders such as depression, mental retardation, or ADHD may exhibit misconduct that “looks like” CD. Further, there may be co-morbid disorders that confound or complicate diagnosis.

Diagnosis requires a multimodal approach. Medical conditions and mental retardation must be ruled out. Neurological conditions must be evaluated. Further, educational skills and deficits, social skills, and family functioning should be evaluated. Take a good history and psychosocial history of the family. It is a good idea to begin by interviewing the parents at least once and perhaps twice before seeing the child or adolescent. Behavior checklists such as the Connors or Achenbach may be valuable. However, one should not rely solely on checklists in making a diagnosis.

Treatment may be approached form several directions based on the initial assessment. Legal sanctions, family therapy, individual therapy, or medical treatment may be used alone or in concert to address the problems associated with CD. A structured or controlled environment is essential in reducing acting out behaviors. First, the clinician must develop a good rapport with the parents. This may be difficult if they believe that the therapist is blaming the parents for the existing problems. Often parents must completely change parenting style and this may appear blaming (Whether or not the disorder is due to parenting deficiencies, one must be cautious to joint with, not to alienate parents.) A clinician may empathize with “having such a difficult child” and state that “having such difficult child means adapting your behavior first to get control of the situation”. Structured contingency/response programs have been shown to be somewhat effective in treating CD. However, parent’s compliance is required and constant monitoring by the clinician is vital. Family therapy may be useful in reducing family conflict and psychopathology. However, this requires parents that are committed to not only their child’s growth, but their own. Individual therapy may be useful if the child exhibits guilt and remorse for their behavior problems. Sometimes inducing guilt may be helpful if the level of continence is diminished. Psychotropic medications may be useful for co-morbid disorders or for controlling impulsive behavior or irritability. If one notes a cyclic pattern to impulsive behavior and extreme aggression in the presence of irritability, consider bipolar disorder as a possible differential diagnosis.